IN THEIR intimate and often intense work with families, early interventionists often struggle with the dynamic complexities of the relationships they strive to develop with families. Forming trusting relationships is seen as key to providing effective interventions for infants and toddlers, but early intervention work evokes strong emotions for interventionists and the families they serve (Brotherson et al., 2010). In addition, greater numbers of families wrestle with complex life challenges that, in turn, create greater demands on the interventionists serving them. In recent years, there has been a growing realization that early interventionists can benefit from interdisciplinary training and ongoing support to assist them in understanding relationships and the “minds of others,” as well as their own feelings associated with working with families (Foley & Hochman, 1997). One primary way in which to provide consistent, ongoing professional development and support is through reflective consultation (Weatherston, Weigand, & Weigand, 2010). Often referred to as reflective supervision when implemented in a clinical setting and/or among mental health clinicians, this professional development support is a critical component of reflective practice, infant mental health, and relationship-based practice, all of which have experienced widespread growth in recent years.
The use of reflective consultation as practiced in infant mental health is based on the premise that increased awareness, knowledge, and understanding of relationship dynamics and the reasons why others think and act the way they do allows early interventionists to consider a broader and deeper range of approaches and strategies for intervention while supporting them in their work (Parlakian, 2002). Reflective consultation fosters the ability to step back and consider the thoughts and emotions in oneself and others (Fonagy, Gergely, Jurist, & Target, 2002). The underlying assumption of the project described in this article is that the ability to reflect is a capacity that can be built, strengthened, and nurtured (Heller & Gilkerson, 2009). While there is a rich clinical literature that describes the process of reflective consultation and its goals, there is little published research that explores the impact of reflective consultation in early intervention (Shahmoon-Shanok, 2010). As additional early intervention programs devote diminishing professional development resources to reflective consultation, there is a need for research that investigates its benefits. This article describes implementation of reflective consultation for early interventionists in Minnesota through the Bridging Education and Mental Health (BEAM) project. The authors describe the results of a pilot professional development project incorporating training and ongoing reflective consultation for two early intervention teams composed of licensed early childhood special educators and related service providers employed by an urban school district. The intent is to begin to establish the effects of reflective consultation on intervention practice as well as its potential to address the stress experienced by early intervention providers in their day-to-day practice.
CONTEXT FOR THE PROJECT
In 1986, the U.S. Congress mandated a range of services to be provided to infants and toddlers with disabilities through what is referred to as “early intervention.” Early intervention is “a statewide, comprehensive, coordinated, multidisciplinary, interagency system that provides early intervention services for infants and toddlers with disabilities and their families” (ED.gov, n.d., Section 631, b-1). According to Early Intervention (Part C of IDEA), the purposes of early intervention services are to
enhance the development of infants and toddlers with disabilities; reduce educational costs by minimizing the need for special education through early intervention; minimize the likelihood of institutionalization, and maximize independent living; and, enhance the capacity of families to meet their child's needs. (www.wrightslaw.com)
Early interventionists seek to work more directly and intensely in partnership with families of infants and toddlers with special needs than do their counterparts in school-age educational programs. Instead of providing services in a clinic or school with the focus on the child, early intervention services are provided in the natural environment, which is usually the home, with the family as the unit of services and support (Allen & Petr, 1996; Epley, Summers, & Turnbull, 2010). Current practice in the field guides early interventionists to do with the family instead of do to the child and family (Bruder, 2000). It is asserted that this partnership/relationship between family members and early interventionists should be the driving force within a family-centered approach (Bruder, 2000) and can be rewarding for both the professionals and the families served, but it can be complex and challenging as well.
The provision of family-centered services has become a foundational tenant for early intervention and early childhood special education and is at the forefront of current training, philosophy, and practice in the field (Bruder, 2000; Sandall, Hemmeter, Smith, & McLean, 2005). On the basis of the family systems theory, intervention is directed to parents and other caregivers in addition to the child (Turnbull, Turnbull, Erwin, & Soodak, 2006). Although family-centered service is considered best practice in early intervention, there is no consensus in defining family centeredness (Epley et al., 2010). Bailey, Raspa, and Fox (2011) describe it as “a philosophy and a set of practices that characterize service delivery” (p. 217). In alignment with the family systems theory, interventionists are encouraged to seek understanding of the child in the context of family and to consider the impact of family characteristics, as well as the interactions among individuals within the family, as they provide intervention and support. Services are designed and delivered within the framework of informing and empowering families. In addition to placing the family as the focus of attention, key elements of family-centeredness that have been identified include capitalizing on families’ strengths to provide individual family services to address family needs and building on family choice by ensuring that families are the ultimate decision makers. In addition, the family–professional relationship is a central concern (Allen & Petr, 1996; Epley et al., 2010). Numerous studies confirm that family-centered practices possessing the aforementioned characteristics contribute to positive outcomes for both children and their families (Bailey et al., 2011).
Although family-centered services lead to positive outcomes for children and families, the intensity of the parent–professional relationship can be difficult for early interventionists to understand and manage effectively without support that addresses the underlying relationship dynamics, including their own emotional responses (Weatherston et al., 2010). In addition, the challenges early interventionists face in the home environment are immediate and powerful (e.g., domestic violence, linguistic and cultural diversity, stressed families with chaotic routines and schedules, risk factors associated with poverty). A growing and troubling concern for early childhood professionals is the frequency with which they encounter mental health needs of the families with whom they work (“Minnesota Infant Mental Health Feasibility Study Report,” 1998). The work with families done in the home environment (or in child care, Early Head Start, or other early childhood setting) requires multiple skills to do well while meeting the many challenges encountered (Brotherson et al., 2010; Rike & Sharp, 2008). The cumulative effect of the intensity of the relationships and the risk factors they encounter in the environment of the families' homes can prove to be an additional challenge for interventionists, especially if they have limited training or opportunity to understand and gain perspective on these issues. The demands of this work can cause interventionists to be overwhelmed, confused, and disappointed in their efforts (Brotherson et al., 2010). Providing regular, ongoing reflective consultation may assist early interventionists in meeting the challenges of working with families in their homes (Hirshberg, 1997).
The goal of reflective consultation is to help early interventionists examine the interactions between themselves and family members, as well as the attendant emotions aroused. Reflective consultation aims to provide opportunities to integrate knowledge, experiences, and feelings to support families and embrace all dimensions of the parent–child relationship and the parent–professional relationship. As a result, early interventionists can make different decisions about interventions and support to families using this larger, more holistic lens with which to view their work. Because of claims about the usefulness of reflective consultation, professionals are actively teaching about and practicing reflective consultation and it is now required in some statewide credentialing systems (Eggbeer, Shahmoon-Shanok, & Clark, 2010). Furthermore, the use of reflective consultation to support Minnesota early interventionists is a growing practice that has received statewide attention and support from the Department of Education and Department of Human Services.
This project describes an interdisciplinary professional development model that provides consultation and support to early interventionists. Using mixed qualitative and quantitative methods, project personnel gathered feedback from participants and the consultant regarding the challenges of their work and their perceptions of reflective consultation to inform next steps in the use of reflective consultation in early intervention. Obtaining the opinions and values from these direct service providers holds the potential of helping administrators and other decision makers decide whether or not to support the ongoing use of reflective consultation.
The BEAM program brought together the University of Minnesota's Center for Early Education and Development, a school district Part C early intervention program, and a mental health clinician in private practice. The project was funded by discretionary federal early childhood special education funds granted by Minnesota Department of Education to the University.
The study participants were 14 early childhood professionals who were members of two interdisciplinary teams who served children birth to 3 years of age and their families by providing Part C services. These teams were housed in an urban school district. They included licensed early childhood special educators and related service providers (e.g., occupational therapists, physical therapists, speech and language specialists). The participants were all female, with a range of years of experience in their fields. The team administrator allowed her staff to choose whether or not to participate in the reflective consultation group. An infant mental health specialist with a PhD degree in clinical psychology who has worked in the field of infant mental health for more than 25 years provided reflective consultation to the teams.
The independent variable involved two components: (a) an awareness-level workshop on infant mental health and (b) reflective consultation provided once a month throughout the school year. At the beginning of the school year and the project, the consultant provided a district-wide workshop for all infant, toddler, and preschool special education staff members. In the workshop, the consultant focused on foundational information about working with families and children within a framework of reflective practice as defined in the field of infant mental health (Neilsen Gatti, Watson, & Siegel, 2011). Following the all-staff training, project staff and school district administrators developed a yearlong meeting calendar with the interdisciplinary early intervention team and the infant mental health consultant. The administrator divided the participants into two groups by geographic area. The first meeting was scheduled in November, and the reflective consultation groups met once a month for 2 hrs each session for a total of eight times across the school year. Because of the voluntary nature of the groups, the number of participants per session varied from five to seven.
The primary focus of these meetings was on developing perspectives and strategies for working with children and families and finding ways to create and maintain a reflective work environment. The reflective consultant used a general format and process as recommended in the field of infant mental health (e.g., Heller & Gilkerson, 2009). For each meeting, the facilitator (a) provided time for reconnecting and checked in to see how things were going for the providers and the program, (b) identified and discussed general themes that had been of concern, (c) explored a specific case/family volunteered by home visitor, (d) created hypotheses, explored home visitor's experiences, thoughts, and feelings, and identified main themes and difficulties, (e) as a group, discussed perspectives, impediments, strategies, and (f) summed up discussion and closed. The reflective consultant used a variety of characteristics of reflective consultation as recommended in the literature. These included active listening, open body language, open-ended questions, time for processing and reflecting, interpreting and validating feelings, and asking follow-up questions (Parlakian, 2001a, 2001b, 2002).
The authors collected three types of data to begin to answer the questions posed earlier regarding the implementation of ongoing reflective consultation: (a) a reflective practice survey, (b) interviews with reflective consultation participants, and (c) an interview with the consultant. The research team collected these data over the course of 10 months.
Reflective practice survey
The authors developed a 12-item reflective practice survey (Table 1), based on a variety of materials (e.g., Erickson, Endersbe, & Simon, 1999; Los Angeles Unified School District, 1999–2000). The survey used a 5-point Likert-type scale (1 being strongly agree and 5 being strongly disagree). The purpose of the survey was to gather information on participants’ knowledge of reflective consultation and opportunities to engage formally and informally in this type of professional development. Participants completed the survey once early in the academic year and again later in the school year.
Interviews with participants
At the end of the school year, the authors asked for volunteers to share their experiences with the reflective consultation groups in a small group interview format of approximately 2 hrs each. The purpose of the interviews was to collect qualitative data on their personal experiences with the reflective consultation group. The questions solicited information about overall impressions of the group; specific strategies learned and implemented at reflective consultation groups; whether and how the groups helped them to feel supported and more effective in their positions; whether and how their beliefs, thoughts, and practices were influenced as a result of reflective consultation; and whether they encountered barriers to implementing reflective consultation. The authors interviewed participants representing the 14 members of the two reflective consultation groups. Because the interviews were conducted in August, a limited number of participants (five) were available for the interviews. The authors recognize that this small convenience sample is not representative of the entire group. In addition, asking volunteers to participate in the interviews may bias the results due to strong positive (or negative) perspectives of those willing to participate in these discussions.
Interview with consultant
Also following the completion of the program, project staff conducted an interview with the consultant to record her perspectives on providing consultation to the interventionists. This was an open-ended discussion allowing the consultant to share her perceptions of the challenges faced by the early interventionists, the types of support provided through the reflective consultation groups, and her advice and suggestions for the future.
The study provided qualitative and quantitative results. Quantitative results from the reflective practice survey are presented below, followed by the qualitative results. Several themes emerged during the analyses related to the context of early interventionists’ work and the effects of reflective consultation in supporting early interventionists.
Quantitative results: Reflective practice survey
The small number of participants (N = 14) did not allow for any statistical analysis of the survey results. Table 1 shows the mean scores of each item of the survey at administrative Time 1 and Time 2. The results across items and across times of administration do not differ greatly. The majority of the items cluster around the middle to middle-high score (3–4). Item 4: “Our team uses informal opportunities to reflect with colleagues (in the parking lot, over lunch, etc.)” scored the highest with a mean score of 4.24 and decreased slightly at the second time of administration. The item scored the lowest was Item 2: “Time is provided in my contract to meet and reflect with colleagues on practices with children and families,” with a score of 2.95 and 2.86 at each time of administration. The item with the largest difference between scores, although relatively minor, is Item 5: “Our team has a safe place to unload experiences and feelings.”
Qualitative results: Interviews
Two main themes related to reflective consultation emerged from the interviews with the participants and the infant mental health consultant. Table 2 lists the questions asked of the participants, the summary of key points, and notable quotes.
Sources of stress on early interventionists
The participants in this pilot project work in the homes of families of infants and toddlers with disabilities. During the interviews, participants expressed a great deal of joy, passion, and fulfillment in their work; however, they also expressed feeling increasing stress due to the challenges of working with stressed families, district budget cuts, paperwork demands, and their own feelings of inadequacy about their ability to fully address families’ needs.
A common concern raised by participants during the interviews was the increasing number of risk factors their families faced. These risk factors included parents with mental illness, violence in the home and community, issues related to families living in poverty, and families raising more than one child with significant needs. Participants reported that chaotic home environments affected service delivery and added stress to their jobs. One participant said, “I'm there to serve one child but I'm often pulled to address the needs of other children or the parent.” Another participant shared, “A lot of us have to let go of a lot before we go home and some of it is really hard stuff to go through.” In the interview with the consultant, she shared that the needs of adult family members with mental health issues weighed heavily on these interventionists.
On the other end of the continuum, working with more affluent families presents challenges as well. During the interviews, participants shared that some of those families did not value the early interventionists’ expertise. They stated that some parents dismissed guidance provided by early interventionists, putting in question their professional legitimacy. This caused these participants to question their own knowledge and expertise.
In addition, participants reported that they were being asked to do more with less. Their district experienced several consecutive years of budget cuts that necessitated larger caseloads. One of the outcomes of increased caseloads was more special education due process documentation. The consultant and the participants reported that this increase in documentation and paperwork created a significant source of stress for the participants. The stress from the paperwork was partly due to the disconnect between their job description and the actual work they were doing or wanted to do with families, leading to continued feelings of ineffectiveness and helplessness. There was an overall sense that the paperwork was not a true reflection of the supports they provided to families.
Because early interventionists provide services in families’ homes, they are often working out of their car and this does not always offer daily opportunities for interactions among colleagues. As one participant said, “I feel pretty isolated if I don't come into the office.” Before participating in the reflective consultation groups, the participants found informal ways to discuss their work with colleagues, as indicated in the reflective practice survey and through the interviews. The consultant reported that their ability to communicate with others on their team “sustained them.” The participants reported that prior to the BEAM project, the administration, recognizing the importance of bringing early interventionists together to discuss their work, had made attempts to provide regular, structured times for case consultation. But administrative issues and tasks gradually took up more and more of the time that had been set aside to discuss cases. The consultant reported that the opportunity to regularly meet with the consultant through this pilot program offered participants their first consistent and ongoing structured time for discussion focused solely on their work with children and families.
In addition, during the interviews the participants expressed the need for structured time to attend to other critical aspects influencing their work with families, especially the influences of relationships and their feelings about their work with families and children. The participants reported that the facilitated reflective consultation group met this need by helping them identify and use their feelings to inform, rather than interfere, with their work as they faced the sometimes overwhelming needs of families. The consultant guided them through this process of stepping back and allowing them to gain different perspectives and strategies for their work. Participants shared that many of the new perspectives gained through reflective consultation led to a shift in understanding of the role of the family and the parent–child relationship, as well as their relationships with families, and a new level of awareness regarding the importance of professional reflection and self-care.
In the follow-up interview with the consultant, she identified continuing specific professional development needs of the participants, such as how to maintain boundaries in their work with families to prevent them from “taking on and taking home” the families’ issues, and how to skillfully navigate information on the topics of defense mechanisms and denial in both themselves and the families they serve. In addition, she reported that participants struggled with how to communicate a diagnosis of an educational disability to families and helping families begin to cope with the “label” their child receives. During the interviews, participants reported that it was particularly challenging to determine the best response to the families’ reactions and feelings of being informed that their child is eligible for early intervention services due to a disability. The consultant reported that she provided ongoing professional development targeting these critical professional development needs during the reflective consultation meetings.
Reflective consultation as a unique and effective professional development and support tool for school-based early interventionists
During the interviews, participants responded positively to the interdisciplinary perspective of reflective consultation. They reported that it was important to participants that a consultant trained in infant mental health practice, rather than an educator or administrator, led the consultation. They felt that if an administrator had tried to facilitate the groups, the time would once again have been usurped by administrative business. They applauded the fact that dedicated time was allocated to the reflective practice and that administrative issues did not “bleed into” the reflective practice time.
In addition, they reported that it was important that they met on a regular, ongoing basis (once a month), which was very different from their prior practice of participating in workshops on different topics during the year. Participants reported that the reflective consultation met their needs on a consistent, ongoing basis. They appreciated the opportunity to gain new perspectives for their work and focus their efforts. During the interviews, one participant reported that “reflective consultation helps us prioritize.”
A purpose of reflective consultation is to focus on feelings and how they affect interactions with others. Participants reported gaining insight into how their emotions and previous experiences affect their own work and interaction with children and families. In the interviews, one participant shared, “The idea to identify own feelings when with (sic) families is a new thing” Another participant said, “Orienting how you're feeling about what's going on is important stuff!” Through reflective consultation, the consultant provided a safe place to explore these emotions and helped participants view these emotions as a helpful way to gain insight rather than viewing them in a judging, destructive way.
Participants in the interviews reported that they discovered new ideas for working with children and families. Many of the new ideas involved a shift in perspective on how they viewed the role of the family and the parent–child relationship. Participants embraced concrete strategies provided by the consultant, such as practicing specific language to use to structure difficult conversations with family members, which the participants referred to as scripts. “The scripts were really helpful—How to respond to difficult families....” In the interviews, they reported that they felt like reflective consultation helped build more positive relationships with both families and coworkers. One participant commented that through reflective consultation she realized, “The disagreement wasn't about us and the parent. It was about the parent connecting with her kid.”
Participants gained insight into how their emotions and previous experiences affect their own work and interaction with children and families. The interviewees reported having more awareness about the importance of professional reflection and self-care.
The consultant reported that she assisted participants in developing a further understanding of concepts and strategies from the field of infant mental health that she had introduced in the training held at the beginning of the year, including: “theory of mind,” the realization that others have thoughts and feelings different from one's own and the ability to predict and explain peoples’ behavior (Symons, 2004), and “parallel process,” characterized by interaction with the supervisor that models a way of “being and doing” with families (Pawl & St. John, 1998).
Participants reported that they felt that their services to families improved through increased awareness, support, and stress reduction. Throughout the consultation, they felt a great deal of support and recognition of the challenges they face as professionals. One participant reported, “It was safe enough and we had to be able to express feelings and look at all the different levels of interaction.” Another said, “She was as careful with us as we would be with someone else's trust we were trying to build.”
In early winter, the district cancelled all early childhood special education staff meetings for the remainder of the school year because of high caseloads. However, the teams asked to continue the reflective consultation meetings and only these meetings. The participants reported that reflective consultation was a very valuable tool that they did not want to lose, especially as caseloads increased and families faced growing challenges. Following the conclusion of the pilot program, the early intervention teams went to the administration to request that their professional development funds for the next year be devoted to reflective consultation, rather than being available to participate in conferences and other professional development activities. Impressed by the testimony of the early intervention staff, the district agreed to maintain reflective consultation led by the consultant. These two actions alone demonstrate the importance of reflective consultation to the participants and their perceptions of the impact on their professional development.
In this article, we have described a pilot professional development project incorporating training and ongoing reflective consultation for two early intervention teams in an urban school district. Reflective consultation is the process of examining with others, the thoughts, feelings, actions, and reactions evoked in the course of working closely with infants and toddlers and their families (Eggbeer, Mann, & Seibel, 2007). The intense and personal nature of creating these partnerships with families requires attention to the complex dynamics of the relationships within families, between families and early interventionists, and among the members of early intervention teams. Reflective consultation as a form of professional development allows early interventionists to develop a clearer understanding of their relationships and reactions to the work and view the family in a multidimensional way. This process builds upon early interventionists’ capacity to provide effective early intervention services.
We used qualitative and quantitative data to evaluate the perceived influence of reflective consultation on early interventionists’ practice. In particular, the interviews provided strong testimonials to the value of reflective consultation for these early interventionists and their work with families. Several recommendations from this pilot project are described below to help translate these findings into practice and suggest directions for future research.
First, implementing reflective consultation requires an administrative team that is open to the potential benefits of a new, ongoing approach to professional development. At the very minimum, administrators must provide time for early interventionists to participate in reflective consultation and dedicate funds to compensate the consultant. At best, the administrative team embraces the importance of relationships by including it in their program mission, as well as providing opportunities for staff members to reflect on their work and the ways in which their own experiences and culture affect their relationships, and using what they understand about relationships to develop effective practices and policies (Copa, Lucindki, & Wollenbeurg, 1999).
Second, to translate this study into practice, the basic elements of reflective consultation, which include reflection, collaboration, and regularity, must be in place (Parlakian, 2001a). Reflection requires someone who is trained to facilitate this type of process and interaction. The participants in this study shared that they preferred the consultant to be someone outside their program because they perceived that it protected the meeting time and kept the focus on reflective consultation. The participants found the addition of the consultant's mental health expertise particularly valuable, but it is not required that the consultant be a licensed mental health practitioner. Other programs have used supervisors, team leads, and peers from a variety of disciplines to provide reflective consultation (Heffron & Murch, 2010; Parlakian, 2002). However, the consultant must have received training to provide consultation and be able to demonstrate the skills described earlier to provide effective consultation. For a detailed description of skills and competencies required to provide reflective consultation, see Heffron and Murch (2010) and Heller and Gilkerson (2009).
The second element of reflective consultation, collaboration and open communication to develop trusting interdisciplinary professional partnerships, is in direct alignment with the team approach of early intervention. Through reflective consultation, the team acts as a community that supports early interventionists in their work with families. The first step in building this community is to establish a climate of trust and safety where the challenges of working with families can be explored without judgment or criticism. This open communication is one of the most reliable signs that sufficient trust exists in the team. If the team does not have this level of trust, then it is important to work on trust building and to examine the current relationships and dynamics of the team members (Heller, Jozefowicz, Reams, & Weinstock, 2004). This is where an outside consultant may be helpful in examining the current relationships, begin to facilitate trust and open communication, and establish a safe place to discuss the work. “When professionals pay careful attention to the quality of our relationships with other professionals, we are supported to do our best work with babies and families” (Eggbeer et al., 2007, p. 5).
The final component is regularity. It is critical to establish a regular and consistent schedule of consultation meetings. The context and goals of the program may dictate the frequency and length of the sessions, but maintaining a consistent schedule of meetings is key. Through administrative support and implementing the three basic elements of reflective consultation, early intervention programs can implement reflective consultation as a unique and effective professional development tool.
Additional research is needed to continue to understand the process and impact of reflective consultation on early interventionists’ job satisfaction and performance. Researchers need to examine more closely the salient features of reflective consultation. Because competencies related to reflective consultation are being included in a variety of licensure credentials, the field must develop a clearer definition of reflective consultation and the specific steps required to implement it effectively. This article focused on a pilot project after 1 year of implementation with a volunteer group. Future research should examine the long-term impact of this ongoing, focused professional development model after several years of implementation. Other important questions relate to the generality of reflective consultation: Does it work for everyone? Should it be a choice to participate? Who benefits the most from this type of professional development model? Finally, specific intervention research is required to investigate the direct impact of reflective consultation on service delivery, including the quality of interactions with families and outcomes for children.
There are limitations to this study. First, the interview participants volunteered their time, so it was not a random sample. Second, the interview data represent a relatively small percentage of the participants. In addition, this program examined the use of reflective consultation using a face-to-face model. Other programs have investigated the use of e-mail, telephone, and software applications such as Skype that allow users to make voice calls over the Internet to provide one-to-one reflective consultation. Given advances in technology, this may be an additional future line of research.
As the first pilot project of its kind in Minnesota, the BEAM reflective consultation project demonstrates that reflective consultation can be provided in a school-based early intervention program, that it is effective in supporting staff, and that participants value it highly. When positioned as ongoing professional development aimed at improving and maintaining quality service provision, reflective consultation emerges as a potentially powerful strategy for facilitating effective, trusting relationships among intervention teams and between interventionists and families, as well as for increasing practitioners’ skills. This, in turn, leads to more effective problem solving and intervention planning and implementation. Reflective consultation provides regular opportunities for early interventionists to gain perspective on challenges and to plan, implement, and reflect on the results of their work. As Weatherston et al. (2010) report, this kind of professional development helps practitioners “feel accompanied as they prepare to go forth and continue their efforts with and on behalf of the family” (p. 23).