Parents in recovery from substance use disorders: Adaptation and implementation research of Mothering from the Inside Out

November 08, 2022

Information

YCSC Grand Rounds November 1, 2022
Elizabeth Peacock-Chambers, MD
Assistant Professor of Pediatrics
UMass Chan Medical School - Baystate

ID8237

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00:00That introduction. Alright,
00:03I'm just going to pull up my slides.
00:07I'm going to complicate.
00:12Alright, you can see that now.
00:16Thank you again for the introduction
00:18and I'll just before I continue on,
00:21I'll just add that I came to this work
00:24as a pediatrician interested in early
00:27childhood development and really it
00:30was through a connection to one of
00:33your former colleagues and mentors to
00:35to many of the people here potentially
00:37in the audience around the call.
00:39Um, Dr. Nancy Suchman,
00:42and I was kind of it was through her
00:45that I found this connection between
00:47early the science of early childhood
00:49development and substance use disorder.
00:51And while we typically save our
00:53acknowledgements to the end,
00:54it felt very important in this setting
00:56to be able to bring her to mind and
00:59really understand that this work
01:01is an extension of her mentorship
01:03and the work that she conducted.
01:05So I have no disclosures to share
01:08with you today and.
01:09My goal is to briefly,
01:12very briefly describe the intersection
01:13between parenting and substance
01:15use disorders.
01:16Many of the folks here in your center
01:18have written the book on this and
01:20provided much of the basic science,
01:21so I'll just cover that briefly.
01:23But really we'll be focusing more so
01:25on key components of evidence based
01:28practices for supporting parents in
01:30recovery and then really in applying
01:32an implementation framework to guide
01:35adaptation of an evidence based practice
01:37for new settings or populations.
01:40So again,
01:41I'm jumping into the first
01:43objective intersection of parenting
01:44and substance use disorder.
01:46I want to also pause on this for just
01:48a moment to say parenting and substance
01:50use disorder is a very broad category.
01:53And for the majority of
01:54the beginning of the talk,
01:55I really will be focusing more so on opioid
01:58use disorder for a number of reasons,
02:00including the some of the relevant science,
02:03but primarily also because
02:04of the public health impact.
02:06We're all probably very familiar with
02:08this CDC graph showing the rapid.
02:10Increase in overdose death rates.
02:12And of course this epidemic
02:14has affected families,
02:16mothers and children such that
02:18substance use and drug related
02:20deaths are now one of the leading
02:22causes of maternal death postpartum.
02:24And similarly we've seen a tripling,
02:27more than tripling really of
02:29substance of infants born with
02:30neonatal abstinence syndrome or
02:32neonatal opioid withdrawal syndrome.
02:34So vastly,
02:35vastly affected,
02:37but the other important piece around.
02:40This particular population is that
02:43pregnancy can be a critical time
02:46for engaging families in recovery.
02:48So not only do we see an increase
02:50in the number of women who will,
02:52for example,
02:53seek medication for opioid use
02:55disorder during their pregnancy,
02:56but we even see through qualitative research,
02:59harm reduction.
02:59If they're not initiating medication,
03:02for example,
03:02they may make choices that reduce
03:05the risk of the impact of the
03:07substance on the unborn child.
03:09And of course,
03:10this has a lot to do with the
03:12maternal brain changes that are
03:14happening around the birth of the
03:16child and preparing for that,
03:18that new bond with the infants,
03:20the healthy preoccupation with the infant.
03:23So it's a it's really a critical
03:25time for reaching out to families.
03:27And while it can be a time where people
03:30may be more open to intervention,
03:32it's also a time where they need
03:34to be more sensitive to stress,
03:36partially because of many of these
03:38brain changes that are happening.
03:40And we see this in at a population level.
03:43So just to Orient you to this graph here,
03:47this is, this is the rate of opioid
03:50overdose events per one million person days.
03:53And on the left side here we have the first
03:56bar is the number of deaths of events,
03:59sorry what the first year before
04:01delivering a prior to conception and
04:03then the second bar graph is the 2nd,
04:062nd graph here is the first trimester,
04:07second and third trimester and you
04:08can see how those events steadily.
04:10Slow down leading up to the birth
04:12of the child.
04:12Right after the child is born,
04:14that level pops right back up to those
04:17preconception rates and then actually is
04:19highest in the six to 12 months postpartum.
04:21And this is population level work that was
04:23done out of the Massachusetts Department
04:26of Public Health showing some of this.
04:29Now, why is this?
04:30We're not entirely sure.
04:31We don't know all the reasons.
04:33There certainly is a population that
04:36disengages with medication for opioid use
04:38disorder after the birth of the child.
04:41But there's also other fundamental
04:43neurophysiological physiologic reasons that
04:46can help us to understand this better.
04:49And I take this figure as an adaptation
04:52of the work of Helena Rutherford here,
04:55showing how there are drug induced brain
04:58changes that may result in decreased
05:00sensitivity to natural rewards as
05:03well as an amplification of stress.
05:05And when that's paired with an infant
05:07who may have challenging temperament
05:09or behaviors, particularly those.
05:11Associated with opioid withdrawal
05:13or a parent who may have difficulty
05:15perceiving some of those infant cues.
05:17You can find a high stress,
05:20low reward postpartum environment and
05:23that particular setup can be can lead
05:27to drug cravings and ultimately relapse.
05:30So that I think is a helpful model
05:32for helping us to understand that
05:34increased risk in the postpartum period.
05:36Now similarly,
05:36not only is it an important time
05:39for the mother,
05:40but it's also an important window
05:42of development for children.
05:43The birth to three, the 1st 1000 days.
05:46And I like this,
05:47this expert panel report that came
05:50out in Pediatrics summarizing a lot
05:52of the literature around what is the
05:56impact of of opioid use disorder on
05:58the cognitive and behavioral long
06:00term outcomes for children and I I
06:03like this report because it really
06:05tempers what we know so.
06:06There is emerging literature,
06:08there is a lot of imperfections
06:10in the literature that's out there
06:12in this population.
06:13But there is emerging literature
06:15revealing an association between neonates
06:18exposed to opioids in utero and the
06:20more long term adverse neurocognitive
06:22behavioral developmental outcomes.
06:24But I think the the piece that
06:27this report makes
06:28really evident is that it's very complex.
06:31It's a highly complex picture.
06:32So I've actually had like
06:34lawyers and judges be like OK,
06:35so when does, when does the.
06:37In utero effects stock.
06:38When we stop worrying about that.
06:39And I'm like, it's not like that.
06:41It's this, it's all intertwined.
06:43It's really more how the genetics,
06:45biology, exposure,
06:46trauma relationship all come together
06:48and we and it's very difficult to
06:50tease it apart and when we focus
06:52too much on that in utero exposure,
06:54we kind of missed the forest for the trees.
06:58But I do,
06:59I do want to focus within this mix
07:01of of complexity on the parent child
07:04relationship because that is and where
07:07we can have a significant impact.
07:09So it brings us to thinking about,
07:11given all of that,
07:12what we know about this important
07:14critical window,
07:15what we know about the needs of of
07:18the neurobiological needs of parents
07:20in the developmental vulnerability
07:21of children during this time,
07:23how do we best support parents,
07:24how do we go from there?
07:26So what we what I'd like to present
07:28to you is the framework that we
07:30have used to kind of guide this
07:32process in helping us understand.
07:34And we really leaned into this appis
07:37framework by Greg Arons which outlines.
07:40An exploration,
07:41preparation,
07:41implementation and sustainment phase
07:44and this framework was really designed
07:47to help in a dynamic process of
07:49adaptation specifically for evidence
07:51based practices that we're going to
07:54be included or developed for a public
07:57service settings and that includes
07:59things like public mental health,
08:02child welfare.
08:02So it was really a good fit
08:04for what we were trying to do.
08:06I would say the other reason
08:07it was a good fit is because
08:09as I shared with you earlier.
08:10Was I was coming to this work as
08:12from the early childhood development
08:14field for as a pediatrician,
08:16I really was not an expert
08:17in substance use disorder.
08:18So I really needed to start at the
08:20beginning at that exploration phase and
08:22just get an understanding of the landscape,
08:25what are the needs of this
08:26Community and what are some of
08:27the gaps and what are some of the
08:28challenges that they're facing.
08:30So I I'm going to summarize a little
08:32bit some of my take home points,
08:34much of it based on our qualitative work,
08:36but some of the take home points
08:38that I gathered from this
08:39exploration phase in terms of.
08:40The critical supports for families
08:42and the first and foremost,
08:43I've mentioned it earlier,
08:44but I'll just reiterate it again,
08:46is medication for use disorder.
08:48So this can be the cornerstone
08:51of treatment for many families
08:53because it's life saving.
08:55And it's been shown to be life
08:57saving and so it is recommended
08:59by the all of the professional
09:01societies that touch families
09:02affected by substance use disorder.
09:04And and yet it's an area where we
09:07still need to work on destigmatizing
09:10and helping make it more accessible.
09:12Because how we deliver this medication
09:15is just as important as the fact that it
09:18can be used to support and and save lives.
09:21So that's one cornerstone.
09:22The other piece that I I've
09:24come to understand better.
09:26And this from the words of women in recovery
09:28and families affected by substance use,
09:30you know, learned it from them,
09:31was really this the importance
09:34of these resources,
09:35the social determinants of health.
09:37And actually, I think my understanding of
09:40it really came together from a teaching
09:42that I received from Doctor Arietta Slade,
09:45where she really equated resources to safety.
09:48So physical safety, emotional safety.
09:51Until we have those needs met,
09:53it's very difficult to do more
09:55of the intensive work.
09:56So I oftentimes like tell our
09:58community health workers you know
09:59like when you're doing that that
10:01case management work like you're
10:02really doing the parent child work,
10:04you're really impacting these diads
10:07and and and we do hear it all the
10:09time from the families we serve,
10:11housing insecurity,
10:11food insecurity in the area where
10:13I am transportation is a huge
10:15issue but they're they're really
10:17battling on many fronts.
10:19So very important to get
10:20these pieces in place.
10:22But as I mentioned and I was really
10:24interested in the parenting support piece,
10:26So what does that look like in
10:28in Massachusetts for us a lot of
10:30that was housed in the through the
10:31Department of Public Health in the
10:34early intervention program and this
10:35is the part C of the individuals
10:37with Disabilities Education Act
10:38home visiting I think they call
10:40it different things here.
10:41It might be birth to three but it's
10:44it was through early intervention
10:45that the Department of Public
10:47Health made this mandate and said
10:49you know we are going to serve.
10:52The population of infants with
10:54neonatal opioid withdrawal.
10:56And so we're going to make that
10:58a qualifying diagnosis so that
10:59they can receive up to one year
11:01of services in the home.
11:03And what are those services look like?
11:05They're essentially,
11:06it's delivered through individual programs,
11:09although they're part of a national model.
11:11It's voluntary.
11:12It can be delivered in the home
11:14or through center based care,
11:16but the goal is really to promote
11:19optimal child development.
11:20And this is a program that was
11:22designed for the general public,
11:23especially for children who have
11:26diagnosis like cerebral palsy,
11:28Down syndrome,
11:29autism and born with prematurity.
11:32But the the Nice thing about this
11:34program too is that it does provide
11:36multi multidisciplinary approach
11:37so you can get OT PT speech,
11:39developmental specialist,
11:39social work and in some cases on
11:42mental health support as well.
11:46And yet again kind of in my
11:48exploration of the of the landscape,
11:50I wanted to understand what
11:52were some of the gaps.
11:53So I mentioned that that program was
11:55designed for the general population
11:56and what what we know from some of
11:59the literature is that many evidence
12:01based parenting interventions that were
12:04designed for the general population
12:06fall short when delivered to mothers and
12:08specifically with substance use disorder.
12:11Why that might be many reasons,
12:13but many of them are more focused on
12:15child behavioral problems in mind.
12:16And not, not not as much.
12:18On the parents perspective.
12:20They might lack some of the
12:21consideration for the physiological and
12:24neurobiological vulnerabilities that I
12:26covered at the beginning of the talk.
12:28And then there is this.
12:30There can be a mistrust of systems
12:32and particularly in the case of
12:34early intervention intervention,
12:35we found that many families might
12:38appreciate stigma in those contacts,
12:40and as such many families exit prematurely
12:44and so they don't often receive the full.
12:47Benefits of the program.
12:48And then the last one which?
12:50Which is probably my biggest soapbox
12:52is this myth that we need to
12:54address recovery and then parenting.
12:56So if we can stabilize the parents recovery,
12:58everything will be OK and then we can
13:00work on the parenting and it'll all be,
13:02you know, you know, beautiful everything.
13:04Everybody will go off into the sunset.
13:06And that's just not the case.
13:08And one, one piece of evidence that
13:10I want to share for this is,
13:12you know,
13:13the idea that even while we as
13:15providers might not believe this,
13:17oftentimes our systems are set
13:18up in this way.
13:19So in,
13:20Massachusetts in.
13:20Particular we air on the side of
13:23kind of separating the parent
13:24child DYAD we're having,
13:26doing some of that individual
13:28work and then reunifying and.
13:30And what ends up happening is there's
13:32this disconnect and not recognizing
13:34that not only does recovery affect the
13:37parenting and the child's outcomes,
13:39but parenting affects the
13:41parents recovery as well.
13:43And there's good evidence to show that
13:46if you can address both at the same time,
13:49you can have better outcomes for
13:50the child and also better outcomes.
13:52For the for the maternal recovery,
13:54again,
13:54I just point out that this is not
13:56the way our systems are designed.
13:57So even in the last, you know,
13:5920 or so years,
14:00there's a more than tripling of
14:02removals to foster care for for
14:04children of parents with substance
14:06use challenges.
14:06So we, you know,
14:07it's just not even though we
14:09might think this,
14:10it's not the way it works out in practice.
14:13And then lastly, not lastly,
14:16but I will mention this is another important
14:18piece of where we oftentimes fall short,
14:20is a failure to explicitly recognize a name.
14:25How?
14:26Substance use,
14:27parenting,
14:28racism and equity all intersect and
14:31this is I think particularly evident
14:34through again through systems.
14:36So the the criminalization of substance
14:39use is is clearly linked to racism,
14:42but so is some of the systems that come
14:46down in a punitive manner on parents and
14:48we know that there's a direct link there.
14:50And then I've shared with you the link of
14:52parenting and substance use disorder as well.
14:54So I think this is this is
14:56another critical piece that we're.
14:57Could be a talk in and of itself,
14:58but we're just starting to
15:00address in some of this work.
15:04So what is the alternative approach if
15:06these kind of if I've listed out for you
15:08the ways in which we oftentimes fall short?
15:11I think the alternative approach for,
15:13you know, for many of us here
15:15is thinking about supporting
15:16the parent child relationship.
15:18So not just individually supporting
15:20the parents or the child,
15:21but having the relationship
15:23be at the center of that work.
15:26And that that relationship based
15:28approach really encourages is
15:30is a bit more reflective.
15:32Sorry, more specific than
15:33we might make it out to be.
15:35But it can,
15:36it can be an approach that helps
15:38parents to reflect on their child's
15:40emotional needs in order to foster those
15:43long standing changes in the child,
15:45parent child interaction.
15:46So it's I,
15:47I say like it's not necessarily, you know,
15:50reflecting in the general sense like oh,
15:52let's just reflect on what
15:53it's like to be a parent,
15:54but really a targeted way of doing so.
15:56Um, and I'll talk more about that when we,
15:58when we talk about our intervention approach.
16:00But this is really the idea
16:02is to decrease the stress and
16:04increase the natural reward.
16:05So in that that postpartum environment
16:07slide that I showed you like how do
16:09we shift the scale so that parenting
16:11actually feels more rewarding and
16:12we can make it less stressful.
16:16OK. So that was the exploration phase
16:19and at at that point there we were really
16:23at the point of adoption decision,
16:25which is how do you find an intervention
16:27that now that you've understood the
16:29landscape and understood the gaps,
16:31how do you decide on an intervention
16:34that fits those that meets your needs?
16:37And so it's really at that point that
16:39I began to become more familiar and was
16:43introduced to mothering from the inside out.
16:46And again, that's the intervention that
16:48was developed by Doctor Nancy Sukman.
16:50But it's a 3 pronged approach in
16:53the original trials where there
16:55was a child care specialist.
16:57Working one-on-one with the child and
16:59then a case manager thinking about those
17:01resources that are important source
17:03of safety and then the the parenting
17:05counselor here on the on the right,
17:07which is really the focus of a
17:10lot of the intervention.
17:12And mothering from the inside out just to
17:14for those who might not be as familiar,
17:16is an evidence based parenting
17:17intervention specifically for parents
17:19with substance use disorders that have
17:21children age one to five years old.
17:23It's delivered through 12 weekly
17:25sessions and was really originally
17:27designed for delivery in the substance
17:30use disorder treatment setting.
17:32And then it the purpose is it's not a,
17:35it's not a, it's not a teaching curriculum.
17:37We're not trying to build skills.
17:39It's really about fostering a
17:40process to address some of.
17:42The strong negative and positive
17:43emotions that come up in parenting.
17:45So that's a key piece of it as well.
17:49How does MO work?
17:50So again when we talk about building
17:52this reflective capacity I just
17:54say you know I I say it's it's very
17:56I said earlier it's very specific
17:58and and this the word that's often
18:01entertained in interchange.
18:02But I use reflection here in this
18:05case is is mentalization.
18:06So for that many of you are all of
18:09you are quite familiar with I'm sure
18:11and that's the capacity to make sense
18:14of behaviors in oneself and others in
18:16terms of underlying thoughts, emotions.
18:18Wishes and intentions.
18:20And it's like, OK,
18:21so I make sense of my behaviors.
18:23Like, we all do that, right?
18:24Like, that's not that hard,
18:26but I actually think it can.
18:28You know,
18:29the idea is not that hard and we all do this,
18:31but actually implementing it in practice
18:33is so much harder than one would think.
18:35And part of that it, like it's twofold.
18:36One is that it's,
18:37it's really a state, not a trait.
18:39So I don't consider myself a
18:41reflective parent.
18:42Like,
18:42I can be a reflective parent and
18:43then my kids can go trick or treating
18:45and be on a sugar high at 8:00
18:47o'clock and I'm just going to be.
18:49Through the roof like all that
18:50capacity goes out the window.
18:52So it's something that we kind
18:54of come back to,
18:55but in particular for the
18:57populations that we serve it's,
18:59it's it's very challenging
19:01and I'll just share the words
19:03of Peter Fonagy that the understanding
19:04of minds is hard without the
19:06experience of having been understood
19:08as a person with the mind.
19:10So when one hasn't had the
19:12experience of their behaviors,
19:13their emotions having been
19:15mentalize by by a caregiver,
19:17it's, it's very difficult.
19:19To then do that for your own children.
19:23So that is essentially the focus of
19:26Mio and what in different terms,
19:29I'll say that it really the the program
19:31works to help parents regulate their
19:34strong emotions in their parenting
19:36role and helps to helps them to
19:39recognize the child's developmental
19:40and emotional needs and then also
19:43fostering a alliance with the provider.
19:46In in two of the efficacy trials,
19:49we've seen that when this has
19:51been delivered in comparison
19:53to psychoeducational control,
19:55there have been improvements
19:56in quality of the parent child
19:58relationship and the child attachment
20:00to the parents as well as reduced
20:02rates of relapse in the parents.
20:04And as you know a pediatrician
20:06who have studied many a parenting
20:08intervention for the pediatric
20:09studying and we do an OK job even in
20:12the general population in terms of
20:13like moving the needle on parenting.
20:16Stress,
20:16maybe depressive symptoms,
20:17but actually changing those parent child
20:20interactions can be very difficult.
20:22So this is one of the things that drew
20:24me to this intervention in particular.
20:25And then the second was this last,
20:28this last point here in blue,
20:31the fact that the greatest impacts
20:33we're seeing among parents with
20:35more severe substance use disorder.
20:36That told me those areas where
20:38we were falling short, like,
20:39OK,
20:40we're addressing it now because those
20:41aren't the parents that are being lost.
20:43They're no longer exiting prematurely.
20:45They're actually the ones who are benefiting.
20:47For the most.
20:49So I I share with you the adoption
20:52decision like how we came to to mothering
20:55from the inside out as an approach.
20:58But then we were set with the question like,
21:00OK, we have an idea,
21:02but can this be integrated into
21:04the early intervention setting?
21:06What adaptations are going to be needed?
21:07Is this, is this going to be feasible,
21:09are people going to like it?
21:10And so those are the questions
21:12that we were wrestling with as we
21:14moved into the preparation phase.
21:16So a lot of people might jump.
21:18From adoption decision to implementation,
21:22right. Like we did all that background work,
21:25we figured out what's going to meet the gaps.
21:27Now let's go do it.
21:29But I actually want to spend a couple of
21:31minutes sharing with you our preparation
21:33phase because I think that this was a
21:36really important piece of of the puzzle.
21:38And what the preparation phase focuses on
21:41is not only thinking about and planning,
21:43figuring out how are we going to
21:45make these adaptations to meet
21:46those gaps and those needs,
21:47but also how do we.
21:49How do we build buy in both
21:52internally and externally in the
21:54community for this for this approach?
21:56And so again just to like reiterate
21:58in terms of our adaptation,
22:00we were taking something that was
22:02designed for delivery and substance
22:04use disorder treatment settings for
22:06children one to five a clinic based and
22:08individual approach to delivery in a
22:10new setting where it was EI provider.
22:12So coming from a more child development
22:15lens beginning at birth which is
22:17extremely challenging time for families
22:18in terms of engaging in services.
22:21We know that from disengagement and
22:22mental health in general during
22:24that time period and a more flexible
22:26location that has the opportunity to.
22:27Involve other family members,
22:29so it's a lot of big changes all at once.
22:33And so we leaned into our community
22:35engaged research methods and drew
22:37from the community in terms of
22:39key stakeholders and developing
22:40advisory panels to guide this work.
22:43And I'll just to summarize Super briefly,
22:45a large body of work here, what what we want?
22:49A couple of the takeaways.
22:50What we figured out was in terms
22:52of the barriers and facilitators to
22:54making this transition to engaging,
22:56we found two two things that I'd
22:58like to highlight.
22:58First was that like, we're all ready to like,
23:00OK, tell me what you want,
23:02tell me what you think about Mio.
23:03How do we do this?
23:04How do we do this better?
23:04And they're like, whoa, whoa, whoa.
23:06Like, let's take a step back.
23:08Like,
23:08this is a paradigm shift for the
23:10home visiting early intervention
23:11program where we need to just even
23:13reflect on like what is it,
23:15what is it like to have the parent
23:18child relationship at the center of our
23:20treatment rather than just the child,
23:22just the parent or this kind
23:25of coaching approach.
23:26And so that was a big take away for for
23:29us. And then the second was through
23:32thinking about barriers and.
23:33Facilitators, we realize that
23:35while early intervention,
23:37this was a hypothesis that we had that
23:39it could address many of the logistical
23:41barriers to getting families into clinics.
23:42So delivering it in the home,
23:44we might be able to reach those
23:46postpartum moms a little bit easier.
23:47Early intervention might help
23:48with those logistical barriers,
23:50but Mio was actually,
23:51from the providers point of view,
23:53could help with some of the emotional
23:55barriers to engagement in those services.
23:57And it was through the training we
23:59were going to need to address both
24:01and figure out how to merge that.
24:03To get the maximum benefit.
24:06The second thing that we did,
24:08which I think was a helpful way
24:10for us to engage our advisory
24:12panel was a process called the
24:14failure modes and effect analysis.
24:16This is akin to root cause analysis
24:18from the quality safety world if
24:20if you all are familiar with that.
24:22But it's a way of thinking
24:24about what could go wrong,
24:26how bad is that going to be and can we
24:29come up with solutions of how to address
24:31that prior to doing our implementation.
24:33I think that's the key thing
24:34because root cause analysis,
24:35you do it.
24:36After the the bad thing happened,
24:38why did it go wrong?
24:39Here we're thinking about
24:41how do we prevent that?
24:42And so we took our advisory panel and
24:44walked through this two day process
24:46of kind of generating potential
24:48ideas and they really helped us think
24:50through again what adaptations were
24:52going to be needed to address this.
24:54And just to summarize very quickly,
24:57the area that we thought was going to be
24:59the biggest challenge was recruitment.
25:01Not surprising,
25:02it's probably the biggest challenge
25:03for most social services in general,
25:06but they helped us to.
25:06To understand what components exactly
25:10might be the cause of mistrust in the
25:13community and why trust was so critical,
25:16particularly in the population of families
25:18affected by substance use disorder.
25:20And therefore,
25:21then how do we maximize our our
25:23implementation protocols and
25:25also our research protocols to
25:27support more psychological safety?
25:29And we took all of that data.
25:31So the key stakeholders work,
25:32the advisory panel work and we this is
25:34next slide is a bit of a busy slide,
25:36but we kind of boiled it down into,
25:38OK, these are the changes,
25:40these are the adaptations that we're
25:41going to make at the recruitment
25:43enrollment phase,
25:44the intervention training and delivery
25:45and the completion and transition phase.
25:48And we call this the promoting
25:50caregiver child attachments and
25:51recovery and early intervention
25:53program very busy slide.
25:54So we could probably talk about any
25:56one of these bullets for a while,
25:58but the one that I will just highlight.
26:00For the purpose of this talk is
26:02the first one.
26:02This we heard early and repeatedly
26:04from people both in in both of
26:07those studies around cultural
26:09sensitivity and what another word
26:11for that might be cultural humility.
26:13And I want to just pause on that
26:14because this is something that
26:16we've been thinking about more
26:17recently within our teams and it.
26:18And it helped me to understand kind
26:20of again this idea of fit and how
26:22mothering from the inside out was going
26:24to be integrated into this new setting.
26:26So from this lens, from the, from the.
26:30Kinds of cultural humility,
26:31humility and anti racism.
26:32I have to say as a pediatrician or
26:34interested in early childhood development,
26:36I have a lot of qualms or have had a lot of
26:39qualms about are are we directing families,
26:42are we guiding families towards
26:44this idea of typical development?
26:46Some of it might be very well
26:48evidence based and some of it might
26:50be more culturally of informed and
26:52doesn't really take into account
26:54or or respect in the same way these
26:56different ways of knowing and these
26:57different trajectories of development.
26:59So so I think I I borrowed.
27:01Hear from the word the words
27:03of Doctor Kennedy to say,
27:05you know,
27:05on the in the one hand that I
27:06think the thing that I feared most
27:08was this idea of assimilation,
27:09assimilationist view where we're
27:11seeing racial or ethnic groups as
27:13culturally or behaviorally inferior
27:15and trying to support cultural or
27:17behavioral enrichment programs to
27:19develop that group in a certain way.
27:22And what Doctor Kennedy would say
27:24with is the anti racism view is this
27:27idea that all racial groups are equal.
27:30None needs to.
27:31Departments and actually we really need
27:33better supports to reduce racial inequity.
27:36So if we could provide that support
27:39for reducing racial inequity,
27:41you know, there would be more thriving.
27:43And,
27:43and I think we've integrated this more
27:46so into our adaptations and training.
27:48And I put this image up here because
27:50the way I think about it and especially
27:52when we're working with families
27:53and the reason that for me this
27:55has been a good fit for my kind of.
28:00Worldview and alignment with this
28:02work is that we're not teaching
28:04parents how to parent.
28:05You know, we're not teaching anything.
28:07I sometimes say that to DC what
28:08are you teaching families? Nothing.
28:09We're not teaching them anything.
28:10They don't need to be taught anymore.
28:13It's just more akin to breathing.
28:15We all breathe.
28:16Nobody needs to teach you how to breathe,
28:18but we can learn to harness our breath
28:20in ways that can be beneficial to us.
28:23And so it's in that process.
28:24What do you need?
28:24How do you need to harness the breath?
28:26Is it for a calming practice?
28:27Is it for to project your voice?
28:29Is it?
28:30You know for these different reasons
28:31you choose the way and what the
28:33purpose is and how and you know
28:34and might just need a little extra
28:36support in that process.
28:37So I wanted to pause on that on
28:40that note before sharing the next
28:42phase which was training and and
28:44again you'll see like I'm getting to
28:47implementation eventually I promise.
28:48But there were these steps
28:49that we needed to take.
28:50So the training for US began as a
28:53beta test and it's a partially the
28:56training involves delivery of MO.
28:59So we were able to learn.
29:00A fair amount, but we began,
29:02we began our train,
29:04our first trainings with
29:05early intervention providers.
29:06Just to tell you a touch
29:07about what that involves,
29:08it's a 16 hour classroom based
29:10training that includes the theoretical
29:12underpinnings of the intersection of
29:14parenting and substance use disorder.
29:16But then a large part of it is
29:18review of a clinical case and
29:20discussion of that case followed
29:22by delivery and that clinical
29:24consultation component and it is
29:26audio recorded for the clinicians
29:28to receive very detailed feedback.
29:30And small portions of it.
29:33Are the folks that we trained
29:35had either a bachelor's degree
29:37or higher in psychology,
29:38social work related fields and they
29:41had to have some experience such
29:43as counseling in the setting of
29:45substance use disorder psychology,
29:47those types of differences.
29:48So they had to have like that
29:51counseling piece experience already.
29:52And we started our our program
29:54in the state of test with four
29:56early intervention practices.
29:57One was very urban,
29:5921 was suburban and two were rural.
30:03Our first training was conducted
30:04in August of 2019 and then
30:07the second round was in 2020.
30:09So we had primarily what we had folks
30:12from the urban and and rural in that
30:14first cohort and same in the second one.
30:16And what you'll see here is that the the,
30:19the providers who completed
30:20were either in the urban or
30:21suburban suburban settings.
30:23We didn't have any rural
30:25providers complete the program.
30:26What this looks like when we
30:28integrate here the the actual
30:29clients that they were working
30:31with during their training program.
30:32You can see the first didactic
30:34took place over here and we had
30:36the two providers that completed
30:38each work with two families.
30:39And then the second didactic
30:41which began here in August,
30:43they each completed the training
30:44with one person and as you can
30:47imagine something happened in between
30:49those two trainings which was the
30:51COVID-19 shutdown and I just want
30:53to pause here for those of you
30:55also working in the home based.
30:57Care like this was devastating
31:00for home based home delivery,
31:02home visiting programs.
31:03Like it was not like a little bit bad,
31:05it was just like,
31:06we can't go in and you want me to
31:08do telehealth with a 6 month old.
31:10Like it was devastating.
31:11So the programs that we worked with,
31:13some of them were laying off
31:14more than half their staff.
31:15They were in crisis mode and
31:17we're approaching them literally
31:19in May of 2020 being like, hey,
31:20do you want to learn something new?
31:22Like it's really cool, come join us.
31:24So I do think the fact that
31:26we recruited 2 new programs.
31:28In May of 2020 is a little bit of a win,
31:31but we did it was a very,
31:32very challenging time.
31:33That being said, the other thing I
31:35want to highlight with respect to
31:37COVID was is at the bottom here.
31:38So we had 11 parents enroll
31:41overall in the training,
31:434 completed the the All 12 sessions,
31:47two completed 8 to 10.
31:49But if you note here there were
31:51four people who did not complete
31:53pre COVID and one post COVID.
31:55So if we could get in the door
31:57and when we did make that.
31:58Contact.
31:58It was surprising for us to learn
32:01that actually retaining them
32:02once we made that transition
32:04to health telehealth was was
32:06better than we anticipated.
32:07So what did we learn from these preliminary
32:10findings from this training process?
32:12We did measure attitudes towards women
32:14and mothers and recovery specifically.
32:16Those attitudes improved among these
32:17providers who who didn't have a
32:19lot of background in substance use.
32:21They all were able to achieve
32:22fidelity to the MMO core components.
32:24And important piece for us is that
32:26they use Mio more frequently.
32:28Than the psychoeducation which
32:30they have been doing for ages.
32:33With respect to parents,
32:34we did see a small increase in
32:36parental reflective functioning
32:37from a score of four to five on
32:40the parent development interview,
32:41and that transition into that score
32:43of five actually means that they're
32:45using some of those mentalizing.
32:49Skills, for lack of a better word,
32:51but more so than seeing the numbers
32:53because again, that was a small trial.
32:55I think it's important to hear what we
32:56what we learned from providers and from
32:59the early intervention providers we heard.
33:01Having been in early intervention for
33:02so long, this is the missing piece.
33:04I could see it, but I didn't
33:06know what to do about it before,
33:08and this is a provider who's been in
33:10early intervention for over 30 years,
33:12another provider said I really think
33:14this is the future of early intervention.
33:16And another one who's a supervisor says
33:18not only is she using it with her clients,
33:20but I feel like it's been beneficial to
33:22share with my staff when they really
33:24have a hard time understanding why a
33:26family might be acting a certain way.
33:27So it's been beneficial in that sense too.
33:31And when I shared with you the the
33:33experience that we had during COVID,
33:35we found that Mio was actually
33:36beneficial beyond the scope that
33:38we had originally planned.
33:39So this mom says, I mean,
33:41to be completely honest,
33:42I really feel like it came at a good time
33:44for me to learn it as and like an individual,
33:46as a parent as well.
33:47It was a really hard time.
33:48I had two small kids at home.
33:50I felt like it gave me some tools, you know,
33:52these things you teach to other people,
33:53but when it's you,
33:54it's sometimes harder.
33:55So I I really feel like it was a
33:57perfect time for me to learn some
33:58of these new skills during such a
34:00challenging time for me and my family.
34:02So we thought, we're going in there,
34:03Oh my gosh,
34:04teaching this during COVID is
34:05going to be awful.
34:05Like, what are you going to think?
34:06And they were like, no,
34:07it came at a good time.
34:08We appreciated it.
34:10And another provider said that she felt if,
34:12if other,
34:13if other providers had had the MO strategies,
34:17they might have been able to engage
34:19families and telehealth better
34:21because she was using those Mio
34:23strategies to engage families herself.
34:25What we hear from the parents
34:27was this kind of comments on the
34:29process and what they took away.
34:31So this is a mom talking to her clinician.
34:34So you asked me so much that it
34:36made me think about it more.
34:37What can my children be thinking
34:39and feeling about this, right?
34:40Like we were just like, oh,
34:41that's like mentalization.
34:42And that it's core and how she changed.
34:46She says I was at, I was patient before,
34:48but now it's different because
34:49I'm thinking about what she could
34:51be thinking and maybe I didn't do
34:52that much before.
34:53So she's really able to distinguish.
34:55You know what she took away from the program?
34:59So now thank you for hanging with
35:01me to get to the implementation
35:02phase because it took a lot of work
35:04and I think it's not,
35:06it should not be under stress that we
35:08really needed to do all this groundwork
35:10to get to the point where we were able
35:12to to implement this at a broader scale.
35:15So we have been able to deliver MO across
35:17the state of Massachusetts now and that has
35:20only been possible through partnerships
35:22with the Department of Public Health and
35:24the Bureau of Substance Addiction Services,
35:26specifically the program
35:28of first steps together.
35:29This was a new program actually at
35:31the time when we were we happen to
35:34be doing this adaptation for home
35:36visiting and in came some opioid
35:38response funding and they had some
35:39of it earmarked for families and they
35:41developed this new home visiting program,
35:43but the program was primarily.
35:45A peer coaching model.
35:47So people with lived experience,
35:49they did have clinicians embedded in the
35:51agencies that work with the families,
35:53but that was kind of one of
35:54the clear distinctions.
35:55So home visiting for families and recovery
35:58and it's as I mentioned across the state.
36:01So you could see from Berkshire County
36:03all the way on the West to the to
36:05the Cape on the right and a couple
36:07of sites for each of those agencies.
36:10And we expanded slowly.
36:11So the first pilot we did was at one
36:14site we had six staff and two clinicians.
36:17The following year we were able to
36:19expand to all of the seven sites
36:21and kind of learn from that process.
36:23And then the most recent training
36:25that we did we and trained folks
36:26at the first steps together sites,
36:28but then we also opened it up through
36:30funding from the from the Bureau
36:32of Substance Addiction Services to
36:34clinicians at substance use disorder
36:35treatment clinics and medical clinics
36:37as well.
36:38And that was our our biggest training.
36:40But I want to point out a difference
36:43from our early intervention work
36:44is that we were training,
36:46as you can see the staff,
36:48we trained like 26 staff and 10 clinicians.
36:50So for the first time we were
36:52training folks who weren't doing that
36:54one-on-one clinical work in addition.
36:55So we had a chance to get their
36:58input on the program.
37:00And when we when we took this that
37:02step to go across different settings as
37:04I as I shared in the previous slide,
37:06we had the opportunity to use
37:08the consolidating framework for
37:10implementation research the C for
37:12framework to help us think about
37:14what are the implementation domains
37:16that were really critical to helping
37:18these different sites.
37:19Like if one did it a little bit
37:20better than the other,
37:21why was that and what we what I show
37:23here on this slide is that just a
37:25few of the components that we felt
37:27like made a really big difference.
37:29So first of all.
37:30Compatibility,
37:30does it align with your values
37:32like in the STD clinic setting?
37:34Do you think that this is an issue?
37:35Is this a problem?
37:36Is this a priority for you?
37:38And likewise in, say,
37:39a agency that's more focused towards
37:41child development and then second,
37:43adaptability both on the
37:45part of the intervention,
37:46could we adapt to the needs of that setting,
37:48but also could they adapt in order
37:51to provide greater communication and
37:54with respect to their regulations
37:56and then leadership engagement,
37:57kind of a clear one, but really where
38:00there were leaders who helped to?
38:02Involve their staff,
38:03support their new counselors
38:04and hold some accountability.
38:07Those are the sites that tended to do a
38:10little bit better in terms of implementation.
38:13So I went, I kind of rushed through
38:15that step in the process a little bit.
38:17I'm happy to talk more about it
38:19and the question answer session
38:20because we've learned a lot.
38:21I guess the one thing I'll pause to
38:23say is that that implementation phase
38:26we were primarily doing as service
38:28delivery that was not a research
38:30endeavor whereas the prior phase,
38:32the training,
38:32the beta test phase and what the work
38:34we've been doing with early intervention
38:36that has been really research focused.
38:38So just a distinction there,
38:40but in all of this work and I
38:42would say this has come up since.
38:43Phase one of exploration,
38:45we have heard time and time
38:46again sustainability.
38:48We want something that's sustainable.
38:49We need to be thinking sustainability
38:52and for us that has been something
38:55that we have tried to address
38:57through our training models.
38:59So rather than training a
39:02handful of folks and, you know,
39:04giving them an apple and they
39:05have that one apple,
39:06can we plant an orchard?
39:07Can we create something that's
39:09more sustainable so that we have
39:12trainers within the state that
39:14can teach the next generation?
39:17That had not been done with mothering
39:19from the inside out to to that date.
39:21And essentially the training model
39:22relied on this expert LED training
39:25where we had these expert level
39:27clinicians who had not gone through
39:29any formal curriculum training the
39:31mental health clinicians directly.
39:32And that was great because
39:34mothers could get the service,
39:35but it didn't give us any new way to get
39:38more trainers and to expand that approach.
39:41So what we what we did was we,
39:44we built a curriculum to take.
39:47Trainers who had been trained by
39:49you know whomever the expert level
39:52clinicians in this case are trainers
39:54and have them come back kind of
39:56feedback into the loop to become
39:58trainers themselves and that's how
40:00we were able to increase our scale
40:03and and cope with the capacity
40:05across the state that was needed.
40:07I guess let me just take a step back.
40:09We don't have all the data.
40:11This is actually hot off the press.
40:13We're still kind of like combing
40:14through it right now to share with you.
40:16So I don't have a lot of the the
40:18quantitative findings from this trial
40:20but or this pilot trial I should say.
40:22But what I will say is we,
40:24we I always lean into the qualitative
40:26work and what we hear from
40:27parents and this is from a mother.
40:29So the mother who received the
40:31intervention from the new clinician,
40:33who got it from the new trainer
40:35and and she said, so I'm like oh,
40:37I hadn't really thought about what.
40:38We thought about it,
40:39or I didn't really take into account like
40:41how I felt about his reaction to something.
40:44It made me really look really
40:46from my child's perspective.
40:47So to hear, to be able to hear the
40:49the mothers of the parents, really,
40:51because we served fathers in this as well,
40:54put it into their own words,
40:56how they experience this approach,
40:58how it changed their relationships
40:59with their children,
41:00was really powerful.
41:04Lessons learned. So I'll I just want
41:06to kind of round out some of this,
41:09this talk and I'm really very happy to
41:11take more questions to talk more in depth.
41:13But just to say that I think for
41:16for me as as I hope I shared with
41:19you they're they're really neat.
41:21We need to be able to focus both on
41:24engagement in the program and the efficacy,
41:26the outcomes of the program at the
41:28same time like we got to be able to
41:29chew gum and walk at the same time
41:31because if we have great outcomes but
41:32we can't get anybody in the door.
41:34You know, that's not that helpful
41:35if we have a really fancy,
41:37flashy, engaging program,
41:38but it doesn't do a whole lot.
41:40That's not as helpful either.
41:41And and I I think,
41:43I hope that our team has tried to
41:45kind of hold those both in mind.
41:47Similarly with adaptation,
41:48like we need to be flexible and meet
41:51the needs of the settings while also
41:53holding true to the core principles
41:55and fidelity to the model if we're
41:58going to maintain that level of effect.
42:01And then this is new to me.
42:02I don't know about how many
42:04trainees we have in the room,
42:05but I was kind of of the mindset,
42:07like, oh,
42:07we have to do this through like these
42:09research protocols and this research setting.
42:11I think I was pretty lucky to stumble
42:13into that implementation work and
42:15have the chance to be learning about
42:17it through program implementation
42:18side by side to our research trials.
42:20And I have to say, like,
42:22I mean, on any given day,
42:23I think I might have learned
42:24more from the program evaluation
42:25than I have from the research.
42:26They complement each other,
42:28but I think the chance to be
42:30able to do both is really was.
42:31Really helpful and something
42:33that I'll probably think about
42:35incorporating into our future research.
42:37The the 4th bullet is probably doesn't
42:39need to be said but there is just
42:42such power of our multidisciplinary
42:44teams and I just have adored getting
42:46to work with psychologists and Amanda
42:48all others and and in general.
42:51But you know we've had we've tried
42:53to incorporate different perspectives
42:55people who bring different strengths
42:57to strengths to the team and then
42:59of course lastly especially given
43:01what I've told you about doing this
43:03in COVID it's taken incredible
43:06persistence definitely.
43:06On the part of the providers themselves,
43:09like the providers that have stuck with us,
43:11I'm just like you are angels.
43:13Like how have you done this?
43:14I don't know.
43:15Their resilience is is incredible and
43:18their flexibility is incredible as well.
43:20But for me,
43:21I think that persistence and that
43:23flexibility comes from being able
43:25to connect to why I do the work.
43:27And that connection is,
43:28is really a commitment to a by
43:30generational approach to supporting
43:32families affected by substance use disorder.
43:35And I I really do think that
43:37in doing taking
43:38that. Approach. In doing that work,
43:39we're addressing the root cause of
43:41the disease that has the potential
43:44to affect future generations.
43:46So with that I will I will conclude and
43:49I hopefully less time for counseling.
43:57This I'll just say a quick thank you.
43:59This as you as you all know this
44:00takes a village and there's a lot
44:02of people involved in this work.
44:03So but appreciated very
44:05much of our our mentors,
44:06the team, our collaborators,
44:08many of whom are here at Yale
44:10and our our community partners.
44:11We have a really strong perinatal
44:13coalition where all of our service
44:15providers get together once a
44:16month and then the first steps
44:18together program has been really
44:19instrumental in this as well.
44:33That that was really great.
44:34You're you're a wonderful speaker and
44:36and I learned so much just quickly.
44:38I thought the coaching model is
44:40is just so positive, you know,
44:42because it's just so much less judgmental.
44:45Everybody wants a coach, right?
44:47Get in better shape, you know,
44:48be a better volleyball player,
44:50tennis player or whatever
44:51and so you know, helping.
44:52These clients with the coaching model
44:54it's just it's just less negative.
44:56So I I compliment that.
44:58I was wondering if you could explain
45:00something just a little bit more
45:02to me and that's the assimilation
45:04versus the anti racism thoughts
45:05because it seems so important.
45:07You know as a provider when you see
45:10something cultural that you worry
45:12about for the kids you know spanking
45:14or violence on screens or you know
45:17lack of trust of clinical perspective,
45:19you know anti vaxxers,
45:21those things you know how to.
45:23How to intervene when you feel
45:26it's important but yet not be?
45:28Critical of the cultural.
45:30Differences and and you know what you do
45:33for yourself in those situations because you,
45:36you're worried about the kids
45:38and that's judgmental and that's,
45:40you know,
45:40critical.
45:40I just know if you had a thought about that,
45:43how you manage it.
45:45I really appreciate you
45:47raising that question.
45:48That's something that I spend a
45:50lot of time thinking about and
45:52so I can share my perspective,
45:54but I'm sure there's other kind of experts
45:56in the in the field on this call today,
45:58I I think that the.
46:02I actually found that for me the
46:06mentalization based approach was the how.
46:09It was how do we approach that?
46:10Because I think it starts
46:13with kind of two things.
46:16Well, not two things,
46:17but the two pieces of it that I
46:19think are particularly important is
46:21curiosity and the not knowing stance.
46:23So in in the example that you gave,
46:25let's take spanking,
46:27that's the wonderful one,
46:28really under like getting
46:30curious and understanding.
46:32I don't know why this parent is choosing
46:35to practice that particular behavior.
46:37So let me try to take a step back and.
46:39Curious with them and understand
46:41I think it is one piece.
46:44And then I think the other piece is that
46:47that the mentalization based approach
46:49really fosters is collaboration.
46:51So in that the clinician parent relationship
46:55that they're developing there is not,
46:58there is not the one holding the
47:00knowledge and teaching the other
47:02and the other person receiving
47:03it's a bringing together of minds
47:06to understand it together.
47:07And so it's not even just hey I'm the
47:09clinician over here being curious
47:11like why are you thinking your child
47:13like me having these feelings.
47:15Words you but like can we get
47:17in this together?
47:17And like think about this together,
47:19why this is happening and as I I think.
47:24Let me give a personal example if it's OK.
47:27But spanking is is one that touches
47:29that touches me directly because so
47:31I'm I'm Latina come from a a Mexican
47:34family can be a traditionally strict family,
47:37and people may see Latina family,
47:39Latinx families as having more
47:42harsh disciplinary styles.
47:44But there is a movement to try to
47:47understand that and to understand
47:49perhaps the role, for example,
47:51of of of colonization.
47:54Of the Mexican, you know,
47:57country and how those potentially
47:59harsh practices may have been
48:01something that was inflicted upon
48:04people there that they internalized
48:06and then inflict on others.
48:08So that's just to take one example,
48:11but I think when we can get
48:14curious together about it,
48:15I I think that's where.
48:19We can, we can begin to kind of like move
48:22the needle if that makes sense. I don't,
48:25I hope I answered your question. Alright.
48:32If I may, I was intrigued by
48:33what you were saying about the,
48:35you mentioned that there is quantitative
48:37data that you're generating from
48:38them from this study as well.
48:39Could you talk to us a little
48:40bit about those outcomes that
48:41you're planning on on measuring?
48:43And I'm just intrigued to see whether
48:44or not the medication for treatment
48:46of substance use disorders is one of
48:49those kind of secondary outcomes that
48:51you're thinking about investigating in
48:53Massachusetts as a functional site,
48:54they're implementing this study.
48:57Great question. I mean in terms
48:59of like retention in that in the
49:01medication for opioid use disorder,
49:03that's a great question.
49:06So for for the implementation study that I
49:10that I showed I guess as well as the train,
49:14the trainer program which
49:15is kind of 1-1 in the same.
49:17One of the main things that
49:18we're looking at is fidelity.
49:19So we're looking at at trainer Fidelity,
49:21we look at changes in
49:24clinician reflective capacity.
49:25So also kind of the idea that.
49:27If we are,
49:28if we're hoping to be able to to change,
49:30the parents reflect the capacity.
49:33What is that?
49:34What happens to the the clinician
49:35themselves and do they change
49:37over the course of the training?
49:38That's a second one on the parents part.
49:40We do look at parent parental
49:42reflective functioning in this case
49:44because it's a bit more broad.
49:46We look at it through a survey
49:48rather than the interview method
49:49which I think is a bit more more
49:52in depth and and we I'm very
49:54interested in parenting stress so
49:56that we've begun to look at that
49:59as a potential outcome particularly
50:01because I'm I'm interested in how.
50:04Parenting reductions in parenting
50:06stress might link to recovery and
50:09and reduce the rate of relapse
50:12and parental depressive symptoms.
50:15I'm actually thinking,
50:16I don't have my slides pulled up,
50:18but I'm I'm visualizing this graph
50:20we have that shows the I showed you
50:22that overdose rates postpartum.
50:23But there's a similar graph that
50:26shows an increase in medication for
50:28opioid use disorder among pregnant
50:30women month by month of pregnancy
50:32and how that goes back down.
50:34Month by month postpartum,
50:35we we definitely ask as secondary
50:38outcomes whether they're engaged in
50:40treatment services and what types.
50:42But, but I think that would be really very,
50:45a very interesting question more at
50:47the population level especially and
50:49we haven't focused on that quite as much.
50:51Even the graph that you're showing
50:52about foster care placements,
50:53as you kind of disseminate
50:55this program more widely,
50:57will there be a statewide
50:59reduction for foster care
51:01placements could be interesting.
51:02Secondary outcome,
51:03absolutely, yeah. Includes the great schools.
51:06Sorry, I was talking the questions there.
51:15Thank you so much for the talk.
51:18The question that I just wanted to
51:21highlight something that you said about
51:23safety and the need to ensure safety
51:25by putting kind of case management
51:28thinking about the family income,
51:30employment and although those
51:32pieces and I see that all the
51:34time with the fathers who I work.
51:36With who have violence and substitute
51:38histories too that if we aren't
51:40addressing all of the stress around
51:41their economic needs their employment
51:43needs the ways they're discriminated
51:45against in the systems then we're
51:47not we're not ensuring safety and
51:48the and the treatment that we're
51:50providing isn't going to be enough.
51:52And so I know we had a conversation
51:53earlier today about systems but I
51:55think that you know how we think
51:56about building this within the
51:58system and So what you said too about
52:00the program evaluation alongside
52:02I agree with that so much because
52:04what we do in a trial in our clinic.
52:07Is so you know controlled and
52:08then you try to put it,
52:10embed it within referrals from DCF or within
52:13other substance use settings or really care.
52:15And you realize all of these other
52:17pieces that are intersecting with the
52:18work and how much they're impacting,
52:20whether the treatment can be
52:22effective or not.
52:24And so I I just think I
52:26appreciate all those comments.
52:27I hope we can figure out ways of
52:30studying how these systems are helping or
52:32impeding the services that we're trying to,
52:35to provide families to impact.
52:37Outcomes, yeah,
52:37that's a that's actually a really,
52:39really good question and I I think.
52:42Yeah.
52:42Just thinking about kind of the
52:44social determinants of health,
52:45for lack of a better word.
52:47But like yes,
52:49how those may impact the effects of these,
52:52of these types of treatments.
52:53And I, I do, I, I see,
52:54I see areas on the call,
52:56but I picture your her triangle,
52:58you know,
52:59of the emotional safety
53:00and the physical safety.
53:01So much like to be able to
53:03get into that reflective work,
53:04into the attachment work.
53:06And it would be really interesting
53:08to look at it more from a
53:09program evaluation perspective.
53:13There was another question over
53:15and I'd encourage anyone that's on
53:16in the zoom room as well please
53:17feel free to unmute and ask doctor
53:19pick up chamber as a question.
53:22Hi. Thank you so much for your
53:24talk and I really appreciated you
53:26talking about the importance of,
53:29you know, looking at the parent child
53:31relationship as the client as opposed
53:33to just the parent or just the child.
53:35And I was wondering,
53:36obviously the intervention is called
53:38mothering from the inside out.
53:39But if as you're expanding
53:41it across Massachusetts,
53:42if it can be adapted for maybe fathers
53:45with substance use disorder or other
53:47caregivers or other family members as well,
53:50if that's something you're thinking about?
53:52Gosh, that's a good question and yeah,
53:54so I will say.
53:56Yes, like that, absolutely.
53:57And I think that goes back to the program
54:00evaluation alongside the research.
54:02So in our trial it had to be you know,
54:06her all the reasons it had to be.
54:08You know that was the evidence
54:09based on these kinds of things.
54:10But once we got into the community,
54:12they were like no, no, no, we have,
54:14we have grandparents taking care of children.
54:16We have fathers like this
54:17needs to be expanded.
54:19And so we,
54:19I would say I look to Amanda like
54:21we've really struggled with this in
54:23terms of maybe marketing or labeling.
54:26We've not changed the name,
54:28but we kind of talked to people
54:30like you can use this with other
54:33caregivers and encourage that.
54:35And and there are some adaptations
54:37that have even studied that further.
54:39There's Amanda's 80s adaptation which
54:42takes took MO to a group model,
54:45but she uses it with all different
54:47caregivers in the group setting.
54:49So yes we like heard that loud and clear
54:53from the community and I think it's.
54:56It's necessary because, again,
54:58it's like these children exist
54:59in this ecosystem, right?
55:01So we have to be able to support it all.
55:04Great.
55:04Thank you.
55:05Maybe mentoring
55:06from the inside out? Yeah, if you keep the.
55:11We're thinking, how do we keep the M?
55:16Ohh. Harrietta, hi.
55:20Hi, Lily, what a great, what a great talk.
55:24What a great talk and how fabulous
55:26to hear the way you've adopted you've
55:29adopted Mio for this different setting.
55:31I really. And so impressed to have you
55:33take us through all the implementation
55:35decisions you made along the way,
55:37just really an exceptional kind of
55:41demonstration of what needs to happen.
55:43I guess the one thing I wanted to add and
55:47appreciate your shout out about safety
55:49is that racism is another major threat,
55:53you know, when you're implementing a program.
55:56And I think to the anti racist perspective,
56:00it's really a mentalizing perspective.
56:02It's really a.
56:03Effective, but let me get to know
56:04you and I'm curious about your ways.
56:06But when you know we're not aware of
56:09how threatening we can be as clinicians,
56:12it really, you know, has a profound impact.
56:15Yes. Yes, no, absolutely. Thank you for.
56:19Thank you for adding that.
56:20I appreciate that I think.
56:23I I think I you know maybe even to the
56:25to the first question didn't respond
56:27comment on that piece but yes the
56:30the the threat that can exist within
56:33the therapeutic relationship yeah
56:34is another important piece of that.
56:37The safety approach and the holding
56:40environment. Thank you so much.
56:43Thank you. All right.
56:47No.
56:57Yeah. Wonderful.