Program Goals

The goals of Mothering from the Inside Out (MIO) are:

• Increase parental reflective functioning
• Improve caregiving sensitivity
• Improve parent-child interactions
• Improve child attachment security
• Decrease caregiver depression
• Decrease caregiver substance use

Logic Model

The program representative did not provide information about a Logic Model for Mothering from the Inside Out (MIO).

Essential Components

The essential components of Mothering from the Inside Out (MIO) include:

• Provided to caregivers individually, either in-person or virtually
• 12-session intervention meant to be delivered in weekly 1-hour sessions
• The development of a strong therapeutic relationship:
• Considered the core of MIO
• Foster a relationship where the caregiver is taken seriously by the clinician, and their thoughts are held in mind by the clinician
• The clinician’s use of a mentalizing stance that is:
• Curious and inquisitive:
• Each caregiver’s mind is acknowledged to be unique and works differently
• The only way to understand the caregiver’s mind is to ask about it
• Room is made for the caregiver to develop their own mind by the clinician inviting them to expand on their thoughts, wishes, intentions, and emotions.
• Not-knowing:
• The opacity of mental states is acknowledged
• Although a child’s thoughts or emotions can never be known for certain, it is helpful to make good guesses based on what is known of the child’s development, temperament, history, etc.
• Transparent:
• Sharing or loaning their own mentalizing process is done by the clinician to provide a window into how to make sense of mental states. For example, clinicians may:
• Describe how they are making sense of a situation
• Acknowledge what they don’t know and can’t know
• Explicitly express their interest and curiosity in the caregiver’s mind and the child’s mind
• Collaborative:
• Rather than teaching or coaching the caregiver, the clinician collaborates and ‘thinks with’ the caregiver to make sense of:
• What the caregiver is thinking and feeling
• How that is impacting their behavior
• How that is playing out in the parent-child relationship
• Child-focused:
• The child is held in mind by the clinician even when the child is not the focus of the discussion.
• With appropriate timing (i.e., when the caregiver has made sense of their own mental states and is regulated), the clinician asks about how the child may be experiencing the situation and what their mental states may be.
• An emphasis on helping the caregiver to engage in self-focused mentalizing first:
• Uses an “oxygen mask” approach, encouraging caregivers to first make sense of their own strong reactions before attuning to their child’s emotional states
• Follows the caregiver’s lead and focuses on what is on the caregiver’s mind
• Considers specific interpersonal situations in detail to identify:
• The caregiver’s internal thoughts and emotions
• How they arose
• How they influenced the:
• Caregiver’s parenting behavior
• Parent-child relationship
• Supporting the caregiver to mentalize for the child:
• Clinicians think together with the caregiver to make sense of the child’s mental states, which guides the parenting approach.
• Specific parenting situations are considered in detail to identify:
• The child’s possible internal emotions and wishes
• How they arose
• How they influenced the child’s behavior
• How this made the caregiver feel
• Providing attachment-based developmental guidance:
• MIO includes discussion of attachment to:
• Contextualize children’s behavior
• Help caregivers make sense of the challenges they may be experiencing with their children
• These discussions serve as a springboard that help inform how the caregiver may then choose to approach parenting in ways that are sensitive and response to their child’s unique needs.

Program Delivery

Parent/Caregiver Services

Mothering from the Inside Out (MIO) directly provides services to parents/caregivers and addresses the following:

• Challenges in parental reflective functioning
• Caregiving insensitivity
• Parenting stress
• Limited understanding of children’s attachment behaviors and emotional needs

Recommended Intensity:

One weekly 50-minute session

Recommended Duration:

12 weeks

Delivery Settings

This program is typically conducted in a(n):

• Birth Family Home
• Outpatient Clinic
• Community-based Agency / Organization / Provider
• Virtual (Online, Telephone, Video, Zoom, etc.)

Homework

This program does not include a homework component.

Resources Needed to Run Program

The typical resources for implementing the program are:

• Personnel
• Clinician with good reflective skills, knowledge of attachment, and knowledge of addiction
• Supervisor who provides reflective supervision
• Space
• Private space for individual therapy (e.g., outpatient therapy room; virtual therapy room via Zoom)
• Technology
• Computer or laptop (with webcam and microphone for supervision and MIO sessions, if being provided virtually)

Manuals and Training

Prerequisite/Minimum Provider Qualifications

• Bachelor’s degree or higher in psychology, social work, or other related field
• Experience in substance use counseling, clinical or counseling psychology, social work, or related clinical discipline

Manual Information

There is a manual that describes how to deliver this program.

Program Manual(s)

Manual details:

• Suchman, N., Decoste, C., Legow, N., Castiglioni, N., & Mayes, L. C. (2018). The Mother and Toddlers Program: An individual therapy for mothers in substance abuse treatment [Therapist Manual]. Yale School of Medicine.
• Lowell, A. F., & Suchman, N. E. (In press). Mothering from the Inside Out: Therapist manual (Revised) [Treatment Manual]. Yale School of Medicine.

Materials provided through training. More information is available upon request through the training contact listed below.

Training Information

There is training available for this program.

Training Contact:

• Amanda Lowell, PhD
  amanda.lowell@yale.edu

Training Type/Location:

Onsite as trainee organization, or via virtual means (Zoom)

Number of days/hours:

16 hours of didactic/classroom training (in person or virtual)
20 hours of weekly clinical training/supervision (virtual)

Implementation Information

Pre-Implementation Materials

There are pre-implementation materials to measure organizational or provider readiness for Mothering from the Inside Out (MIO) as listed below:

There is a readiness assessment entitled, Mothering from the Inside Out (MIO): Training & Learning Collaborative, application which provides a detailed description of the requirements involved for sites, supervisors, and clinicians participating in the MIO training.

The application solicits information regarding:

• Organizational Assessment
• Agency:
• Number of clinical staff total
• Number being trained
• Client population served
• Population of parents with young children
• Type of services agency typically provides
• Number of cases for each full-time clinician
• Typical frequency and length of client visits
• Supervision: Model used for supervision.
• Financial sustainment: Any clinician fees/reimbursement structure that may impact MIO training or delivery.
• Sites are asked to consider how MIO sessions will be supported and fit into existing service structure.

Participant Assessment

• Supervisor:
• Name
• Contact info
• Experience bringing child-parent services to parents in recovery from substance use disorders
• Comfort offering supervision that includes attention to attachment, parent-child relationship, and parenting capacities
• Clinicians:
• Name
• Contact info
• Experience bringing child-parent services to parents in recovery from substance use disorders
• Knowledge of key components of MIO intervention (reflective practice, child development, social/emotional needs of parents)
• Acknowledgement of requirements and commitment to MIO training

Materials are available upon request from the Director of Implementation Research (see contact information at bottom of the entry).

Formal Support for Implementation

There is formal support available for implementation of Mothering from the Inside Out (MIO) as listed below:

Implementation support is provided by the Director of Implementation and Quality Improvement (see contact information at bottom of the entry). Support is provided via videoconferencing and email across the spectrum of implementation from pre-implementation to sustainment in the following ways:

• Outreach to local agencies, describing MIO and the training process, answering questions
• Organizational Readiness Assessment: Reviews application with site directors/supervisors/clinicians and answers questions
• Communication about training requirements, logistics, and expectations
• Facilitate virtual training logistics (e.g., Zoom tech support, CEU credits)
• Facilitate formation and communication about supervision groups
• Manage access to training recordings and material via a password protected platform
• Meeting with clinicians and communicating with site directors/ supervisors to initiate MIO delivery (e.g., identification of families, consent of parent participants, audio-recording devices, safe storage of audio, sharing audio on Zoom)
• Oversee fidelity assessments
• Conduct follow-up exit interviews for quality improvement purposes and to assess and assist in sustainment of MIO after training

Formal support is available for the duration of the MIO training and delivery, approximately 28 weeks.

Fidelity Measures

There are fidelity measures for Mothering from the Inside Out (MIO) as listed below:

Fidelity has been assessed in research studies using audio/video recorded treatment sessions that are coded by trained coders. Coders evaluate fidelity on 10 scales that assess therapist alliance building (i.e., general therapeutic skills), psychoeducation (i.e., non-MIO) interventions, and mentalization-based (i.e., MIO-specific) interventions. There have been multiple revisions of this fidelity tool developed across three clinical trials. Generally, the goal of the revisions has been to reduce the measure to the fewest, most robust markers of fidelity to the treatment model.

• DeCoste, C., Peacock-Chambers, E., Borelli, J. L., Rosenberger, P., Suchman, N. E. (2022). Mothering from the Inside Out and parent education counselor fidelity and competence rating scales and coding procedures manual, including counselor statements and ratings from treatment sessions supplement. (4th ed.). Internal publication. Yale University School of Medicine.

A version of this fidelity tool has been adapted for clinicians to self-reflect and evaluate their adherence to MIO after completing each of the 12 sessions during their training case. For specific information about this clinician-friendly fidelity tool, please contact the training contact listed in the previous section.

Established Psychometrics:

The internal reliability, interrater reliability, discriminant validity, and predictive validity of the fidelity measure have been documented; however, there is no single publication describing the psychometric properties of the fidelity measure. Information concerning the development and psychometric properties of the original measure and the two revisions can be found in the publications listed below:

• Suchman, N. E., DeCoste, C., Castiglioni, N., McMahon, T. J., Rounsaville, B. J., & Mayes, L. C. (2010). The Mothers and Toddlers Program: An attachment-based parenting intervention for substance-using women: Post-treatment results from a randomized clinical trial. Attachment & Human Development, 12(5), 483–504. https://doi.org/10.1080/14616734.2010.501983
• Suchman, N. E., DeCoste, C., Rosenberger, P., & McMahon, T. J. (2012). Attachment-based intervention for substance using mothers: A preliminary test of the proposed mechanisms of change. Infant Mental Health Journal, 33(4), 360–371. https://doi.org/10.1002/imhj.21311
• Suchman, N. E., DeCoste, C. L., McMahon, T. J., Dalton, R., Mayes, L. C., & Borelli, J. L. (2017). Mothering from the Inside Out: Results of a second randomized clinical trial testing a mentalization-based intervention for mothers in addiction treatment. Development & Psychopathology, 29(2), 617–636. https://doi.org/10.1017/S0954579417000220
• Suchman, N. E., DeCoste, C., Borelli, J. L., McMahon, T. J. (2018). Does improvement in maternal attachment representations predict greater maternal sensitivity, child attachment security and lower rates of relapse to substance use? A second test of Mothering from the Inside Out treatment mechanisms. Journal of Substance Abuse Treatment, 85, 21–30. https://doi.org/10.1016/j.jsat.2017.11.006
• Suchman, N. E., Borelli, J. L., & DeCoste, C. L. (2020). Can addiction counselors be trained to deliver Mothering from the Inside Out, a mentalization-based parenting therapy, with fidelity? Results from a community-based randomized efficacy trial. Attachment Human Development, 22(3), 332–335. https://doi.org/10.1080/14616734.2018.1559210
• Lowell, A. F., DeCoste, C., Dalton, R., Dias, H., Borelli, J. L., Martino, S., McMahon, T. J., & Suchman, N. E. (2023). Mothering from the Inside Out: Results of a community‐based randomized efficacy trial testing a mentalization‐based parenting intervention for mothers with addictions. Infant Mental Health Journal, 44(2), 142–165. https://doi.org/10.1002/imhj.22043

Implementation Guides or Manuals

There are implementation guides or manuals for Mothering from the Inside Out (MIO) as listed below:

Train-the-Trainer manual: This is a workbook that accompanies a virtual training. The contents include:

• Introduction to Train-the-Trainer
• Training agreements
• Training agenda and outline:
• Context for Train-the-Trainer
• Teaching skills
• Giving and receiving feedback
• Preparing a “mini Lesson” of MIO
• Homework
• Training Case Vignette
• Clinician Fidelity Self-Reflection form and tip sheet
• Parent information card

This manual is available upon request from the Director of Implementation Research (see contact information at bottom of the entry).

Implementation Cost

There are no studies of the costs of Mothering from the Inside Out (MIO).

Research on How to Implement the Program

Research has been conducted on how to implement Mothering from the Inside Out (MIO) as listed below:

• Ordway, M. R., McMahon, T. J., De Las Heras Kuhn, L., & Suchman, N. E. (2018). Implementation of an evidenced‐based parenting program in a community mental health setting. Infant Mental Health Journal, 39(1), 92–105. https://doi.org/10.1002/imhj.21691
• Suchman, N., Berg, A., Abrahams, L., Abrahams, T., Adams, A., Cowley, B., DeCoste, C., Hawa, W., Lachman, A., & Mpinda, B. (2020). Mothering from the Inside Out: Adapting an evidence-based intervention for high-risk mothers in the Western Cape of South Africa. Development and Psychopathology, 32(1), 105–122. https://doi.org/10.1017/S0954579418001451
• Suchman, N. E., Borelli, J. L., & DeCoste, C. L. (2020). Can addiction counselors be trained to deliver Mothering from the Inside Out, a mentalization-based parenting therapy, with fidelity? Results from a community-based randomized efficacy trial. Attachment & Human Development, 22(3), 332–351. https://doi.org/10.1080/14616734.2018.1559210
• Peacock-Chambers, E., Buckley, D., Lowell, A., Clark, M. C., Friedmann, P. D., Byatt, N., & Feinberg, E. (2022). Relationship-based home visiting services for families affected by substance use disorders: A qualitative study. Journal of Child and Family Studies, 31(8), 2121–2133. https://doi.org/10.1007/s10826-022-02313-1
• Peacock-Chambers, E., Moran, M., Clark, M. C., Borelli, J. L., Byatt, N., Friedmann, P. D., Suchman, N., Feinberg, E. (2023). Adaptation of an evidence-based parenting intervention for integration into maternal-child home-visiting programs: Challenges and solutions. Implementation Research and Practice, 4. https://doi.org/10.1177/2633489522115102
• Lowell, A., Suchman, N. E., Byatt, N., Feinberg, E., Friedmann, P., Peacock-Chambers, E. (2023). Parental substance use and home visiting programs: Implementation considerations for relationship-based treatment. Infant Mental Health Journal, 44(2), 166–183. https://doi.org/10.1002/imhj.22041

Relevant Published, Peer-Reviewed Research

Additional References