Mothering from the Inside Out: Results of a community‐based randomized efficacy trial testing a mentalization‐based parenting intervention for mothers with addictions
Open accessAbstract
Mothering from the Inside Out (MIO) is a mentalization‐based parenting intervention developed to address challenges common among mothers experiencing substance use disorders (SUDs) and previously deemed effective when delivered by research clinicians. This randomized clinical trial was designed to test the efficacy of MIO when delivered by community‐based addiction counselors in Connecticut, USA. Ninety‐four mothers [M(SD)age = 31.01(4.01) years; 75.53% White] caring for a child 11–60 months of age were randomly assigned to participate in 12 sessions of either MIO or psychoeducation. Caregiving, psychiatric, and substance use outcomes were assessed repeatedly from baseline through 12‐week follow‐up. Mothers who participated in MIO showed decreased certainty about their child's mental states, and decreased depression; their children demonstrated increased clarity of cues. Participation in MIO was not associated with the same degree of improvement that was observed in prior trials where MIO was delivered by research clinicians. However, when delivered by community‐based clinicians, MIO may be protective against a deterioration in caregiving over time often seen in mothers with addictions. The drop in efficacy of MIO in this trial raises questions about intervention‐intervenor fit. Research should examine factors influencing MIO effectiveness to close the science‐to‐service gap common in the dissemination of empirically validated interventions.
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MIO has been associated with reduced rates of relapse in multiple clinical trials.
“MIO has been associated with reduced rates of relapse and depressive symptoms, improved caregiving, and enhanced child attachment in multiple clinical trials (Lowell, DeCoste, et al., 2023; Suchman et al., 2008; Suchman et al., 2010; Suchman et al., 2011; Suchman, DeCoste, et al., 2017; Suchman, Ordway, et al., 2016)”
From Home‐based family recovery supports: Feasibility, acceptability, and adoption of training home visitors in “Mothering from the Inside Out” (2025) · cites this paper as Lowell, DeCoste, et al., 2023
The Previous MIO Trials section reports a lower proportion of heroin relapses during follow-up in a prior trial. The Results section of this community-based trial reports that opioid use increased in the comparison group but not the MIO group; it does not report a reduced relapse rate. Thus the paper supports a relapse finding, but not reduced relapse rates across multiple trials. (LLM, conf=0.83)
Experimental — accuracy not yet measuredMIO has been associated with enhanced child attachment in multiple clinical trials.
“MIO has been associated with reduced rates of relapse and depressive symptoms, improved caregiving, and enhanced child attachment in multiple clinical trials (Lowell, DeCoste, et al., 2023; Suchman et al., 2008; Suchman et al., 2010; Suchman et al., 2011; Suchman, DeCoste, et al., 2017; Suchman, Ordway, et al., 2016)”
From Home‐based family recovery supports: Feasibility, acceptability, and adoption of training home visitors in “Mothering from the Inside Out” (2025) · cites this paper as Lowell, DeCoste, et al., 2023
The Previous MIO Trials section reports improved child attachment security only in a subgroup of one earlier trial; it found no overall effect in that trial. The Results section (Secondary Parenting Outcomes; page unavailable) reports no significant improvement in attachment security in the 2023 trial. Thus the paper supports a qualified association, not enhanced child attachment across multiple trials. (LLM, conf=0.89)
Experimental — accuracy not yet measuredMothers in this study completed more MIO sessions overall than in the comparison.
“However, when compared to the training of community-based SUD counselors, fewer EI providers completed the MIO training (4 of 10 EI providers compared to 8 of 10 SUD counselors) and duration of training for EI was much longer (average 10 weeks for SUD counselors), though mothers in this study completed more MIO sessions overall (Lowell, DeCoste, et al., 2023; Suchman, Borelli, et al., 2020).”
From Home‐based family recovery supports: Feasibility, acceptability, and adoption of training home visitors in “Mothering from the Inside Out” (2025) · cites this paper as Lowell, DeCoste, et al., 2023
The Results (Preliminary Analyses; page unavailable) report that mothers in the cited community-based SUD trial attended 57.25% of MIO intervention visits. This supplies a benchmark for the comparison, but the paper does not report session completion by mothers in the citing study, so it cannot establish that they completed more sessions. (LLM, conf=0.82)
Experimental — accuracy not yet measuredMIO has been associated with reduced depressive symptoms in multiple clinical trials.
“MIO has been associated with reduced rates of relapse and depressive symptoms, improved caregiving, and enhanced child attachment in multiple clinical trials (Lowell, DeCoste, et al., 2023; Suchman et al., 2008; Suchman et al., 2010; Suchman et al., 2011; Suchman, DeCoste, et al., 2017; Suchman, Ordway, et al., 2016)”
From Home‐based family recovery supports: Feasibility, acceptability, and adoption of training home visitors in “Mothering from the Inside Out” (2025) · cites this paper as Lowell, DeCoste, et al., 2023
MIO has been associated with improved caregiving in multiple clinical trials.
“MIO has been associated with reduced rates of relapse and depressive symptoms, improved caregiving, and enhanced child attachment in multiple clinical trials (Lowell, DeCoste, et al., 2023; Suchman et al., 2008; Suchman et al., 2010; Suchman et al., 2011; Suchman, DeCoste, et al., 2017; Suchman, Ordway, et al., 2016)”
From Home‐based family recovery supports: Feasibility, acceptability, and adoption of training home visitors in “Mothering from the Inside Out” (2025) · cites this paper as Lowell, DeCoste, et al., 2023
Fewer EI providers completed the MIO training (4 of 10 EI providers) compared to community-based SUD counselors (8 of 10).
“However, when compared to the training of community-based SUD counselors, fewer EI providers completed the MIO training (4 of 10 EI providers compared to 8 of 10 SUD counselors) and duration of training for EI was much longer (average 10 weeks for SUD counselors), though mothers in this study completed more MIO sessions overall (Lowell, DeCoste, et al., 2023; Suchman, Borelli, et al., 2020).”
From Home‐based family recovery supports: Feasibility, acceptability, and adoption of training home visitors in “Mothering from the Inside Out” (2025) · cites this paper as Lowell, DeCoste, et al., 2023
The Next steps in implementation section says community-based addiction counselors received training and delivered interventions with fidelity, but gives no training-completion count. I searched for “8 of 10,” completion counts, and EI providers; no passage in our copy reports the 4-of-10 versus 8-of-10 comparison. (LLM, conf=0.76)
Experimental — accuracy not yet measuredDuration of training for EI was much longer than for community-based SUD counselors (average 10 weeks for SUD counselors).
“However, when compared to the training of community-based SUD counselors, fewer EI providers completed the MIO training (4 of 10 EI providers compared to 8 of 10 SUD counselors) and duration of training for EI was much longer (average 10 weeks for SUD counselors), though mothers in this study completed more MIO sessions overall (Lowell, DeCoste, et al., 2023; Suchman, Borelli, et al., 2020).”
From Home‐based family recovery supports: Feasibility, acceptability, and adoption of training home visitors in “Mothering from the Inside Out” (2025) · cites this paper as Lowell, DeCoste, et al., 2023
The Next steps in implementation section says community-based addiction counselors received MIO training and supervision, but gives no training duration. Searches for “10 weeks,” counselor training duration, and training completion found no passage comparing their training with EI providers’ training. The paper directs readers to Suchman et al. (2020) for training outcomes, but our copy does not establish the claimed comparison. (LLM, conf=0.74)
Experimental — accuracy not yet measured
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Cited by
Sorted by citations
Carlone, C., Milan, S., Decoste, C., Borelli, J. L., McMahon, T. J., & Suchman, N. E. (2023) · Infant Mental Health Journal · doi:10.1002/imhj.22046 · Cited by 35 · see citing works
Self-citationLongobardi, E., Morelli, M., Brunetti, M., Sette, S., Spataro, P., & Laghi, F. (2025) · Infant Mental Health Journal · doi:10.1002/imhj.22164 · Cited by 3 · see citing works
Joyce, K. M., Delaquis, C. P., Alsaidi, T. H., Sulymka, J., Conway, A., Garcia, J., Paton, A., Kelly, L. E., & Roos, L. E. (2025) · Addictive Behaviors · doi:10.1016/j.addbeh.2024.108241 · Cited by 5 · see citing works
Harfouche, F., Martins, F. F., Carvalho, H., Volkert, J., da Cruz, A. S. M. R., Oliveira, E., Santos, M., Fragoeiro, Â., Moreira, C., Mota, C. P., et al. (2024) · Journal of Infant Child and Adolescent Psychotherapy · doi:10.1080/15289168.2024.2417571 · Cited by 3 · see citing works
“These include a home-visiting programme for first-time mothers (Sadler et al., 2013), individual therapies for mothers with substance use disorders (Lowell et al., 2023; Suchman et al., 2008), a group intervention for parents and babies in prison (Baradon et al., 2018), and psychoeducational…”
Porreca, A., de Carli, P., Filippi, B., Bakermans-Kranenburg, M., van IJzendoorn, M. H., & Simonelli, A. (2024) · Development and Psychopathology · doi:10.1017/s0954579424000026 · Cited by 2 · see citing works
“…(Greenson, 2018; Knekt et al., 2011), suggesting the need to integrate the treatments provided with modules specifically focused on parent-child relationship which could be more rapid and effective in supporting quality of care (Lowell et al., 2023; Mayes, 2023; Suchman et al., 2004, 2006).”
Stob, V., Slade, A., Brotnow, L., & WOOLSTON, J. L. (2023) · Journal of Infant Child and Adolescent Psychotherapy · doi:10.1080/15289168.2023.2228719 · Cited by 2 · see citing works
Dawson, N., Sleed, M., & Chunga, E. (2025) · Infant Mental Health Journal · doi:10.1002/imhj.70018 · Cited by 1 · see citing works
“…between levels of PRF and both educational level (Alismail et al., 2022; Arkle et al., 2023; Brophy-Herb et al., 2023; Halfon & Besiroglu, 2021; Lowell et al., 2023) and socio-economic status (Arkle et al., 2023; Stack & Meredith, 2018), with lower levels of both associated with lower PRF.”
Peacock‐Chambers, E., Jurkowski, B. L., Kangas, S., DeCoste, C., McMahon, T. J., Borelli, J. L., Feinberg, E., Byatt, N., Zayde, A., Lowell, A. F., et al. (2025) · Infant Mental Health Journal: Infancy and Early Childhood · doi:10.1002/imhj.70019
Self-citationHanetz‐Gamliel, K., & Shoval, N. G. (2026) · Children and Youth Services Review · doi:10.1016/j.childyouth.2026.109243
- Authors
- Lowell, A. F., DeCoste, C., Dalton, R., Dias, H., Borelli, J. L., Martino, S., McMahon, T. J., & Suchman, N. E.
- Affiliations
- Yale University (US)
- University of California, Irvine (US)
- Corresponding author
- Lowell, Amanda F.
- Venue
- Infant Mental Health Journal
- Publisher
- Wiley
- Published
- 2023-03
- Volume
- 44
- Issue
- 2
- Pages
- 142-165
- ISSN
- 0163-9641 (ISSN-L)
- 1097-0355
- PMC
- PMC10050102
- OpenAlex
- W4322758391
- Cited by
- 15
- References
- 52
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 3 · 2023: 5 · 2022: 1
- FWCI
- 4.08
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Infant Mental Health Journal (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- National Institutes of Health (R01 DA017294, K02 DA023504, T32 DA019426)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
- Health Sciences › Medicine › Epidemiology › Substance Abuse Treatment and Outcomes
- Keywords
- maternal substance use disorder, maternal depression, parenting quality, infant mental health, psychoeducation
- MeSH terms
- Mentalization, Adult, Child, Cues, Female, Humans, Mothers, Parenting, Substance-Related Disorders
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