ELIZABETH MURDZIA, who stopped using heroin during pregnancy with the help of methadone, remembers rocking her newborn as he underwent methadone withdrawal at Baystate Medical Center in Springfield. Murdzia, 29, was terrified he would be taken from her because in Massachusetts, opioid use during pregnancy triggers a child welfare investigation. One nurse told her – incorrectly, it turns out – “You’re not getting your son back.”
Sam O. was two years into recovery when her daughter was born in 2019. But a history of destabilizing heroin use made her feel unfit to parent. “I would always feel like I’m not doing the right thing,” the 34-year-old Westfield resident said. Gripped by anxiety, she suffered recurrent nightmares about drowning her infant child.
Both women credit a Springfield-area pilot program run out Baystate with helping them survive the stresses of early motherhood without returning to heroin. Mothering from the Inside Out (MIO) is part of an initiative launched by the Executive Office of Health and Human Services for at-risk families called FIRST Steps Together. It is a 12-week psychotherapeutic intervention designed for new moms with histories of chronic substance use.
Research shows these women are more likely than other mothers to lose custody of their young children, to suffer postpartum depression, and to feel shame and stigma. That’s a potentially dangerous combination. According to a 2018 Massachusetts General Hospital study of 4,154 pregnant women in Massachussets with opioid use disorder, overdose risk increases steadily after delivery, peaking at seven to 12 months postpartum.
Women now account for roughly one-third of US opioid overdose deaths, up from a quarter in 1999. In the American opioid crisis, their overdose fatality rate has risen faster than men’s. Many existing treatment programs don’t serve mothers very well, according to Cresta Jones, an associate professor and obstetrician-gynecologist at the University of Minnesota Medical School who specializes in treating opioid use disorder. For one, she says, there is “significant stigma” facing “pregnant and parenting individuals” who use drugs. Lack of childcare at treatment sites is another barrier to care.
Mothering from the Inside Out is a judgement-free zone. Abstinence is not required, only an effort at recovery. And while it is funded by the National Institute on Drug Abuse and the federal Substance Abuse and Mental Health Services Administration (via the Executive Office of Health and Human Services), MIO is not, strictly speaking, a drug treatment program. Rather than focus on a woman’s substance use, MIO focuses on her mind.
The program is the brainchild of the late Yale University psychologist Nancy Suchman. She described Mothering from the Inside Out as a program “designed to promote parental reflective functioning.” It seeks to help clients identify and regulate their own feelings and meet the needs of their child, promoting secure attachment. Therapists call this “mentalization.”
MIO counselors meet clients weekly at home – or, if they are unhoused, in another safe location. There’s no agenda: They talk about whatever is bothering the client, whether unpaid bills or their mom’s refusal to help with childcare.
“The therapist, rather than telling the mother how to solve the problem, will become curious about the mother’s own mental and emotional experience of the problem and try to help her have a better sense of her own emotional experience,” explained Suchman in a 2018 talk on MIO. “That’s actually a way of becoming better regulated.”
Once clients have learn to regulate their own stress, counselors begin asking them similar questions about the child’s feelings, encouraging emotionally reflective parenting. Counselors also nudge clients to consider how their personal history influences their reactions to their child’s behavior.
If these seem like useful lessons for any parent, that’s by design. “There are no perfect parents” is a refrain at MIO.
But moms with substance use disorder “don’t get the same benefit of the doubt that other parents get,” said Elizabeth Peacock-Chambers, the pediatrician and Baystate researcher who launched MIO in Springfield in July 2019. At least 20 clients have since completed the program, making Springfield the largest pilot to emerge from Suchman’s clinical trials of MIO at Yale. (Smaller pilots have run in the Bronx, Philadelphia, and South Africa.)
Though everyone in the Springfield program has struggled with substance use, drugs rarely dominate the conversation during sessions, said Shalonda Nicholson-Mabry, an MIO counselor in Springfield. She finds childhood trauma, sexual violence, and depression are more frequent topics.
Treating clients at the intersection of their multiple identities – as parents, as people in recovery, as trauma survivors – is a relative novelty among both substance use and parenting programs.
“There are all sorts of evidence-based parenting programs out there,” said Amanda Lowell, a Yale researcher who worked with Suchman until her death in 2020. “The problem is that those programs, 99 percent of the time, have been conducted in research on low-risk families.”
Meanwhile, standard drug treatment programs concentrate on substance use, sidelining parenting-related challenges.
“We need to be thinking both/and,” said Peacock-Chambers. “A person’s experience as a mother and parenting has a direct impact on her recovery. And vice versa: For the child, their long-term health outcomes…are very much impacted by the parent-child relationship and that parent’s substance use disorder,” she said.
MIO’s mentalizing approach, which Jones, the University of Minnesota researcher, called “innovative,” seems to be working.
In clinical trials undertaken with 130 MIO clients in New Haven, 12 weeks of MIO worked better on many metrics than 12 weeks of parenting education. Two studies show improvements in mothers’ reflective functioning and caregiving sensitivity, as well as deeper parent-child attachment. MIO clients also scored lower on measures of depression and were less likely to relapse. These outcomes were not observed after parental coaching.
Peacock-Chambers said clinical trials have not yet proven, however, that the program is also “changing the developmental trajectory of the child.”
The Yale team was recently awarded $100,000 by pharmaceutical company Alkermes for a 15-person clinical trial to determine how, neurobiologically speaking, MIO works. The study will examine neural responses to infant cues like crying and smiling before and after MIO. Brain scans could reveal changes to the brain’s “stress and reward circuitry,” according to one neuroscientific theory Lowell cited.
MIO clients, though, attribute the program’s positive effect to something totally unscientific: vibing with their counselor. Murdzia emphasized being “comfortable to just spill, to pour myself out” during sessions. Sam O. said her counselor “did really good getting me to open up.”
“A trusting bond between client and counselor is essential” to the program’s success, according to Lowell. But that feature is also something of a liability: You can train clinicians in “mentalization,” but you can’t teach personal chemistry.
That’s just one aspect of MIO that makes the initiative harder to scale up than a straightforward pharmacologic intervention for substance use disorder like nalaxone or methadone distribution.
“We know it works at a small scale,” said Lowell. “But we don’t yet know how it translates into the real world where there are real pressures around billing, funding, staffing, burnout, and countless other barriers.”
Another challenge to scaling up a highly personalized therapy-based program is training and supervision, according to Baystate chief resource officer Peter Friedmann. Friedmann is helping Peacock-Chambers rigorously evaluate the Springfield pilot. To deploy the program in the “real world” – Peacock-Chambers’s goal for MIO – he said counselors must deliver MIO “in a way that is going to be generalizable and reliable.”
“It’s a big challenge for these kinds of things,” but not “insurmountable,” Friedmann said.
Murdzia, MIO’s first Springfield client, hopes more women facing the stigma and struggle of drug use have the same opportunity to show their potential as a parent.
“If you can give a person that one chance and the right tools, you can see a success story,” she said. “You can see plenty of success stories.”
Catesby Holmes is a reporter and editor based in Brooklyn. She is currently a fellow at Harvard University’s Shorenstein Center on Media, Politics & Public Policy.