Mothering From the Inside Out: A Mentalization-Based Intervention for Mothers Enrolled in Mental Health Services

Saturday, 29 July 2017

Monica Roosa Ordway, PhD
Nursing, Yale University School of Nursing, West Haven, CT, USA
Lourdes De Las Heras Kuhn, MS
Columbia University School of Social Work, New York, NY, USA
Thomas McMahon, PhD
Yale University School of Medicine, West Haven, CT, USA
Nancy E. Suchman, PhD
Yale University School of Medicine, New Haven, CT, USA

Purpose:  A cornerstone of parenting is managing dyadic psychological distress. However, among those struggling with mental illness, the dynamic and fluctuating nature of adult psychopathology complicates the parent-child relationship and challenges mental health clinicians due to the paucity of evidenced based mental health programs focused on parenting. The process of mental health intervention adaptation and implementation with vulnerable populations is not well described in the literature. We worked as a community-partnered team to adapt and pilot an empirically-supported intervention program for mothers of infants and toddlers in an outpatient mental health clinic that primarily serves a low income community. The conceptual frameworks of mentalization theory and parental reflective functioning (RF) provide a foundation for understanding the mental states (thoughts, emotions, intentions) underlying one’s own and another’s behavior that can help a parent break the viscous cycle of psychological distress and dysregulated relationships. We suggest that there are potential benefits of developing and evaluating interventions for parents with mental illness that target parental RF. To date, however, there have been no reported efforts to pilot such interventions with parents who struggle with mental illness. Considering the demonstrated efficacy in two randomized clinical trials with mothers enrolled in treatment for substance abuse, the aim of this study was to examine the preliminary feasibility, acceptability and efficacy of adapting Mothering from the Inside Out (MIO) for use at an urban community mental health clinic. The adapted MIO intervention is delivered by an interdisciplinary group of clinicians (nurses, social workers, psychologists) and involves 12-weekly, 1-hour individual therapy sessions focused on helping mothers make sense of their child’s and their own emotional experience within the parent-child relationship. In this study, we were interested in: 1. determining whether community-based clinicians could deliver MIO with sustained fidelity, 2. examining the preliminary feasibility, acceptability and efficacy of MIO when delivered by clinicians in a community mental health center, and 3. replicating prior tests of the proposed treatment mechanisms identified in the two RCTs.

Methods:  This trial was conducted on site in a satellite clinic of a large, urban community mental health center that serves children, adolescents, young adults and adults. The clinic is located adjacent to a small northeastern city where many clients are exposed to urban problems (e.g., crime, poverty, minimal affordable housing) typically identified with larger cities. Interested mothers who were enrolled in outpatient services themselves or who had a biological child enrolled in outpatient services at the treatment center were eligible for treatment if they were caring for a child between birth and 84 months of age. All mothers who consented received 12 sessions of a manualized mentalization-based intervention called Mothering from the Inside Out (MIO) that was originally designed for mothers enrolled in treatment for drug addiction. Mother-child dyads were eligible to participate if the mother was English speaking and caring for a child between birth and 84 months of age (the target child in the study) and either the mother or target child was enrolled in the outpatient mental health treatment program where the study was conducted. Treatment attendance and alliance served as measures of feasibility and acceptability, respectively. Maternal outcomes included reflective functioning, parenting stress and psychiatric distress. Mother-child interaction outcomes included maternal sensitivity, child involvement and dyadic reciprocity. Seventeen mothers caring for a child between birth and 84 months of age consented to participate and completed an initial intake evaluation and baseline assessments. Treatment fidelity was measured using a scale developed for the randomized trial involving substance using mothers. Treatment attendance and alliance served as measures of feasibility and acceptability, respectively. Treatment outcomes included maternal reflective functioning, psychiatric and parenting stress, and mother-child interaction quality.

Results:  Our findings indicated that MIO was feasible and acceptable when delivered in the community-based setting and that all maternal indices improved. As shown in Table 1, mean RF score showed a moderate increase from baseline to post-treatment (d = .34). Potential RF also showed a moderate increase from baseline to post-treatment (d = .35). Child-focused RF showed a large increase (d = .64) whereas self-focused RF showed no increase (d = .04) from baseline to post-treatment. At the end of 12 sessions, mothers had also reported their experience of parenting and psychiatric stress had fallen to ranges that were considered within normal limits (T<60 on the Brief Symptom Inventory; d = -.41). Similarly, findings for the group mean for depression were also found and the magnitude of this change from baseline to post-treatment corresponded to a medium effect (d = -.58). Support was found for the proposed mechanisms of change: Therapist fidelity to the unique MIO treatment components predicted improvement in maternal RF (r = .53, p = .03) which, in turn, was associated with improvement in quality of mother-child interactions (r = .43, p = .08). With regard to implementation, key lessons from this implementation include: 1. The importance of formative work to build community relationships ; 2. The importance of designing plans for training and reflective supervision that fit within the flow of the clinic and can tolerate disruptions; 3. Use of an interdisciplinary approach is feasible with the development of a plan for communication and the support of a trained reflective clinical supervisor.

Table 1. Effect size (d) for treatment outcome differences from baseline to 12 weeks



12 weeks


Maternal Reflective Functioning


Mean RF

2.85 (.58)

3.11 (.60)


Potential RF

4.12 (.86)

4.53 (.80)


Child-focused RF

2.91 (.51)

3.42 (.64)


Self-focused RF

2.81 (.72)

2.85 (.72)


Parenting Stress

Personal Distress

30.35 (9.73)

26.71 (10.74)


Dysfunctional Interaction

21.06 (5.58)

21.00 (8.09)


Difficult Child

30.59 (8.57)

27.82 (8.12)


Psychiatric Symptoms

Global Psychiatric Distress (BSI; T Score)

62.35 (10.01)

55.94 (11.9)


Depression (BDI)

16.88 (9.26)

10.06 (7.39)


Mother-Child Interaction

Maternal Sensitivity

3.39 (.75)

3.41 (.72)


Child Involvement

3.28 (.87)

3.34 (.78)


Dyadic Reciprocity

3.28 (1.06)

3.27 (1.06)


Conclusion: These findings add to a growing body of evidence showing the validity of this treatment model for improving mother-child relationships in high risk dyads where psychoeducational instruction and behavioral coaching have proven insufficient. These findings suggest that a mentalization-based parenting therapy for mothers involved with mental health services may enhance the effects of the mental health services that target their psychiatric symptoms. The key lessons from the implementation advance the scientific knowledge available to healthcare managers and researchers who are looking to adapt mental health clinical interventions for a vulnerable population.