Mothering from the Inside Out A mentalizationbased therapy

Mothering from the Inside Out: A mentalization-based therapy for mothers in addiction treatment Nancy Suchman, Ph. D. Associate Professor Yale University School of Medicine Department of Psychiatry and Child Study Center University of Maryland Department of Social Work September 28, 2018 the 1

Rewarding behaviors that promote species survival (eating, procreation, social interaction) Think of the last time you enjoyed a particular food…. . s I feel satisfied! Let me focus on this! Let me do that again! That felt great! Dopamine released! Let me remember where, when, and how this happened! 2

Neural circuitry of parenting 3 Strathearn, Li, Fonagy, & Montague, 2009. Pediatrics

Parenting and the Brain: Reward for parenting behaviors that insure species survival 4 Infant Cue Brain chemical reward brings pleasure and reduces stress Sensitive, timely response Strathearn, Li, Fonagy, & Montague, 2009. Pediatrics

Maternal addiction and parenting As a group, mothers with substance dependence histories show Lower sensitivity to infant cues More intrusiveness More harsh punitive parenting More withdrawal More neglect Why? Mayes & Truman, 2002. Handbook of Parenting 5

Neuroscience of Addiction: The dopamine flood Dopamine Release X 20! 6 Immediate! Long-lasting! Volkow, Fowler, & Wang, 2003. Journal of Clinical Investigation

Neurological Response: Reduce Receptors How does the brain respond to the dopamine flood? Volkow, Fowler, & Wang, 2003. Journal of Clinical Investigation 7

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Neural circuitry of parenting and addiction 9 X X Kim, Iyengar, Mayes, Potenza et al. , 2017. Human Brain Mapping

Neuroscience of Parenting and Addiction: A pernicious cycle Infant Cue May look to substance to regulate affect Fight or Flight Overcontrol Withdrawal No neural reward, heightened stress

Implications for intervention Treat addiction and parenting at the same time for a positive synergistic effect Target emotional dysregulation related to the mother-child relationship (and other relationships) Allow the mother to lead you to her dysregulated affect. Assist the mother in noticing, understanding and regulating affect. Help the mother recognize and understand her child’s emotional needs and cues. Mentalization-based-intervention: Promote emotional regulation in attachment relationships 11

Mentalizing : What is it? Why is it important? How does it develop? 12

Mentalizing in everyday life 13

Mentalizing in everyday life 14

Why is mentalizing important? Mindblindedness – the antithesis of mentalizing Distinguish where our own thought process ends and another’s thought process begins. Distinguish intrapersonal mental processes from interpersonal communication Distinguish intrapsychic events from external reality Make sense of, evaluate and ultimately regulate visceral affective states 15

Automatic and implicit mentalizing 16

Deliberate and explicit mentalizing Did he just look away because he’s angry at her? Or is he preoccupied with something else? I wonder if you’re feeling guilty because you know that I’m disappointment. Is my daughter having a tantrum because we had to leave the park before she felt ready? Is she tired? Does she miss her father? Has our move upset her? 17 Are you wondering if your enjoyment of your profession might have inspired your daughter to become a doctor? Do you think your relapse was triggered by the sadness you were feeling when you remembered your partner’s illness?

As arousal increases mentalizing capacity diminishes 18 Notice bigger more complex emotions and how they affect emotion behavior in others Notice bigger more complex emotions and how they influence own behavior A U O R L A S Notice bodily states or simple emotions Take action to discharge emotions

19 Mentalizing vs. Mindfulness

How does mentalizing develop? 20 Kim, 2015. Personality Disorders: Theory, Research, and Treatment http: //www. your-baby. org. uk/early-interactions/marked-mirroring-showing-they-understand-theirbabys-emotions

When does mentalizing develop? FALSE BELIEF TEST – post-mentalizing https: //www. youtube. com/watch? v=RSFS 1 na. B 6 Fk&spfreload=10 21

FALSE BELIEF TEST – pre-mentalizing https: //www. youtube. com/watch? v=41 j. Sd. OQQpv 0&spfreload=10 22

Parental Reflective Functioning How the parent makes sense of his/her own and the child’s behavior in terms of underlying cognitive and emotional states Parent Development Interview (PDI) Addendum to the Reflective Function Scale coding manual The PDI is coded on a -1 to 9 scale. Scores > 5 represent basic Parental RF Scores < 3 represent absence of Parental RF 23 Slade, Bernbach, Grienenberg, Levy, & Locker, 2004. Addendum to…RF Scoring Manual. Unpublished manuscript Aber, Slade, Berger, Bresgi, & Kaplan, 1985. The Parent Development Interview. Unpublished protocol

Parental Reflective Functioning (Pre-tx = 2, Post-tx = 4) 24

Psychosocial History Parental Reflective Functioning era Th era pis t Th M e-B IO as ed nc ide Ev MIO INTERVENTION Mentalizing for Mother 25 Child-Mother Relationship Referral for Further Evaluation are lyildc ental Ch opm ed m vel De Infor are ildc t Ch cialis Spe Mentalizing Stance Developmental History / Screening py Psychiatric and Substance Use Therapeutic Alliance RE-ASSESSMENT FOLLOW UP Addiction Treatment Centre MI O ASSESSMENT Research Program Model - MIO Weekly clinical supervision Alliance-building Child-led interactive play Ongoing observation / assessment Mentalizing for Child Opportunity for child to “work through” Developmental Guidance Modeling for the mother Attachment-Based Parenting Working Alliance / Outreach Ongoing Needs Assessment / Advocacy Consultation w/ Outside Adult-Tx Providers End-of-Treatment Referrals Case Manager Case Management Team observations inform MIO Treatment Ongoing Needs Assessment / Advocacy Consultation with Outside Child-Tx Providers

26 What is Mothering from the Inside Out (MIO)? A brief, supportive, individual parenting psychotherapy fostering a process more than specifying a content. Emphasis is on the development of the capacity for Parental Mentalizing: The capacity to think explicitly about mental states (thoughts, wishes, intentions, emotions). The capacity to recognize / tolerate one’s own mental states and think about how these are affected or influenced by the child. The capacity to recognize / tolerate the child’s mental states, consider them within a developmentally-informed attachment perspective, and think about how they are affected or influenced by the parent.

ASSESSMENT Research Program Model - MIO era py 27 Mentalizing for Child Developmental Guidance Attachment-Based Parenting Th era pis t Th M e-B IO as ed MI O Mentalizing for Mother ide nc Mentalizing Stance Ev MIO INTERVENTION Therapeutic Alliance

Mentalizing Stance Not Knowing, Inquisitive, Curious Stance Mental states can’t be known for certain, we can only guess. Encourages and supports the mother to use / develop mentalizing capacity. Simply asking about mental states helps activate the mentalizing process for mothers. When mentalizing stance is lost (during advice giving, behavioral prescribing, interpretation, or theorizing), the patient’s mentalizing process is interrupted. 28

Mentalizing for the Mother Talking with the mother as though the best way to understand her decisions, relationships and behavior is by talking to her as though she has a mind. Identifying moments when mentalizing is lost (fight or flight mode). Inviting the mother to explore mental states (thoughts, wishes, intentions, and emotions) underlying her behavior during stressful interactions with her child or others (times when mentalizing is lost). Therapist lends own mentalizing capacity (offers possibilities, transparent about own thought process) Truly collaborative (accepting responsibility for errors) Oxygen mask approach: The mother is the patient 29

Mentalizing for the Child Talking to the mother as thought the best way to understand the child’s behavior and interactions is to think about the child as though s/he has a mind. Inviting the mother to consider the child’s mental states (thoughts, wishes, intentions, emotions) during stressful moments / interactions. Offering possibilities, being transparent about own mentalizing process, helping to distinguish child’s thought process from mother’s. Offering directly relevant developmental guidance about the child’s cognitive abilities. Shifting focus to child during reunions. 30

Attachment-Based Parenting Guidance about child cuing and miscuing. Behavioral guidance about child’s emotional needs and parent’s role as a secure base and safe haven. 31

32 MIO Randomized Clinical Trials

33 Clinical Trials Randomized Clinical Trials Two Completed Randomized Trials in outpatient substance abuse treatment setting. One Ongoing Randomized Trial where addiction counselors are randomize to training and delivery of MIO vs Comparison. Community-Based Pilot Trials Community – based mental health clinicians were trained to deliver MIO in an outpatient mental health treatment center Western Cape Province, South Africa – high risk mothers receiving services at tertiary (public) hospitals.

Client Population Substance Using (Primarily heroin, prescription opioids) Mental Illness (Depression, Anxiety, PTSD, Personality D. O. ) Child-Welfare Involved Public Assistance Limited or Unstable Family and Social Support Trauma History Caucasian, African American, Hispanic Enrolled in Addiction, Mental Health or Child Guidance Outpatient Services Caring for a Child from Birth to 7 Years of Age 34

ASSESSMENT Research Program Model – Active Comparison (Parent Ed) Psychosocial History Addiction Treatment Centre Parental Reflective Functioning Developmental History / Screening Psychiatric and Substance Use ion P Co arent un sel or cat du t. E ren Pa PE INTERVENTION are lyildc ental Ch opm ed m vel De Infor re ldca Chi ialist c Spe Parenting Strategies Child-Mother Relationship Referral for Further Evaluation Therapeutic Alliance Readable Pamphlet Review 35 Weekly clinical supervision Alliance-building – dedicated specialist Child-led interactive play Ongoing observation / assessment Developmental Guidance Opportunity for child to “work through” Self-Care RE-ASSESSMENT FOLLOW UP Interpersonal Relationship Stragegies Working alliance / outreach Ongoing Needs Assessment / Advocacy Consultation w/ Outside Adult-Tx Providers End-of-Treatment Referrals Modeling for the mother Case Management Team observations inform MIO Treatment Ongoing Needs Assessment / Advocacy Consultation with Outside Child-Tx Providers

36 Two randomized controlled trials Now evidence-based for: Primary outcomes - maternal reflective functioning, maternal representations of the child Secondary outcomes - maternal sensitivity, maternal caregiving behavior, maternal opiate use See: Suchman, De. Coste, Castiglioni, Mc. Mahon, Rounsaville, & Mayes (2010). Suchman, De. Coste, Mc. Mahon, Rounsaville, & Mayes (2011). Infant Mental Health Journal. Suchman, De. Coste, Mc. Mahon, , Dalton, Mayes, & Borelli (2017). Development and Psychopathology. Suchman, De. Coste, Borelli, & Mc. Mahon, 2018. Journal of Substance Abuse Treatment

37 2 nd Randomized Clinical Trial • Substance abusing mothers of infants and toddlers (1 to 5 years old).

Parent Development Interview s e at t s al 38 es t t ta g a s n t r i l m s d l y s ta vio n a n e t a n e ha ut s f e r b e m b lo tri d t w a e n o ce t u w la pl h n o n a d m e v si ds flue ce tes sic er sa f i y n n h o h a sta ta in ld p co u n s u , n n l o f r nd i r i a t s e , e t i o d a n vi re es or en n g r k a c u or m m h c co za e i u e w of B r B S es t en -1 1 2 3 4 5 6 Reflective Functioning Scale 7 8 9

39 Maternal Reflective Functioning 5. 5 5 Potential RF Score (PDI; Slade et al. , 2003) d >. 20 (medium effect) d <. 50 (large effect) 4. 5 MIO 4 PE 3. 5 3 PRE POST FU

Assessing parent-child interaction • Toys were chosen to activate the child’s attachment needs by creating a situation of mild stress or uncertainty 40

Coding Interactive Behavior 41 • Interactions are coded using the Coding Interactive Behavior (CIB) scales (Feldman, 1998) • The CIB is: – a global coding system for coding adult-child interactions – consists of 43 behavior codes: 22 adult/parent, 16 child, and 5 dyadic codes 1 2 3 4 5 – each rated on a scale: a little a lot

42 Mother-Child Interaction (CIB; Feldman, 1998) MIO 4 Maternal Sensitivity Score d <. 20 (no effect) PE d >. 20 (medium effect) 3 Pre Post 3 -mth FU 1 -yr FU

43 Mother-Child Interaction (CIB; Feldman, 1998) MIO 4 PE d >. 20 (medium effect) Dyadic Reciprocity Score d <. 20 (no effect) d >. 20 (medium effect) 3 Pre Post 3 -mth FU 1 -yr FU

Child attachment at post-treatment: Low vs. high addiction severity 40 Secure Insecure 30 20 10 0 MIO Low MIO PE Low PE High 44

45 Maternal Substance Use (TLFB; Fals Stewart et al. , 2000) 20 % Percent Positive per Month 10 % MIO d = -. 20 (small effect) F = 2. 20, p <. 10 d >. 20 (medium effect) 0% 1 st month of TX 3 -month FU

Mechanisms of Change 46 Therapist Effort Maternal Response Mother-Child Interaction Mentalizing Maternal Sensitivity Therapeutic Alliance Psychiatric Distress Behavioral Guidance Substance Use Child Attachment Secure Attachment

47 RF Dimensions and Parenting Scores Self-focused RF Child-focused RF Sensitivity to Cues . 10* . 01 Response to Distress . 00 . 02 Social-Emotional Growth Fostering . 08* . 05 Cognitive Growth Fostering . 08* . 00 Suchman, De. Coste, Leigh, & Borelli, 2010, Attachment & Human Development

Current Community-Based Randomized Trial Most evidence-based interventions do not go to scale Precipitous drop in effect size in real world settings Current ongoing NIH-funded 5 year community-based efficacy trial Advisory board with community stake holders 20 addiction counselors randomly assigned to deliver MIO vs PE 75 mothers randomized to date – targeted enrollment = 100 Onken, Carroll, Shoham, Cuthbert, & Riddle (2014). Clinical Psychology Science

Training Clinicians in Mentalization. Based Therapies 49 Scant research on training clinicians to deliver mentalization-based interventions Relatively brief training is possible. Clinicians need to have adequate RF. Clinicians need to have RF that is higher than the patient for treatment to be effective. Clinicians need to meet the patient at their RF level for treatment to be effective. Ackman, 2012. Psychoanalytic Inquiry. Diamond, Stovall-Mc. Clough, Clarkin, & Levy, 2003. Bulletin of the Menninger Clinic. Ensink, Maheux, Normandin, Sabourin, et al. , 2013. Psychotherapy Research. Gullestad & Wilberg, 2011. Psychotherapy Research.

d Clinician Reflective Functioning ro e h ild h rc s te n ca a st l ta be rre e f in m al t en 50 s te ta s ng izi l a ow h , es t ta ior e e n c s ot e al n l av m t m e a m n r t h to n e e n i h f e e m ic b ce re ct h m o n t e d ff e f w é re o nc a h e es m f e y c e c o i r e r fr cl u flu ren an l t r s f a a r o in o u fe n o t , i l r e c v d r a o o t r, a w lle ze h i e o ex ors e l l e e t v c a p vi b r n eth in sa e m e o r i t r n o o d ha e og c e l e f e e , g c d db re rk t et ica e e, en t l n r pl c o p nc an fe m ha a m re w e o i c i u tes e S R C D ey N M a th st 1 2 3 4 5 6+ Reflective Functioning Scale to nt

Results (n=15) 51 Potential Clinical RF 5 98 d=. 4 d =. 71 3 2 1 PRE POST MIO PE Suchman, Borelli, & De. Coste (under review).

Clinician RF and Maternal RF 52 Therapist RF at the end of training correlated with maternal RF at the end of treatment. N = 71 Therapist RF Parental RF . 23 † Self-focused RF . 21 † Child-focused RF . 26 *

Change in Maternal Representations of the Child in MIO vs PE Completers A thematic qualitative analysis of the nature of change in maternal representations of the child in MIO vs PE completers Working Model of the Child Interview Trial 2 – Baseline, Post, 13 week follow up Coder’s clinical summaries 53

Self-reflection Beginning to sense the child’s internal experience Recognizing and responding to the child’s emotional needs Sense of delight and discovery about recent developments Changes in child’s response to separations New efforts to understand child’s needs during challenging behaviors Ø New healthy preoccupation with child Ø Less preoccupation with guilt Ø Less mocking and fewer malicious attribution Ø New tolerance of challenging behavior Ø New Acceptance of the Caregiving Role Ø Ø Ø 54

Take Aways Try adopting a not-knowing stance – give parents room to develop their minds in relation to their children – changes in parenting will follow Encourage and entrust parents to be curious and inquisitive – to wonder about their children’s behavioral cues, developmental tasks, internal experiences. Their children will experience themselves held in the mind of the parent – which helps a health sense of self grow. Learn to tolerate and empathize with parents’ strong emotions about parenting. If they can mentalize these emotions, with your help, they can regulate them and have room in their minds for their children’s big emotions and attachment needs. 55

56 Thank you For reprints: nancy. suchman@yale. edu NIH Funding: 1 R 01 DA 17294; 2 R 01 DA 17294; 3 R 01 DA 17294; K 23 DA 14606; K 02 DA 023504