“There’s no book on parenting,” says Cynthia Hunter-Gamble, mom, grandmother, and person in recovery. “They might come out with books, but you know, every child is totally different.”
Every parent is different, too. And parents—like children—grow, learn, and change. That’s a fundamental premise behind “Parenting from the Inside Out,” an intervention now being tested at West Haven Mental Health Clinic, a satellite clinic of Connecticut Mental Health Center.
Originally designed for people like Hunter-Gamble, who struggled with drug addiction when her children were young, today the expanded “Parenting from the Inside Out” program at West Haven Clinic supports parents in recovery from mental health problems, as well as parents whose children are in mental health treatment at the clinic.
What sorts of challenges do parents in recovery face? For this story I asked three parents, all people in recovery, to step back and reflect on their experiences with parenthood.
Antjuan
“A father’s not made by his genes,” reflects new dad Antjuan Sherard, 21, over coffee near his Section 8 apartment. “He’s the person that’s there for you, cares for you, protects you in the right way—just a little bit, enough to enable you to do things on your own.”
Sherard says he learned from his own absentee father how not to be a father. He describes his life as a smart yet volatile kid who got into a lot of fights, was expelled from school, and went in and out of the hospital before he ended up in a residence run by the Connecticut Department of Children and Families (DCF). After chafing against the lack of free time at the residence, he grew to appreciate its tight structure and daily routines. He excelled there, reaching the highest level of accomplishment awarded to residents. At 18, he aged out of DCF and was accepted as a client in the Young Adult Service (YAS) program at West Haven Mental Health Clinic.
News that he was to become a father changed Antjuan’s life. After a tangled negotiation with the social service system, he and his partner found stable, affordable housing.
“DCF was going to get involved if we didn’t have housing by the time the baby was born,” he explains. With a part-time job, educational aspirations, and a mental health clinician he trusts, Antjuan is doing well. And while he is benefitting from the supports he has, he also wants from social service agencies what mental health professionals call the “dignity of risk.”
“What happens when we get our own place and we’re not in the program anymore?” he asks. “We have to make these mistakes as parents. We have to. If we don’t, we don’t learn from them. We don’t change.”
Kevin
Kevin Johnson, 55, began his fatherhood journey during a different era when “recovery-oriented care” was not the norm. He was 21 when his first child, a girl, was born.
“I was the happiest man on earth,” recalls Johnson. “Her being born gave me a sense of purpose.”
Johnson, now a Recovery Support Specialist at the Yale Program for Recovery & Community Health, has never known his father or mother. He was reared in the foster care system in New York, living in six different households by the time he turned 18.
“I had a lot of challenges,” he reflects, “being that I’d been diagnosed early in my life with mental illness. I didn’t know how to be a father, but I knew I had the will to be a father.”
Today, Johnson has a very close relationship with his two children, both college graduates. Looking back, he seems almost amazed that things turned out so well.
“My relationship with the mental health system was more strained than supportive,” he says of the tumultuous years when his children were growing up. “They didn’t believe in me being able to raise a child.”
Johnson says he “didn’t look the part of being a great parent.” With “rage, attitudes, and resentments,” coupled with suicide attempts and alcoholism, he struggled mightily. “A lot of stuff went on back in the day,” he says. “I’m surprised that I did become successful as a parent, because the mental health system was built at that time around separating.”
Fifteen years ago, Johnson moved to Connecticut. He went to Bridgeport Mental Health Center, which he calls a “total new beginning” and the place where he began to redefine what recovery could mean. Eventually, he was recruited to become a recovery support specialist by researchers from the Yale Program for Recovery and Community Health, who recognized his talent.
“The struggle still continues for me,” he says, “but now it’s all about me. I don’t have the motivation of my kids any more. My kids were always my motivating rock.”
Cynthia
“Children are a gift,” says Cynthia Hunter-Gamble, who like Kevin Johnson is a recovery support specialist at the Yale Program for Recovery and Community Health. “God puts that child in your life. It’s like a plant. You water it and see it blossom.”
Cynthia Hunter-Gamble, 34 years a parent, says she grew up with parents who were good providers but not very affectionate. She was determined to show affection to her children—until drugs got in the way.
“Using (drugs), I separated away from being so affectionate,” she recalls. “Once I got clean, I realized how much that affection helps a child grow.”
Hunter-Gamble’s drug problem led to DCF placing her children with relatives. During the period when she was abusing drugs, she lost one child in a tragic accident. She also served seven consecutive years in prison. “DCF got involved,” she says, “and placed my children with family members.” Hunter-Gamble never lost her parenting rights; she remained close and connected to her children throughout their childhoods, even though she did not have custody of them. She says that she finally realized that by using drugs, she was self-medicating for depression. Today, as a recovery support specialist, she works with people on their recovery, giving back the wisdom she has gained throughout her life.
“It’s important that, as a parent, you allow your children to know who you are,” says Hunter-Gamble. “Every day is not peachy dory. Some days I get depressed, I get lonely, I get angry. Sometimes, I look back over my life and know that I could have done things differently. But I can’t go back there…I have to look forward, so I build a new foundation with my children.”
Parents in the Mental Health System
“We have relatively little knowledge of the extent to which there are parents in the mental health and substance abuse treatment system nationwide,” says Thomas McMahon, PhD, director of West Haven Mental Health Clinic. “Most behavioral health systems do not systematically collect data on the parenting status of their clients.”
If general population statistics are a guide, the number is large. According to the National Health Interview Survey published in 2000, 74% of women and 65% of men in the US have ever had a biological child. Most adopt the social role of parent. Many adults also assume parenting roles for children who are not their biological children.
Despite its joys and rewards, parenthood is a demanding job requiring physical, mental, and emotional skill and stamina. In the US, adults at all socio-economic levels find it difficult to enjoy their children (for more information, see The Trauma of Parenthood). For those in recovery and/or living in poverty, the challenges can be enormous. Parents with mental illness or addiction face stigma on many fronts. They may be stereotyped as solitary individuals without family ties, or as unfit to care for children. As Cynthia, Antjuan, and Kevin reveal, they may struggle with housing provisions, custody issues, poverty, the legal system, DCF, or all of the above. On top of all that, they may experience debilitating mental health symptoms that also impact their children. And they have the same complicated day-to-day journey that every parent has: how to care for children, provide for them, keep them safe, and prepare them for the future.
And then there’s love. For people in recovery, many of whom experienced devastating losses and traumas before becoming parents, parenthood may restore their sense of hope and purpose.
So for mental health professionals, what is the key to supporting the many individuals in recovery who are parents?
Parenting from the Inside Out
Psychologist Nancy Suchman, PhD, a pioneer in the area of working with parents in recovery, developed “Parenting from the Inside Out” from her observations about the developmental needs and experiences of mothers in recovery. Contrary to many approaches that focus on the child’s needs and developmental stages, hers begins in a different place: with the parent.
The basic idea, she says, is to help the parent better understand her or his own mental and emotional experiences as a parent. This is the first step toward developing empathy (including self-empathy), managing one’s emotions, and not becoming overwhelmed by the stress of parenting.
“When a mother is upset over an experience she had with her child, it’s important not to jump too quickly to the child’s distress without first considering the parent’s distress,” explains Dr. Suchman. “We first try to empathize with the mother’s point of view and help her understand how she arrived there.”
“Once a parent appreciates his or her own state of mind and feels that her experience is truly accepted and understood by the therapist, she can make ‘room’ in her mind to think about her child’s experience from a more calm and regulated mental stance. Importantly,” she adds, “we’re not teaching relaxation strategies. We’re helping parents make sense of their own experience.”
Mentalization Theory
The model is based on “mentalization theory,” which originated with the work of Peter Fonagy and colleagues in London. The capacity to “mentalize,” also called “reflective functioning,” is our ability to make sense of our own and others’ emotional experiences in context. Reflective functioning is thought to begin developing in infancy, when parents play a critical role in fostering it.
“There is clear data showing that as the capacity for reflective functioning goes up, relapse rates go down,” explains Dr. Suchman. “We believe this capacity to mentalize provides parents with a critical foundation for managing their own emotions and, importantly, helping their children to develop this reflective capacity. Improving a parent’s capacity for reflective functioning supports recovery at the same time as it promotes healthy parent-child relationships.”
Dr. Suchman says that mothers in treatment are often working on many things at once. The program helps them develop realistic expectations for themselves and their children.
“People in recovery who are parents are often feeling tremendous failures,” she continues. “They may idealize what a parent should be without recognizing the very difficult nature of the task. Sometimes they are expecting too much of themselves and losing perspective on the challenges they face. Often, they don’t have accurate information on what to expect from their young children developmentally. So we help to fill in the gaps.”
Not a Parenting Class
Dr. Suchman notes that her program is not a parenting class and there is no set curriculum. “Each parent-child pair is different,” she explains, “and we feel it’s very important for the developmental guidance we provide to be personally relevant.”
“We want to help parents establish a clear and strong sense of themselves as parents,” Dr. Suchman explains. “Sometimes the system inadvertently does the opposite—it demands extraordinary efforts from parents and consequently diminishes their sense of self-efficacy. Reflective functioning is at the core of this self-agency-building process. It enables a parent to better understand her or his own emotional needs separate from a child’s, and to address both sets of needs in constructive ways.”
Dr. Suchman has studied the intervention—originally named “Mothering from the Inside Out”—extensively with mothers in recovery from drug addiction. It started as a group modality but is now practiced as individual therapy. After two randomized trials showing the efficacy of the individual therapy model, Dr. Suchman’s program is considered an “evidence-based” treatment for substance abusing mothers. (For more on those results, read here and here.)
By bringing the program to West Haven Mental Health Clinic, Dr. Suchman and Dr. McMahon are testing its effectiveness with parents in treatment for mental health problems. The goal is to collect pilot data that would enable the team to pursue funding for a larger grant. It’s a great example of how research and clinical care are integrated throughout CMHC: research supports more research, and eventually, evidence-based practices are implemented on a bigger scale.
At West Haven Clinic, Dr. Suchman and her team are training pre- and post-doctoral psychology interns and psychiatry residents in the model. Retention rates among clients have been high; most completing the first twelve weeks of the program have opted to do an additional twelve sessions.
The program recently opened to fathers as well as mothers. West Haven clients are eligible to participate, as are parents whose children are in mental health treatment at the clinic.
Mary Anne Parisi is one of those who completed “Parenting from the Inside Out.”
“My experience was truly a blessing,” she says. Before she began the program, Parisi says she was overwhelmed and constantly felt like a failure when dealing with her three children.
“It taught me how to stop, take a second, and try to understand what I’m really upset about before I respond,” she explains. From there, she could try to understand what her child was going through. “It has worked for all my children,” she says.
Today, she says, “I have a much better line of communication with my kids…I enjoy having my kids now. We’re not without our moments, but I don’t allow the guilt to eat me up anymore.”
Parisi says she would recommend the program to anyone. “It’s wonderful for any parent who struggles with their children. I can’t stress how important this is for people’s mental health in our society right now...there are a lot of people out there who could use this program.”
An Integrated Setting
Dr. McMahon notes that West Haven Mental Health Clinic is uniquely situated to develop and test “Parenting from the Inside Out” because it treats both adults and children. At West Haven, members of child, young adult, and adult clinical teams communicate regularly and share a number of cases. Staff members strategize and coordinate care for families. The integrated set-up extends the program’s reach.
Early intervention with stressed parents and their children can promote positive parent-child relations. It can help parents feel better about themselves as parents and decrease the risk for emotional and behavioral difficulty in children. Clients and their children benefit most directly, but theoretically there are public benefits too: as parents and children do better, the costs to society—in terms of social, behavioral health, and educational services—go down.
The Journey Continues
Antjuan Sherard’s baby is mobile now. Clearly, Antjuan adores him. “I put him on the bed, he ended up on the floor!” he exclaims. He ponders the baby’s inner life: “I started getting interested in the emotions he gave out. Are you born with instincts? Are you not?”
Antjuan, keenly interested in philosophy and ethics, hopes to take college courses in both fields. These are key details of a young parent’s life—the personal strengths and passions that will inform his experience and values as a parent going forward. It’s born out in Dr. Suchman’s research, Cynthia Hunter-Gamble’s recovery journey, and Kevin Johnson’s life experience: the quest for self-understanding is at the core of parenthood.
“You can teach parenting, but you can’t teach fatherhood,” Johnson says. “There are basic guidelines as to what parenting is, but to be a father has to come from within that person’s soul.”
Johnson says his journey as a father has really been about self-knowledge. “That was my biggest battle: trying to figure out who I am and what identity, if any, I could have from within myself.”
Looking back on her early years as a mother, Cynthia Hunter-Gamble puts it this way: “I wasn’t healthy—emotionally and mentally and physically. I had to get me together.”
I ask Antjuan if he will eventually share his personal history with his son.
“Oh, I wouldn’t mind,” he replies. “I would just say, ‘Look, just don’t go off what I’ve done.’ I’m not saying all my choices were bad, because look where I am now…
“But if he doesn’t turn out like me, that’s great. I would love that, because I want him to be him.”