Use of Self in Relationship-Based Infant-Family Practice — Comprehensive Notes

Key ideas and purpose

The article articulates and defines the use of self construct in relationship-based intervention in the infant and family field.
Introduces descriptors to operationalize clinical processes and reflective practice skills for supervision with trainees and new practitioners.
Emphasizes Schon’s distinction between reflection in action and reflection on action; provides supervision diálogues and examples to illustrate opportunities for enhancing clinical process.
Argues that a practitioner’s greater understanding of how internal experience impacts intervention helps develop an authentic voice.
Provides definitions, descriptors, and phases involved in developing use of self.
Anchors change dynamics in clinical work through careful attention to feelings, beliefs, and internal worlds of both clinician and client.

Foundational definition and background

The use of self is defined as the capacity to observe and be aware of one’s own thoughts, feelings, and behaviors as a key source of communication in various clinical experiences (1994 reference in the article).
It includes recognizing judgments, wishes, intolerances, hot buttons, or fears activated in clinical encounters.
The internal worlds of others are viewed as equally diverse and unique.
Use of self is an active, dynamic, and intersubjective process linking one’s own internal world with others’ internal worlds.
The term expands upon psychoanalytic concepts of transference and countertransference.
Foundational influences include:
- Bion’s concept of containment (1978)
- Winnicott’s work on the analytic and mother–infant relationship, play space, curiosity
- Kleinian concept of projective identification (Seligman, 1999)
- French’s concept of negative capability (borrowed from Keats; applied to clinical work)
In infant-family practice, the term first appeared in Bertacchi & Coplon (1992): professional use of self includes self-awareness and willingness to explore what a particular family scenario may bring up for the intervener.
Fenichel (1992) included this in a broad anthology on supervision and mentorship; subsequent writers in infant mental health use the term in supervision as a relationship for growth.
The authors operationalize a working model of use of self by expanding and modifying Heffron’s (2002) Developing Competencies in Infant and Early Childhood Mental Health, used to guide trainee evaluations and reflective dialogues.
The descriptors were designed to help supervisees recognize and discuss clinical processes in sessions with families.

Use of self descriptors: 12 items in 4 categories

The authors present 12 descriptors grouped into 4 broader clinical-process categories:
- $12$ descriptors total; grouped into $4$ categories.

Reflective practice

Awareness and ability to monitor and reflect on ways work with families can evoke past/present personal experiences of the clinician or the family on a conscious or unconscious level.
Understanding that the clinician’s personal characteristics, clinical context, style, and professional role influence the interactive process through conscious and unconscious means.
Ability to observe individual behavior and the interactive exchange with others, reflect on these dyadic and systems processes, and attribute relational meaning.

Translation of reflection into action

Ability to consider, observe, and monitor the impact of interactions on the family and talk with the family about this in a way that is potentially meaningful for them.
Ability to use self-knowledge and to think about the client’s experience to help formulate therapeutic responses.

Relationship awareness

Ability to understand and accept that each family is unique and will perceive the clinician and intervention through their own experience.
Ability to create reciprocity and comfort/friendliness with a family by allowing normal everyday social interactions without losing a sense of purpose and safety about role and reason for involvement.
Negative capability or the ability to tolerate strong affect and ambiguity, recognizing not knowing or not understanding behaviors and motivation.
Ability to recognize and think about internal pressures that can press toward an emotional response and urges to act.

Internalized professional self

Ability to maintain professional boundaries in various settings (home, center, or community).
Ability to listen to the family and discover what is important to them about their child and themselves, and then collaborate on behalf of the child despite pressures of the clinician’s agenda.
Ability to set the frame for the work as focused on parent-child relationships despite distractions.

Operationalizing use of self: reflective practice in action and on action

Putting clinical processes into practice requires reflection in action and reflection on action (Schon, 1983).
Reflective practice in action:
- Involves using self-knowledge to reflect on affect, actions, and intentions; reflect on process of formulating intervention strategies during moment-to-moment decision making.
- Reflection in action: observe oneself in the moment, attend to what is happening between self and others; hallmark of interpersonal process across clinical disciplines.
- Piagetian view: reflection helps accommodate new information and create expanded schemas.
- Schon’s description of thinking in action: surprise, puzzlement, or confusion in unique situations; prior understandings implicit in behavior.
Example 1: reflection in action with a foster-parent and infant (Jake, Meg, Billy): internal dialogue questions lead to better engagement; demonstrates multiple perspectives and internal deliberation to expand intervention.
Example 2: reflection in action with a somber infant: experiment with peek-a-boo to elicit interest; rapid internal consideration of whether to involve parents; decision-making grounded in family knowledge and infant cues.
Reflection in action broadens and enhances intervention; if only knowledge were applied, may offend or misread cues.
Reflection on action (later reflection): think after the fact in supervision, case conferences, or consultations; increases understanding for future interventions.
Two-part process of reflection on action:
- Internal review: thinking, writing, or reviewing video material.
- Interactive review: with supervisor/colleague to explore layers of meaning, implications for interventions, and next steps.
Parallel process: the effect of a relationship on other relationships; in supervision/consultation, awareness and presence can influence and strengthen reflective capacity in others.
Supervisors use parallel process to teach clinical skills and to foster shared awareness of use of self.

SKILLS DEVELOPMENT IN CLINICAL PROCESS (operationalizing use of self)

The 12 descriptors draw on a specific set of key skills to define clinical and interpersonal processes when working with families.
The authors emphasize training programs’ use of these skills through reflective practice dialogues and supervision.

Perspective taking

Perspective taking is the capacity to see others’ points of view (baby, child, spouse, family member) and to explore behavior from different sociocultural and economic contexts.
Understanding without necessarily condoning is crucial, especially when alternative practices may be dangerous for a child.
Supervisors model and scaffold perspective taking to help trainees broaden understanding.
Example dialogue: supervisor asks about a case of undocumented domestic violence, prompting trainee to consider shelter options, family expectations, and cultural context; the aim is to broaden the trainee’s understanding and empathy.

Foreground vs. background thought (visualizing thought in action)

Visualizing thought as occurring in the foreground vs. background of the mind.
Background questions are developing and less ready to be asked; foreground questions are asked when rapport is established and timing is right.
Clinicians should not let background questions intrude on listening, empathizing, and affective attunement.
Clients also have background questions (trust, willingness to listen, etc.) that can influence the session.

Recognizing and living with a “press”

A press is an internal affective pressure prompting action; examples include the urge to pick up a crying infant or to persuade a parent to see things one’s own way.
Presses can be triggered by protective urges, disciplinary training, cultural beliefs, or moral imperatives.
Detecting and exploring the press can unlock client experience and clarify clinician values.
Supervisors use transcripts to help trainees uncover undiscovered presses affecting work.

Inhibiting actions (slowing down)

Inhibiting premature action requires reflection, consultation, and collaboration before responding.
“Hydroplaning” metaphor: rapid action with little reflection; a speedboat gliding over water surface.
Trainees learn to slow down, observe details, and avoid acting on first impulse.
Example: a trainee’s impulse to scold a parent for conflicting statements is explored with supervision.

Holding the tension

Holding the tension means tolerating conflicting ideas, anxieties, or presses without pushing for a specific outcome.
Clinician can suspend action while seeking understanding; supervisors may hold the tension for trainees.
An example: navigating a parent’s noncompliance with ophthalmology follow-up while maintaining focus on child welfare.

Reframing a parent’s interpretation/representation of the child

Reframing offers a different view of a child’s actions or a parent’s attributions to suggest a more positive or developmentally appropriate meaning.
Questions origin of meanings (projection, developmental stage, cultural beliefs).
Example supervision dialogue reframes a parent’s worry about spoiling a child to explore underlying concerns and avoid confrontation.

Somatic observations and countertransference

Use somatic observations to discuss countertransference and physiological responses.
Example: a trainee notices ice-cream cravings after sessions; supervisor reframes as a discussion about hunger and attention in the home, using physiological cues to explore affect and interaction.

Gentle inquiry in promoting use of self

Gentle inquiry is a questioning style that helps the trainee examine thinking and actions with minimal defensiveness.
The supervisor remains open, avoids fixing answers, and maintains pace suitable for trainee’s processing.
Example dialogue shows a supervisor guiding a trainee through contemplation of how personal experiences influence work with Anna’s sleep issues.

Deploying feelings to highlight concerns

Clinicians may use their own feelings to illuminate concerns and plan with clients.
Supervisors model tentative, uncertain, and reflective stances to encourage trainees to discuss day-to-day feelings with clients.
Example: supervisor expresses concern about a father’s depression and stimulates a discussion about potential medication discussions for the father, shifting focus from housing tasks to parental well-being.

PHASES IN LEARNING THE USE OF SELF AND REFLECTIVE PROCESS

Development is not linear; four phases are described:
- Phase 1: Initial confusion about concepts and heightened self-consciousness;
- Phase 2: Awareness of moments where use of self could be used, but difficulty translating to interventions;
- Phase 3: Struggle to find words to express feelings or insights, with copious note-taking;
- Phase 4: Increased active awareness of use of self, deeper understanding of self and others, and ease in applying reflections to interventions.
Phases are not strictly sequential; clinicians may move forward and backward.
Outcome: greater confidence, more sophisticated skills, and an authentic clinical voice.

Concepts that confuse in use of self

Training across multidisciplinary infant-family practice reveals several confusing concepts:

The stranglehold of neutrality

Professionalism is not the absence of feelings or biases; it is the process of acknowledging and understanding them to inform practice.

Boundaries, scope of practice, and limits

In-home or community-based work, the clinical frame is created by the clinician; rigid frames may hinder culturally responsive responses.
Boundaries may involve questions like what to do if an unknown adult appears, or how to respond when asked health questions in a non-mental health context.
Trainees should discuss boundary issues in supervision to learn appropriate responses.

Interpretation versus attunement

The impulse to educate or provide interpretations should not overshadow attunement to families’ needs.
Attunement involves careful listening, respectful responses, and development of understanding of a family’s ways and hopes.
Attunement-focused approaches tend to improve parental reflective capacities and trust.

“Supportive” approaches

Support should not equate to unconditional niceness or withholding difficult topics; supportive work involves dialogue, feedback, and collaboration to identify needs and goals.
Supervisors should model and teach how to raise difficult topics and manage potential discomfort without harming the therapeutic alliance.

Strength-based work

Strengths can build parental competence, but misinterpretations occur when strengths are offered as denial of concerns.
Effective strength-based work involves sensitive listening, tolerating affect, and holding tension amid parental worries.

Cultural sensitivity and competency

Cultural sensitivity extends beyond knowledge of other cultures; it requires awareness of one’s own values and beliefs and an appreciation of diversity within groups.
Cultural matching does not imply sameness; clinicians must observe, ask questions, and tolerate different child-rearing values.
Supervisors should address sociocultural topics with use-of-self skills to prepare trainees for real-world challenges.

Summary and implications for training

The goal is to elaborate and operationalize the use of self so it can be broadly applied in the infant and family field.
A set of descriptors facilitates critical analysis of components and related clinical skills.
Mastery of these skills is considered a basic step toward developing an authentic clinical voice.
Training should provide multiple opportunities to reflect on action in supervision, case conferences, and peer discussions to build the capacity to reflect in action in day-to-day work.
The authors acknowledge individualization in learning use of self but advocate for structured discussion and consistent practice to promote growth.
The capacity to reflect in action is deemed essential for authentic practice and for effective relationship-based work with families.

References (selected cited works in the article)

Bertacchi, J., & Coplon, J. (1992). The professional use of self in prevention. In E. Fenichel (Ed.), Learning through supervision and mentorship…
Bion, W. R. (1978). Four discussions with W. R. Bion.
Eggbeer, L., Fenichel, E., Pawl, J. H., Shanok, R. S., & Williamson, D. E. (1994). Training the trainers…
Fenichel, E. S. (Ed.). (1992). Learning through supervision and mentorship…
French, R. (2000). Negative capability…
Furman, E. (2002). On transference and countertransference…
Gillkerson, L., & Shamoon-Shanok, R. (2000). Relation- ships for growth…
Heffron, M. C. (1999, 2002). Balance in jeopardy; Developing competencies in infant and early childhood mental health.
Lieberman, A. (1990). Culturally sensitive intervention…
Norman-Murch, T. (1996). Reflective supervision…
Orange, D. (1997). Countertransference, empathy…
Sandler, J. (1976). Countertransference and role responsiveness…
Schon, D. (1983). The reflective practitioner…
Seligman, S. (1999). Integrating Kleinian theory…
Shamoon-Shanok, R., Gilkerson, L., Eggbeer, L., & Fenichel, E. (1995). Reflective supervision…
Winnicott, D. W. (1949, 1971). Hate in the countertransference; Playing and reality…