Addiction, adversity, and attachment—Supporting families impacted by parental substance use

Transcript

• 00:00Everybody. We're going to get
• 00:02started. So I'm delighted to
• 00:04introduce today's Grand Rounds speaker,
• 00:06Doctor. Amanda Lovell. For many
• 00:08of you, she's a very
• 00:09familiar face. She was at
• 00:10the Charles Stuckert Center for
• 00:11about eight years before recently
• 00:13becoming the clinical director of
• 00:14Bay State Medical Center's new
• 00:16SAMHSA funded center for young
• 00:18children and families in Springfield,
• 00:19Massachusetts.
• 00:21Doctor Lowell is a licensed
• 00:22clinical psychologist. She's an assistant
• 00:24professor at the University of
• 00:25Massachusetts,
• 00:26Chan Medical School, Baysay, as
• 00:28well as being an assistant
• 00:29professor adjunct here in the
• 00:30Charles Study Center.
• 00:32So I had the distinct
• 00:33honor of mentoring doctor Lowell
• 00:34during some of her time
• 00:35at the Charles Study Center,
• 00:36and I've worked closely with
• 00:37her on a number of
• 00:38research studies.
• 00:39She's a true scientist and
• 00:41practitioner.
• 00:42Her program of translational research
• 00:44studies the impact of addiction,
• 00:46adversity, and attachment
• 00:47on parental neuropsychological
• 00:49and behavioral responses to infant
• 00:51cues.
• 00:52As you'll hear about today,
• 00:53she uses an infant mental
• 00:54health framework to apply these
• 00:56findings to developing and refining
• 00:57interventions for parents with substance
• 00:59use disorders.
• 01:01Her work currently focuses on
• 01:02narrowing the science to service
• 01:04gap and supporting effective, equitable
• 01:06and accessible implementation
• 01:08of evidence based practices for
• 01:10parents of addictions in community
• 01:12settings. So please extend, a
• 01:14very warm welcome to doctor
• 01:15Lowell, and thanks for being
• 01:16here today.
• 01:22Hello.
• 01:23Hi. Good afternoon.
• 01:25Good to see you all.
• 01:26It's been a while since
• 01:27I've been here in person.
• 01:29So it's really nice to
• 01:30be here speaking about this
• 01:31work specifically.
• 01:34So thank you for the
• 01:35very kind introduction.
• 01:38Post has spotlighted your okay.
• 01:40Great. Okay.
• 01:42All right. So we can
• 01:43just go ahead and get
• 01:44started. I'm gonna be speaking
• 01:45today about addiction, adversity, and
• 01:47attachment,
• 01:48and their intersection and how
• 01:49that informs,
• 01:51the ways that we support
• 01:52families.
• 01:54Alright. Just a couple of
• 01:55disclosures before I get started
• 01:57that my work is currently
• 01:58funded by, SAMHSA as well
• 02:00as the National Child Traumatic
• 02:01Stress Network,
• 02:02and I've received funding from
• 02:04plenty of other places
• 02:05and have been really fortunate
• 02:07to have funding to do
• 02:08the work that I'm gonna
• 02:09be speaking about today.
• 02:12All right.
• 02:13So our agenda for today
• 02:15is to first begin by
• 02:17speaking about some of the
• 02:18background of parental addiction and
• 02:20its intersectionalities.
• 02:22We're also going to speak
• 02:23a bit about neuroscience,
• 02:25and how that helps us
• 02:26understand this, intersecting problem.
• 02:29And then we're going to
• 02:30speak some about clinical approaches
• 02:31and, how they're informed by
• 02:33that background in neuroscience,
• 02:35as well as then bridging
• 02:36the science to service gap.
• 02:38Okay.
• 02:39I'll try to leave about
• 02:40ten, fifteen minutes at the
• 02:41end for questions and discussion.
• 02:45All right. So in terms
• 02:46of our background,
• 02:47just wanna begin with a
• 02:48couple of statistics.
• 02:50All right.
• 02:51So just to kind of
• 02:53describe the gravity of this
• 02:55challenge or this intersecting problem,
• 02:57and its prevalence in in
• 02:59our country. So over twenty
• 03:01one million children
• 03:02live with a parent who
• 03:03uses substances in the United
• 03:05States.
• 03:06And over two million of
• 03:07those children
• 03:08live with a parent who's
• 03:09been diagnosed with a substance
• 03:11use disorder. So these are
• 03:12no small numbers.
• 03:15And on the other side
• 03:16of that equation is that
• 03:18seventy percent of people who
• 03:19use opioids have children. Right?
• 03:21So most people who have
• 03:22opioid use disorder,
• 03:24are parenting, right, or have
• 03:27parented at some point,
• 03:28or have filled some sort
• 03:29of parenting role. Okay? So
• 03:31there's a very large overlap
• 03:33here.
• 03:34And we see that over
• 03:35fourteen thousand people per year
• 03:38are admitted,
• 03:39for substance use treatment while
• 03:40pregnant.
• 03:43We've also seen an eighty
• 03:44three percent increase in neonatal
• 03:47opioid withdrawal syndrome in the
• 03:48past about decade, a little
• 03:50over a decade.
• 03:51So these, facts and figures
• 03:53have kind of been climbing
• 03:54over time.
• 03:55And neonatal opioid withdrawal syndrome
• 03:57is what we used to
• 03:58really call neonatal abstinence syndrome,
• 04:00just kind of a a
• 04:01less stigmatizing
• 04:02term
• 04:03for the physiological,
• 04:05symptoms that we see in
• 04:06infants who have been prenatally
• 04:08exposed and then are born
• 04:09and experiencing withdrawal symptoms.
• 04:12Okay.
• 04:12So an increase in
• 04:14this challenge, and that equates
• 04:16to about one baby every
• 04:18twenty four minutes who's born
• 04:19with neonatal opioid withdrawal symptoms.
• 04:23This is,
• 04:24these are big numbers, right?
• 04:27We also see that, you
• 04:29know, different states have different
• 04:31requirements
• 04:32around the importance of notifying
• 04:34the Department of Children and
• 04:35Families or Child Child Protective
• 04:36Services.
• 04:37And across the board in
• 04:39our most recent kind of
• 04:41survey,
• 04:42we've seen that there have
• 04:43been over forty five thousand
• 04:44notifications to Child Protective Services
• 04:46nationwide,
• 04:48due to prenatal exposure specifically.
• 04:50Okay?
• 04:53Most of those are screened
• 04:55in as,
• 04:57requiring some sort of response
• 04:59from DCF, whether that's a
• 05:00full investigation
• 05:02or, some sort of alternative
• 05:03response that is related to
• 05:05child welfare. Right? So only
• 05:07about twenty percent
• 05:09of kids, you know, live
• 05:10births that are notified to
• 05:11DCF as being related to
• 05:13prenatal exposure kind of get
• 05:15screened out as not needing
• 05:17any sort of involvement from
• 05:18child welfare. But most are
• 05:19getting, you know, some sort
• 05:21of response.
• 05:23No small numbers. Right? Which
• 05:25is, you know, these figures
• 05:27on this slide in particular
• 05:28related to child protective services
• 05:31are valid in some ways
• 05:33because there are many risks
• 05:34to children, right, associated with
• 05:36parental substance use.
• 05:38So absolutely there are risks
• 05:40associated with prenatal exposure itself.
• 05:42Right? So we talked about
• 05:44neonatal opioid withdrawal, and there's
• 05:46also plenty of neurobiological
• 05:48differences that we see,
• 05:50when a child has been
• 05:51exposed to substances prenatally. And
• 05:53that varies from substance to
• 05:54substance, but we also know
• 05:55that most parents who are
• 05:57using substances pre when they're
• 05:58pregnant are using more than
• 06:00one substance.
• 06:02And so it's really hard
• 06:02to tease apart what substance
• 06:04causes what neurobiological
• 06:06difference, when prenatal exposure happens.
• 06:09But we do know that
• 06:10they kind of coalesce in
• 06:11three domains, meaning
• 06:13sensory motor development, arousal motivation
• 06:16and reward, and then executive
• 06:18functioning and emotion regulation. Right?
• 06:20And we know that these
• 06:21are all kind
• 06:22of they cluster into certain
• 06:24kind of mental health disorders
• 06:25or learning problems or, kind
• 06:27of neurodevelopmental
• 06:28disorders.
• 06:30We also know that early
• 06:32childhood exposure to a parent's
• 06:34substance use has lasting impacts
• 06:36as well.
• 06:37And one of those main
• 06:38mechanisms is around caregiving. Right?
• 06:40And we'll talk some when
• 06:41we get into neuroscience about
• 06:43the ways
• 06:43that substance use itself
• 06:45impacts caregiving at the neural
• 06:47level. But it also affects
• 06:49things like caregiving sensitivity
• 06:51and a parent's ability to
• 06:52attune to their child's emotions,
• 06:56and a parent's capacity to
• 06:57mentalize. And we'll talk a
• 06:58bit more about that later.
• 07:01And early childhood exposure to
• 07:03a parent's substance use also
• 07:04very often,
• 07:06intersects with other stressors,
• 07:08and as well as other
• 07:09traumas. Right? So grief related
• 07:11to potential parental
• 07:13substance overdose,
• 07:15neglect, other trauma or violence.
• 07:18And then there are plenty
• 07:19of other co occurring contextual
• 07:21factors. Right? And cumulative risk
• 07:23has an impact. Right? This
• 07:24is not occurring in a
• 07:25vacuum.
• 07:27So absolutely there are risks
• 07:29to children. So child welfare
• 07:30involvement
• 07:31is going to be inherent,
• 07:33as part of the profile
• 07:34of experiences that these families
• 07:36have.
• 07:37But there are also risks
• 07:38to parents. Right, when,
• 07:41substance use and parenting
• 07:43come together. Right? And so
• 07:44here we have some information
• 07:46that talks about
• 07:48how
• 07:49pregnancy and postpartum
• 07:51create this
• 07:53real decrease or pregnancy creates
• 07:55a real decrease in substance
• 07:57use,
• 07:58especially as parents begin to
• 08:01learn that they're pregnant
• 08:03or begin to the baby
• 08:05becomes real or begins moving.
• 08:08And we can really develop
• 08:09a mental model of a
• 08:10baby. And there's some real
• 08:12motivation around decreasing substance use.
• 08:14Right? So we see a
• 08:15sharp decrease
• 08:17in substance use in pregnancy,
• 08:18which is encouraging. Right? We
• 08:20might say, oh, wow, pregnancy
• 08:21is a protective factor,
• 08:24factor, which is great.
• 08:26And there's a concern here
• 08:28that we also see this
• 08:28really sharp
• 08:29increase in overdose
• 08:31immediately after our baby is
• 08:32born.
• 08:33And you could think of
• 08:34a variety of reasons for
• 08:35that, right?
• 08:37We could think about how
• 08:38there's no longer a motivation
• 08:40to decrease
• 08:41or abstain from use because
• 08:43there's no longer a direct
• 08:44physiological impact on an infant
• 08:47who's in utero. That's not
• 08:48the case anymore. But also
• 08:50think about the stress of
• 08:51parenting. Right? And think about
• 08:53the stress of an infant
• 08:54with needs.
• 08:55Think about the stress of
• 08:56an infant who maybe is
• 08:57a bit dysregulated because of
• 08:59their own prenatal exposures.
• 09:02Think about,
• 09:04the isolation
• 09:05of early parenthood.
• 09:07Right.
• 09:09And then the thing that
• 09:10I'll point out here is
• 09:11that very bottom bar,
• 09:13where rates become even higher
• 09:15than they were prior to
• 09:16conception.
• 09:18And we could think about
• 09:19the reasons for that. Right?
• 09:20When a kiddo is six
• 09:21months old, what are they
• 09:23doing? Right? They we're moving.
• 09:24We're shaking. We're
• 09:26making noise. We're having, opinions,
• 09:28and we have got a
• 09:29little developing personality.
• 09:31Right?
• 09:33A bit different than the
• 09:34passive
• 09:35itty bitty infant that, you
• 09:37know, we had in those
• 09:37first six months.
• 09:39Right? So this is concerning.
• 09:42So there are risks to
• 09:43parents.
• 09:44And then ultimately, really, we
• 09:46see risks to families at
• 09:48large. So many states, like
• 09:49I was saying, consider parental
• 09:51substance use a literal form
• 09:53of child abuse,
• 09:54even though research shows that
• 09:56parental substance use is not
• 09:58an equivocal or perfect predictor
• 10:00of child maltreatment. Right? But
• 10:02they're still really equated
• 10:03in our systems to a
• 10:04certain degree.
• 10:07And child removal itself is
• 10:09associated with increased parental overdose
• 10:12and substance use too, which
• 10:14then
• 10:15further reduces,
• 10:17likelihood of reunification.
• 10:18Right?
• 10:20So there are risks to
• 10:21families.
• 10:22Parental substance use is often
• 10:24considered child abuse. And I
• 10:25wanted to kind of highlight,
• 10:27but as we move into
• 10:28this next slide, this image,
• 10:30I took a screenshot from
• 10:32a resource that's available on
• 10:34the US Department of health
• 10:35and services, health and human
• 10:37services website.
• 10:38Right child welfare information gateway
• 10:40children's bureau. Like, these are
• 10:42legit
• 10:43federal.
• 10:45Agencies,
• 10:47but if you take a
• 10:48close look at the image,
• 10:50we see a sweet kiddo
• 10:52with Down syndrome. Right? And
• 10:54so I am just curious
• 10:57about
• 10:58the ways that.
• 11:00Our society is,
• 11:02equating.
• 11:03Right?
• 11:04A genetic
• 11:05disorder with prenatal exposure potentially.
• 11:08Right? We don't we don't
• 11:10have evidence that they are
• 11:13related and here we are.
• 11:14Right? So I'm concerned about
• 11:16stigma and misinformation. Right?
• 11:19And that stigma is really
• 11:20strong.
• 11:22And I'd even encourage I
• 11:23I very often will begin
• 11:24a talk like this with,
• 11:27what comes to mind when
• 11:28you see that this is
• 11:29what I'm gonna be speaking
• 11:29about today? Right? And where
• 11:31do you find yourself aligning?
• 11:33Or what do you imagine
• 11:34are the solutions to this
• 11:35really big problem
• 11:37that
• 11:38I, that I raise? Right?
• 11:40These really
• 11:41striking figures.
• 11:42But really, there's a lot
• 11:43of stigma that this topic
• 11:45naturally activates.
• 11:47And those are
• 11:49somewhat in or in part
• 11:51caused by the cognitive and
• 11:52cultural models that are activated
• 11:53on our own minds in
• 11:55our society,
• 11:57based on whatever topic we're
• 11:58talking about, and in this
• 11:59case, parental substance use. Some
• 12:01research that I did a
• 12:02few years ago suggested
• 12:03that when we survey folks
• 12:05kind of across the country
• 12:06and ask them to talk
• 12:07about what they're thinking,
• 12:09when we raise this topic,
• 12:10a few core themes come
• 12:12up.
• 12:13And one is the theme
• 12:15that or, you know, folks
• 12:17across the country
• 12:19indicate that they believe that
• 12:21this is a problem caused
• 12:22by a lack of knowledge.
• 12:24So here's a quote that
• 12:25we have, from somebody who
• 12:27said they make sense of
• 12:28this problem
• 12:29by saying that parents aren't
• 12:32educated.
• 12:34The parents aren't educated to
• 12:35understand that this is not
• 12:37just, oh, well, I I
• 12:38messed up on a test,
• 12:40but this has high stakes.
• 12:41Right?
• 12:43Another theme that comes up
• 12:44when folks discuss the topic
• 12:46of parental substance use is
• 12:48believing that it's caused by
• 12:49selfishness.
• 12:50So we have a quote
• 12:51from somebody who said, I
• 12:52think everyone growing up in
• 12:54America knows that you're supposed
• 12:55to stay away from drugs
• 12:56and alcohol while you're pregnant.
• 12:58But you may choose to
• 12:59anyway because if you're not
• 12:59as mentally sound or feeling
• 13:00like you have things together,
• 13:00you're less likely to care.
• 13:06Developing inside of you. Right?
• 13:08So these are real things
• 13:09that real people have said
• 13:10that we surveyed,
• 13:11and interviewed, right, around the
• 13:13country.
• 13:15This is what gets brought
• 13:16up. Right? So there's there's
• 13:18real stigma. There are these,
• 13:19cultural models that are activated.
• 13:21There's also an acknowledgment,
• 13:23which I'm appreciative of in
• 13:25some ways,
• 13:26that there are contextual stressors
• 13:28that,
• 13:29influence parental substance use, which
• 13:31is very much the case.
• 13:32Right? That there are stressors
• 13:34like poverty and trauma. Right?
• 13:36And an acknowledgment that addiction
• 13:38is a disease, right, in
• 13:39many ways, and that there
• 13:41are biological processes, that it's
• 13:42not about a choice. Right?
• 13:43So good. We can we've
• 13:45learned what we can kind
• 13:45of capitalize on if we
• 13:47think kind of in the
• 13:47framework's way,
• 13:50you know, which things we
• 13:51should we should be pointing
• 13:52out. But anyway,
• 13:54this stigma, I think, has
• 13:55a lot to do with
• 13:56some of the
• 13:57child welfare involvement that we
• 13:59see.
• 14:00And here are even some
• 14:01figures that kind of demonstrate
• 14:03some of that, which is
• 14:05suggesting that when,
• 14:08substance use parental substance use
• 14:10is part of a clinical
• 14:11picture of a family, they're
• 14:12significantly more likely to have
• 14:14whatever other child maltreatment
• 14:17report be substantiated
• 14:20compared to when only domestic
• 14:22violence
• 14:23was part of a child
• 14:24welfare report or when neither
• 14:25were reported and it was
• 14:26just child welfare.
• 14:30Okay. We've seen this number
• 14:32climb significantly,
• 14:34in the past twenty years
• 14:35as you can see here.
• 14:37And then the last kind
• 14:38of big fact and figure
• 14:39that I'll point out is
• 14:40that this is most common
• 14:42for infants.
• 14:43Right? We're one year of
• 14:45age and older. Like, we're
• 14:46seeing the kind of this
• 14:47the
• 14:48this intersection of parental substance
• 14:49use and child welfare is
• 14:51most common and most salient
• 14:52in kind of early childhood
• 14:54and early parenthood.
• 14:58Because of all of this,
• 14:59I think I've convinced you
• 15:00that this is a big
• 15:01problem, but because of all
• 15:02of this, we often throw
• 15:03a lot of services at
• 15:05families. Right? So we might
• 15:07say, okay, take care of
• 15:08substance use. Right? Get substance
• 15:09use treatment, mom or dad.
• 15:11We're gonna also give you
• 15:12a peer recovery coach. Right?
• 15:14And make sure you're keeping
• 15:15on top of your methadone
• 15:16maintenance. Get there every day.
• 15:18Stick with NA. That's good
• 15:20for you. Maybe you get
• 15:21an individual therapist. Do some
• 15:22DBT.
• 15:23Oh, wait, you've been through
• 15:24trauma. Let's get you some
• 15:25trauma focused treatment.
• 15:27Oh, you're depressed. Okay. Like,
• 15:28let's make sure we have
• 15:29a psychiatrist on board. You've
• 15:31got a kiddo. We're concerned
• 15:32about them and their safety.
• 15:34Let's get DCF involved.
• 15:36Let's get a parenting class
• 15:37as part of your case
• 15:38plan.
• 15:39Oh, you're pregnant again. Let's
• 15:40make sure you're on top
• 15:41of your prenatal care. And
• 15:42we'll make sure that there's
• 15:43a plan of safe care
• 15:44so that when you go
• 15:45have your baby, that the
• 15:46hospital is satisfied with how
• 15:47you're gonna care for them.
• 15:49Then there's postnatal care for
• 15:50your own self.
• 15:52Okay. Now you gotta get
• 15:53back to work. Let's get
• 15:54childcare involved.
• 15:56Yada yada yada. Right?
• 15:58It's a lot. Preschool,
• 16:01five o fours,
• 16:03IEPs.
• 16:04It's a lot.
• 16:06It's overwhelming,
• 16:07right, for for anybody.
• 16:10And it puts parents in
• 16:11a bind. It really, really
• 16:12puts parents in a bind.
• 16:13Right? So there's a decision
• 16:15to be
• 16:16made to engage. Right? And
• 16:18in which case, ideally,
• 16:20we'll experience benefit. Right? If
• 16:21we can take advantage of
• 16:22all of those things, maybe
• 16:23there's something I can get
• 16:24from each one. Right? If
• 16:25I have the executive functioning
• 16:27to kind of
• 16:29gel it altogether.
• 16:30But it can be really
• 16:31overwhelming. And I'm also making
• 16:33myself and my family vulnerable,
• 16:34right, in a lot of
• 16:35ways. Right? A little bit.
• 16:37So top left, we have
• 16:38the card sauce store.
• 16:41Thank you.
• 16:43Right. So I make myself
• 16:44vulnerable in a few different
• 16:45ways. One of which is,
• 16:47vulnerable to identification,
• 16:49right, by child welfare or
• 16:50legal systems. Right? But the
• 16:52other being that it's just
• 16:53vulnerable,
• 16:55right, to engage in support.
• 16:57It just is.
• 17:00I can also make the
• 17:00choice to not engage. Right?
• 17:02So I might be able
• 17:03to avoid identification or I
• 17:04might be able to avoid
• 17:06being really vulnerable,
• 17:07but then I don't receive
• 17:08support that really could have
• 17:09been helpful.
• 17:10And if I'm pregnant, then
• 17:12I probably am gonna be
• 17:13identified at some point anyway.
• 17:15Right.
• 17:17It's, I think, really summed
• 17:19up well by some research
• 17:20from twenty sixteen by one
• 17:22of my former co fellows,
• 17:23Amanda Van Schaik,
• 17:25who who interviewed mothers
• 17:27and to understand how they
• 17:28were thinking about
• 17:30entering treatment while they were
• 17:32pregnant.
• 17:33And we have a mom
• 17:34who says I was so
• 17:34traumatized by child welfare that
• 17:36I didn't want them to
• 17:36be able to attract me,
• 17:38so I didn't go to
• 17:38the doctor.
• 17:42That's that's a concern
• 17:43for for me,
• 17:46and makes me really think
• 17:48about how do we stop
• 17:49traumatizing families, right? How do
• 17:52we be supportive?
• 17:54So but our systems, I
• 17:55think, are experiencing a double
• 17:57bind as well, right? So
• 17:58there's a choice to kind
• 17:59of report or support. I
• 18:01choose those words. I don't
• 18:02think that they're mutually exclusive,
• 18:04but I think that they're
• 18:06a nice rep. So, that's
• 18:07why I did that. But
• 18:08anyway, so to to report,
• 18:09right, to get child welfare
• 18:11involved or to kind of
• 18:12layer on a gazillion services,
• 18:14we might reduce reduce some
• 18:16of the risks that I
• 18:16was talking about,
• 18:18reducing risk for the trauma
• 18:19that children experience.
• 18:21And also we might risk
• 18:24attachment disruption,
• 18:26which we know
• 18:27influences
• 18:28risk for later mental health
• 18:30problems.
• 18:31And like I mentioned, increases
• 18:32risk for parental
• 18:34overdose. And then if we
• 18:36as a system or as
• 18:37a set of systems decide,
• 18:38okay, our technique or our
• 18:40approach is going to be
• 18:41support over
• 18:43report,
• 18:44children, you know, keeping children
• 18:46in homes, for example, might
• 18:47still potentially expose them to
• 18:48inconsistent or non attuned caregiving.
• 18:50So that's not ideal.
• 18:52And, and other trauma, again,
• 18:53not ideal.
• 18:54And we avoid potential attachment
• 18:56disruption and caregivers are maybe
• 18:58potentially motivated,
• 19:00and remain hopeful,
• 19:02around engaging in recovery supports.
• 19:06The trick is that
• 19:08that support that I talked
• 19:09about is so overwhelming and
• 19:11non intersectional
• 19:12and the things that are
• 19:13accessible
• 19:15aren't always great. I'm not
• 19:16saying that we don't have
• 19:17evidence based treatments. It's not
• 19:18what I'm saying.
• 19:20They're not always
• 19:21available. They're not always,
• 19:23accessible. They're not always,
• 19:26obtainable by families, right? Depending
• 19:28on communities and a variety
• 19:30of factors.
• 19:31The The other thing is
• 19:32that support for people with
• 19:33substance use disorders
• 19:35are often peer led, twelve
• 19:36step, disease centric, medication assisted,
• 19:39developed with males in mind
• 19:41only,
• 19:42and
• 19:43parenting is really not kept
• 19:45in mind.
• 19:46Right. And then on the
• 19:47other hand, support for parents,
• 19:49things that are evidence based
• 19:51and are scaled up and
• 19:52unavailable in communities,
• 19:54are often skills based, or
• 19:57behavioral or focus on the
• 19:58child and how to either
• 19:59address or prevent misbehavior,
• 20:02or they're like child parent
• 20:04psychotherapy, for example, which is
• 20:05an amazing treatment, but really
• 20:07focused on the child. Right?
• 20:08It's we've got child first,
• 20:10not,
• 20:11kind of parent child relationship
• 20:12or parent first. And here
• 20:14we are, and the parent's
• 20:14the one that's holding the
• 20:15whole thing. Right?
• 20:18So unsurprisingly,
• 20:20we often see that they
• 20:21miss the parents' needs and
• 20:22are minimally effective for parents
• 20:23with substance use disorder and
• 20:25not surprisingly associated with premature
• 20:27exit.
• 20:29Not ideal.
• 20:31Some of that is because
• 20:32of what I was mentioning
• 20:33doesn't pay attention to the
• 20:35intersectional identities of parents who
• 20:37are in recovery. So a
• 20:38parent in recovery
• 20:39is not the same thing
• 20:41as a person in recovery
• 20:42who happens to be a
• 20:43parent, right, or a parent
• 20:44who happens to also have
• 20:45a substance use disorder.
• 20:48Right? There's an intersection here.
• 20:50But parents really notice
• 20:52that services and systems don't
• 20:55get that. Right? So for
• 20:56example,
• 20:58we have a mom who
• 20:59says that my child's pediatrician
• 21:00said, well, is my is
• 21:01your child okay? And he
• 21:03never and he asked how
• 21:04he's developing, how he's responding,
• 21:05but he never asked how
• 21:06I was.
• 21:07Then on the flip side,
• 21:08we have a substance use
• 21:09treatment kind of
• 21:11oriented program who's when a
• 21:13parent said, if we're in
• 21:14group and our kid starts
• 21:16crying or needs a change,
• 21:17they don't let us go
• 21:18change them or else we
• 21:19don't get credit for group.
• 21:23This is a problem. Right?
• 21:25So there's gotta be a
• 21:26better way
• 21:28of understanding,
• 21:29the intersection of these problems,
• 21:31the the complex issues around
• 21:33parenting and substance use. And
• 21:35there's gotta be a better
• 21:36way of, like, putting that
• 21:37all together so we understand
• 21:38how to support families. So
• 21:41this is where we take
• 21:42a sharp left turn to
• 21:44neuroscience.
• 21:45Right?
• 21:46And I I promise it
• 21:47will make sense.
• 21:49And and we're not just
• 21:50like it's not just totally
• 21:51separate. It makes a lot
• 21:52of sense when we get
• 21:53into it. Right?
• 21:55So when you see a
• 21:56picture when you see this
• 21:58baby, right, I want you
• 21:59to actually, like, take two
• 22:00seconds to think, like, what
• 22:01did it feel like to
• 22:02see this baby?
• 22:04What came to mind? How
• 22:05did it feel? I didn't
• 22:06hear any audible, like, oh,
• 22:08but, like, I often do.
• 22:10Yep.
• 22:11And there's a reason for
• 22:12that. Right? And it's because
• 22:14babies
• 22:15naturally
• 22:16activate reward processes in our
• 22:18brains. Right?
• 22:19So for example, right, when
• 22:21you see that picture of
• 22:22that baby, a few things
• 22:24happen.
• 22:26So right, you see this
• 22:27child
• 22:28and neural circuits are activated,
• 22:30associated with reward. So your
• 22:32amygdala says to itself, that
• 22:34felt so good. Right? Your
• 22:36hippocampus is saying, okay, I'm
• 22:38gonna remember where and when
• 22:39and how this happened.
• 22:41Your nucleus accumbens is gonna
• 22:42say, okay, I wanna do
• 22:44this again and again and
• 22:45again.
• 22:47Prefrontal cortex executive functioning is
• 22:49saying, okay, we're gonna focus,
• 22:50we're gonna plan, we're gonna
• 22:51make this happen.
• 22:53And then, of course,
• 22:54dopamine, serotonin, oxytocin, all that
• 22:56good stuff is released.
• 22:58Right? This is lovely. Right?
• 23:00And and totally
• 23:02then
• 23:03makes sense for why people
• 23:04would engage in caregiving when
• 23:05it is stressful. Right? Like,
• 23:07it's hard. Caregiving isn't all
• 23:09hearts and flowers, but we
• 23:11do it anyway, and here's
• 23:12why. Right?
• 23:14I'll take two seconds just
• 23:16to kind of
• 23:17nod to the research behind
• 23:19this,
• 23:20much of which was done
• 23:21by our own Helen
• 23:22Rutherford, and Linda Maes for
• 23:24that matter.
• 23:25So there are adaptive neurobiological
• 23:27mechanisms involved with parenting,
• 23:29that I just really reviewed.
• 23:31The long and short of
• 23:32it is that blood flow
• 23:33in the brain of a
• 23:35parent
• 23:36is increased when one is
• 23:38looking at their own baby,
• 23:40right, more than a picture
• 23:41of an unknown baby.
• 23:43This is also true, like
• 23:45when you see a baby
• 23:45smiling, right, that's, that's more
• 23:47rewarding
• 23:48than, when you're looking at
• 23:50a picture of a baby
• 23:50who's, like, frowning.
• 23:53Okay.
• 23:54Some EEG and ERP research
• 23:56that we've, that, that Helen
• 23:58has done has also suggested
• 23:59that kind of greater neural
• 24:01responses,
• 24:03associated with kind of attention
• 24:05allocation
• 24:06are associated with
• 24:08interest and curiosity in a
• 24:10child's mental state.
• 24:11Okay.
• 24:13What this winds up looking
• 24:14like in reality is we
• 24:16have an infant who gives
• 24:18a cue.
• 24:19The reward centers of our
• 24:20brain, the reward circuits in
• 24:22our brain are activated and
• 24:23we engage in caregiving
• 24:25and
• 24:26there's a nice gorgeous cycle.
• 24:28Right? Secure attachment achieved. Check.
• 24:30Right?
• 24:32We also know that it's
• 24:33not always that simple for
• 24:35caregivers,
• 24:36with substance use disorders. Right?
• 24:38There's all this DCF involvement.
• 24:40There's challenges with sensitivity and
• 24:42attunement, mentalization.
• 24:45But the question is why.
• 24:48And so we have the
• 24:49same brain. Right?
• 24:51And you'll see the same
• 24:52things that are activated
• 24:55when we look at photos
• 24:56of babies are activated when
• 24:58substances are used. Right? So
• 25:00there is a reinforcing neural
• 25:01reward
• 25:02of substances.
• 25:04So when you engage in
• 25:05substance use, would you look
• 25:07at that? Right? Our amygdala
• 25:09is activated. It says that
• 25:11that felt really good. Our
• 25:12hippocampus is activated. Let me
• 25:14remember where and when and
• 25:15how this happened.
• 25:16Nucleus accumbens says, let's do
• 25:18this again and again.
• 25:20And our prefrontal cortex is
• 25:21like, okay, we're gonna focus
• 25:22on this. We're gonna plan
• 25:24for this.
• 25:25And we've got dopamine and
• 25:26serotonin that are released, but
• 25:27it's super fast and super
• 25:29strong
• 25:30Far far more so than
• 25:31when you just see
• 25:33an infant.
• 25:36I don't like to use
• 25:37the word hijack, but it
• 25:39is a word that has
• 25:40been used. Right? There's kind
• 25:42of an overriding,
• 25:44overpowering,
• 25:45perhaps, right, of these same
• 25:47neural circuits.
• 25:48So, of course, that's gonna
• 25:49get in the way of
• 25:49parenting.
• 25:51Right?
• 25:51Here's some research,
• 25:53behind that. Right? So,
• 25:56earlier work looked and compared
• 25:58parents with and without substance
• 26:00use disorders
• 26:01and showed that parents without
• 26:02substance use disorders
• 26:04had greater activation and reward
• 26:06kind of circuits in the
• 26:08brain compared to
• 26:09parents without subs or parents
• 26:12with substance use disorders.
• 26:15And then some of the
• 26:16work that I've done with
• 26:17Helena,
• 26:18has looked at kind of
• 26:19the speed and strength of
• 26:21neural response.
• 26:22And one of the most
• 26:23interesting findings that I think
• 26:25we had was that,
• 26:28parents without substance use disorders
• 26:31have a differential response to
• 26:32high distress versus low distress
• 26:34cries.
• 26:35So nonclinical moms,
• 26:37were listening to babies' cries
• 26:39and had a stronger reaction
• 26:40to a high distress
• 26:42cry compared to a low
• 26:43distress cry. Makes sense.
• 26:45We did not see that
• 26:46differentiation when it came to
• 26:47parents with substance use disorders.
• 26:50And instead of it being
• 26:51a blunted or dampened response,
• 26:53we actually saw that they
• 26:54were both equally high,
• 26:56in activation
• 26:58in response to both a
• 26:59high distress cry as well
• 27:00as a low distress cry.
• 27:02So think about just how
• 27:04activating
• 27:04the sound of an infant
• 27:05cry can be.
• 27:07And
• 27:08if our if a brain
• 27:09doesn't differentiate between the two
• 27:11and is just as activated
• 27:12by something low distress.
• 27:14Right. What does that mean
• 27:15for
• 27:16stress levels and for relapse,
• 27:18for example, right, and for
• 27:20caregiving?
• 27:22So Helena really synthesized a
• 27:24lot of this work and
• 27:25spoke to the reward stress
• 27:27dysregulation
• 27:28of parenting and addiction, where
• 27:30a parent in recovery has
• 27:32a decreased sensitivity to natural
• 27:34rewards
• 27:35and an increased,
• 27:37sensitivity to stress. Right?
• 27:39And then you've got a
• 27:40stressor
• 27:42in the form of an
• 27:42infant who has needs,
• 27:44who gives cues and needs
• 27:46things from a parent.
• 27:48It's a high stress and
• 27:49low reward postpartum environment,
• 27:51which may lead to cravings
• 27:52and, of course, then substance
• 27:54use and relapse, which then
• 27:55continues that cycle
• 27:57of,
• 27:59those brain changes.
• 28:00Okay.
• 28:03For me as as a
• 28:04as a clinically, a very
• 28:06clinically focused person,
• 28:07I have tended to look
• 28:09at it this way,
• 28:12and recognize that stress
• 28:14overpowered reward.
• 28:16And
• 28:17my then mission has been,
• 28:19okay, like, how do we
• 28:20tip those scales? Right?
• 28:23But with that stress overpowering
• 28:25reward, what you might see
• 28:26instead
• 28:27of this lovely cycle
• 28:28is, an infant gives a
• 28:30cue. And then instead of,
• 28:33the reward response in the
• 28:34brain or the reward circuits
• 28:36in the brain being activated,
• 28:37we've got stress responses
• 28:39activated.
• 28:42Fight, flight, fawn, freeze.
• 28:45And And then, again, unsurprisingly,
• 28:48we might see a return
• 28:49to use. It's not one
• 28:50hundred percent of the time
• 28:51that's not what I'm saying,
• 28:52but I'm just talking, like,
• 28:53kind of in general.
• 28:57Right. So this is a
• 28:58concern.
• 28:59And this is the point
• 29:00in the talk where I
• 29:00want to acknowledge that addiction
• 29:03and adversity are inextricably
• 29:05linked. It's very hard to
• 29:07study
• 29:08addiction without acknowledging or understanding,
• 29:11that trauma is
• 29:13usually part of the picture.
• 29:14Right. It's usually part of
• 29:15the experience of somebody who
• 29:17faces addiction.
• 29:19And a lot of our
• 29:20neuroscience, like we're not quite
• 29:22there in terms of the
• 29:23neuroscience to be able to
• 29:24tease those, those things apart.
• 29:29So that's a future direction.
• 29:30But,
• 29:32what I wanna point out
• 29:33is that
• 29:35parents with substance use disorders
• 29:37very often have experienced both
• 29:38childhood and adulthood trauma, as
• 29:41well as acute or, like,
• 29:42big t trauma and chronic
• 29:44trauma,
• 29:45little t trauma,
• 29:46attachment trauma. Right? So, like,
• 29:48my little star right there
• 29:49because to me, that helps
• 29:51me make sense of it's
• 29:52not just about
• 29:54the big things that happen
• 29:55to you, but it's about
• 29:56how your reactions to those
• 29:58big things have been
• 30:00understood by a caregiver.
• 30:02Right?
• 30:04So my favorite quote that
• 30:05I put in every talk
• 30:07is
• 30:07this, right? So understanding of
• 30:09minds is hard without the
• 30:10experience of having been understood
• 30:12as a person with a
• 30:13mind.
• 30:15Very often parents with substance
• 30:17use disorders have not been
• 30:18understood as a person with
• 30:19a mind by their own
• 30:20caregiver.
• 30:21There are very much intergenerational,
• 30:24patterns here.
• 30:28When we've spoken to caregivers
• 30:31about their wishes and their
• 30:32needs around how they want
• 30:33to be supported,
• 30:35And we have proposed
• 30:37ideas for them about what
• 30:39if we were to support
• 30:41you in this way that
• 30:42focused on parenting and substance
• 30:44use at the same time,
• 30:46or,
• 30:47was focused on your parent
• 30:48child relationship in the context
• 30:49of addiction.
• 30:51Parents react in a really
• 30:52positive way and know, yes,
• 30:54actually that would be super
• 30:55helpful because us parents in
• 30:57recovery need that sort of
• 30:58thing because we never had
• 31:00the upbringing.
• 31:02Right? So
• 31:03this is, you know, there's
• 31:04a theoretical, like it makes
• 31:06sense theoretical. There are underpinnings
• 31:08and
• 31:08parents in real life are
• 31:10saying, yeah, this would be
• 31:11super helpful.
• 31:13Okay. So this brings us
• 31:15to the clinical approaches,
• 31:17and what we've
• 31:18worked really hard to do
• 31:21to kind of pull all
• 31:21of what I just talked
• 31:22about together,
• 31:24and do right by families.
• 31:25Right? So as a reminder,
• 31:29this is often what we
• 31:30throw at families,
• 31:31and it's overwhelming.
• 31:33I
• 31:34I find it incredibly kind
• 31:36of anxiety provoking when I
• 31:37look at it, and I'm
• 31:39I'm not facing the many
• 31:40intersectionalities
• 31:41or marginalized identities that families
• 31:43in recovery are. Right?
• 31:46So to simplify,
• 31:48I've already kind of said
• 31:48this, this is my goal.
• 31:51Right? And so with this
• 31:53as our guidepost,
• 31:54I begin to then get
• 31:56really excited about the different
• 31:57ways that we might not
• 31:59add on more services, but
• 32:01really tailor services and integrate
• 32:03services. Right? So we'll get
• 32:05to that.
• 32:07But some research had to
• 32:08be done first,
• 32:09about how to tip those
• 32:11scales, or what might lead
• 32:13to the most kind of
• 32:15bang for your buck when
• 32:16it comes to tipping those
• 32:17scales.
• 32:18And some work by my
• 32:19late mentor, Doctor. Nancy Sookman,
• 32:21suggested
• 32:22that it was going to
• 32:23be really important to focus
• 32:25not solely on the child,
• 32:26that parenting support shouldn't just
• 32:28be child focused,
• 32:30and
• 32:31substance use support shouldn't be
• 32:33just adult focused,
• 32:35but rather how do we
• 32:36combine them and and focus
• 32:37on
• 32:38not parent and child and
• 32:40the relationship.
• 32:41Right?
• 32:42So she developed a model
• 32:44called mothering from the inside
• 32:45out.
• 32:46It's an individual
• 32:48parenting psychotherapy
• 32:49designed specifically for moms in
• 32:51recovery,
• 32:53who are caring for children
• 32:54five and under.
• 32:56And she really made the
• 32:57argument that it needed to
• 32:59shift that support for families
• 33:00like this
• 33:01needed
• 33:02to needed to move from
• 33:04focusing on behavior to focusing
• 33:05on relationships and being mentalization
• 33:07based. Right? So in other
• 33:09words, making sense of behavior,
• 33:11a parent's own behavior
• 33:12and the child's behavior in
• 33:14terms of underlying mental states
• 33:16and letting that guide then
• 33:17a parent's response
• 33:19with the support
• 33:20of a therapist who understands
• 33:22them as a person with
• 33:23a mind, gives them that
• 33:24space.
• 33:25Okay.
• 33:27There are five core components
• 33:29to it, and it is
• 33:30manualized
• 33:31in a way that talks
• 33:33about the progression of these
• 33:35five components, although it's not
• 33:36session by session. Right?
• 33:38So first and foremost, building
• 33:40a strong therapeutic relationship in
• 33:42which the caregiver or the
• 33:44patient
• 33:45is understood
• 33:46person with a mind, as
• 33:48a parent with a mind,
• 33:49and,
• 33:51is safe in that relationship
• 33:54with a therapist who has
• 33:56earned trust,
• 33:58epistemic trust, ideally.
• 34:03Second,
• 34:04the therapist has to maintain
• 34:05a reflective stance throughout. We'll
• 34:07come back to this in
• 34:08the next slide.
• 34:10And then
• 34:12facilitating
• 34:13self focused reflection and prioritizing
• 34:15that beginning with that, like
• 34:16an oxygen mask, right,
• 34:19where a caregiver is able
• 34:21to reflect on their own
• 34:22mental states and how they
• 34:24then influence their behavior
• 34:26as a person
• 34:27and as a parent
• 34:30and as a child, their
• 34:31their own selves. Right?
• 34:33And then moving from there
• 34:36to understanding what the child's
• 34:37behavior is saying, what the
• 34:39child's needs are,
• 34:41what the child's,
• 34:43how to make sense of
• 34:44the child's behavior in terms
• 34:45of underlying mental states,
• 34:47and then being able to
• 34:48tie tie it together by
• 34:50providing when appropriate developmental guidance
• 34:52that is very much attachment
• 34:54informed.
• 34:55K.
• 35:00So in terms of the
• 35:01mentalizing stance or a reflective
• 35:02stance,
• 35:04what I think is important
• 35:05to consider is that it's
• 35:07not just what we say,
• 35:08but it's how we say
• 35:09it. Right? And so being
• 35:11able to provide our interventions
• 35:13with curiosity,
• 35:15by being able to hold
• 35:17a not knowing stance of
• 35:18non
• 35:20expert, and one that is
• 35:21collaborative,
• 35:22where we make meaning mutually
• 35:23together.
• 35:25And there's a negotiation,
• 35:27and there's playfulness.
• 35:29Being transparent about one's own
• 35:31mental states and one's own
• 35:32intentions,
• 35:34creates a lot of safety.
• 35:35And then, again, like, attachment
• 35:37focused or focusing on the
• 35:38child when it's appropriate, right,
• 35:39or focusing on the relationship
• 35:41when there's space for it.
• 35:44Keep this in mind. Right?
• 35:48I swear we'll come back
• 35:48to it.
• 35:50So
• 35:52it's very encouraging. There there's
• 35:54been a lot of research
• 35:55that shows really promising results
• 35:57when it comes to
• 35:59taking this approach or providing
• 36:01this intervention,
• 36:03mothering from the inside out.
• 36:04So compared to parenting psychoeducation,
• 36:08using a mentalizing approach,
• 36:10a la mothering from the
• 36:11inside out, is associated with
• 36:13improved parental reflective functioning,
• 36:15improved maternal sensitivity when we
• 36:17watch parents and children play
• 36:19together,
• 36:21as well as increased dyadic
• 36:22reciprocity
• 36:23and,
• 36:24even improved child attachment security
• 36:26looking using even the strange
• 36:28situation.
• 36:30We also see that mothering
• 36:31from the inside out is
• 36:32associated with decreased parental substance
• 36:34use
• 36:35and decreased depression,
• 36:37decreased
• 36:38negative emotionality or kind of
• 36:39irritability when playing with kids,
• 36:42and decreases in the child's
• 36:43withdrawal from their parent. Right?
• 36:45These are not findings that
• 36:47we saw in parents who
• 36:49received psychoeducation.
• 36:52And these were all parents
• 36:54that were in substance use
• 36:55treatment. Right? They were all
• 36:56in substance use treatment. We
• 36:57only saw decreases,
• 36:59significant decreases in the mothering
• 37:01from the inside out group,
• 37:02not in the psycho ed
• 37:03group, even though they were
• 37:04all getting substance use treatment.
• 37:06Right?
• 37:07So that begins
• 37:09to make me start thinking
• 37:11about what's happening here that
• 37:12we're not actually targeting substance
• 37:14use or depression,
• 37:16but that's improving
• 37:17for caregivers when we're improving
• 37:19the parent child relationship.
• 37:21Pretty cool.
• 37:24And
• 37:25those studies were in tightly
• 37:26controlled research settings,
• 37:28with research clinicians.
• 37:30So that's a little bit
• 37:32of a problem. So then
• 37:33the question becomes, how do
• 37:34we bring this to the
• 37:34real world? How do we
• 37:36bring it to scale? Because
• 37:37that's not reflective of of
• 37:39what's out in the community
• 37:40or what's gonna be available
• 37:41in the community.
• 37:44So let's end with bridging
• 37:45the science to service
• 37:47gap.
• 37:47Right.
• 37:49So what I mean by
• 37:50that is there is a
• 37:52a known phenomenon,
• 37:53when it comes to evidence
• 37:55based treatments
• 37:56where they are developed
• 37:58in really rigorous randomized controlled
• 38:00trials. They were eloquently designed.
• 38:02They are fantastic. You see
• 38:04fabulous results. You're like, sweet,
• 38:06let's get it out there.
• 38:08And then you fall off
• 38:10this cliff.
• 38:12And,
• 38:13it's no it's not implementable,
• 38:15right, because it's too clunky
• 38:17or you lose all of
• 38:18the efficacy
• 38:19that's no longer effective,
• 38:21because
• 38:22there wasn't time spent making
• 38:24sense of what is really
• 38:26needed here to make this
• 38:27work in the real world.
• 38:30So this is what we
• 38:31want to avoid.
• 38:33Okay.
• 38:34So work that I recently
• 38:35did with my colleague,
• 38:37up at UMass
• 38:38is,
• 38:39really looked at the barriers
• 38:40and facilitators
• 38:41of providing
• 38:43mothering from the inside out
• 38:44or mentalization based parenting support
• 38:46to parents with addiction. You
• 38:48know, what is gonna get
• 38:49in the way and what's
• 38:50going to be super helpful,
• 38:52and how should that inform
• 38:53our next steps?
• 38:54Steps? What we found is
• 38:55that,
• 38:57there are some real barriers
• 38:58to care for these families,
• 39:00including things like
• 39:01the location of the service
• 39:03delivery and a parent feeling
• 39:05safe and comfortable in that
• 39:07location,
• 39:10on top of then just
• 39:11the actual issue of transportation.
• 39:13Right?
• 39:15And, and there's just a
• 39:16general lack of trust in
• 39:18systems.
• 39:19Okay.
• 39:22On the other hand, there
• 39:22were some facilitators when we
• 39:24when we raised this idea
• 39:25of, hey, what if we
• 39:27brought mothering from the inside
• 39:28out into this setting or
• 39:30this setting or this setting?
• 39:31Right? So home visiting or
• 39:33early intervention, or in Connecticut,
• 39:34it's birth to three,
• 39:36was one of the places
• 39:37that we explored, hey, what
• 39:38if we brought it into
• 39:39this setting?
• 39:40And parents were pretty enthusiastic
• 39:42about it. And they indicated
• 39:44they were really encouraged by
• 39:45the idea that they would
• 39:46have
• 39:47early intervention providers who are
• 39:49super focused on child development,
• 39:58they were thrilled at the
• 39:58idea that they might have
• 39:59supports that provide that work
• 40:01but also understand parental addiction
• 40:03or parental substance use.
• 40:06And other facilitators included kind
• 40:08of the, the real emphasis
• 40:10on the relationship.
• 40:11Okay.
• 40:12What we,
• 40:13concluded by understanding is that
• 40:16mothering from the inside out
• 40:17could potentially address some of
• 40:18the emotional
• 40:19barriers to engaging in services
• 40:21that were traditionally child focused,
• 40:25and that bringing it into
• 40:26preexisting services
• 40:28without reinventing the wheel,
• 40:30could
• 40:31potentially address some of the
• 40:33logistical barriers like transportation,
• 40:36or needing
• 40:37to develop another
• 40:38relationship among the gazillion that
• 40:40we already expect people to
• 40:41establish
• 40:42in a group that's already
• 40:43pretty, like, not sure if
• 40:44they wanna trust people.
• 40:47So that was encouraging.
• 40:49Some of the other work,
• 40:50right? So in addition to
• 40:51bringing it into home visiting
• 40:52or early intervention,
• 40:54another idea that, Nancy Slipman
• 40:56had was to have addiction
• 40:58counselors provide this support because
• 41:00people are already going to
• 41:01the methadone clinic. So let's
• 41:03have it there and let's
• 41:05have it be real world
• 41:06clinicians.
• 41:07So step one was to
• 41:09even see, can
• 41:10substance use counselors be trained
• 41:12to provide
• 41:13this kind of intervention or
• 41:15support with any degree of
• 41:17fidelity?
• 41:19So could, could people who
• 41:21have maybe bachelor's degrees or
• 41:22like substance use counselor certifications
• 41:25provide a mentalization based psychotherapy?
• 41:28So she trained them and
• 41:30that's where kind of I
• 41:31began coming on board, and
• 41:33we did a lot of
• 41:34training and supervision together of
• 41:35substance use counselors. It was
• 41:36some of the most fun
• 41:38work of of my life,
• 41:39and I miss it every
• 41:40day.
• 41:41And the good news was
• 41:43that
• 41:44the answer was yes, that
• 41:46we could train counselors to
• 41:47provide it with fidelity when
• 41:48we looked and and rated
• 41:49their their adherence to the
• 41:51model. So then step two
• 41:53was to compare
• 41:54the efficacy
• 41:55of
• 41:56MIO, mothering from the inside
• 41:58out, to psychoeducation
• 42:00as provided by substance use
• 42:01counselors.
• 42:04So we found some promising
• 42:06results.
• 42:07They weren't quite as robust.
• 42:09So we saw an improvement
• 42:11in children's clarity of cues
• 42:12when interacting with their caregivers.
• 42:15We also saw parents decrease
• 42:16in their certainty about their
• 42:18children's mental states, which to
• 42:19me means increased flexibility, which
• 42:21I'm okay with, I'm happy
• 42:22about,
• 42:23and and decreases in parents'
• 42:25depression. So those are still
• 42:26nice results. They're just not
• 42:27quite as amazing,
• 42:29as when provided by research
• 42:31clinicians.
• 42:34And something to also look
• 42:36at and keep in mind
• 42:37is that for the psychoeducation
• 42:38group, we saw some deterioration
• 42:40in their functioning.
• 42:42Right?
• 42:44So their substance use actually
• 42:46increased.
• 42:48Their children's compliance decreased. Their
• 42:50children's clarity of cues decreased.
• 42:52Children's responsiveness to their caregiver
• 42:54decreased,
• 42:55and the contingency of their
• 42:57children's behavior decreased.
• 42:59So, over time, we saw
• 43:00this deterioration
• 43:02in this group,
• 43:03and we did not see
• 43:04that deterioration for mothering from
• 43:05the inside out. So,
• 43:08there's this idea that MIO
• 43:10might be protect protective in
• 43:11certain domains.
• 43:12Right?
• 43:13And prevent this deterioration,
• 43:16when provided by
• 43:18treaters in the community. That
• 43:20doesn't mean that it's still
• 43:21the best fit for a
• 43:22kind of treater. There might
• 43:23still be kind of an
• 43:24intervention and intervener
• 43:26fit challenge there,
• 43:28which just makes me really
• 43:30interested in where do we
• 43:31bring it next? Who are
• 43:32the right people? Where is
• 43:34the right venue? What is
• 43:35the right setting?
• 43:36Where do we go from
• 43:37here?
• 43:38Right? So,
• 43:41the other other research needs
• 43:42to happen in order to
• 43:43understand why did we see
• 43:44these less robust outcomes? And
• 43:46again, what does that mean
• 43:47for implementation?
• 43:50My colleague Lily Peacock Chambers
• 43:52up at UMass,
• 43:53received an R01,
• 43:56pretty recently to conduct a
• 43:57hybrid type two effectiveness implementation
• 44:00trial in order to
• 44:01have equal emphasis looking at
• 44:03effectiveness outcomes,
• 44:05so parent child like clinical
• 44:07outcomes as well as implementation.
• 44:09So she's going to be
• 44:10examining,
• 44:11clinic, clinician, and client factors
• 44:13that go into
• 44:15understanding what the outcomes are
• 44:17and that service barriers are
• 44:19facilitators.
• 44:20So that's really exciting. I'm
• 44:21really honored to be a
• 44:22co investigator on that project.
• 44:24And then for for me,
• 44:26I think some of the
• 44:27other future directions include quality
• 44:29improvement projects. Right? So instead
• 44:31of throwing the kitchen sink
• 44:32at parents, like that really
• 44:33big overwhelming scary slide,
• 44:36how do we begin to
• 44:37integrate mothering from the inside
• 44:38out across systems of care
• 44:40and across early parenthood? Right,
• 44:42from pregnancy,
• 44:44and prenatal care. Right? So
• 44:45I think about OEDYN clinics.
• 44:46I think about maternal fetal
• 44:47medicine,
• 44:49as well as substance use
• 44:50treatment clinics, which is you
• 44:51know, I'm encouraged by places
• 44:53like the App Foundation have
• 44:54like, pregnancy teams, which is
• 44:55nice.
• 44:57I think about labor and
• 44:58delivery and maternity units. I
• 45:00think about eat sleep console
• 45:01and the integration
• 45:03of the really wonderful work
• 45:04that Matt Grossman has done
• 45:06around decreasing the length of
• 45:08hospital stay using non pharmacological
• 45:10care,
• 45:11for infants who are prenatally
• 45:12exposed. And then how do
• 45:13we use some of the
• 45:14principles
• 45:15of mothering from the inside
• 45:16out,
• 45:18to really focus on what
• 45:19the parents' needs are. Right?
• 45:21So I think that that's
• 45:22been something that that I've
• 45:23wanted to see more of,
• 45:25and that I, in my
• 45:26clinical work, have heard parents
• 45:28want more of.
• 45:30I think about,
• 45:31the implementation of mothering from
• 45:33the inside out using through
• 45:34NICU follow-up. Right? So this
• 45:36is a population that very
• 45:37often is part of NICU
• 45:39follow-up clinics.
• 45:42And
• 45:43if NICU follow-up clinics kind
• 45:45of are fortunate to have
• 45:46longitudinal support of caregivers,
• 45:48I think about the many
• 45:49ways that this is a
• 45:50population that could be better
• 45:52served,
• 45:53by using again the same
• 45:54principles that mothering from the
• 45:55inside out carries.
• 45:58And then we've talked about
• 45:59early intervention,
• 46:00in home outpatient,
• 46:01a nod to
• 46:02FBR.
• 46:04Family treatment court, I think,
• 46:05is another really interesting, place.
• 46:06So in actually Hamden County
• 46:08up in,
• 46:09Springfield, Massachusetts, that's, you know,
• 46:12mothering from the inside out
• 46:13has actually been
• 46:14adopted as the primary,
• 46:17clinical option that parents are
• 46:19sent to. And so they're
• 46:20sent kind of into
• 46:22different agencies in the community
• 46:24of,
• 46:25that each have providers that
• 46:26are trained in mothering from
• 46:27the inside out that I
• 46:28myself have trained. So that's
• 46:30really exciting. It's a nice
• 46:31opportunity.
• 46:33Mhmm.
• 46:34And then lastly,
• 46:35right, this is where I
• 46:36said, I swear I'm gonna
• 46:37come back to this. Right?
• 46:38And you've heard me say,
• 46:39what about the principles? Right?
• 46:40So it's not just about
• 46:41best practices and not just
• 46:43about providing MIO as an
• 46:44intervention,
• 46:45but what are the principles
• 46:46underlying
• 46:47MIO that we can lend,
• 46:50across systems of care and
• 46:52across professionals? Right? So regardless
• 46:54of what kind of work
• 46:56you're providing or what kind
• 46:57of support you're providing, what
• 46:58your professional training background is,
• 47:02how can you use a
• 47:03mentalizing
• 47:04frame to provide that support
• 47:06so that families feel safe
• 47:08and heard and understood and,
• 47:09like, their
• 47:11intersecting
• 47:12identities
• 47:13are cared for.
• 47:14Right.
• 47:15So fortunate to also have
• 47:17funding from PCORI and from
• 47:18Apricus Principle
• 47:20to, develop a training that
• 47:22we're calling Early Relationships
• 47:23across systems, that takes this
• 47:25mentalizing stance,
• 47:27and applies it to,
• 47:29whatever type of work a
• 47:31professional is engaged in. So
• 47:32we've been fortunate to train,
• 47:34some
• 47:36childcare
• 47:37centers in this recently,
• 47:38and some other kind of
• 47:39home visiting paraprofessionals,
• 47:40community health workers,
• 47:42doulas,
• 47:43etcetera.
• 47:46And then lastly,
• 47:47up in up across the
• 47:48state of Massachusetts,
• 47:50I'm fortunate to work with
• 47:51this program called First Steps
• 47:53Together,
• 47:54that provides
• 47:56it's a peer led service
• 47:57that also has clinicians
• 47:58that are part of the
• 48:00work, and we've been able
• 48:01to train, all clinicians across
• 48:02the state of Massachusetts and
• 48:03mothering from the inside out.
• 48:05But peers are also trained
• 48:06again in these principles,
• 48:08and we've seen some really
• 48:09promising outcomes
• 48:10there. So really, the sky
• 48:12is the limit.
• 48:14And I will end there.
• 48:16We've got I did it.
• 48:18We've got ten minutes,
• 48:20but also happy to kind
• 48:21of answer any questions and
• 48:23a big thank you for
• 48:24for having me and for
• 48:25my collaborators. So thank you.
• 48:37So much about that kind
• 48:38of questions.
• 48:44That that was really wonderful.
• 48:45Your excitement just, you know,
• 48:47is contagious here. I have
• 48:49one question for you.
• 48:50I've been working with this
• 48:51wonderful group of nuns in
• 48:53in Bridgeport,
• 48:55at a literacy center. And,
• 48:57what they do,
• 48:59just incredible group of people,
• 49:02they asked the women in
• 49:03this literacy center what was
• 49:05helpful,
• 49:06every one of them, and
• 49:06and what did you want?
• 49:07And they all wanted their
• 49:09basic needs met. Mhmm. You
• 49:10know,
• 49:12diapers,
• 49:13food for their kids, a
• 49:14safe bed.
• 49:16My my question to you
• 49:17is, and and I understood
• 49:19some of what you got
• 49:20at with this, but when
• 49:21you ask
• 49:22these substance abusers what it
• 49:24is that they really want,
• 49:27and and you said to
• 49:28be heard and to be
• 49:28understood, but could you just
• 49:30address that a little bit?
• 49:31What what are they really
• 49:32asking you for?
• 49:35Sure.
• 49:37Sure. I think one thing
• 49:40is
• 49:41decreased stigma and improved understanding,
• 49:44and so I try to
• 49:44avoid the term substance abuser.
• 49:47So that would maybe be
• 49:48one of the first things
• 49:49that I
• 49:51would
• 49:53encourage in a setting like
• 49:54this.
• 49:57And then we have, I
• 49:58think, really
• 49:59the wish from mothers who
• 50:02are in recovery
• 50:03from substance use disorder,
• 50:05something that they express that
• 50:07they wish.
• 50:08I think basic needs are
• 50:09a big piece,
• 50:11and and help communicate that
• 50:13we see
• 50:14that their needs are more
• 50:16than just the really heady
• 50:18stuff that I think we
• 50:19often think about.
• 50:21But to be seen and
• 50:22to be heard, is your
• 50:23question to is is it
• 50:25to tease apart what that
• 50:26means?
• 50:27No. Just just, you know,
• 50:30how how far you get
• 50:31down to, you know,
• 50:33what and the surface when
• 50:35they start what they really
• 50:36want in order to do
• 50:37that Sure.
• 50:38Sure. Sure.
• 50:39So
• 50:40so often and, again, like,
• 50:41in in our research settings,
• 50:46we would often have folks
• 50:47enroll
• 50:48in the parenting program, is
• 50:50kind of how it was
• 50:51described.
• 50:52And they would say that
• 50:53their reason was because they
• 50:55wanted to,
• 50:56A, manage their ch their
• 50:58toddlers' behavior. Because and it
• 51:00was like when the kiddos
• 51:00were toddlers, that's when they
• 51:01were like, I need help.
• 51:03Right? So wanting to manage
• 51:04toddler behavior.
• 51:05And then we even had
• 51:07a lot of parents be
• 51:07able to say and have
• 51:09some degree of insight and
• 51:10say, I just want to
• 51:11do things differently.
• 51:13Right? And so we'd say,
• 51:15got it. We can that's
• 51:16what we're here for. Right?
• 51:17But there's,
• 51:18I've often been astounded and
• 51:20impressed and amazed,
• 51:22the ways that
• 51:24this very specific population
• 51:27of
• 51:28caregivers who are in recovery
• 51:30and having that intersection
• 51:32have the insight and the
• 51:33vulnerability to say, like, that
• 51:35did not look so hot
• 51:36when I was a kid,
• 51:38and I wanna do it
• 51:38differently. I don't know how.
• 51:40Please help me.
• 51:43And that's where the fun
• 51:44is. Thank you. Yeah. Yeah.
• 51:47And I think we have
• 51:48a question from Catherine Barb.
• 51:49Catherine, if you want to
• 51:51jump in.
• 51:52Sure. Thank you. Thank you
• 51:53so much for this talk.
• 51:54Can you guys hear me
• 51:55okay? Yep. Yeah. Cool.
• 51:58I have a question. I
• 52:00just recently and I don't
• 52:01wanna overtalk it because I'm
• 52:02still
• 52:03trying to figure out what
• 52:04we're doing, but I just
• 52:05recently joined a work group
• 52:06with, the Department of Children
• 52:08and Families
• 52:09focusing on birth to five
• 52:10kiddos and and families of
• 52:12birth to five kiddos.
• 52:15Some of what we're looking
• 52:16at are risk factors, safety
• 52:18concerns.
• 52:19My inclination
• 52:21is that we're going to
• 52:21be working on psychoeducation
• 52:24with these families. Can you
• 52:25talk a little bit about
• 52:26that psychoeducation
• 52:27piece that actually resulted in
• 52:29some harm with these families
• 52:32and,
• 52:33what what that looked like,
• 52:34what the research showed, and
• 52:36and any insights that I
• 52:37could glean from that would
• 52:38be really helpful. Yeah. I
• 52:40mean, I I would
• 52:43Let's say it's a good
• 52:44it's a really good question.
• 52:45I would hesitate
• 52:47and I apologize if it
• 52:48if it looked as or
• 52:49if if my way of
• 52:50communicating about psycho ed
• 52:53made it look like it
• 52:54was associated with harm. Because
• 52:55I think
• 52:56where what I take away
• 52:58from those findings is that
• 53:00and what because what we
• 53:01have to keep in mind
• 53:01is that this is pre
• 53:02to post treatment, right? And
• 53:04so there's a passage of
• 53:05time that's happening.
• 53:07And so
• 53:08what there's also research indicating
• 53:10is that families with substance
• 53:11use problems
• 53:13tend to generally just show
• 53:15a deterioration
• 53:16over time
• 53:17anyway, right? So kiddos
• 53:19wind up having behavior problems
• 53:21as they mature
• 53:22and parents struggle a bit
• 53:24more and become maybe a
• 53:25bit more depressed as this
• 53:27kind of unfolds,
• 53:28that's just the general trajectory
• 53:30that research shows can happen.
• 53:32And so my argument, I
• 53:33think, is that psycho ed
• 53:34just, like, doesn't prevent that
• 53:35from happening. Right? It doesn't
• 53:37it's not the protective buffer
• 53:38that we might hope it
• 53:40is, whereas a more mentalization
• 53:42frame,
• 53:43was able to kind of
• 53:44bolster that and prevent it
• 53:46from from deteriorating
• 53:48as it naturally would over
• 53:49time. Does that make sense?
• 53:53Yeah. It does. Thank you
• 53:54so much. Yeah. That's that's
• 53:56very helpful. But but still
• 53:57a lot to think about
• 53:58as we're rolling out some
• 53:59of these,
• 54:01these ideas and and providing
• 54:03some feedback.
• 54:04So thank you. Yeah. Yeah.
• 54:06Always open to discuss
• 54:08this topic.
• 54:10Hi. Thank you so much
• 54:10for your talk. My name
• 54:12is Victoria. I'm one of
• 54:13the child fellows.
• 54:14And, in a past life,
• 54:16I worked as a substance
• 54:17use treatment counselor for parents,
• 54:19who are mandated to treatment
• 54:20through,
• 54:21drug courts in Inglewood, California.
• 54:23So a lot of what
• 54:24you shared really resonated,
• 54:26for me in that work
• 54:27and kind of adding to
• 54:29that question, I was also
• 54:30thinking about the parental psycho
• 54:32ed piece and was thinking
• 54:33about the,
• 54:35clinic that I worked at
• 54:36was an an abstinence only
• 54:39model.
• 54:39And so
• 54:41I found it didn't really
• 54:42utilize harm harm reduction frameworks.
• 54:44It was definitely nonrelational
• 54:47in its field
• 54:48field and kind of, like,
• 54:49used a very moralizing
• 54:51view, you know, a moral
• 54:53failing type of view of
• 54:54addiction. So I was wondering
• 54:55in the,
• 54:56settings that you worked at,
• 54:58were they mostly kind of
• 54:59abstinence
• 55:00only type of models?
• 55:02Or,
• 55:03was it varied? And did
• 55:05you notice, like, a difference?
• 55:07It definitely varied. In my
• 55:08work in Florida, that was
• 55:10abstinence only.
• 55:11Hard hard stop.
• 55:13You were in residential, and
• 55:15you you went and you
• 55:16had a day pass and
• 55:17you used something and you
• 55:18came, you're out.
• 55:20Right? In Connecticut,
• 55:21I was doing much more
• 55:22work with, like, kind of
• 55:23in the outpatient setting and
• 55:25there were slip ups and
• 55:26that was
• 55:27part of the deal. Right?
• 55:28So,
• 55:31and I think that that
• 55:32holds a much more mentalizing,
• 55:33you know, I think that
• 55:34that's much more kind of
• 55:35simpatico with
• 55:36with,
• 55:37a mentalizing
• 55:38frame. But, oh, that's really
• 55:39interesting. Thank you for
• 55:41sharing your experience.
• 55:44That's that's an interesting world.
• 55:49So thank you. This is
• 55:51a really terrific talk, and
• 55:52I resonated with me a
• 55:53lot. And I just wanted
• 55:54to share that there
• 55:56your results are consistent
• 55:58with I've started doing similar
• 55:59work with substance using fathers
• 56:01using a mentalization
• 56:03focused intervention
• 56:04and
• 56:06the relapse or the substance
• 56:07use outcomes are similar that
• 56:09when we compare it to
• 56:10the exact same thing that,
• 56:11that Nancy Suckman used the
• 56:13parent education,
• 56:14as the comparator, that those
• 56:16getting
• 56:17something that was more focused
• 56:18on the parent and the
• 56:19child together.
• 56:21The fathers were less likely
• 56:23to relapse after they were
• 56:24discharged from residential treatment.
• 56:26So I think there is
• 56:28something
• 56:28about like, not that the
• 56:30education is harmful necessarily, but
• 56:32it doesn't have the same
• 56:33protective factor. They don't feel
• 56:34as seen or as part
• 56:35of the relationship, like you
• 56:37said, and that the improved
• 56:39relationship is really what
• 56:41is protective, I I think.
• 56:42I think that's what you
• 56:43were saying. Yeah. Yeah. Well,
• 56:44and the bidirectional nature of
• 56:46it. Right? So the old
• 56:47way of doing it used
• 56:48to be like, get clean
• 56:50and sober and then focus
• 56:51on parenting. But what I
• 56:53think really we see is
• 56:54that by focusing on parenting,
• 56:55it kind of goes back.
• 56:57And so the synergy and
• 56:58bidirectionality
• 57:00of it is
• 57:01really exciting. And I But
• 57:02not focusing on the mechanics
• 57:04of parenting. Like this is
• 57:06how you
• 57:06discipline your child. More like
• 57:08how do you be in
• 57:09relationship and understand your child,
• 57:11right, which I think is
• 57:12the key to what you're
• 57:13saying.
• 57:14Yes. Thank you. Yes. Yes.
• 57:15Yes.
• 57:20Any other final questions for
• 57:22Amanda, either in the room
• 57:23or on Zoom?
• 57:28Great. Well, if not, then
• 57:29just all that's left is
• 57:30to thank you once again
• 57:31for talk. Talk.