Since 2002 rates of heroin and other opioid use among US women have doubled, and the increase is particularly apparent among non-Hispanic whites and those living in the Northeast (Jones et al. 2015). The Substance Abuse and Mental Health Services Administration (SAMHSA) reports that 5.4% of US pregnant women aged 15–44 in 2012–2013 used illicit substances during pregnancy (SAMHSA 2014). Publicly funded addiction treatment programs do not capture pregnancy status at intake, but data from 2014 estimate that 2% of enrollees in these programs were pregnant women. Although pregnancy is often thought of as a time when women are highly motivated for treatment, many do not report their substance use due to shame, stigma, lack of confidence, and fear of losing their infant to child welfare (Spielman et al. 2015). It is equally important to note that these women often have extensive histories of childhood and adult trauma and present with co-occurring mental health disorders (Kaltenbach 2013). Their infants are at risk for cognitive, social, and emotional difficulties due to in utero exposure and the quality of relationships with caregivers and caregiving practices (Nair et al. 2003; Salo and Flykt 2013). Even when women do seek treatment and commit to sobriety during pregnancy and early parenting, few interventions exist to address the complexities of their histories, current lives, and the parenting process they are about to embark on. In the following paragraphs, we first briefly review what is known about pregnant and parenting women with SUDs in terms of trauma history, mental health, child development, and mothering. Second, we describe the status of existing programs. Third, we provide a conceptual framework for our intervention. Finally, we offer details about Project BRIGHT (Building Resilience through Intervention: Growing Healthier Together), an attachment-based evidence-informed dyadic intervention for mothers in treatment for opioid addiction and their young children, including a composite case example.

Research suggests that pregnant and parenting women with SUDs are more likely to have family histories of substance misuse, high rates of complex trauma, and co-occurring mental health disorders. These factors alone, regardless of substance misuse, are correlated with suboptimal parenting (Kaltenbach 2013). Additionally, posttraumatic stress disorder (PTSD) and SUDs are often correlated. A review of 72 studies on parental PTSD symptoms and parent-child interactions found some support for the notion that these parents are less likely to be emotionally available and more likely to have negative perceptions of their children (however, some of the reviewed studies did not show these associations). In the affected dyads, children tended to be more easily dysregulated or distressed than children of parents without PTSD (van Ee et al. 2015).

Approximately 60–80% of infants born exposed to opioids develop neonatal abstinence syndrome (NAS). NAS contributes to problematic infant neurobehavior and long term may impact hyperactivity, short attention span, and memory problems. Studies of neonatal opioid exposure also indicate increased risk of low birth weight, respiratory complications, and infant mortality (Behnke et al. 2013). Children who are substance-exposed are at increased risk for an insecure or disorganized attachment, likely due to parents’ co-occurring mental health disorders and transactional effects between the parent and child (Salo and Flykt 2013). These findings suggest that interventions must focus on the parent-child relationship, as well as aspects of parental well-being, in order to augment protective factors in place for the child and the dyad (Salo and Flykt 2013). Although the full impact of prenatal opioid exposure on children’s long-term development is not yet fully understood, given the risks associated with maternal opioid use and this fragile beginning, support for the mother during and after pregnancy is recommended in order to promote healthier dyadic outcomes (Logan et al. 2013).

The attachment relationship is essential to the infant’s overall development, including trust, promoting what is referred to as the secure base. It is health promoting in parents as well, as the formation of an attachment relationship provides a sense of pleasure, connection, and competence for the primary caregiver (Slade 2005). From this trusting relationship, a child feels safe navigating potentially stressful situations. The pleasure and reward parents often feel during attachment are compromised when SUDs interrupt the healthy functioning of motivation and reward systems in the brain. As the substance-exposed newborn may have particular difficulties regulating his or her various states of sleep and hunger, the mother’s responsive care is particularly essential, yet she is less able to read and respond to her baby’s cues (Pajulo et al. 2012). Studies have also found greater levels of maternal intrusiveness, where a parent overrides the child’s ongoing behavior and redirects to a parent-led activity (Hans et al. 1999). Given the centrality of the attachment relationship in young children’s development, the mother’s decreased responsiveness to her infant, intrusiveness, and the dysregulation of the mother-infant dyad are particularly detrimental.

Pregnancy and preparing for motherhood often motivate women with SUDs (particularly involving opioids) to consider treatment, given the fear and guilt regarding the impact of their substance misuse on their unborn child and the increasing rate of infants’ removal by child welfare (Rutherford et al. 2013). This motivation provides an optimal treatment opportunity. Hence, treatment programs that simultaneously address women’s recovery and parenting are well suited for this time. Historically, many programs intended to support mothers in recovery have been centered on didactic parental education that reduces problematic parenting with the goal of improving child behavior. Outcome intervention efficacy has been mixed, perhaps in part because they do not take into account the extensive parental trauma histories and neurobiological changes (Suchman et al. 2004). A shift in researchers’ understanding of the centrality of parent-infant relationships in improving outcomes is slowly beginning to favor relational interventions grounded in attachment theory (Bromberg et al. 2010; Pajulo et al. 2006; Suchman et al. 2008). A 2015 review of 21 studies of treatments for SUDs and parenting recommended concurrent enrollment in treatment programs to address substance misuse and parenting, which represents a shift in the historic trend of focusing solely on the individual in early recovery. One important caveat is that the parenting intervention begins with a focus on psychological processes such as development of emotion regulation mechanisms, before fully addressing effective parenting strategies (Neger and Prinz 2015). Difficulties with emotion regulation are common in people who misuse opioids. Furthermore, emotion regulation skills are crucial as parents help shape their child’s emotional experiences and they have a regulatory function within the parent-child relationship (Rutherford et al. 2013).

Given the challenges facing mothers with SUDs and subsequent risks to the parent-child relationship, interventions that foster trust and attachment provide a necessary support. Studies have validated attachment-based interventions which focus on addressing parental internal representations, those beliefs and expectations held about one’s self and important others developed through transactions with primary caregivers and the environment (Fonagy et al. 2002). An additional specific focus of these interventions is reflective functioning (RF), or the capacity of the parent to understand her own and her child’s feelings, needs, and motivations and link these inner states with external behavior (Slade 2005). “A mother’s capacity to hold in her own mind a representation of her child as having feelings, desires, and intentions allows the child to discover his own internal experience via his mother’s representation of it” (Slade 2005, p. 271). If a parent can hold in mind her child’s mental states, she is more likely to behave in an optimal way toward that child, decreasing the likelihood of neglect or maltreatment. Even with histories of trauma, parents with high RF are more likely to have securely attached children; conversely, low RF is associated with hostile and withdrawn parenting leading to decreased social competence in children (Grienenberger et al. 2005). An explicit focus on working at the representational level and building RF for mothers with SUDs and their children is supported by evidence from the work of Suchman (Pajulo et al. 2012; Suchman et al. 2010). An intervention approach that addresses attachment and RF is essential as many of these mothers yearn to parent their children but may have limited skill sets given their own histories of trauma and being poorly parented. Increasingly, their children are removed from their care at birth, leaving the mothers bereft and in need of an effective intervention that will support their recovery from opioid misuse, enhance the possibility of reunification with their child, and encourage optimal parenting practices.

Project BRIGHT is an evidence-informed dyadic parenting intervention initially developed for the use in residential treatment programs for mothers with SUDs and their young children birth through five (2009–2012) and subsequently delivered in outpatient opioid treatment settings (2012–2016). BRIGHT is offered as an enhancement to substance use treatment and not as an addiction treatment on its own. Sessions can start in pregnancy, as the mother is beginning to anticipate the birth of her baby, soon after the infant is born or during the toddler or preschool years. Number of sessions can vary, but, optimally, the parent and child meet with the clinician for approximately 9–12 months, although progress has been noted with as few as 10–12 sessions. Early findings demonstrate that BRIGHT is associated with improvements in maternal mental health and parenting capacities (Paris et al. 2015).

BRIGHT is informed by principles and techniques of the evidence-based child-parent psychotherapy (CPP; Lieberman and Van Horn 2005; Toth et al. 2006) and strategies derived from infant mental health interventions for vulnerable parent-infant dyads (e.g., Slade et al. 2005) including parents with SUDs (Suchman et al. 2010). CPP is a dyadic intervention for parents and young children affected by trauma and mental health difficulties, firmly based in attachment theory. Like CPP, BRIGHT is a dyadic therapeutic model, using play and relationship-focused activities to improve parent-child interactions and overall development. Clinicians promote developmental progress through play, physical contact, and language; offer unstructured developmental guidance; help parents provide protective behavior; translate the meaning of children’s feelings and actions for parents; provide emotional support and empathic communication; and provide concrete assistance with problems of daily living. Relying on current best practices for mothers and infants affected by parental addiction, BRIGHT clinicians work to build emotion regulation skills and reflective functioning as mechanisms for a parent to become attuned to her child’s emotional and behavioral needs. Additionally, the clinician helps the dyad to regulate strong emotions that emerge in the parenting process and link past relationships to present parenting, promoting attunement and sensitivity to the child.

Given that BRIGHT integrates the principles of CPP and infant mental health with research on the impact of addiction on parenting, one main tenet of the intervention is the importance of shifting among therapeutic stances emphasizing recovery, processing and integrating trauma, and attending to parenting and the mother-child relationship. We initially work to engage the dyad in treatment through listening to the parent and child’s needs and narratives and demonstrating that we can tolerate difficult emotions. While we are not providing addiction treatment, we explore a parent’s recovery from active addiction, question what has promoted and prevented healthy recovery in the past, and acknowledge that difficult affect can be a trigger to relapse. As we build initial rapport with mothers in early sessions, we explicitly state that we want to hear when their recovery is threatened or when they have had a relapse. Our main goals in BRIGHT treatment include (1) integrating of past and present parental internal representations, (2) supporting self-narratives of competence and confidence, (3) encouraging parental reflective functioning, (4) developing playful moments of pleasure and connection, and (5) promoting optimal protective behavior in parents. The following sections will provide details of the BRIGHT intervention including a composite case example.

Because we deliver a trauma-informed intervention, we are explicit with parents about collecting information about traumatic events in their lives and the lives of their children, as well as about their symptoms of distress and PTSD. We gather this information using standardized instruments and clinical interviews.