This study evaluated methods for training community-based clinicians to deliver a mentalization-based parenting intervention in an addiction treatment setting. Mothering from the Inside Out (MIO) targets psychological deficits associated with early stages of addiction recovery by fostering improvement in parental reflective functioning, the capacity to make sense of strong emotions in oneself and the child. Fifteen addiction counselors were randomized to training in MIO versus a Parent Education comparison, and completed eight training sessions and a clinically-supervised 12-session training case. As predicted, MIO and PE counselors demonstrated fidelity to their respective interventions during the training case. At the end of training, MIO counselors showed greater improvement than PE counselors in clinical reflective functioning, the capacity to make sense of a patients' mental and emotional experiences. Implications for training community-based counselors in evidence-based attachment interventions are explored.

As a group, substance-abusing parents are at risk for maladaptive parenting. The association between substance abuse and parenting may result, in part, from parents' emotional disengagement from the parent-child relationship, which makes perceiving and responding to children's cues more challenging. In this study, we examined whether substance-abusing mothers' levels of disengagement from their relationship with their children (ages 2-44 months), operationalized in two different ways using parenting narratives (representational and linguistic disengagement), prospectively predicted children's engagement and disengagement cues during a structured mother-child interaction. Within a sample of 29 mothers, we tested the hypotheses that greater maternal disengagement at Time 1 would predict a decrease in children's engagement and an increase in children's disengagement at Time 2. Results indicated that representational disengagement predicted a decrease in children's engagement cues whereas linguistic disengagement predicted an increase in children's disengagement cues. Results provide partial support for a reciprocal, iterative process in which mothers and children mutually adjust their emotional and behavioral disengagement with one another.

While research suggests that the therapeutic alliance is important in predicting outcomes of psychotherapy, relatively little is known about the development of the alliance or the moment-to-moment components of the relationship and how they combine to create an alliance, which may represent a serious limitation in existing methods of measurement. Language style matching (LSM), or the degree to which unconscious aspects of an interactional partner's language mimic that of the other partner, is a promising, unobtrusive measure of interaction quality that could provide novel insight into the therapist-client alliance. In this article, we present a theoretical argument regarding the trajectory of therapist-client LSM across therapy sessions, as well as potential precursors and consequences of LSM. We then report on a pilot test of our hypotheses that examined how LSM, clients' relational histories, and clients' symptoms were associated within a therapeutic context. Using a small sample of substance dependent mothers (N = 7, 100% Caucasian women) enrolled in a randomized controlled trial of psychodynamic psychotherapy lasting 12 sessions, we examined client and therapist LSM across 4 of the 12 sessions. We found that, on average, LSM decreases over the course of treatment. Furthermore, greater client interpersonal problems prospectively predict lower early LSM in therapist-client dyads, which in turn predicts greater posttreatment psychiatric distress. Results generate questions for future research and support further investigations of LSM as one index of the quality of interactions between therapist and client.

Parental reflective functioning (RF) has garnered tremendous support as a predictor of secure attachment in infancy, though little work has examined RF among parents of older children. In this study, we used a high-risk community sample of parent-child dyads (N = 117) to explore whether parental RF comprises self- and child-focused factors, whether parental RF is associated with parent and child attachment security, and whether parental RF mediates the association between parent and child attachment security. Results suggested that parental RF can be characterized as having both self- and child-focused components, and that child-focused parental RF is associated with child but not parent attachment security. Further, child-focused parental RF indirectly mediates the association between parent attachment avoidance and child attachment security. These findings extend previous work on parental RF to parents of school-age children and, in so doing, inform developmental models of attachment relationships in middle childhood. Discussion focuses on the importance of these findings in informing theory, prevention, clinical practice, and policy.

In this study, we replicated a rigorous test of the proposed mechanisms of change associated with Mothering from the Inside out (MIO), an evidence-based parenting therapy that aims to enhance maternal reflective functioning and mental representations of caregiving in mothers enrolled in addiction treatment and caring for young children. First, using data from 84 mothers who enrolled in our second randomized controlled trial, we examined whether therapist fidelity to core MIO treatment components predicted improvement in maternal reflective functioning and mental representations of caregiving, even after taking fidelity to non-MIO components into account. Next, we examined whether improvement in directly targeted outcomes (e.g., maternal mentalizing and mental representations of caregiving) led to improvements in the indirectly targeted outcome of maternal caregiving sensitivity, even after controlling for other plausible competing mechanisms (e.g., improvement in maternal psychiatric distress and substance use). Third, we examined whether improvement in targeted parenting outcomes (e.g., maternal mentalizing, mental representations of caregiving and caregiving sensitivity) was associated in improvement in child attachment status, even after controlling for competing mechanisms (e.g., improvement in maternal psychiatric distress and substance use). Finally, we examined whether improvement in maternal mentalizing and caregiving representations was associated with a reduction in relapse to substance use. Support was found for the first three tests of mechanisms but not the fourth. Implications for future research and intervention development are discussed.

Mothers with histories of alcohol and drug addiction have shown greater difficulty parenting young children than mothers with no history of substance misuse. This study was the second randomized clinical trial testing the efficacy of Mothering From the Inside Out (MIO), a 12-week mentalization-based individual therapy designed to address psychological deficits commonly associated with chronic substance use that also interfere with the capacity to parent young children. Eighty-seven mothers caring for a child between 11 and 60 months of age were randomly assigned to receive 12 sessions of MIO versus 12 sessions of parent education (PE), a psychoeducation active control comparison. Maternal reflective functioning, representations of caregiving, mother-child interaction quality, and child attachment were evaluated at baseline and posttreatment and 3-month follow-up. Mother-child interaction quality was assessed again at 12-month follow-up. In comparison with PE mothers, MIO mothers demonstrated a higher capacity for reflective functioning and representational coherence at posttreatment and 3-month follow-up. At 12-month follow-up, compared to PE cohorts, MIO mothers demonstrated greater sensitivity, their children showed greater involvement, and MIO dyads showed greater reciprocity. As addiction severity increased, MIO also appeared to serve as a protective factor for maternal reflective functioning, quality of mother-child interactions, and child attachment status. Results demonstrate the promise of mentalization-based interventions provided concomitant with addiction treatment for mothers and their young children.