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NRF Manual – Version 1.0 (1/2018) i © 2018 Lillas / NRFGC

NeuroRelational

Framework (NRF) Manual: Reducing Toxic Stress and Growing

Relationships in Families & Communities

Connie Lillas, PhD, MFT, RN

NRF Manual – Version 1.0 (1/2018) ii © 2018 Lillas / NRFGC

NeuroRelational

Framework (NRF) Manual: Reducing Toxic Stress and Growing Relationships in

Families & Communities

(Version 1.0)

By

Connie Lillas, PhD, MFT, RN

Based on content from Lillas, C., & Turnbull, J. (2009). Infant/Child Mental Health,

Early Intervention, and Relationship-Based Therapies: A Neurorelational Framework

for Interdisciplinary Practice. New York: W.W. Norton

© 2018 Lillas / NRF Global Communities

NRF Manual – Version 1.0 (1/2018) iii © 2018 Lillas / NRFGC

Table of Contents

INTRODUCTION & OVERVIEW

Chapter 1: Critical Public Health Problems 1 Chapter 2: Big Picture Concepts in Using the NRF’s Three Steps 17 Chapter 3: The Clinical Use of the Self and Our Professional Roots 37 NRF STEP 1 Chapter 4: Step One, the Foundation to Resilience, the Roots to the Tree 59 Chapter 5: Orientation to Interview and Use of the Cultural Self 79 Chapter 6: Using our Hearts, Hands, and Heads in Understanding Parallel Process and Dyadic Patterns 99 NRF STEP 2 Chapter 7: Step 2, Levels of Engagement, the Use of the Pyramid 109 Chapter 8: Levels of Engagement Rating Scale in Step 2 129 NRF STEP 3 Chapter 9: Macro and Micro Approach to the Four Brain Systems, the Four Stories and the Use of the History Worksheet and Needs Assessment 141 Chapter 10: Regulation Brain System 169 Chapter 11: Relevance Brain System 195 Chapter 12: Sensory Brain System 235 Chapter 13: Executive Brain System 257

NRF Manual – Version 1.0 (1/2018) 4 © 2018 Lillas / NRFGC

Chapter Three The Clinical Use of the Self and Our Professional Roots

Reading accompanying this chapter: NRF Textbook Chapter 3, 109-114; Finding An Authentic Voice,

Use of Self Article; & Reflective Supervision/Consultation - What Is It and Why Does It Matter?

The NRF has several key “landmarks” that place it within a particular zeitgeist of clinical modalities. As

already mentioned in Chapter One, the NRF has a dynamic systems theory base, dedicated to using

systems science as its research paradigm, placing itself firmly in the public health arena as a unique way

to tackle the complex, messy public health problem of toxic stress, delays in the quality of engagement,

and compromises in brain architecture. The NRF is dimensional in its approach, valuing underlying

dimensions to behavior that cut across many different categories. The NRF is strongly

neurodevelopmental in its approach to understanding human behavior. Neurodevelopment is our guide

on multiple levels and the “value added” expertise that we bring to our parents and our communities

when we join with them on the journey of discovery together. The NRF is keenly relationship-based in its

approach to working with others, within its own communities, as well as across NRF communities. In this

regard, the importance of reflecting upon oneself, being open to feedback about oneself, and at attitude

of “always growing and learning” from each other is a “prerequisite” to learning the details of the three

clinical steps. The relational and reflective emphasis here is critical as to how we go about creating

competent communities. Instead of a task to master, the essence of the NRF is an unfolding relational

process to engage in that uniquely builds cross-sector relationships and communities.

This emphasis aligns with a core value of Infant Mental Health (IMH) models and practices referred to as

“Reflective Practice.” Some of you will be quite familiar with the concept of Reflective Practice and for

others, this may be completely new. [Please read the two clinical articles provided for you to orient you

to the five core concepts of Reflective Practice] For those of you new to the idea of Reflective Practice

SHORT REVIEW OF CHAPTER TWO’S CONCEPTS:

1. A review of the four learning phases to the NRF is provided.

2. An overview of the NRF’s three steps their links with the metaphor of a tree (roots,

trunk, and branches) is reviewed.

3. The significance of toxic stress and the long-term consequences of allostatic load from a

retrospective and prospective research methodology is discussed.

4. The open learning system as a model that holds the tension between positive and

negative valences for learning the NRF is introduced.

5. Small group and community guidelines are introduced.

6. The NRF communities are introduced and the use of social network analysis for looking

at community system’s change is featured.


with an emphasis on ourselves as therapeutic agents in working with families, this can be quite

daunting. I encourage you to be curious about this process. If you come from a tradition that did not

prepare you for self-reflection, we see this as the chance for new growth and adventure with yourself.

We encourage you to find someone to walk through this process with! It’s a journey that can be shared.

Reflective Practice is considered an essential ingredient in being an infant mental health and early

intervention practitioner. To this end, the hallmarks of Reflective Practice are being written about and

research is being conducted to learn more about the process and impact (Sheryl Goldberg, MI, 2015.

What is it and why does it matter? Addt’l refs). In the Reflective Practice literature, there are five

essential elements to reflective practice that help define it. Each core concept, with its common

understanding within IMH is listed in the table below, along with the additional ways the NRF applies its

unique contributions to these core concepts. The way these factors are linked with the NRF and how

they each are elaborated on by the NRF is described here in the paragraphs below as well.

Table 2. Connections between Reflective Practice Literature and NRF Principles

Reflective Practice (RP) NRF Links to Reflective Practice (RP)

Professional Use of Self

The capacity to observe and be aware of one’s

own internal thoughts, feelings, and external

behaviors, as an important source of

communication and information in clinical

experiences (Heffron, Ivins, & Weston, 2005,

pg. 324)

Building self-awareness through the…

● Use of the Four Colors (body level)

● Use of HHH (interpersonal level)

● Understanding our own four stories

Parallel Process

“The effect of a relationship upon other

relationships” (Heffron, Ivins, & Weston,

2005, pg. 327)

Similar dynamics occurring on multiple levels

● Use of the four colors

● Use of HHH

● Understanding our own four stories

Working Alliance

Attunement to a family through careful

listening with intent to understand and to

build trust

Use of Heart self/skills

Use of the Therapeutic Triad

Genuineness

Showing non-possessive warmth

Accurate empathy

http://www.cyc-net.org/cyc-online/cycol-0606-

heslop.html

http://www.cyc-net.org/cyc-online/cycol-0606-heslop.html



Follow the parents’ lead into the deeper need

Understanding the Story

Understand the story about the baby, the

family, their history, context, needs

Understanding the Four Stories

Use of the four stories:

the early story (regulation),

the developmental story (sensory),

the emotional story (relevance), &

the educational/learning story (executive)

Holding the Baby in Mind

Noticing what the baby brings to the

relationship; how does the baby experience

things?

Holding the Family System in Mind

There are three types of “clients” that we have

all at once:

the parents;

the baby;

the relationships

1. The professional use of the self

a. This is a critical principle in the NRF that aligns with the relational aspects of the NRF,

wherein relationships are the greatest source of healing in our work. There is an

assumption here that all practitioners have had some training in this process and see it

as a lifelong goal to continue refining oneself. If this is new for you, it can be

overwhelming to have to consider looking more carefully at one’s own behaviors and

understanding one’s own process with families! However, the use of oneself is such a

powerful and important concept, it precedes the learning of the three clinical steps by

being Chapter #3. This chapter organizes the use of ourselves when we are at our best.

2. Parallel process

a. The NRF uses the primary colors of green, red, blue, and red/blue to describe our

Autonomic Nervous System as to who we are at our best (Chapter 3) and under stress

(Chapter 4). In addition, the use of ourselves from the perspective of the triad of Heart,

Hand, and Head (otherwise referred to as HHH) metaphors are aspects of personalities

and skill sets that emerge during different interpersonal contexts. We will be using these

to discuss parallel processes, which are ways that our own dynamics parallel the lives of

our children and families. A more complete definition of parallel process is to follow.

This HHH triad will also be elaborate to look at our professional roots, looking for


similarities or differences one might have with one’s own proclivities and one’s

professional training.

3. Working alliance

a. Having a working alliance is essential for all relationships to grow and thrive. This

requires the use of one’s Heart skills to connect to parents, to follow their lead in

tracking their concerns, and to validate and mirror their emotional experiences. These

guidelines build and sustain relationships by having an empathic bond that is created.

While the conversation often goes beyond this, into hand and head levels of

engagement, heart is always where a therapeutic relationship begins. Of course, as one

begins to be with the parent/child dyadic relationships, following the infant/child’s lead

is an equally important principle and guideline.

b. While this decade there are evidence-based treatment competitions about which EBT is

most effective, competition between therapeutic approaches has been around for a

long time. A seminal study by Truax & Carkhuff in 1967 led to the conclusion that no

matter what therapeutic modality one used, the “triad” of genuineness, non-possessive

warmth, and accurate empathy were elements of a positive outcome. http://www.cyc-

net.org/cyc-online/cycol-0606-heslop.html While this was followed by many studies

that either replicated or refuted these results due to the quality of the study, in the end,

after many reviews, the conclusion was “If study after flawed study seemed to point in

the same general direction, we could not help believing that somewhere in all that

variance there must be a reliable effect” (Orlinksy & Howard, 1979, pg 288-89, in

http://www.sageofasheville.com/pub_downloads/EMPATHY_WARMTH_AND_GENUINE

SS_IN_PSYCHOTHERAPY.pdf

4. Understanding the story

a. The story of each parent and child is important. The NRF uses four stories accompanying

four brain systems as a way to understand and honor Individual Differences for each

person in the family system, children and parents alike. These four stories are based

upon the regulation system as holding the “early story” surrounding the pregnancy and

early life, the sensory system as holding the “developmental story” of matching or

mismatching developmental milestones, the relevance system as holding the

“emotional story” of emotions, memories, and meaning making that includes trauma

histories, and the executive system as holding the “learning and educational story.”

5. Holding the baby in mind

a. While validating the parental experiences and their concerns is where things begin in

the therapeutic working alliance, the NRF views the baby as part of a dynamic system.

The NRF expands this concept of holding the baby in mind, to holding the “system” in

mind, working to emphasize the transactional dynamic of relationships being co-

created. In essence, there are three facets that are held in mind that the practitioner is

juggling in the art of working with families; the parents, the baby/child/youth, and the

relationship each dyad has with each other.



http://www.sageofasheville.com/pub_downloads/EMPATHY_WARMTH_AND_GENUINESS_IN_PSYCHOTHERAPY.pdf

http://www.sageofasheville.com/pub_downloads/EMPATHY_WARMTH_AND_GENUINESS_IN_PSYCHOTHERAPY.pdf


I have sequenced these in a particular order, beginning with the use of ourselves as our starting point.

This chapter will focus on the first three reflective practice items - the use of ourselves, parallel process,

and the working alliance. The other items will unfold in other chapters as they pertain to working with

our families.

A cultural awareness of ourselves, in concert with these five elements of reflective practice will be

integrated along the way, with specific elements from Dr. Valerie Batts’ VISIONS curriculum. These

elements enhance and expand the professional use of ourselves. These are necessarily tied, hand in

hand, with each other and will continue to grow in influencing each other in the years to come.

Let’s begin with the “use of ourselves.” The NRF provides a rubric for us to engage in both a personal

reflective process as to “who we are” and a way to look at our professional selves in terms of how we

engage and use ourselves in relationship to our families. This rubric has multiple layers to it. You are

being introduced to the first couple layers of it now referred to as Heart, Hand, and Head (HHH)

personal and interpersonal styles [please read in NRF Textbook, Chapter 3, pages 109-114]. As far as we

know, the origins of HHH began as a personality theory at Michigan State in the 1970’s (see NRF

Textbook Chapter 3). As such, we will first begin to look at our individual differences in our personalities

through this lens. In addition, the NRF, has expanded these individual styles into several other layers: 1)

interpersonal modes that play out in the development of our personal selves, 2) interpersonal modes

that play out in our personal and professional relationships with our reflective supervisors/facilitators

and our families, 3) a developmental paradigm that mirrors both parenting and practitioner skills in

building healthy relationships, 4) formats that organize parenting curriculums as to how parents are

taught to parent, and 5) a philosophical metapsychology that is reflected in our professional curriculums

as to how we are taught to practice.

Right away, just by listing all of these layers, we immediately need to look at how we define the next

important concept on our Reflective Practice list, the term “parallel process.” The term parallel process

emerged from the significant role the supervisory/facilitator-practitioner relationship has had to do with

creating a warm, safe, and mutually respectful relationship wherein there is room to be curious and to

“hold” the emotional impact the family is having on the practitioner. What’s somewhat magical about

this relationship is that what transpires and emerges in terms of feelings and thoughts in either or both

participants of the supervisor-practitioner relationship, often has great meaning in deeply

understanding the dynamics) in the family system one is working with, as a “parallel process.” Thus, the

supervisory-practitioner relationship can be a relationship within a relationship. The NRF makes a point

to extend this concept, understanding that the dynamics of the supervisory-practitioner relationship can

“parallel” the dynamics that occur in the practitioner-parent relationship, the practitioner-child

relationship or within the family system one is working with. The safety of the supervisory-practitioner

relationship helps “hold” the range of the hope, joy, despair, confusion, and complexity that may be

playing out with the family, within the practitioner, and within the supervisory-therapist relationship.

Parallel process, in its emergence as a concept, resides here.

The NRF takes this concept and expands it to include more layers. Being rooted in dynamic systems, the

parallel process within a certain set of relationships may also be obvious or hidden in other relationships

as well. Dynamic systems theory reminds us of the “messiness” of how dynamics overlap and bleed over

from one subset to another. As we begin to look at the Heart, Hand, and Head dynamics, it’s possible to

recognize how a similar dynamic in one’s personal relationship when either at one’s best or under stress


(next chapter), may be playing out in a professional relationship with a family member and a reflective

supervisor, perhaps with one’s administrative supervisor, as well as how one’s personal dynamics of

HHH may be simpatico with one’s theoretical and professional training lens.

The concept of dynamics occurring on multiple layers links up with a Bronfenbrenner view of multiple

dynamics occurring on different systemic levels concurrently. While the NRF has been looking at the

personality/personal and family/interpersonal layers for quite some time, we add depth to the system's

dynamics when we include the community, societal, and institutional domains (Batts). Thus, the NRF

combines all these layers now to define parallel process as simultaneously, similar dynamics occurring

on multiple levels from the personality of individuals, to familial and interpersonal levels, to

community and treatment team levels, and to societal and institutional contexts - including our

clinical and theoretical training. The community level refers to people that you know and rely on -

which includes the treatment team. Society levels refer to people you often do not know, yet one is

interfacing with these people who work within institutions that affect our daily lives. Institutions also

refer to where we received our educational and disciplinary knowledge. Culture - how we define art,

beauty, and values - is inherently embedded in all of these concentric circles.


Introduction to the Interpersonal Modes – Heart, Hand, & Head

The NRF uses the concept of Heart, Hand, and Head dynamics as a way to organize understanding the

Parallel Process that can occur on so many various levels at once.

Let’s now have an orientation to one’s personal use of Heart, Hand, and Head dynamics on a personality

level, which reflects our individual differences. These three dimensions are all in dynamic tension with

one another and as I explain each one, you may find that you have a dominant style in one, just like

most of us are either right or left-handed. However, the other dimensions are often present in lesser

degrees or get quickly activated depending on the context one is in.

The HHH dynamics exist under conditions of safety and when we are at our best. The physiology that

matches this is the green zone. HHH dynamics also emerge when challenged or under threat. In this

chapter, we will focus on the HHH dynamics that occur under safety in the green zone. In the next

chapter we will focus on the HHH dynamics that occur under challenge or threat.

Heart

Heart personalities are naturally warm, engaging, and empathic. It is easy for them to follow another’s

lead and to track another’s need. Reading nonverbal cues in others is often an accompanying strength.

In general, this style prefers harmony, so there is an emphasis on repairing relationships when there is

conflict. They want to know, how are we doing emotionally? A simple metaphor for this dimension is a

personality that functions as a “heart” oriented towards feeling.

Hand

Hand personalities are naturally active, structured, and can execute a plan really well. If given a choice,

they prefer to be doing something with others. It’s easy for them to take the lead, setting up policies

and procedures that keep things organized and moving forward. Furthermore, they press for results.

They want to know, is this working? In contrast to predominantly seeking harmony, they can tolerate


conflict (a rupture) and can be direct with others. A simple metaphor for this dimension is a personality

that functions as a “hand” oriented towards doing.

Head

Head personalities are naturally able to stand back and reflect on things before acting on them. They

can stay neutral while gathering more information. Due to their ability to slow things down, they often

are good negotiators, educators, and problem-solvers. They often prefer to function independently of

others and are self-reliant. They want to know, how or why did this happen? A simple metaphor for this

dimension is a personality that functions as a “head” oriented towards thinking.


The triangle (on the next page) allows you to see these dimensions and the first question to ask yourself

is - what is your dominant style? Personal reflection:

In order to flush this out, I often guide folks into thinking about who they are at their best by

recalling a natural disaster that affected you in some way, as a significant event yet from an

observational stance (not from actually being “in” the hurricane - that would be a different

conversation when HHH are activated under significant threat). For example, for those of you

from the United States, Hurricane Katrina is a natural disaster that many of us vicariously

watched as the city of New Orleans was devastated. If this is not a relevant example, please

think of a situation, where you experienced a compelling event that motivated your compassion

when you were not actively a participant in the experience.

• What is (was) your initial reaction to that event?

• The heart motif is to first feel moved by the event. Did you feel compassionate? Sad?

Frustrated? Were you moved to send money or prayers? This would be the heart style

dominating.

• The hand motif is when you are moved to help, your first tendency is to jump in and do

something, also known as “Just Do It!” In regard to the hurricane, your first choice (if

you had the time and money) would have been to go down to New Orleans to assist in

cleaning up or rebuilding the city. This would be the hand style dominating.

• The head motif is when something of importance occurs and your first tendency is to

pause, and say, “Wait a minute, what’s going on here?” Until you can figure out what is

happening, you will pull back and observe the situation in order to understand the

context. You might spend time reading all of the articles, carefully watching the news

unfold, asking important questions: Why did this happen? Why did it take so long to get

help? How will this be prevented from re-occurring? This would be the head style

dominating.

Choose what you think is your first reaction and what we would refer to as your dominant style.

(Adapted from Emotional Styles of Behavior, Michigan State University, 1968).


The Strong Achiever

is comfortable initiating action, giving

directives, coordinating, and prefers

pressing for results in responding to

situations in life.

The Logical Thinker

is comfortable gathering knowledge,

using logical analysis, appealing to

rules and facts, and prefers self-

reliance in responding to situations in

life.

The Friendly Helper

is comfortable expressing warmth and

empathy, compromising in conflict, and

prefers harmonizing relationships in

responding to situations in life.


Blends and Combinations of Interpersonal Modes

At the same time, the “forced- choice” that I just asked you to make does not account for the variety of

“selves” that we have and the fact that these can shift at different times in your life with different

contexts. As we know, the traditional western model uses a categorical way for both assessing and

understanding things, based on categories, such as the idea that you are either pregnant or you are not.

This misses the complexity not only of the world in general, but people in particular. The dimensional

approach sees people as a complex combination of many different traits, where some may stand out as

dominant ones, while others tend to be hidden or not activated at the moment even though they are

actually present. This is also true with the feeler, doer, and thinker, where you may have a dominant

style or set of traits but you also have other traits that you may have to look harder for to be able to

identify or they will emerge in different contexts as blends. Those of us who are blends often want to be

seen as more complicated than a single style, and can feel “put in a box” if we have to choose between

only one of only three styles. What are these other possibilities? (Please note: if one finds this type of

exploration interesting, there are multiple ways of looking at personalities, each with their own

contributions, such as the Myers-Briggs https://www.16personalities.com/free-personality-test or the

Strength Deployment Inventory http://www.personalstrengths.com/).

The Head-Hand blend or Logical Helper is the person who not only pauses to reflect on the situation,

thinks about what is going on and what to do about it, but does not feel finished or complete until

actually following through and accomplishing the intended goal. When this Logical Achiever sees a

problem with a team member’s play on the court, he or she first takes the time to figure out the best

way to remedy it, and only then takes the steps necessary to counsel or, if necessary, confront the other

person until a reasonable solution is put in place. If the other team member is not interested,

uncomfortable, or resistant to a solution proposed by the pure type of the Logical Thinker, the Head

person will often not press his or her point due to personal discomfort with the “tough” emotions of

frustration and defensiveness. The Logical Achiever, however, is not put off by such a challenge, and

perseveres in the face of such interpersonal stress to make sure his or her plan is carried out.

(Adapted from Emotional Styles of Behavior, Michigan State University, 1968).

https://www.16personalities.com/free-personality-test

http://www.personalstrengths.com/


The Head-Heart blend or the Logical Helper is the person who not only pauses to reflect on the situation, but thinks about who is involved, and analyzes what is the best way to help them with the situation. When this Logical Helper sees a problem with a team member’s play on the court, he or she first takes the time to figure out the best way to remedy it, and then takes the steps necessary to engage with the other person. The Head-Heart person will adjust their strategy, depending upon what is the best way to work with this individual. If this other team member is not interested or resistant to this proposal, the Logical Helper will empathically explore what is uncomfortable for them in order to come up with a mutually agreed upon solution.

The Heart-Hand blend is the person who initially will conduct a needs assessment through empathic exploration with others, and then takes an advocacy role to make sure those needs are met, even if he or she has to fight to make it happen. When this Friendly Achiever sees a problem with a team member’s play on the court, he or she responds immediately to the situation, often taking the cheerleading role to both reassure and encourage them. If the other team member is uncomfortable with the “pep talk” offered by the Friendly Achiever, this Heart-Hand person can be relentless with his or her positive attitude and faith in the team, even if down 20-2 in the volleyball game.

The final blended style is the “all of the above” combination of Head-Hand-Heart. A strong suit of this “Jack or Jacqueline of all trades” is a flexible and balanced approach to the game. The strategy of how to play, motivating others to do their best, and keeping an eye on the morale of all of the players are each given equal weight. This Logically Achieving Helper responds to each situation based on which of these thinking, or doing, or feeling priorities seems to be standing out at the moment. His or her personal goal is to be able to feel clear, competent, and compassionate in all three areas. The Head-Hand-Heart person also often feels uncomfortable being “put in a box” by being described by any particular kind of label, instead preferring to be seen as “a whole person” or more complex than any single description.


Going back to the example of Katrina, and viewing yourself from a dimensional perspective, begin to

think about what you might have done first, second, or third. Would you have aspects of several of

these that could have emerged given the time and funds to do them? Another way to look at your own

breadth of “selves” is to consider a different context. If you take a different type of significant event,

such as a personal loss of a loved one dear to you, see if a different aspect of your heart, hand, or head

emerges. Would a blend emerge differently with a personal loss versus a natural disaster?

HEART

HAND

The Strong Achiever

is comfortable initiating

action, giving directives,

coordinating, and prefers

pressing for results in

responding to situations

in life.

The Logical Achiever

uses logical analysis to

problem solve, and then is

comfortable in strongly

pursuing implementation of

their plan.

The Logical

Thinker

is comfortable gathering

knowledge, using logical

analysis, appealing to

rules and facts, and

prefers self-reliance in

responding to situations

in life.

The Logical Helper

uses logical analysis to

problem solve, and then

is committed to using this

knowledge to help others.

HEAD The Logically

Achieving Helper

uses a balance of logic,

empathy, and action to

address the needs of the

entire team and to bring

harmony to the situation. The Friendly

Achiever

uses empathic concern to

identify needs, and then

actively pursues meeting

these needs.

The Friendly

Helper

is comfortable expressing warmth and empathy, compromising in conflict, and prefers harmonizing relationships in responding to situations in life.


Using Heart, Hand, and Head as a Developmental Paradigm for Parenting and Practitioner Skills

The NRF values all three of these dimensions and sees them as integral to healthy parenting skills and

the art of being therapeutic in working with our infants, children, and parents. The NRF’s sequence of

Heart, Hand, and Head is intentional because it views these as offering a developmental profile for how

relationships mature. There are many parallel processes that exist between parenting and practitioner

skills. For example, developing a “working alliance” (the third core feature of Reflective Practice) with

parents requires healthy heart skills to build an experience of safety and trust with them. Being warm,

engaging, a good cue reader, and an empathic listener is so important to a good therapeutic beginning.

In general, the same dynamics apply to establishing safety, comfort, and joy with a newborn. The first

year of life’s priority is to support the relational dance so that a mutual falling in love with one’s baby

can occur. We believe this is just the right place to start with co-creating a relationship with anyone.

The next phase of parenting often requires the provision of guidance and direction. As infants become

motoric, from crawling to walking, childproofing the house is essential for safety; additional guidance

and direction for safety includes setting boundaries and limits that protect and keep us healthy. Our

need to use infant car seats and to buckle up came out of this desire to protect our children and

ourselves. What are things an infant/child can and cannot do? Each family’s values come into play here,

but there are general guidelines that are often adhered in our western culture such as brushing one’s

teeth, eating with some regularity, holding a parent’s hand when crossing the street, observing the

green-yellow-red lights in our neighborhood, having a bedtime routine, etc. These are the hand skills of

parenting that can set up a sequence and follow through.

As parenting progresses and infants turn into toddlers, the parental “no” emerges. From a NRF

standpoint, the key here is for the “no” to be paired with the “yes.” A saying goes, “for every ‘no’ there

needs to be at least a couple of ‘yeses’”. The art of parenting here is the hybrid blend of being empathic

and staying sturdy at the same time. I’d say this starts early on and certainly applies to the early years

and the teenage years, both potential times for more tumultuous developmental dynamics. In our

culture, this heart/hand blend is not always promoted, and it is more common to see parenting

curriculums about one or the other rather than both.

Living in this dialectic from the start is a NRF principle that spills over as a parallel process when it comes

to the practitioner skills of creating a heart/hand blend. The “framework” aspect of setting up a

schedule with parents, holding to the rhythm of that hour being for this specific family, starting and

stopping on time, are all a part of using our hand skills for setting up and following through with a

structure that leads to an experience of our being reliable. At the same time, the NRF’s promotion of a

dialectical blend between heart and hand also plays out in another way. We are to be engaging and

good listeners to our parents’ concerns, able to follow their lead, while at the same time, bringing our

professional guidance and direction in neurodevelopmental functions to the discussion. We are here to

build trust, safety, and to guide. The NRF’s three clinical steps are a part of that guidance we offer

parents, as we add depth and breadth – sometimes helping parents change their appraisals as to the

meaning of their child’s behaviors.

The third phase of parenting and professional relationships is one of collaboration and reflection. As

toddlers turn into young children, their capacity to speak and to have more “top-down” self-control can

emerge. With this, comes more capacity for conversation. Now, parents take the solid foundation of the


dialectic in being both empathic and sturdy into a collaborative spirit of negotiation. The child’s

viewpoint is empathically understood; the parent’s point of view is also clearly stated; now, being able

to negotiate from these two points of view launch parent/child relationships into healthy, robust

discussions, compromises, and reflections. As parents move through these phases of developmentally

with their children using their best heart, hand, and head skills – we see how mutual empathy, mutual

respect, and now mutual empowerment is built into the relationship. Experiencing these

heart/hand/head dynamics in an ever-growing continuous fashion are in-part, how we grow a self that is

grounded in being kind and thoughtful towards ourselves and others (heart), an ability to speak up for

oneself and to be assertive (hand), and the capacity to have a private self and to be reflective (head)

[more on this in the Executive brain system’s functional capacities]. These personal and interpersonal

ways of being help us to grow an integrated self that can be both separate and connected to others at

the same time. While these developmental phases with an infant/parent develop over time, the

parallel process in the parent/practitioner relationship is accelerated. In real-time, the practitioner is

holding all three points of reference – following the parent’s lead (heart) while being able to provide

guidance and direction (hand) while entering into a spirit of collaboration (head). These all are occurring

during the early phase of assessment and are necessary dynamics to hold and embrace throughout

intervention. The process of integrating these different aspects of ourselves in our personal and

practitioner lives is an ongoing process of maturation. In some ways, it’s never ending! By being a part of

a NRF community, we make a commitment to always maturing in our personal and professional

development. If you are a new practitioner, using these parts of yourself may seem overwhelming! We

want to acknowledge that and encourage you to feel free to let someone in the NRF community know

this. We are all learning. Buddy up with someone who may have these professional parts of him or

herself more naturally integrated by being a practitioner with years of experience. These skills are

sometimes organic and sometimes well-earned through concentrated efforts to integrate ourselves!


This figure shows the parallel process of heart/hand/head skills from a parenting and practitioner point

of view.

Please refer to the “Interpersonal Modes that Support Coordination for Parents & Practitioners” and

the “Interpersonal Modes that Can Contribute to Load Conditions for Parents & Practitioners” in

chapter 3 on the website.

Clinical traditions and the strengths they bring to our history and training.

We end this chapter by linking the clinical traditions with their philosophical underpinnings. The NRF

values these traditions and yet does see them as needing to be judiciously used. They are each powerful

and from the NRF’s perspective meant to be used together to provide balance as development in all

relationships moves forward.

Heart: Humanistic and Strength-based Traditions. These traditions value the importance of validating the human experience with sensitivity and kindness

from the humanistic tradition. The philosophy in this tradition supports that if people are treated with

respect, with validation of their own subjective experience, they will grow and thrive. Feelings are often

used as the vehicle for gaining knowledge or truth. Optimism is characteristic of this perspective,

believing in the human potential for goodness. Maslow is identified as a contemporary Humanistic

theorist. The clinical models emerging from this tradition are known as “strength-based” and “client-

centered” traditions. These are commonly used in Early Intervention (Dathan Rush and M’Lisa Sheldon:

www.coachinginearlychildhood.org) and Child Welfare systems of care

(https://www.childwelfare.gov/pubs/acloserlook/strengthsbased/). In more recent times within mental

health realms, the humanistic traditions are known as Rogerian (from Carl Rogers in psychology circles)

or Kohutian (from Heinz Kohut in psychoanalytic circles). These psychologists were both at the

University of Chicago during the same era, yet unfortunately, never acknowledged each other. In Infant

Mental Health circles, Susan McDonough’s Interactive Guidance and David Old’s Nurse Family

Partnership would be seen from this perspective.

A common factor in large systems of care embracing this heart approach is the pendulum swing that

occurs when practitioners are trained in a top-down, traditional medical models where the practitioners

are used to telling parents what to do and doing it for them, and the service delivery system wants to

shift to being client-centered. An example of this from the Early Intervention field is when the service

provider, who works in a clinic, suggests the parent drop of his or her child for the hour while s/he goes

and runs errands (this was my experience as a parent). The treatment is oriented towards “fixing” the

child without the parent’s involvement and without taking place in a natural environment.

Often, when shifting from a top-down strong and forceful hand approach to a heart approach, there is a

pendulum swing that occurs. The extreme of the use of the heart perspective would be when the

practitioner solely follows the parent’s lead and is afraid to bring his or her own clinical expertise to the

discussion. For example, in one Early Intervention (EI) site, the practitioners felt that they only could

offer support to what the parents asked for and wanted, so much so, that talking about the colors of

stress or stress recovery was prohibited because that was not concretely following the parent’s lead.

Over time, usually, this evens out, yet not always, and some practitioners may need support to offer a

blend in following the parent’s lead while integrating their clinical expertise. One EI system resolves it

http://www.coachinginearlychildhood.org/

https://www.childwelfare.gov/pubs/acloserlook/strengthsbased/


this way. They follow the parent’s lead as to the goal that is set for his or her child, yet, they are free to

use the NRF’s clinical steps in reaching that goal. So, for example, in order to participate in feeding at the

table - the parent’s stated goal -- the parent and child have criteria involving small steps as to how to

reach that goal. Here, the capacity to get into the green zone and to share joy, along with motor skills,

become a part of the treatment strategies to help the parent achieve their desired goal for their child.

Hand: Empirical and Behavioral Traditions.

The hand tradition’s strength is providing practical guidance through the use of behavioral principles.

Empiricism challenged the pessimistic world view that we are products of our innate biology. Rather

than focusing on the innate and the “internal world”, the focus became upon the “blank slate” that

could be changed through actual sensory-motor experiences. Being able to control the external

environment, through positive and negative reinforcement, holds the promise of shaping behavior into

behavior that is compliant. The behavioral tradition, at its best, uses a healthy hand via “guidance” by

providing structure for parents by breaking down goals into small steps. There are many versions of

Behavioral approaches (see link to Using Contingency Management to Change a Behavior You Want To

Change). LINK HERE. As one can see, there are some less desirable methods that engage punishment

and negative reinforcement that the NRF views as problematic, due to these methods likely reinforcing

stress responses and traumatic experiences. This would fit with the “harsh hand” approach that cuts

across parenting, administrative, and practitioner approaches that are autocratic in nature (more about

this in the next Chapter with the Hand Under Stress). The NRF supports the latter versions of Methods 5

through 8, especially ones which are reinforcing positive behaviors we value (such as shared joy) and

attending to the meaning and antecedents of the stress response behavior by doing a careful chain

analysis (the NRF uses the help of Step 3 to look for the multiple meaning of the triggers).

The medical model historically has used a directive, top-down approach with “patients.” While this is

currently viewed with a critical lens, there are ways in which some participants can be comforted by

having someone “in charge” guiding one through a stressful medical procedure. Healthy hand behavior

includes someone who individually assess the needs and is a clear communicator of these needs to the

parents, whether it’s their own needs or his or her child’s needs. There are real advantages to having a

kind heart combined with a clear hand providing direction and guidance when it the context calls for it.

There are also many ways in which this privileged position of power has been abused with the use of

arrogant hand behaviors where the “doctor knows best”. “Informed consent” is now really being re-

evaluated and challenged. The current perspective is shifting the power differential away from the

“doctor” into a collaborative process. This shift correlates with the terms “shared decision making” and

“evidence-based decision making.” Unfortunately, the terms Evidence-Based Treatment and Evidence-

Based Practice quickly became conflated with the rise of the “evidence-based” movement (referenced in

Chapter One). Slow in coming, the concept of Shared Decision Making is restoring some of the

imbalance that Evidence-Based Treatments (EBTs) created, wherein the use of an EBT automatically

trumped family choice and professional wisdom.

This picture visually represents the increasing complexity of Shared Decision-Making component parts

and contextual factors. This picture supports the most complex definition of Evidence-Based Decision

Making, which is what the term Evidence-Based Practice was meant to represent all along (from the

Institute of Medicine).


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2698591/

It is the blend of holding the tension with all of these parts that is so important to keep in mind. The NRF

supports the balance of multiple dimensions, and holding the tension of them all, even when they are in

conflict. The dangers of pendulum swinging towards the “heart” of medical care, where the

client/patient satisfaction is the number one goal, have been noted. Some hospitals are reaching for

high client/patient satisfaction that includes providing amenities such as valet parking, custom-ordered

meals, flat screen TVs, and VIP lounges in exchange for loyalty to the hospital. Nurses are being trained

to practice scripts that are geared towards improving client/patient satisfaction. This article sited below

notes that when client/patient satisfaction goes into an extreme direction, overriding sound research

and practitioner expertise, the medical care can go down with it, in inverse proportions. In several

hospitals that scored higher than the national average in patient satisfaction, they also had poorer

medical outcomes. The stance that the patient is the customer/consumer and therefore is always “right”

can end up with high satisfaction scores, along with serious health outcomes, including death. Just as it

is unsafe to have the simplistic view that the “doctor” or “practitioner” is always right, it is the same

when one swings to the client or the parent with the same carte blanche authority. I believe a parallel

process exists when unreflective authority is given to parents, principals, and priests, when denial and

dissociation may be keeping the secrets of child abuse, which is also an epidemic. Distinctions between

client preferences and client needs have to be made. The dogmatic approach to anyone of these prongs

being the way to approach health care, or any type of care, from the NRF’s point of view, is dangerous.

Neither research, nor the client’s preference, nor the client’s context, nor the professional’s expertise

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2698591/


can replace the need to be engaged in all of these dynamics at once. It is the blend of a kind heart that

honors each parent and child’s voice, with the strength of the practitioner’s expertise providing clear

communication from assessing the complexity of needs, with a presentation of options and research-

based viewpoints that can guide shared decision making.

http://www.theatlantic.com/health/archive/2015/04/theproblemwithsatisfiedpatients/390684/?utm_s

ource=atlfb

Hand: Rationalistic Traditions.

The head traditions represent the underlying philosophy of rationalism. This perspective values

reflective capacities. Thinking, gaining insight, and meaning-making is often the vehicle for how

knowledge or truth is derived. In contrast to the empirical viewpoint of being sensitive to the external

behaviors and controlling the rewarding or punishing environment, rationalism values the internal world

of the parent and child. There is a pessimistic trend built-in to these traditions due to a belief that the

human race is prone towards a repetition of what is most familiar to us from an unconscious or implicit

memory system that we all inherit from the accumulation of our lived experiences. A range of

psychoanalytic perspectives that value insight (Freud/Jung/Klein), as well as cognitive-behavioral

traditions that value changing thoughts and beliefs (Ellis/Beck/Bandura) are well positioned in this

tradition. The emphasis on the use of the narrative for healing purposes belongs in this sector. For

example, Child Parent Psychotherapy makes use of the child’s symbolic play to understand the trauma

narrative and works with the parent for them to construct their own narrative, linking his or her past

with the present; Trauma Focused CBT sees the trauma narrative as the goal of processing the traumatic

event(s). In this sense, these traditions are neurodevelopmentally “top-down.” Along with this tradition

is a value of neutrality with the ability to stand back to observe oneself. The reflective parenting (ref),

the mindfulness movement (Siegel), and mentalization (Fonagy) perspectives that have gained

momentum would be placed here.

An Example of a Heart-Hand Blend

Existentialism and Gestaltism are presented as examples of a heart-hand blend.

As an example of bridging the gap between polarities, Existentialism bypasses the either/or of optimism

versus pessimism, engaging in the mixture of positively and negatively valenced lived experiences

(Frankl/Yalom). Existentialism holds the tension between the horror of what life can bring (e.g.,

Holocaust –pessimism) and the human spirit to find meaning in the midst of tragedy (e.g., finding the

strength to survive the Holocaust and meaning-making in life despite extreme suffering –optimism)

http://www.viktorfrankl.org/e/logotherapy.html. It also embraces the dialectic of the freedom of

personal choice that’s accompanied with responsibility.

Gestaltism supports the active “doing” aspect of being engaged in life. “Doing” through lived

experiences is often the vehicle for how knowledge or truth is derived. This tradition highlights that

authentic lived experiences are primary vehicles for change. The neurobiology of brain development

supports this perspective as well –that we are changed from ‘what fires together wires together’.

http://www.ncbi.nlm.nih.gov/books/NBK64939/; http://www.gestalt.org/yontef.htm. What’s most

healing from this point of view is the authentic relationship the clients have with a practitioner who is

fully engaged in the process of the relationship (Buber). Process leads over content.

The NRF is a strong supporter of providing new procedural experiences of healing for parents and

children through coaching and mentoring despite previously enacted experiences of abuse and neglect.

http://www.theatlantic.com/health/archive/2015/04/theproblemwithsatisfiedpatients/390684/?utm_source=atlfb

http://www.theatlantic.com/health/archive/2015/04/theproblemwithsatisfiedpatients/390684/?utm_source=atlfb

http://www.viktorfrankl.org/e/logotherapy.html

http://www.ncbi.nlm.nih.gov/books/NBK64939/

http://www.gestalt.org/yontef.htm


The NRF holds the tension between optimism and pessimism, living in the dialectic that both of these

polarities are a part of authentic lived experiences that are accepted and integrated. The NRF supports

the tradition of Floortime, a highly interpersonal approach, and applies it to early intervention and

infant mental health alike, wherein the goal is to balance following the child’s lead while also expanding

the play. Role plays and any form of procedural practice (such as practicing the NRF’s three steps)

incorporates learning by “doing.” The NRF’s bias is also towards healing which occurs through authentic,

therapeutic relationships.

The NRF’s perspective honors all of these traditions and sees them as all a necessary part of creating a

holistic approach to the use of the self, parenting, and the development of healthy relationships. The

heart must be there for the glue and motivation for connection to be present; the hand provides safety

through boundaries, gentle guidance through sound principles, and activities that create powerful lived

experiences of being together; and the head gives us space to reflect, conceptualize, to slow down, and

to learn from each other. The balance and holding the tension amongst these is important (stability)

along with the freedom to move into one space or another, according to the context (flexibility), is

invaluable.

Several continuums have been presented in the discussion of these philosophical underpinnings to how

we view challenges and what needs to be done to heal the difficulties involved. Before we look at the

big picture that holds these historical traditions, take a moment to locate yourself and your training

biases to see where you land on these continuums. You may change your mind as you continue to think

about these, but embedded in the philosophical, psychological, and treatment options are some of

these questions.

Examples of dialectical continuums

Human nature can be destructive Human nature “naturally” grows and

often repeats itself into optimal functioning

Pessimistic Optimistic

Life is largely pre-determined and unfolds Life is determined by

individual choices

Deterministic Freedom


Decisions are based upon logical options Decisions are based upon

pursuing priorities

Thinking Feeling

This triad of heart, hand, and head, with underlying philosophical differences from different venues,

supports the clinical use of ourselves at our best. We continue to work on the integration and maturity

of these three forces in our lives for the rest of our lives. Again, please take some time to locate your

training history and what life has taught you about these perspectives. Which ones are you prone to

use? Where do you see your blends? How does this compare with your personal and interpersonal

inventory? Are there similarities or differences between your personal style, interpersonal mode, and

professional training history? What are they?


Original Author Trevor M. Dobbs, 2000; Adapted by C Lillas, 2016

Reflective Practice Guiding Principles:

In summary, the literature on Reflective Practice (Supervision) highlights five essential elements to a

positive reflective practice relationship and the “‘active ingredients’” that make this relationship special.

The following list is ordered according to how this chapter related these to NRF guiding principles.

1. Professional use of the self: the NRF uses stress (red, blue, and combo) and stress recovery

(green) colors along with HHH as the core use of the self. Integrated into this process is the

Cultural Awareness of the Self that integrated the VISIONS curriculum by Dr. Valerie Batts which

will be presented in Chapters 5 and 10 to 13.

2. Parallel process: the core of Infant Mental Health is our capacity for creating, building, and

sustaining relationships. The supervisory-practitioner relationship is a relationship within a

relationship. The dynamics of the supervisory-practitioner relationship can “parallel” the

dynamics that occur in the practitioner-parent/child relationship or within the family system one

is working with. The safety of the supervisory-practitioner relationship helps “hold” the

complexity of the hope and despair that may be playing out with the family, within the


practitioner, and within the supervisory-therapist relationship. The NRF expands this concept to

hold many potential parallel processes, as dynamic systems are often messy and similar

dynamics can be involved in multiple facets of relationships.

3. Working alliance: this is the “heart” side of building and sustaining relationships, fostered with

validation, mirroring and an empathic bond that is created.

4. Understanding the story: NRF uses four stories from four brain systems to hold the

parent/child’s experiences. These will be discussed in Chapters 10, 11, 12, and 13.

5. Holding the baby in mind: the NRF expands this to holding the “system” in mind, working to

emphasize the transactional dynamic of relationships being co-created between the child and

parents as well as with the practitioners.

The engagement of Reflective Practice appreciates “wondering” together about the processes involved

in the family dynamics and between the practitioner and children/parents. The NRF holds a balance

between being curious and discovering together as well as having a structure that helps us find meaning

together. The three clinical steps help a practitioner organize “knowing” something about the family

system. We refer to this as stability. Combined with that is continuing the process of wondering and

discovering together. We refer to this as flexibility. The NRF embraces stability with flexibility as a

central organizing theme we will find throughout its many layers. This segues us into Chapter Four

where we begin to learn about the roots to the tree, the foundation of our nervous systems.


Chapter Four Step One, the Foundation to Resilience, the Roots to the Tree

Reading material for Step One, Chapter 4 in the NRF Textbook

ORIENTATION TO GLOBAL CONCEPTS and WORKSHEETS FOR STEP ONE

Conceptual Guiding Principles to Step One, Phase One. These are the concepts that you must understand

well enough before you embark on conducting the Interview for Step One and gathering data for this

step from your families. It is recommended that you first walk through the concepts and filling out the

Early Phase Assessment form for Step One on yourself in relationship to a significant other in your life.

This way, you are learning how to apply the material to yourself first. Encoding the material for yourself

is a great way to bring a comfortable sense that you already have experience using these steps! If you

skip this part, you will be filling out an Early Phase Assessment form on an active case that you are

SHORT REVIEW OF CHAPTER THREE’S CONCEPTS:

1. There are five basic elements to the use of Reflective Practice that is a cornerstone to

the practice of Infant Mental Health

a. The Professional Use of Oneself

b. Parallel Process

c. Working Alliance

d. Understanding the Story

e. Holding the Baby in Mind

2. The NRF expands these concepts and elaborates on the use of these concepts. The

Professional Use of Oneself, Parallel Process and Working Alliance are of particular

emphasis in Chapter Three.

3. The Professional Use of Oneself and Parallel Process are organized around the triad of

Heart, Hand, and Head. These three dynamics depict personality propensities and

interpersonal modes that can occur on many levels.

4. The Heart is focused on warmth and empathy with feelings being a priority. The Hand is

focused on organization and results with doing being a priority. The Head is focused

upon knowledge and reflection with thinking being a priority. These are metaphors for

many dynamics that play out in relationships and developmental processes.

5. This triad also forms the basis of philosophical differences that have influenced the

clinical landscape of theory development. It’s important to find oneself as a person and

professional in these triads.

The goal for any maturing practitioner is to continue to develop the skill, strength, and blend of

all three of these personal and professional capacities.


working with and mapping out your own responses as the parallel process unfolds across the three

steps.

Assessment is Intervention, Intervention is Assessment:

From the very start, with each step and the cycling back to each step, this basic dynamic principle

applies. Assessment is intervention and vice versa. The “assessment” process is ongoing and ever

evolving. In doing so, one is always intervening, whether in the moment with a psychoeducational

comment about noticing the green zone in oneself, parent, or child; playing back a video clip where the

parent is noticing and responding to a subtle stress response in his or her child; or providing a co-

regulatory gesture without comment such as lowering the light, slowing down the pace in the room, and

providing a healthy snack for a hungry parent or child.

The roots to the tree:

The foundation to health and the function of our nervous system is our Autonomic Nervous System,

which can also be referred to as our “automatic” nervous system. The foundation here is organized

around our sleep-awake cycle. There are seven states of arousal in this sleep-awake cycle that help us

understand our health. Step One has a lot of impact on the rest of the tree! If the roots are not deeply

rooted with both stability and flexibility, this will affect the trunk and the branches to the tree. Thus, you

will find that a careful and thorough understanding of Step one will help you with Step two and Step

three! Step one carries a lot of overlap in the first Level of Engagement of Step Two and with the first

brain system in Step Three - regulation, which has a lot of overlap with the relevance system as well.


Flexibility with Stability:

The concept of “health” across and within all three steps is the paradox of flexibility with stability. This

dynamic and dialectic will show up in many formats throughout the NRF. The balance and dialectic of

these two forces is a critical application towards understanding health. It is of utter importance in Step

One. This concept is taken from the meaning of the term – allo (flexibility) stasis (stability) – which

physiologically is the ability to flexibly move into a stress response and the ability to move back into

stability.

Health, in this first step, which overlaps with the Regulation System means that all three stress

responses are useful and adaptive. This will emerge later in the Regulation System’s functional capacity

that asks if there is an adaptive use of all three stress responses. The three primary stress responses we

will be working with, and their corresponding colors – the red/blue/combo zones are, in and of

themselves, are not “bad” or unhealthy. Rather, each of them is necessary! However, too much

flexibility results in chaos and one could stay moving in and out of stress responses without stress

recovery. Conversely, too much stability results in rigidity, without the flexibility to shift into different

stress responses when it’s adaptive and necessary. So, the balance here is that one can recover back to

stability while also having the flexibility to move into stress responses when the context calls for it. In

physiological terms, the NRF defines stability as having the capacity to cycle into deep sleep during one’s

sleep cycle and getting back to the green zone during the awake cycle.

Thus, two states of arousal signify conditions of safety expressed through our physiology:

deep sleep and the green zone.

Self-regulation and co-regulation:

A core dynamic is the balancing act between self-regulation and co-regulation. This is another NRF

dialectic – rather than either/or we need both in varying degrees throughout our lifespan. A general

principle is that the more vulnerable one is, regardless of the cause, the more co-regulation one needs,

while the sturdier one is, the more self-regulation capacities are possible. From the cradle to the grave,

there are periods of time where there can be an increase in vulnerability, and in general, we are more

vulnerable the younger and older we are. Thus, in its clinical application, the more vulnerable the child’s

nervous system is, the more co-regulation will likely be needed. At the same time, the more vulnerable

the parent’s nervous system is, the more likely the parent will need to be co-regulated. The practitioner

often has the role of co-regulating the parent, in tandem while also co-regulating the child. As the

parent has more self-regulation, the practitioner can support the parent’s co-regulation of his or her

own child. As either the parent or the child improves in this or her green zone, progress can be made.

These are non-linear systems, so the port of entry for improving regulation in each dyad may be through

the child, the parent, or both.


The dance of this dialectic is always with us. Daniel Stern, in his seminal book, The Interpersonal World

of the Infant (1985), discussed this dialectic from infancy forward. Traditional theory at the time viewed

infants as merged at birth and the developmental gains were to become differentiated over time with

the long-term goal of healthy development being –independence (Margaret Mahler, et. al.). Stern

posited that actually infants are not merged and unable to tell the difference between themselves and

their mother, and that the ability to merge and to fall in love was actually an accomplishment. However,

an accomplishment that necessitated both parties being able to be separate, so that, healthy

attachment behavior involved being separate and healthy separation behavior involved being

connected. Thus, the dialectic of separation and attachment is ongoing and becomes more complex

over time, yet, for a lifetime. (Note: for communal cultures, the description of this dance does not

necessarily apply in this fashion, as infants are often carried or worn and co-slept with 24/7).

In concert with this “western” view of attachment, the Circle of Security offers a lovely metaphor and

training for parents to enhance their capacity to understand their children’s need for both separation

and connection and to read these cues. It is based upon this dialectic, that, as I get my needs met for

connection and I feel safe, through co-regulation, I can now get my needs met for branching out to

explore, and to self-regulate. Exploration at its best is done when the infant/child and parent are in the

green zone. Stress cues are often signals that it’s time for connection. By getting stress recovery through

co-regulation, there is a renewed sense of safety and off the crawler or toddler goes! A lovely

movement back and forth between these dynamics of being separate and off to explore with needing

connection and back for more refueling is ongoing. And, as I mentioned, this is a never-ending

occurrence across the lifecycle. This is very different than teaching parents that the goal is

independence; we believe the goal is actually, interdependence. Hopefully, though, with maturity our

exploration reaches out to broader arenas as our connection grows deeper. The lovely metaphor is that

the Circle of Security offers is this. As the child moves out into the world, s/he is at the top of the circle;


as the child moves back in for comfort and connection, the child moves to the bottom of the circle. A

parents’ loving hands are holding the circle at the top and the bottom so that both can occur.

http://circleofsecurity.net/wp-content/uploads/2012/02/JCCP-COS-Published-Article.pdf

Vygotsky’s Zone of Proximal Development:

How much co-regulatory support should one offer? The concept of the “zone of proximal development”

is that one basically mirrors the NRF’s “titration principle”. The simple version of this means that if the

child or adult can self-regulate one supports that capacity. However, if one needs support to get to a

particular state of arousal or level of functioning, the person with more capacity supports the other to

be successful. This is different from doing it “for” the more vulnerable partner and not to be confused

with a co-dependent response of having to perpetually rescue someone (the heart under stress). This

does mean that one offers the “just right” dose of support to be successful. This does mean that one

also allows his or her child to be challenged and led to the “just right” dose of stress so that he or she

can build stress tolerance and stress resilience.

http://circleofsecurity.net/wp-content/uploads/2012/02/JCCP-COS-Published-Article.pdf


Zone of Proximal Development: "the distance between the actual developmental level as determined

by independent problem solving and the level of potential development as determined through

problem-solving under adult guidance, or in collaboration with more capable peers" (Vygotsky, 1978,

p. 86).

NOTE: the degree of co-regulation needed will show up on the Rating Scale for the Levels of

Engagement in Step Two, phase Two. That Rating Scale is used to assess how much support and

scaffolding is needed for the parent, the child, or both.

ORIENTATION TO THE SEVEN STATES OF AROUSAL AND THE FOUR COLORS

The seven states of arousal along a continuum:

There are seven states of arousal that are a part of a continuum and are in themselves, a dynamic

system, with varying degrees of both the gas and the brake pedal in play. While this is only one pattern,

there is an inverse relationship at times, where, at one end, there is the gas pedal of the autonomic

nervous system that produces the red zone, flooded state, and at the other end, from the side of the

brake pedal of the autonomic nervous system, deep sleep.

You can see here the continuum from deep sleep with the full-on brake pedal to the red zoned flooded

state with a full-on gas pedal. When one has an intact nervous system, these states of arousal are meant

shift smoothly throughout a 24-hour sleep-wake cycle.

LOW deep sleep active sleep drowsy hypoalert=blue zone

alert processing=green zone hyperalert=combo zone flooded=red zone HIGH

[Note: For ease and for creating an intuitive connection to one’s states of arousal, the four wake-states

have been color-coded. The colors are very specific to the autonomic nervous system (ANS) and the links

with the gas and brake pedals ties to physiological activity and behavior. In this regard, the NRF’s colors

are not to be confused with other programs that use colors. Folks who want to use other paradigms

with colors, such as Zones of Regulation, are welcome to, but it’s important to hold onto the integrity of

the NRF’s use of colors as having specific meaning to the ANS.]

We now will walk through the seven states of arousal that range from the deep side of the brake pedal

with deep sleep to the high side of the gas pedal with the red zone, flooded state.

Deep sleep. Deep sleep represents when the brake is fully engaged, and it is a restorative state on a

cellular level for our bodies. (see pages 132-3; Table 4.2 on page 134 in the NRF Textbook). Notice the

body is at midline; the respiratory and heart rate will be slow and there is no body movement. We are

meant to be “shut down” in this state! In relationship to sensory input, it takes a large amount of input

to awake us. Folks have slept through earthquakes and intruders into their home during deep sleep

because we are in such a deep state of slumber.


Web site on sleep: https://sleepfoundation.org/sleep-topics/children-and-sleep

Active sleep. As one matures, there are different levels of sleep. Adults cycle through four phases of

sleep. Infants have two sleep states, deep sleep and light sleep. Light sleep is also equated with “active

sleep”. For infants, this means that during the first six months when infants are actively moving around,

this could be misconstrued as the infant is awake. In fact, this might be a phase of light sleep that will

cycle back to deep sleep so it’s important to not intrude at this juncture unless s/he really wakes us.

Active sleep for an older youth and adult is equated with REM sleep. Here, only our eyes are making

rapid movements rather than all of our body.

https://sleepfoundation.org/sleep-topics/children-and-sleep


Drowsy state. This is truly a transitional and “in-between” state, whether on our way down to sleep or

on our way up to the green zone. As this is in a slower and lower zone than blue, the glassy eyes can be

accompanied with a yawn, rubbing of the eyes, and the intermittent closing of one’s eyelids. The more

that occurs, the more one may just nod off or go to sleep. When waking up, there may be a period of

time where one is still a bit sleepy, moving slowly, and walking around with one’s eyes half open as one

is orienting to one’s morning routine. While this state is not often talked much about, it is a healthy sign

of a nervous system that one can cycle through the drowsy phase. It shows us that there is an ability to

slowly relax and to have a smooth transition between the awake and sleep cycle. This is one of the

important functional capacities in the regulation system (step 3) – smooth transitions. Infants, children,

youth, and adults who do not cycle into a drowsy state make abrupt transitions from the sleep-

awake/awake-sleep cycle. Examples are young children who are running around until they collapse, fast

asleep on the couch or the floor. Or an infant who wakes up from sleeping, immediately screaming or

crying.

Blue zone. Next, in the smooth progression through the all of the sleep-awake zones, the blue zone is the

first awake state of arousal from the parasympathetic side of the nervous system, associated with the

brake pedal. Blue zone behavior has its own continuum. Here one is awake and not drowsy. The blue

zone behavior can stretch from daydreaming behavior to dampened-down behavior, accompanied with

glassy or glazed eyes and flat facial features with no signs of emotions. This continuum extends into

depression and all the way to dissociation.


Notice the glassy, glazed eyes; the flat face with no signs of emotion; the low tone in the cheeks; the

sensation of looking through you, rather than at you.

Green zone. The green zone represents the state in which we are calm, alert, and present. It is the state

in which we all are at our best, with the most connection to all of our brain systems and the fullest

capacity to learn and to engage. The green zone represents a lovely balance between one’s gas and

brake pedal. The parasympathetic side of the ANS is the “vagal nerve” - our 10th cranial nerve. It

innervates all of our organs from our eyes and face, all the way down to our gut and genital areas. This

vagal nerve has two branches to it. For simplicities sake I’ll refer to one part as “more mature” and the

other part as “more primitive.” The more mature slide is something known as the “vagal brake”. This

vagal brake allows us to have varying degrees of excitement (gas pedal) and varying degrees of

dampening down (brake pedal) by modulating our heart and respiratory rate so that we can have a

range of excitement and quiet periods, all while in the green zone. In other word, this vagal brake

modulates us! Without it, or when it does not function well, we are quick to either go blue or go red

very quickly (Porges, 2004). This is the contribution from the ANS side and the regulation system’s side

that either supports our green zone functioning well or contributes to the green zone being unstable.

This is easy to recognize with premature infants, where their vagal brake would naturally be more

immature, and it can be harder to stabilize their green zone without extra care and support from

multiple brain systems. There is a direct link here with the degree of sensory stimulation one can handle.

The stronger the vagal brake is, the more likely one can handle quite a bit of stimulation, while staying in

the green zone. Without a strong vagal brake, one is more likely to experience “normal” levels of

stimulation as too much challenge or threat.

Porges on You Tube: How Your Body Makes the Decision

https://www.youtube.com/watch?v=ivLEAlhBHPM

https://www.youtube.com/watch?v=ivLEAlhBHPM


Notice the bright, shiny eyes – this is a central feature to the green zone at any age. The face shows

emotion and joy, and we can see that this infant is alert with has focused eyes on the adult/caregiver

engaging with him/her. Again, this is the state for learning and engagement and the NRF views these

two as completely intertwined! Engagement is learning and vice versa. Later, when you see the arousal

curve, you will notice that the green zone is at the top of the bell-shaped curve which alerts us to fact

that we have the most capacity for attention at the top of the curve.

Combo zone. It used to be thought that the gas and brake pedals were mutually exclusive – as one went

up the other went down. We now know that it’s more complex than that. The combo zone has an

inherent mix of both the gas and the brake pedal. This is why it’s both red and blue! The autonomic

nervous system is its own dynamic system, wherein there are at any point in time, variations of the

red/blue sides engage with more or less of each type of input. [Note: While some people turn this zone

into purple, my preference is to keep its colors true to red and blue].

Thus, the combo zone behavior has its own continuum as well. The more the gas pedal is involved, the

more “active” the anxiety is. This can include whining, crying, a furrowed brow, and clinging behaviors.

The more the brake pedal is involved, the more “quiet” the anxiety becomes. This can include a quiet

wariness with raised eyebrows, wide eyes, and pursed lips but the rest of the body is stiff in its tone with

hypervigilance.


Notice the raised eyebrows, the wide eyes in all of the pictures; pursed lips (second picture); and a look

of surprise (third picture). The first picture shows a bit of widened nostrils - nasal flaring. This is an

example of the “quiet” side of the combo zone, where there is hypervigilance and wariness.


Red zone. The red zone is for the sympathetic side of the nervous system, associated with the gas pedal.

Red zone behaviors have two valences to them – a positive and a negative one. The positively valenced

red zone is about behavior that is hyperexcited, flitting, super silly, or manic behavior. The negatively

valenced red zone is about behavior that is distressed, with crying, screaming, yelling, angry/aggressive

tones. Within the research literature, these behaviors are associated with “externalizing” behaviors.

Notice that both pictures show scrunched up faces and closed eyes with open mouths that are crying.

Notice that the picture to the left has an infant whose body is still midline, however, with his arms to

his/her side. There is still some motor organization here, despite being in a flooded state. Each state can

have “more or less” organization to it! This is an important nuance to these states of arousal. Some

infants, children, youth, and adults have very “clean” states where they are organized and show the

zone very clearly. Notice the picture to the right, his/her body has more motor extensions to it and the

more flailing around, this state might be more “disorganized”. This applies to any age, wherein we can

be in the red zone and if angry, one might have enough cognitive leeway to still argue one’s case quite

eloquently to a supervisor wherein you feel you deserve a refund on a product that is not working. This

might just work, and you might get a refund. On other hand, if you one is in a disorganized state and

angry, the conversation tends to degenerate into blaming and attacking the product and the supervisor

– likely resulting in a different outcome - s/he may very well hang up on you and there will be no

refund!

Take a moment to reflect on your own body cues. The full worksheet with body cues is coming up and

beginning to think about your own stress markers and you own preponderance of what zone may be

your “go-to” is not a bad idea!


Safety, Challenge, and Threat:

Safety, challenge, and threat are points along a continuum. “Allostasis” represents the healthy side of

stress recovery under conditions of safety and the range of all three stress responses under conditions

of challenge and threat, as long as the threat is short-lived. This flexibility allows your tree to “blow in

the wind without losing its roots”. In Chapter Three, you were oriented to your HHH relational style

under conditions of safety, when you are able to function from the green zone. “Allostatic load”

represents a loss of healthy balance, referred to as “toxic stress” wherein the stress responses are

occurring too frequently, lasting too long, and/or chronically present under conditions of threat, that are

frequent or ongoing. Here, the roots may be damaged, or the tree may be uprooted. The following

section links up the colors of stress with the relational styles under stress – whether from challenge or

threat.

ORIENTATION TO THE COLORS WITH RELATIONAL HHH UNDER CHALLENGE, AND THREAT

HHH Under Challenge and Threat

Once you have identified the body colors and have a good sense as to what the distribution of these

colors is, you now can very begin to pair up the relational style as well. In Chapter Three you were

oriented to your Heart, Hand, and Head personal and interpersonal styles under conditions of safety and

the green zone. Now, once there is a challenge or a threat, whether real or imagined, we go into a stress

response, and along with the body state there is a HHH relational style that often matches our combo

zone, red zone, and blue zone. These are very distinct relational styles that match our body state. Each

one of the green zone HHH styles has strengths and a “shadow” side as well!

As you probably recall, the combo zone is physiologically a state of anxiety. The heart, whose strength is

to be responsive to others when in the green zone, when anxious under stress, can go in a couple of

directions. One pathway the anxiety and hypervigilance can go is to become too controlling and

intrusive. The worry is obsessive becoming invasive to others in this way. Tracking another person too

closely is suffocating because there is not enough necessary space (*the dialectic of separation and

connection is necessary). Another pathway for the anxiety to go is towards wanting to please others.

With this style, there is a tendency to defer to whomever the dominant pressure is coming from. The

desire for harmony can now become at-risk for co-dependency, being too concerned about hurting

other’s feelings, with difficulty tolerating healthy conflict and holding to healthy boundaries. As a

potential co-dependent partner, this relational style is at-risk for connecting to someone who can be

abusive, a domestic violence partner, and/or a substance user. Whether in a personal or a professional

context, when involved with conflict or uncomfortable disparities—dysfunctional rescuing can become

the “go-to” strategy (Batts, Visions, The Cultural Awareness of the Self,

https://www.fresnostate.edu/chhs/ccci/documents/Dr.Valerie.Batts.03.07.13.powerpoint.presentation.

pdf).

The red zone is physiologically a state of too much excitement, too much distractibility, or too much

aggression. The hand, whose strength is to offer guidance, to be directive, and to tolerate conflict, when

agitated under stress, now is at-risk of becoming too demanding, threatening, and at an extreme,

abusive. Again, these body zones and relational styles tend to link up in dynamic patterns with others

(more on this in phase 2). Whether in a personal or a professional context, when involved with conflict

or uncomfortable disparities –blaming the victim or blaming the system can become the “go-to”

strategy (Batts).

https://www.fresnostate.edu/chhs/ccci/documents/Dr.Valerie.Batts.03.07.13.powerpoint.presentation.pdf

https://www.fresnostate.edu/chhs/ccci/documents/Dr.Valerie.Batts.03.07.13.powerpoint.presentation.pdf


The blue zone is physiologically a state of flat affect with often, low muscle tone, that is described by

depression, dissociation, or being locked into one’s private world and shutting others out. The head,

whose strength is to be neutral and reflective, now is at-risk of becoming too detached, dismissive, and

at an extreme, neglectful. Whether in a personal or professional context, when involved with conflict or

uncomfortable disparities –detaching, denying the conflict, or becoming passive-aggressively avoidant

can become the “go-to” strategy (Batts).

Please refer to the “Interpersonal Modes that Support Coordination for Parents & Practitioners” and

the “Interpersonal Modes that Can Contribute to Load Conditions for Parents & Practitioners” in

chapter 3 on the website.

All of us as practitioners and the families we work with will go into these body states and relational

styles. The question is, will these remain adaptive or will they become toxic stress patterns for us, our

family life, the families we serve, the institutions we work in, and the communities we live in? As Bruce

Perry so aptly stated, “States Become Traits” –so when we are left too long or too frequently in stress

responses, these become toxic to our bodies and our relationships. As mentioned in Chapter One,

what’s underneath the long-term outcomes of the ACE’s links with medical, psychiatric, and substance

use challenges, is the changing neurobiology of our stress and stress recovery system. Here, now, are

the four toxic stress patterns that we all want to be able to identify in ourselves, our personal families,

the families we serve, the institutions we work for, and the communities we live in. The parallel process

of toxic stress can be in all of these layers to our lives at once!

ORIENTATION TO TOXIC STRESS

Stress Responses to Threat and Toxic Stress:

There are four toxic stress patterns within the “allostatic load” purview. This means that any one of the

three primary stress responses can go into any one of these four patterns. This is a spot that


practitioners can get confused. It’s common when you are first learning about stress responses to refer

to the “red zone” for every stress response. It’s common in our culture to think of stress as

“flight/flight.” While this is a very common response, it is not the only stress response. So, be aware that

continuums of combo zone/anxiety and continuums of blue zone/sadness/depression can also fall into a

toxic stress pattern.

1. Pattern #1. This pattern pertains to stress responses that occur too frequently and too quickly.

These stress responses have a quick upswing, rather than a slow, smooth transition. (this has a

link with one of the functional Regulation Capacities (#X) to have smooth transitions between

states of arousal).

2. Pattern #2. This pattern is referring to a lack of habituation to a challenge and transition that

over time, one should be able to acclimate to. For example, a three-year-old who screams in a

red zone state for thirty minutes every day when transitioning to pre-school, even though it’s

been the same daily transition for four months to the same pre-school with the same teachers.

Transitions include whether an infant/child habituates to any new schedule, whether it’s from a

move, a new school, a new living arrangement from a divorce or a removal from one’s home in

the child welfare context. Children with sensory processing disorders and autism will often have

this toxic stress pattern.

3. Pattern #3. This pattern is related to a prolonged stress response even after the challenge or

threat has been removed. For example, one stays in a combo zone state even after an exam has

been taken and passed.

It is assumed that in toxic patterns 1, 2, and 3, that there is stress recovery back to the baseline health of

the deep sleep cycle at night and the green zone awake cycle during the day. Toxic pattern number four

is distinct in that either the awake cycle, sleep cycle, or both are disrupted.

4. Pattern #4. Now, the stress response has become a chronic red/blue/combo zone which often

includes disrupted sleep cycles as well. Here, we have the underpinnings to externalizing

behaviors with the red zone state of arousal staying activated and we have the underpinnings to

internalizing behaviors with the combo zone of anxiety and the blue zone of depression staying

activated. This pattern creates the most wear and tear on your body and brain.

The NRF Interview process is now integral to beginning to use a common language with the parents

about their child and themselves. Getting the baseline data as to the frequency of the stress responses,

the duration of them, and the intensity is important for one to know where one has begun. Is there an

adaptive stress pattern? Is there a toxic stress pattern? Is there a discrepancy between what the parents

report and what you observe? Recall that this is not uncommon and part of the work in helping parents

learn to cue read their infant/child and themselves. We now embark on learning the Interview Process

for Step One.

ORIENTATION TO ENGAGING PARENTS WITH STEP ONE

Guiding Principles to Approaching Step One With Parents:

[Please refer to the Interview Guidelines Booklet for extra support in this Chapter’s material provided

online]. In general, there are three guiding principles to conducting any interview and engaging in a

therapeutic process.


Principle #1, Using Flexibility with Stability. The principle of flexibility with stability applies to any

interview process and especially for Step One. There is an optimal balance one hopes to achieve.

Offering a semi-structured interview with specific questions to ask about the sleep/awake cycle offers

stability to the process. At the same time, having flexibility to the interview process allows the

practitioner to also follow the parents’ lead.

Principle #2, Offering a Balanced Clinical Use of the Self. Heart/hand/head skills have been introduced in

Chapter Three (they will be elaborated on in Step One, Phase Two). A basic understanding of these

three concepts is critical to any engagement process. Heart skills support the practitioner following the

parents’ lead. Hand skills support the practitioner taking the lead by providing neurodevelopmental

guidance and direction. Head skills support the practitioner building a collaborative process of shared

engagement with the parents. The key here is for there to be a balance between these three clinical

styles. These are all fluidly being used in real-time. While it’s important to acknowledge that parents

know the most about their child, carefully and empathically understand his/her concerns, it’s important

to acknowledge that as practitioners, we bring a breadth and depth of knowledge about

infant/child/family neurodevelopment to the discussion. From this point of view, the goal setting

involves a mutually collaborative process between parent and practitioner. We offer empathy, guidance,

and collaboration to the interview process. The collaborative process is thus a shared-decision making

experience as the needs and goals from both the family and practitioner are digested and discussed. For

some systems of care, such as Early Intervention, where the goal is derived solely from the parent’s own

concerns, the practitioner’s guidance emanates during the implementation of these goals into practice.

FYI: According to the most recent trends in medicine, which has historically been primarily a “top-down”

presentation to families, the movement towards shared decision-making with informed consent from

the patient's side is now being presented as the “new era” in informed consent. {Spraz, Krumholdtz, &

Moulton, published online JAMA, April 21, 2016. The New Era of Informed Consent: Getting to a

Reasonable Patient-Standard Through Shared Decision Making] This gets back to the “true” meaning of

Evidence-Based Practice as defined by the Institute of Medicine, as discussed in Chapter Three, which is

the three-pronged process of the best of evidence, with the best of professional wisdom, with the

family’s values and informed consent. It’s all three of these factors that become part of a healthy

decision-making process.

Commentary on the exclusive use the “heart” skill. Much of the strength-based movement has been in

reaction to the practitioner’s taking the lead by dominating the clinical milieu, telling parents what to

do, and not engaging with them. With the pendulum swing in the other direction, however, there are

other things that get missed by not having a balance between heart, hand, and head skills. Many a

practitioner has come to me with goals that are not aligned with basic child development guidelines

(e.g., parent(s) wanting his or her infant to learn to read or to have bladder and bowel control (as a note,

in some tribal cultures infants have bowel and bladder control at an early age); wanting to discipline

his/her child with hostility and corporal punishment because it’s how the parent was raised and s/he

“turned out ok”; stopping a sensory seeking child from body movement or jumping because it’s

annoying and disrespectful behavior to parental authority; protecting his or her child to the point of

never wanting his or her child to have a stress response, etc.). When queried, the response has always

been that “this is what the parents want to work on and I’m here to follow their lead.” This has also now

led to many practitioners afraid to do anything but to follow the parents’ lead in their goals.

Unfortunately, a movement to correct a problem, without restoring balance, can also create its own


dilemma. If we, as practitioners, did not have anything to bring or add to the discussion of goal setting,

there would be not be a need for us to be there. It’s important as practitioners to hold the tension

between following, guiding, and collaborating. As mentioned in Chapter 3, these developmental

principles also apply to parenting skills, so modeling these is very important on many levels. By engaging

with parents on all three of these dimensions, one is modeling the use of these, helping parents being

able to offer these relational dynamics with their children! (See Chapter 3)

Principle #3, Being aware of our own appraisals and discrepancies. [Note: the language used in this

section may be offensive to some and may sound judgmental. The NRF is always open to new ways of

using language that will reduce offensiveness. At the same time, the concepts must be accurately

“translated” and the meaning of the concepts is not to be minimized.]

Being aware of our own biases during the assessment interview and ongoing therapeutic process is

critical. This is why our mapping ourselves is an essential part of using the NRF and why the NRF’s

curriculum is being wedded with VISIONS cultural/equity curriculum. We can carry overly positive and

overly negative biases and appraisals regarding any number of cultural and dominance/non-dominance

dynamics that may show up during our relationships with the families we serve. These have a “home” to

be processed in our Reflective Practice group or individual supervision. Of course, this can be a parallel

process with our parents. Our parents can also have their own overly positive and negative biases and

appraisals towards themselves, their children, us as practitioners, and any number of cultural and

dominance/non-dominance variables.

Another parallel process that can occur with ourselves and with our parents is a discrepancy between

what we say, what we do, and our non-verbal body language. These discrepancies can mean many

different things, but they are important to note and to keep in mind. Are they clues as to parts of

oneself that one is unaware of? Are they clues as to parts one is attempting to hide? Are they related to

an overly positive or overly negative valenced appraisal system? From a mental health standpoint, an

overly positive appraisal system can be at risk for denying risks or delays that are present; an overly

negative appraisal system can be at risk for projecting past traumas and injuries from other relationships

onto his or her child.

It is common for the early rounds of conversation about stress recovery and stress responses to not

match as much as they could between the parental reporting and the actual behavior. For verbal

children, he or she may be more “accurate” than his or her parent is. Any time one is learning how to

understand behavior there may be discrepancies. The NRF sees this as part of the learning process and

an open learning system that has to learn and unlearn in a continuous process. Give parents time to

learn the colors and what they mean. A practitioner can use real-world, real-time examples as they are

occurring in a play session to refer to in the moment, if appropriate, or to reference later if captured on

video or by memory. Sorting out what is a “defensive” response in which a parent may want to deny a

stress response has to be sorted out from a lack of awareness about one’s own body state and states in

one’s child.

Commentary on the timing of this Step One Interview. Many practitioners have paper trails that must be

completed at the front end of opening a case to invoice for their time. The interview for Step One can be

done during the “early phase” of the assessment process. Remember that the point of the Interview in

Step One is to get the conversation begun about the child’s sleep patterns, green zone capacities, and


stress responses, and to later pair these responses up with the parent’s parallel processes as well. This is

not a one-time conversation. This is an ongoing conversation that will have a life of its own over time.

Commentary on the paradigm shift inherent in Step One. However, the reason for this conversation taking

the lead in the semi-structured interview process is to begin the process of a paradigm shift in the

understanding of a child’s behaviors. There is a widespread common assumption that the infant/child’s

behavior is “just behavior”. Much of our culture holds a “simple problem, simple solution” approach to

understanding the meaning of an infant/child’s behaviors. This quickly leads to a popular cultural view of

the child that his or her “behavior” is about compliance or non-compliance and the simple solution to

shaping behavior is the use of positive reward, punishment, or extinction (ignoring the behavior).

The use of the colors provides a specific re-orientation to the meaning of behavior being linked with

stress and stress recovery. Capacities for stress recovery can be linked with safety and stress responses

can be linked to degrees of challenge and threat. Finding out all the meanings as to what constitutes the

challenge and threat belongs in Step #3. Here, at this early phase, we are mapping out the stress

recovery and stress response pattern in the infant/child and parents, trying to determine if it is an

adaptive or toxic pattern.

Self-reflection: Is this a paradigm shift for you?

In terms of the degree of challenge or threat, the NRF makes links with the continuum of trauma. Toxic

stress patterns are often the result of trauma. Here we see that trauma also occurs on a continuum.

While the term “trauma” is often automatically connected to children who have entered the child

welfare system it is important to understand that the NRF sees toxic stress and an underlying dynamic to

any diagnostic category and that many other diagnoses, such as Autistic Spectrum Disorder, are in toxic

stress patterns as well.


ORIENTATION TO THE WORKSHEETS USED IN STEP ONE

Step One Worksheets to Use with Self, Parents, and Families:

The actual order of these worksheets is organized from the simple to the more complex. The feedback

from many practitioners is that they prefer to start off using the Arousal Curve or the PIE in introducing

the colors and concepts, because it’s so simple to use. One is encouraged to try these different

worksheets to find one’s own comfort zone.

Refer to Arousal Curve in Chapter Four on the Website:

This arousal curve captures some of the earlier work that I did in working to represent the continuum of

the seven states of arousal and how they are linked to the Autonomic Nervous System (ANS). The

yellow color and stars are meant to portray conditions of safety, with the highlights being cycling into

deep sleep at during the sleep cycles, with the calm, alert state during the awake cycles. The relevance

of using a bell-shaped curve is to highlight that the top of the curve “just right” state (now, referred to as

the green zone) supports optimal and peak capacity to learn and to engage. Once you start going down

the side of too much red or blue in your nervous system, you start losing that optimal zone with the

most flexibility. At first the red zone for “fight/flight” predominated the literature on stress responses.

Next, the brake response side was recognized, and the blue zone became known (Porges, ref). The NRF

would refer to this as a “flat” response. Most recently, it is understood that the ANS is actually a

dynamic system and that both the red and blue can interact with varying degrees of intensity. This gets

us to the combo zone of “fright” where both the gas and brake are on. The greater the red zone, the

more movement; the greater the blue zone, the less movement. The term “freeze” often pertains to

both “fright” and “flat” wherein the child or adult is both dissociative and frightened (Lillas & Turnbull,

2009). Freeze also can occur with dissociation alone, without hypervigilance (Porges, ref).

Refer to PIE in Chapter Four on the Website:

The advantage to this version of the colors is its simplicity in that there are only a few words per zone.

Some of these words are descriptive of the behavior within each zone (e.g., glassy eyed) and others are

more descriptive of a feeling tone (e.g., anxiety) that resonates with the zone. One can always give

examples of one’s own self-states, if one is comfortable with that, and can present it in a matter-of-fact

manner. Communicating that first of all, these stress responses are normal and a part of a healthy stress

response cycle as one adapts to the context.

Refer to PIE Instructions and Excel format in Chapter Four on the website:

This allows the NRF practitioner to create individualized PIE’s for each parent/infant/child for your

baseline and as you get to know each family better. It’s recommended to create a baseline PIE and then

to check it more frequently on the front-end –monthly, and then at least once a quarter. Any changes in

the baseline dynamics, such as the frequency of the stress responses, the duration, and the intensity is

showing your gains and progress. The research chapter (9) will go into details as to what paper/pencil

pre-and post-measures the NRF is using for tracking the stress responses, as well as the accompanying

physiological activity data we are collecting for our evidence-base. For those of you that are not using

any of these parameters, your PIE is your documentation that helps one qualify your child/family for

services and tracks your progress. If there is no progress in your case, then always go back and go

deeper into Step #3 to find out what the underlying culprits are that need to be addressed.


Refer to Awake States of Arousal (Vertical) in Chapter Four on the Website:

The advantage to this worksheet is that it’s a good one to use for practitioner to practitioner when first

introducing the states of arousal and the colored zones. Its strength is that the left-hand column lists a

great deal of nonverbal cues that cluster to form a state of arousal. This is very important for

practitioners to know that it is the cluster of these cues that constitute a “state of arousal” or a “zone.”

It’s important to make the connection that these nonverbal cues are sensory-motor input to the baby!

So, one of the first things the NRF advises one to do when working to up-regulate an infant/child/adult

from blue to green or to down-regulate an infant/child/adult from red/combo to green is to think about

all the non-verbal cues and how slow or fast they are emitting from the parent/provider. When we get

to Step #3, phase 2, you will learn how we use the principle of “matching” or “countering” in order to

figure out how to best regulate the infant/child/adult from a sensory-motor port of entry.


Refer to Awake States of Arousal with Check Boxes (Horizontal) to Chapter Four on the Website:

The strength of this worksheet is that it has the check boxes for parents and practitioners alike to check

off. These nonverbal cues lean towards younger ages, but many of them apply across the lifecycle.

Again, these zones cut across ages and cultural lines, representing the physiological activity of our

nervous system.

One downside is that parents can get confused, thinking that they have to have every marker in order to

qualify being in a particular state of arousal or zone. One often needs to explain to parents that one is

not looking for every marker, but how does her or his child show these different zones? What are key

markers that signify their child, or they are in any particular state?

It’s also important to know that these zones can be crisp and clear, meaning that some nervous systems

are very clean as to what state of arousal one is in. Other nervous systems, often more vulnerable ones,

are “muddy”. This often means that there may be non-verbal cues from the red zone (e.g., flailing), the

blue zone (e.g., glassy eyes) and the combo zone (e.g., whimpering). Premature infants and others with

nervous system vulnerabilities are often less clean in their presentation of each state.

With your having some preparation as to the Approach and an orientation to Step One’s Worksheets,

we move to the next chapter which guides you through the use of this information in a semi-structured

or organic Interview process to gather the actual data for Step One. In addition, the application of Step

One to the Use of Ourselves and the Cultural Awareness of Ourselves deepens.

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