The Mom Power “tree” metaphor
With the use of the tree metaphor, mothers discover how to meet a child’s needs while exploring and connecting with a caregiver, how to repair a disruption in the relationship, how to co-regulate a child’s emotions, and how to create an atmosphere of warmth, joy, and delight in which their child can learn and grow. They learn how a child’s sense of self develops through this balancing of exploration and connecting and through daily experiences of having their needs met. In addition, parents explore what experiences from the past might impact their parenting and what current experiences may be affecting their children.
In addition to learning about attachment during group sessions, parents have the opportunity to practice separations and reunions in a supportive environment that allows them to experiment with new ways of relating to their children and to put into practice the skills they are learning in class. The intervention encourages mothers to gain insight and increase reflective capacity through supportive exposure to attachment-based parenting principles.
Each session also includes a focus on self-care. The self-care skills utilize strategies derived from DBT and mindfulness and guided imagery to improve affect regulation and decrease symptoms associated with depression, anxiety, and PTSD. There is a growing body of evidence that mind-body skills such as these are effective for preventing and treating stress, depression and anxiety, PTSD, traumatic brain injury, and pain syndromes (e.g., Hofmann et al. 2010). When mental health symptoms are under control and mothers are not distracted by these symptoms, they have increased capacity to attend to their children’s feeling and needs and are more capable of self-reflection. The focus on parenting and self-care is interwoven throughout the manual and each session.
While manualized, the curriculum is also highly personalized and interactive and meant to create a welcoming, trust-building atmosphere, in order to plant the seed that relationships, both with peers and professionals, can be “safe and satisfying” for the mothers. As outlined above, the Mom Power intervention curriculum blends therapeutic elements consistent with several evidence-based practices. The group delivery also adds practices informed by social learning theory (Grusec 1992). As the group process evolves over time, the psychoeducational component decreases and gives way for more “therapeutic reflection” and insight generating processes, using strategies such as the “Wondering and Response Wheel” (Fig. 11.2). This wheel helps parents walk through a process that begins with observation of child behavior, then generating inferences about the child’s underlying feelings and needs, and, finally, formulating a response. The “wheel” implies that this process is often iterative and that after responding parents can then again observe their child’s behavior to determine if the response was effective in addressing the child’s feelings and needs. Mom Power intervention goals are to create “buy-in” for treatment, provide mental health and parenting psychoeducation, enhance self-care and stress coping skills (thereby reducing depression and anxiety), and, finally, enhance mothers’ reflective capacity so that they can utilize these reflections to enhance sensitive parenting.
Wondering and Response Wheel
The key treatment principles of Mom Power are safety, trust building, enhancing self-efficacy through empowerment and skill-building around self-care, problem-solving, emotion regulation, and parenting. Mom Power accomplishes this by delivering five core components (see Fig. 11.3):
Enhancing social support. Many of our participants feel isolated in their lives often due to teen parenting, family dysfunction, poverty and lack of transportation, or separation due to military service or incarceration. Mom Power enhances social support through two key facets. First, the group sessions create a shared experience with opportunities for informal relationship building among participants; give mothers a sense of comradery, knowing that they are not the only ones facing these challenges; and can act to decrease stigma of seeking services. Sharing a meal together is a powerful way to build connections in a relaxed atmosphere. Additionally, the curriculum includes a session where mothers are invited to bring a “parenting partner” guest (e.g., the child’s father or mothers’ spouse, friend, relative, or other key support person) to the sessions, thus also enhancing “buy-in” from critical “others” in the mother’s world. Additionally, facilitators provide resources and encourage ongoing activities that offer the opportunity for building social support such as community programs, library story time, or parenting support groups.
The attachment-based parenting education curriculum emphasizes responsiveness and sensitivity to young children’s separation and reunion experiences. The curriculum introduces key topics in parenting and child development. Engagement in activities is designed to practice skills and reflect on interactions while also emphasizing attachment concepts in an effort to help mothers identify and address children’s emotional needs. The program explicitly avoids directives about specific parenting behaviors (e.g., spanking) and instead shares research-based knowledge while encouraging thoughtful reflection on the part of the parents to decide what behaviors are in keeping with their values and goals. Parents learn how to function as a secure base and a safe haven for their child; how children need to explore and to connect with a caregiver; how to meet a child’s needs for attention, help, and enjoyment when exploring; how to meet a child’s need for parents to nurture, restore, and repair when connecting; co-regulation, balanced parenting, and how to repair a disruption in the relationship with their child; and when to lead and when to allow their child to lead, when to support, and when to set limits.
Mental health and self-care practice teaches mothers how to reduce their own distress during emotionally evocative parenting moments and how to recognize their own emotional dysregulation such as depression and trauma-related anxieties. To help mothers build a “self-care toolkit,” each group session ends with hands-on practice of one evidence-based stress reduction “skill” including guided breathing, visualization, relaxation, or mindfulness. These concrete skills increase mothers’ sense of efficacy in addressing their own symptoms. They also serve to normalize the need for mothers to take care of themselves in addition to taking care of their children. Mom Power teaches parents how to manage their stress and symptoms so that they can be more grounded and present for their children. These mind-body skills help increase distress tolerance and affect regulation. By helping parents regulate their own feelings, we help them to increase their capacity for co-regulating with their children.
Guided parent-child interactions emphasize creating safe and predictable routines for both mother and child. When mothers leave for their group sessions, “goodbyes” are acknowledged and reunions are anticipated using songs or games. Children learn that it is “safe” to be left briefly because their mothers will come back if they need comfort. At reunion, the group facilitators are able to observe and support reunions in “real time” and help mothers recognize and respond to their children’s emotional needs in that moment. Mothers are encouraged to anticipate, observe, and reflect upon these separations and reunions, as well as identify ways they might want to “try something new” to address their children’s feelings during separation/reunion.
Connecting to care involves identifying and connecting women to ongoing care beyond the Mom Power program (if this is indicated). This is a critical component of the model, as we know that in 10 weeks we can’t give participants everything they need to know to parent successfully until their children reach adulthood. During the individual sessions (midway and at the end of the group), the facilitators have the opportunity to discuss unresolved areas of challenge and to provide individualized, tailored information for connecting mothers to services in their communities. The facilitators are very hands-on; for example, they make phone calls with the mothers to community agencies and problem-solve potential barriers to engagement.
Mom Power core components
In addition to adhering to the core components outlined here, the Mom Power program also combats structural barriers to engagement identified in prior research (e.g., Dumas et al. 2007), by providing weekly transportation to and from group sessions, a shared meal during group sessions, and no-cost childcare, as an integral part of the Mom Power model.
Through a relationship with the facilitators in which the facilitators play the role of secure base/safe haven, a participant has the experience of having her thoughts and feelings held in mind by the facilitators. Facilitators do this by creating a welcoming environment where all thoughts and feelings are respected and welcomed, where the facilitators reflect and validate feelings, and where the facilitators respect the participant’s pace. Facilitators not only present educational material but also meet the participants’ needs while they are exploring and when they need connection. Facilitators provide support and encouragement when participants are trying new skills and ways of interacting with their children.
Moreover, when we focus on self-care, we are signaling to the mothers that we care about them as individuals and that their well-being is important. We not only want them to focus on the feelings and needs of their children, but we want them to know that focusing on their own feelings and needs is important as well. We believe that women can be better mothers when they make taking care of themselves a priority.
Mom Group facilitators and the Child Team leader meet weekly for face-to-face consultation with a Mom Power supervisor to process aspects of the group sessions. This opportunity to reflect on observations and plan for tailored interventions is a critical part of the model, providing therapists with an opportunity to reflect on their own experiences, plan for the session, and think together strategically regarding how to best support each mother and child. In addition, following each group session, the entire Mom Power staff participate in a 20–30-min debrief session, sharing observations of that day. The Child Team’s observations of child play and peer interactions are shared with Mom Group facilitators. Child Team members are updated about relevant challenges faced by the family that may have surfaced during the Mom’s Group and may impact the child’s behavior. This debrief session was introduced to facilitate information flow across both the Mom and Child Teams and to empower the whole team to share one common therapeutic stance toward each family.
11.3 Summary of Research Findings
Our research studies have confirmed that Mom Power participants are high-need families with significant risk factors, including trauma exposure, psychopathology, poverty, and single parenthood (LePlatte et al. 2012; Muzik et al. 2015). Despite this, the program has proved to be acceptable and engaging to parents with >65% retention. Participants reported that they received helpful parenting information from the intervention, that they felt welcomed by the friendly facilitators, and that they felt more supported and made connections with other women in the group as a result of the intervention (Muzik et al. 2016). The effects of the Mom Power program in improving parenting and mental health have been evaluated in two empirical studies. First, in an “open” trial (i.e., no control group) with 99 mothers completing Mom Power, we found that the program decreased mothers’ depression, PTSD, and caregiving helplessness and improved parenting confidence, social support, and connection to care (Muzik et al. 2015, 2016). In a randomized, controlled trial we found that mothers who participated in Mom Power showed improvements in mental health symptoms and parenting stress and an increase in “balanced” maternal representations and in maternal reflective capacity, that is, insights regarding their parenting qualities and their children’s thoughts, feelings and needs (Rosenblum et al. 2017a, b). There were no significant changes in the control group. The differential results of the Mom Power versus control condition on maternal mental health and parenting were even more accentuated for mothers with a history of interpersonal trauma (Rosenblum et al. 2017a, b). Furthermore, more recently, a neuroimaging study showed first pilot results supporting that mothers undergoing the Mom Power intervention display changes to their “parental social brain” indicative of greater reflective capacity and empathic attunement towards their children compared to those mothers in the control group (Swain et al. 2017; Muzik et al. under review).
11.4 Case Vignette
The family described here represents a common clinical presentation to the Mom Power group. It illustrates many of the risk factors present in many Mom Power participants and exemplifies the type of change we frequently see in mothers over the short time frame of the intervention.
Keisha1 was a 22-year-old, African American woman, who was referred by her primary care physician to the Mom Power group. During her childhood, Keisha experienced abuse and neglect and was in and out of foster care. Keisha was a single parent to two young children: 3-year-old DeShawn and 8-month-old Latrice. She had experienced intimate partner violence in her relationship with DeShawn’s father. At her initial individual session, she described DeShawn as being “mean” and “rotten” and explained how he would “act out,” “try to hurt [her],” and “never listen.” Keisha reported high levels of depressive symptoms and moderate PTSD symptomatology prior to the intervention. She later shared with us that she was initially resistant to coming to group, but liked the idea that she would “get some time away from the kids” and a free meal and decided to give it a try.
In the first few sessions, we observed that Keisha was very focused on Latrice during separations and reunions and that during these times DeShawn would get more dysregulated and act out, even becoming aggressive at times. When we first introduced the tree metaphor and discussed meeting children’s needs for connection in addition to exploration, Keisha had a hard time acknowledging that DeShawn had a need for connection, describing him as “very independent” and commenting that he “doesn’t care if I’m even here, unless he wants to bother me.” Staff introduced the group to the concept of “confusing signals”—the idea that children may signal their need for connection with confusing and counterintuitive behavior.
Over time, as group progressed, Keisha began to realize that she was seeing Latrice as having needs, but had not considered that DeShawn had needs as well. Following one particularly hard reunion during which Keisha had entered the Child Team room midway through a session to feed Latrice and upon her arrival DeShawn had run around the room knocking other children’s toys out of their hands and ripping a picture off the wall, staff suggested that Keisha use the Wondering and Response Wheel to decode DeShawn’s confusing behavior. Keisha first described the behavior she saw (running around, being destructive). Next, drawing on the tree metaphor, staff wondered together with Keisha about whether DeShawn’s acting out behavior might indicate his need for connection and therefore a “building roots” moment. Keisha was at first unsure what DeShawn was feeling, but noted that he seemed to be feeling a combination of overly excited and angry, and maybe even some jealousy. As they thought this through together, Keisha was able to see that DeShawn needed help in restoring his emotional balance. Staff worked with Keisha to develop a plan to try something new on her next reunion with DeShawn. Together they decided that staff would call ahead to the Child Team prior to reunion so that they could bring DeShawn to greet Keisha in the hallway, thereby giving Keisha the chance to reunite with him one-on-one without having to worry about Latrice at the same time. In addition, Keisha also identified several “restoring emotional balance” strategies to try, including “calming feelings first” and “identify and label feelings.” Staff were supportive and reinforced her goal, noting that these strategies might help calm the situation down in the moment and would help her to recognize and acknowledge both the children’s and her own feelings in these challenging situations. When, with the support of staff, Keisha put the plan in to action, DeShawn was much more regulated and well behaved. At the following session, as Keisha processed how it had gone with the group, she acknowledged feeling surprised by how much these strategies had helped her children and had also helped her to feel more emotionally regulated and in control of the situation.