Substance Abuse and Addiction

Abstract

New developments in the treatment of mothers and infants affected by opioid addiction point to the promising effects of interventions that adopt a developmental perspective, occur concurrently with addiction treatment, and target the parent–infant relationship as early as possible. In this article, the authors provide general guidelines for clinicians who wish to use attachment-informed, mentalization-based approaches to support mother–child relationships during a mother’s recovery from addiction. They share an update on research from Mothering From the Inside Out (MIO), an evidence-based individual parenting therapy developed for mothers in addiction treatment.

In recent years, heroin and prescription opioid abuse by women in their childbearing years have been increasing exponentially. Women of childbearing age now comprise the majority of patients entering opioid abuse treatment programs (Cicero, Ellis, Surratt, & Kurtz, 2014). An increase in prescription opioid misuse by pregnant women has been linked to a stark increase in the proportion of women needing treatment for opioid abuse. Although overall rates of admission to substance abuse treatment programs among pregnant women have remained stable, the proportion of admitted pregnant women reporting a history of prescription opioid misuse has increased from 2% to 28%. The rising prevalence of opioid use during pregnancy has led to an increase in associated adverse neonatal outcomes such as neonatal abstinence syndrome (NAS). More than 50% of opioid-exposed fetuses will subsequently develop NAS, and overdose has surpassed hemorrhage, pre-eclampsia, and sepsis as a cause of maternal mortality (Jones & Fielder, 2015). The number of infants in the U.S. diagnosed with NAS has grown nearly 5-fold since 2000 such that an infant with NAS is born every 30 minutes (Patrick, Davis, Lehmann, & Cooper, 2015; Patrick et al., 2012).

The Neuroscience of Addiction and Parenting

Recent developments in the neuroscience of addiction and parenting may help to explain the challenges faced by many mothers with opioid use disorders who are caring for young children, as they transition to a caregiving role. Chronic substance abuse often results in the release of excessive amounts of pleasure-inducing neurotransmitters such as dopamine in the brain that, in turn, trigger dramatic changes in neural circuitry (Volkow, Koob, & McLellan, 2016). Dopamine and other neurotransmitters play an important role in rewarding human behaviors that are essential for survival (e.g., caring for offspring). When the brain becomes flooded with dopamine (as happens with drug abuse), it adapts by making the neurotransmitter less available for uptake and absorption. One consequence of the resulting neurochemical imbalance is that behaviors such as caregiving that are ordinarily reinforced with intense experiences of pleasure are now experienced as neutral or stressful. The experience of stress during caregiving may even function as a trigger for relapse to substance misuse (Rutherford, Potenza, & Mayes, 2013). Emerging evidence from neuroimaging studies (Kim et al., 2017; Landi et al., 2011) now suggests that mothers with histories of chronic substance misuse experience less neural reward in response to caring for their young children than mothers with no substance misuse history. Managing emotional distress in the parenting role (the parent’s and the child’s) is therefore a critical capacity to monitor and promote while mothers are in recovery from addiction.

Implications for Intervention

New developments in the treatment of mothers and infants affected by opioid addiction point to the promising effects of interventions that adopt a developmental perspective, occur concurrently with addiction treatment, and target the parent–infant relationship as early as possible (Grossman, Osborn, & Berkwitt, 2017; Suchman, Pajulo, & Mayes, 2013). The management of emotional distress in the caregiving role is critical to optimal infant development (Sroufe, Egeland, Carlson, & Collins, 2005) and may also promote a parent’s successful recovery from addiction and capacity to experience reward and delight as a caregiver early in addiction recovery. A promising new therapeutic approach to assisting mothers in addiction treatment and caring for young children involves supporting the mother’s capacity for parental reflective functioning (Suchman, 2017). Parental reflective functioning (also called mentalizing) is the ability to make sense of the infant’s and parent’s own strong emotions and how they impact specific behaviors and the parent–child relationship. Because of its role in helping parents understand and regulate emotion, parental reflective functioning can be of particular benefit to mothers in addiction recovery, not only for promoting improvement in the caregiving relationship but also for promoting improvement in maternal abstinence from substance use. For example, in one randomized trial, mothers exposed to a parenting intervention targeting parental reflective functioning showed a moderate decrease in heroin relapses whereas mothers exposed to a psychoeducational comparison showed a small increase in heroin use (Suchman, DeCoste, McMahon, Rounsaville, & Mayes, 2011).

Using Attachment-Informed, Mentalization-Based Interventions With Mothers in Addiction Treatment

Although mothers who are recovering from addiction vary widely in their capacity to care for young children, they are often struggling to manage strong emotions associated with the parenting role. Following are some general principals and guidelines for clinicians who wish to use attachment-informed, mentalization-based approaches to support mother–child relationships during a mother’s recovery from addiction.

It Takes a Village

Addiction is a complex disease with many moving parts. Episodes of relapse during recovery are common and should be expected, but they often precipitate a series of potentially catastrophic events (e.g., child neglect, domestic violence, health problems, job loss, and eviction). Parenting intervention efforts must be well-integrated and coordinated with other addiction-focused services to promote quick, supportive, coordinated action when higher levels of support or supervision are needed.

Addiction Is a Disease Not a Moral Weakness

The social stigma associated with addiction becomes compounded for mothers in addiction recovery and often causes them to avoid seeking treatment and parenting support when they most need it. Understanding the science of addiction and parenting helps family and child guidance specialists avoid the pitfalls of harsh and judgemental attitudes toward parents in addiction recovery.

Parent Worries Run Deep

Almost all mothers with addictive disorders are profoundly worried about the impact of their substance abuse on their children. Some will have an easier time recognizing and articulating their concerns and fears than others. Very few mothers in addiction recovery are immune to concern and caring for their children.

The Transition to Parenthood Is a Critical Window

The transition to parenthood is often a critical opportunity for intervention because parents often experience heightened motivation levels for addressing their addictions at this juncture in their lives. Caring for a young child can be viewed by a parent as a deeply meaningful opportunity to successfully navigate their addiction recovery. Clinicians can harness this motivation by encouraging parents to take steps they have long been considering and are now ready for, including taking better care of themselves and their family.

Expect Barriers to Treatment and Invest in Outreach

Perhaps no psychiatric population incurs more barriers to entering and remaining in treatment than mothers with addictive disorders. Precipitous declines in financial, occupational, and relational stability; repeated exposure to social stigma (even among professional health service providers); potential legal repercussions; shame and fear about the impact of substance misuse on offspring; discouragement about treatment from peers and romantic partners; along with other factors, often work in concert as powerful forces that interfere with participation and progress in treatment. Committing program resources to persistent outreach is therefore critical. Beyond providing concrete assistance with material losses and shortfalls, outreach can convey to parents that their presence is appreciated, important, and missed, and that the program continues to hold them in mind in their absence. During long absences (e.g., incarceration), well-wishing letters that sustain a connection can be very meaningful to parents and may be the only correspondence they receive during their absence.

The Infant Needs the Mother to Mentalize

Although the infant is an active and communicating participant in the dyadic regulation and attachment formation process, the parent’s capacity to mentalize about states of mind (her own and the infant’s) is central to the parenting and addiction recovery process. Strong negative emotions, intense cravings, withdrawal symptoms, traumatic memories, and representational distortions can all interfere with a mother’s capacity to make room in her mind for her child. Working individually with the parent allows time and space for the mentalizing process to unfold. The infant is still a primary focus of the therapy—held in mind by the therapist and brought to mind in the session at the most optimal times (e.g., when the mother is able and ready to hold the infant in mind).

Alliance, Alliance, Alliance—Offer Emotional and Concrete Support

Although a strong therapeutic alliance alone is not sufficient to stimulate parental mentalizing without a therapeutic alliance (Suchman, DeCoste, Borelli, & McMahon, 2018; Suchman, DeCoste, Rosenberger, & McMahon, 2012), parents with addiction problems are understandably likely to disengage from treatment. Repeated exposure to social stigma likely exacerbates this phenomenon. Keeping alliance as the intervention priority is therefore critical. Alliance building often involves taking the parent’s requests seriously and accommodating them as much as possible. Having supplies on hand (e.g., diapers, snacks, inexpensive toys) and conveniences accessible (e.g., bus passes, public phone, changing table) provide concrete evidence of your willingness to support. Early in the therapeutic relationship, material supplies may help promote progress toward a stronger and deeper trusting interpersonal alliance. Although it is often beyond the scope of the therapist’s role to provide material support or case management, when the therapist communicates material and service needs to other professionals in the treatment program on the parent’s behalf, the result is often a stronger therapeutic bond.

Mentalize for Parent First—the Oxygen Mask Analogy

When a parent is preoccupied by emotional states (e.g., guilt, shame, anger, disappointment) there is often little or no room in her mind for the child (Suchman & DeCoste, 2018). Helping the parent untangle her own internal states first can often help her feel more grounded, more connected, and more able to shift attention to her child’s experience. We often borrow the oxygen mask analogy from flight attendants to emphasize this strategy (where passengers are encouraged to secure their own masks first before securing their child’s). Other therapeutic approaches to managing emotion (e.g., cognitive behavioral, trauma-informed therapies) often discourage focusing on internal emotional states because of concerns about emotional flooding. In mentalization-based therapies, internal emotional states are brought to the patient’s attention so that they can be tolerated, thought about, understood, and managed. In the Circle of Security Parenting Program, parents are also encouraged to recognize intrusive emotional states (i.e., Shark Music). In mentalizing interventions, a further step is taken to explore and understand the nature and source of the Shark Music in greater detail.

Manage Unrealistic Expectations for Children

Parents may have unrealistic expectations of their children’s capacities that gravitate toward expecting too much too soon. A toddler may be expected to have a longer attention span or self-discipline. A preschooler may be expected to have manners. Although didactic approaches to teaching child development are discouraged, timely developmental guidance during mentalizing interventions can be helpful in establishing a more realistic timeline for the child’s unfolding capacities.

Maintain a Curious, Inquisitive Stance

Simply asking “What do you think was going through his mind” can be a powerful intervention for a parent. “It never occurred to me to think about that before” or “I never thought of my 2-year-old as having a mind” are common responses. Just asking the question stimulates new thoughts and understanding about the child’s state of mind and behavior that were previously unavailable to the parent, such as “I think he’s trying to tell me that he wants my attention” or “I think he’s feeling stressed from all the arguing.” Simply asking a parent about her own internal experience can shift the focus from a litany of complaints to a meaningful recognition of her own difficult emotions and a better understanding of her mentalizing lapse.

Follow the Parent’s Lead

In a therapy session, the parent is often able to lead the therapist directly to the mentalizing lapse that needs attention. If a therapeutic alliance is established, the parent will often naturally gravitate to stressful topics (e.g., challenging interactions and relationships) where their emotions are overwhelming. Following the parent’s lead often opens the door to important opportunities to restore mentalizing. If the child is not the focus, the clinician can hold the child in mind and find the appropriate time to ask about the child’s experience in relation to the stressor. If a therapeutic alliance has been ruptured, the therapist can focus on helping the patient mentalize about the rupture. (e.g., “It seems that it’s hard to tell me about your day right now. I’m wondering if you might be feeling upset with me.”)

Offer Alternative Interpretations While Remaining Inquisitive and Collaborative

When simply asking about what a child might be thinking elicits confusion, offering your own hypotheses can help. However, it’s important to model opacity rather than certainty and to keep the process open and collaborative. “I was wondering if he might be wanting some physical contact with you, or maybe he wants to hear your voice. What do you think?” In this way, the clinician maintains a curious, inquisitive stance and invites the mother into a collaborative thought process about the child.

Listen Closely for Changes in Reflective Capacity and Mental Representations

Changes in parental reflective functioning and representations of the child and the caregiving relationship are more often subtle than obvious (Suchman & DeCoste, 2018). Clinicians who listen carefully and respond authentically to these changes help parents to also note them more directly. “You seem to be noticing more directly how disappointed you were. I’m wondering if you’re aware of this.” “You’re noticing that he wanted to be closer to you. What’s that like for you?” “You’re seeing the things you like about him as well as the things you don’t like. Sometimes he feels like an angel to you and other times he feels like a rascal. Can you tell me more about when your experiences shift like that?”

Keep Expectations Realistic and Take the Long View

Changes in parental capacity to mentalize take time, perhaps more time than changes in behavior. When they occur, they tend to endure, although circumstances of emotional arousal may mitigate them momentarily. It’s important for the clinician to take the long view. A parent may need several or even many invitations from the clinician to mentalize about a challenging situation or relationship before mentalizing becomes more automatic and spontaneous.

Videotape the Therapy Sessions

Having a chance to look back on a session and review it with colleagues provides an opportunity to think more clearly about the parent, the dyad, and the therapeutic relationship outside the pressures and demands of the therapy session. For less seasoned clinicians especially, opportunities for supervisors to observe clients directly can often enhance the effectiveness of the supervision and the support experienced by the supervisee. A balance between the therapist’s direct reporting about what she remembers and experiences in the session and direct conjoint observation of the patient with the supervisor can enhance and accelerate the learning process for the therapist. It must ultimately be the mother’s choice whether or not a session is videotaped. If she knows that the purpose of videotaping is to ensure that the therapist is providing the best intervention possible, and if the video camera is trained on both mother and therapist, her anxiety about the camera can often be lessened.

Offer Supportive, Reflective Supervision

Working therapeutically with parents and children affected by addiction is emotionally demanding and draining work. The life histories of parents in recovery often involve painful losses, feelings of hopelessness and despair, and traumas and abuses that were incurred in early childhood and continue to resonate during adulthood. Holding the developing child and the developing parent in mind in a mentalizing intervention is often very challenging. Both often have complicated developmental histories and experiences to be considered and understood. It is a nearly impossible task for any single clinician or supervisor to hold both parent and child in mind. Incorporating a team or milieu approach to thinking about dyads can help therapists consider the experiences of both in the caregiving relationship.

Carving time and space regularly for a safe, reflective process where clinicians can explore their own responses to patients and children is also essential for supporting both patients and the clinical staff and preventing clinician burnout. Service providers need emotionally supportive work environments that offer clinical supervision where reactions to sad and tragic circumstances can be communicated and processed without repercussion. Service providers also bring their own life-stories, experiences, and memories into the relationship with varying degrees of awareness. Supervision can encourage awareness of how the clinician’s past experiences might be influencing decisions about how to intervene and also the clinician’s reactions to the patient. The boundaries of the therapeutic relationship can also be influenced by the clincian’s personal history and tested by the patient and therefore require careful and ongoing consideration.

Mothering From the Inside Out Research Update

Mothering From the Inside Out (MIO) is an evidence-based individual parenting therapy developed for mothers in addiction treatment (Suchman, 2017; Suchman, DeCoste, Ordway, & Bers, 2013). MIO targets the maternal capacity for reflective functioning with the expectation that indirect benefits for child attachment security and maternal abstinence from substance use will unfold as the parent’s mentalizing capacity improves. MIO has been evaluated in two completed randomized clinical trials (see Suchman, 2017, for a summary of research findings). In the following section, we summarize our most recent findings from MIO research.

How Does Addiction Severity Impact Treatment Outcomes?

In our second randomized clinical trial testing MIO versus a psychoeducation comparison intervention, we found that mothers with more severe addiction histories (e.g., opioid and cocaine use initiation during adolescence, family histories of addiction) who were enrolled in MIO were most likely to show improvement in reflective functioning and the attachment security of their children was most likely to improve by the end of the 12-session intervention (Suchman et al., 2017).

Does Improvement in Parental Mentalizing Lead to Improvement in Child Attachment Security?

In an initial test of treatment mechanisms using data from the first randomized clinical trial, we found that improvement in maternal reflective functioning predicted improvement in mother–child interaction quality at the end of treatment and maternal substance use at the end of a 6-week follow-up period (Suchman et al., 2012). In a replicated test of mechanisms using data from the second randomized trial, we found that improvement in maternal mentalizing capacity was associated with improvement in child attachment security at the end of treatment (Suchman, DeCoste et al., 2018).

How Do Mental Representations of Caregiving Change During MIO Therapy?

In a qualitative study examining the nature of representational change for mothers who completed MIO (Suchman & DeCoste, 2018), we identified meaningful patterns of change. One pattern suggests that representations are often behavioral at the beginning of treatment (e.g., “My child has a nice smile, is already walking and talking” and become more internal by the end of treatment and/or 3-month follow up (e.g., “My child likes to be close to me” and “My child has a fun personality”). Another pattern involves a decrease in mocking statements about the child. (e.g., a mother refers to her child as “an annoying monkey” at the beginning of treatment but no mocking is evident at the end of treatment or follow up). A third pattern involves increasing expressions of joy, delight, and preoccupation with infant at the end of treatment.

Can Addiction Counsellors be Trained to Deliver MIO With Fidelity?

In a community-based clinical trial, we are testing MIO’s efficacy when delivered by addiction counsellors in an outpatient addiction treatment setting. Because addiction counsellors don’t often have backgrounds in child development or previous training in mentalizing, one study aim is to examine the effectiveness of MIO training for promoting improvement in clinician reflective functioning and achieving sustained treatment fidelity (Suchman, Borelli, & DeCoste, 2018). In our first test with 15 addiction counsellors who were randomly assigned to training in MIO versus a psychoeducational comparison, we found that addiction counsellors showed sustained fidelity to their assigned intervention in an individually supervised training case following a 16-hour training seminar. We also found that MIO (but not comparison) counsellors demonstrated significant improvement in their mentalizing capacity by the end of their first training case.

Conclusions and Future Directions

Taken together, research findings continue to demonstrate the benefits of attachment-informed mentalization-based treatments for mothers and young children affected by maternal addiction. Preliminary findings also indicate the need for future research on bringing these interventions to scale on site in addiction treatment programs. Although preliminary empirical and anecdotal evidence suggest that parental enjoyment and delight in the parenting process can return following targeted interventions, it will be important to examine whether these improvements register at a neurobiological level. Outcomes from our third clinical trial will also show whether MIO continues to show strong treatment effects when delivered by addiction counsellors trained to deliver the intervention with sustained fidelity. Finally, future research should examine the optimal timing and sequence of mentalization-based therapy in relation to other effective dyadic parenting interventions. It may be that parents in recovery from addiction who develop stronger capacities for mentalizing will benefit more from dyadic interventions and parent coaching. A stronger reflective capacity is likely to mean there is more room in the parent’s mind for the child.

Biographies

Nancy E. Suchman, PhD, is a licensed clinical psychologist and an associate professor in the Psychiatry Department and Child Study Center at Yale University School of Medicine. Since 1995, Dr. Suchman has been developing and evaluating parenting interventions for mothers in treatment for addiction and mental illness in the United States and internationally.

Cindy L. DeCoste, MS, is a research associate in the Department of Psychiatry at Yale University School of Medicine. Since 2004, she has been the project director for Dr. Suchman’s research program focused on developing and evaluating attachment-based parenting interventions for mothers with substance use disorders. She has been involved in multiple aspects of the development, implementation, and evaluation of both the Mothering From the Inside Out mentalization-based parenting intervention and the psychoeducation comparison intervention. She is a clinical trainer and supervisor for counselors delivering the psychoeducation intervention, and she has expertise in methods for assessing child attachment, parent–child interactions, and parental representations and reflective functioning.