Finding an Authentic Voice: Use of Self in Relationship-based Infant-Family Practice

Introduction and purpose

• Article title: Finding an Authentic Voice: Use of Self in Relationship-based Work
• Authors: Mary Claire Heffron, Barbara Ivins, Donna R. Weston
• Context: Infant-family field; aims to articulate and define the use of self in relationship-based intervention
• Goals:
  • Define use of self and provide descriptors to operationalize clinical processes
  • Ground training for supervisors, trainees, and new practitioners in reflective practice
  • Distinguish reflection in action vs. reflection on action (Schon)
  • Use supervision dialogues and examples to illustrate clinical processes and address confusions
• Core claim: A deeper understanding and comfort with internal experience in relation to intervention leads to an authentic clinical voice
• Working definition (developed in the article):
  • Use of self is the capacity to observe and be aware of one’s own thoughts, feelings, and behaviors as a source of communication and information across clinical experiences
  • Includes recognition of clinicians’ judgments, wishes, intolerances, hot buttons, fears activated in encounters
  • Includes awareness that others’ internal worlds are diverse and equally unique
  • In relationship-based work, use of self is the vehicle by which information, knowledge, and support are provided to a family
• The construct expands on psychoanalytic concepts of transference and countertransference; integrates others’ theoretical contributions (e.g., containment from Bion; Winnicott’s ideas on play; projective identification; negative capability)
• Rationale for the descriptors: For training programs, supervisors, and trainees to develop mastery of processes and reflectivity, leading to an authentic voice

Foundational concepts and theoretical influences

• Transference and countertransference in psychodynamic/psychoanalytic work; literature is varied and sometimes confusing
• Bion’s containment integrated into use of self; Winnicott’s emphasis on space, curiosity, and play; Kleinian concept of projective identification
• French’s concept of negative capability (adapted for infant-family practice)
• Because infant-family practice spans diverse early intervention disciplines, a descriptive, practical definition is needed for home visiting work
• Historical roots in the field: Bertacchi & Coplon (1992) on professional use of self; Fenichel (1992) on supervision and mentorship; subsequent work in supervision and reflective practice

Use of Self: Descriptors and structure

• The article provides a set of descriptors to operationalize use of self; intended for interactive use in supervision and reflective dialogue
• 12 descriptors are grouped into 4 broader categories of clinical processes:
  • Reflective practice
  • Translation of reflection into action
  • Relationship awareness
  • Internalized professional self

USE OF SELF DESCRIPTORS: Reflective Practice

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

USE OF SELF DESCRIPTORS: Translation of Reflection into Action

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

USE OF SELF DESCRIPTORS: Relationship Awareness

6) Ability to understand and accept that each family is unique and will perceive the clinician and the intervention through the lens of their own experience.
7) Ability to create a feeling of reciprocity and comfort/friendliness with a family by allowing for normal everyday social interactions without losing a sense of purpose and safety about role and reason for involvement with the family.
8) Negative capability or the ability to tolerate strong affect and situations that are ambiguous, realizing that these involve not knowing or not understanding behaviors and motivation.
9) Ability to recognize and think about experienced internal pressures that can “press” toward an emotional response and urges or wishes to act.

USE OF SELF DESCRIPTORS: Internalized professional self

10) Ability to maintain professional boundaries in a variety of intervention/treatment settings such as home, child development center, or other community setting.
11) Ability to listen to the family and discover the things that are important to them about their child and themselves and then collaborate with the family on behalf of the child despite pressure of clinician’s agenda.
12) Ability to set the frame for the work as focused on parent-child relationships in spite of multiple distractions.

Operationalizing Use of Self: Reflective Practice in Action and on Action

• Reflective practice involves using self-knowledge to reflect on affect, actions, and intentions; and to reflect on intervention strategy formulation during moment-to-moment decision making
• Reflection in action (Schon, 1983):
  • Ongoing capacity to observe oneself and consider what is happening internally while attending to interpersonal dynamics
  • Piagetian view: accommodation of new information through reflection, creating new schemas for expanded perspective
  • Example 1 (Reflection in action): Jake (trainee) works with a new foster parent Meg and a 12-month-old Billy; internal dialogue explores frustration, assumptions, gender-related concerns; questions lead to a genuine dialogue that benefits Meg and Billy
  • Example 2 (Reflection in action): A clinician uses a peek-a-boo moment to engage a somber infant and weighs whether to involve parents; quick internal review of possibilities shapes the intervention
• Reflection on action: think after the fact in supervision, case conferences, or consultation; retrospective review helps understand how thoughts influenced interventions
• Process of reflection on action is two-part: internal review (thinking/writing/recording) and interactive discussion with a supervisor/colleague to explore layers of meaning, implications, and next steps
• Parallel process: in supervision/consultation, the relationship can reflect or influence other professional relationships; supervisors use parallel process to help trainees internalize active awareness of dynamic relationships in clinical work
• Practical use: supervision dialogues showcase parallel process to teach clinical skills and understanding of use of self

Operationalizing use of self: Skills development in clinical process

• The descriptors draw on a specific set of skills to define the clinical and interpersonal processes in interacting with families
• Perspective taking: ability to see others’ viewpoints (baby, child, spouse, family member), including context; critical in difficult sociocultural and economic contexts; understanding without necessarily condoning a practice allows introduction of alternatives once the other’s perspective is understood
• Perspective-taking in training: supervisors model this capacity to trainees; includes dialogues about cases (e.g., undocumented domestic violence survivor) to broaden trainee perspectives
• Visualizing thought: foreground vs. background thinking; some questions are formulated in the background and only asked when trust is established; foreground questions are asked at opportune moments
• Press (affective internal pressure): internal urges to act prompted by emotional responses (e.g., in the room with a crying infant); recognizing and understanding presses helps avoid unhelpful interventions; helps clarify trainees’ values and beliefs
• Foreground vs. background: trainers help trainees recognize which curiosities to pursue and when; awareness of background questions (trust, credibility, appropriateness) is important for attunement
• The press and unexamined pressures can lead to missteps if not explored; supervision transcripts illustrate how to uncover and manage presses
• Inhibiting actions (slow-down): ability to reflect, consult, and collaborate before responding; avoid hydroplaning (rapid action with no reflection); examples show delaying a response to consider implications and to invite parent reflection
• Hydroplaning metaphor: a speedboat skimming surface; slowing down fosters thoughtful interventions
• Holding the tension: tolerate conflicting ideas and multiple pressures without forcing an outcome; helps trainees hold back urges while exploring options; supervisors model this by maintaining tension to support trainee’s processing
• Reframing (reframing a parent’s interpretation/representation of the child): offering alternative views of a child’s actions or parent attributions; explore origins (projections, developmental understanding, cultural beliefs); use to promote more developmentally appropriate interpretations
• Somatic observations as a route to countertransference: clinicians’ physiological responses (e.g., craving ice cream after sessions) can reveal emotional states; exploring these can inform interventions; turning terms like “hunger” into analytic questions to understand clients’ hunger for attention
• Gentle inquiry: a questioning style that promotes self-examination with minimal defensiveness; aims to reveal multiple meanings and respond to trainee’s readiness; not a pedagogical drill, but a mutual discovery process
• Deploying feelings: using clinicians’ own feelings purposefully to influence interventions; supervisors model and guide the trainee in articulating and using these feelings constructively

Phases in learning the use of self and reflective process

• Phase 1: Initial confusion about concepts and heightened self-consciousness; discomfort with clinical interventions
• Phase 2: Moments where use of self could be used, but translating feelings into interventions is hard
• Phase 3: Struggle to find words to express feelings; heavy note-taking and concern about personal lens intruding into practice
• Phase 4: Greater awareness of self and others; more ease in using this awareness to stay attuned to families while constructing interventions
• Note: These phases are not strictly linear; clinicians may move back and forth between phases
• Outcome: With practice, clinicians develop confidence, a broader skill set, and an authentic clinical voice

Concepts that confuse (and clarifications)

• The stranglehold of neutrality
  • Trainees may believe professionalism requires eliminating biases and feelings; supervision helps normalize these processes and promotes self-knowledge as a clinical asset
• Boundaries, scope of practice, and limits
  • In-home/community settings, frames differ from clinic settings; clinicians must adapt boundaries and frames while maintaining safety and confidentiality; examples include in-home boundaries around food, shoes, unknown visitors, and handling health questions or referrals
• Interpretation vs. attunement
  • Education and cognitive-style interventions can be powerful but must not override attunement; balance between delivering insights and being with families; attunement fosters parents’ reflective capacity and trust
• “Supportive” approaches
  • Support should include honest dialogue, feedback, and exploration of concerns; avoid unconditional niceness that silences difficult topics; supervisors model constructive confrontation and care
• Strength-based work
  • Emphasizes recognizing parental strengths without using them to shut down concerns; true strength-based work involves listening, tolerating affect, and holding tension while parents move through worries
• Cultural sensitivity and competency
  • Self-awareness of one’s cultural values is essential; cultural matching does not imply sameness; clinicians must appreciate migration, adaptation, regional differences, and family histories; use of self in supervision helps address sociocultural topics thoughtfully

Summary and implications for practice

• The authors propose a structured set of descriptors to understand and develop use of self in infant-family practice
• Mastery of the descriptors is a foundational step toward an authentic clinical voice
• Training should incorporate structured discussions, consistent application in supervision, and ongoing reflection on action in day-to-day work with families
• The goal is to enable clinicians to move beyond explicit content to explore reactions, beliefs, and internal experiences in service of more reflective, relationship-based interventions
• Recognition that learning use of self is individualized; practice is enhanced by consistent, reflective dialogue and opportunities to observe, try out, and discuss use of self in supervision and fieldwork

References (selected)

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• Bion, W. R. (1978). Four discussions with W. R. Bion. Clunie.
• Eggbeer, L., Fenichel, E., Pawl, J. H., Shanok, R. S., & Williamson, D. E. (1994). Training the trainers: Innovative strategies for teaching relationship concepts and skills to infant/family professionals. Infant and Young Children, 7(2), 53–61.
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