**5. Therapeutic goals**

The therapist formed a clinical impression that the child's early experiences with neglect and a disrupted attachment relationship had created a sensitization where he did not trust that his basic needs would be met. The therapist, in conjunction with the mother, designed a therapeutic plan that consisted of weekly dyad visits for the child and the mother and developmental guidance and consultation with the child care teachers and the parenting specialist. The treatment goals emphasized the importance of a trusting and secure attachment relationship with the mother, offering the child interactive co-regulation, providing supportive transitions from mother to child care, creating features of safety in the classroom and living environments, and alleviating the mother's symptoms of distress.

#### **5.1 Foster a secure mother-child attachment relationship**

The mother had difficulty putting her child to sleep in his crib and tolerating his night terrors. She revealed that being unable to soothe him brought up feelings of rejection and doubt as a mother. The therapist assured the mother that her solid commitment to her recovery and mental health treatment, as well as seeking therapeutic and developmental support for her child improve her ability to care for him.

The therapist helped the mother to understand that the birth of a prenatallyexposed infant is stressful for both mother and baby, especially if there is a lack of social support. The therapist clarified that ongoing stress can overwhelm a mother and weaken her ability to care for her baby. If there is a worsening of mental health and substance problems that go untreated, the unintentional consequence can lead to child neglect and a foster home placement.

The therapist explained that young children who experience early trauma see the world as a dangerous place. When your child is avoiding going to sleep and waking up screaming or running away from you, his brain and body are saying that he is scared. His fears are triggered automatically by something that reminded him of a stressful experience. In these moments, your son needs to receive cues that you are physically and emotionally present to keep him safe. He is saying, I am scared, and I want you to support me even when I run away from you. Please approach me slowly and gently, sing softly and tell me I am safe and that you will stay and take care of me.

Together, the therapist and mother listed attachment behaviors that the child used to signal distress. These included crying during separations from the mother to the child care and to his crib, night terrors, and running away and rejecting comfort from her and the teachers. The process of going over these behaviors allowed the mother to reflect on her son and their attachment relationship, and to share her own observations and concerns. The therapist explained that once his attachment needs are consistently met, he would begin to feel secure and start to explore his environment and other social relationships. She reassured the mother that responding sensitively to her son's attachment behaviors would generate a sense of security that he is looking for and the expectation of an available mother in times of upset. The therapist clarified that your child requires your physical presence, even when he runs away from you, to decrease his stress. At this stage of development, he is too young to be able to call upon his mother's image and a mental model of his attachment figure as a form of self-soothing.

#### **5.2 Assist early regulation of basic physiologic functioning**

The mother's own mental health challenges and substance use history compromised her ability to regulate her son's sleep pattern. The mother was worried

#### *From the Shadow to the Light: Navigating Life as a Mother with a History of Substance Use… DOI: http://dx.doi.org/10.5772/intechopen.94073*

because she felt helpless when her son resisted going to sleep in his crib or when he woke up screaming during the night. She, herself, was sleep deprived and feared the consequences involved in breaking the program's safe sleep protocol of no bed sharing. She wanted help putting him to sleep in his crib and how to respond to his night terrors.

The therapist explained that sleep is an anxious time of separation for young children, especially if they have a history of being removed from the mother and placed in a foster home. The therapist worked with the mother to create a consistent nighttime routine for placing her child to sleep in his crib and for alleviating his night terrors. It began with a bath to help him relax followed by calming activities such as reading his favorite books. The mother was to quietly hold her son and speak calmly and softly until he showed that he was drowsy and ready to sleep before laying him gently in his crib. She was encouraged to sit by the crib and stay near her child and not leave his side until he was in a deep state. The therapist identified the child's different states of arousal and showed the mother how to regulate his arousal levels by altering the environment and looking for cues that he is tired in order to support a smooth state transition to sleep.

The mother shared with the therapist that she was feeling sleep deprived and asked the therapist to meet with the recovery program's mental health and substance use counselor to incorporate a rest period as part of her daily treatment schedule. The mother also asked the therapist to meet with the child's teachers to reinforce the therapeutic goals in the classroom to ensure that he was getting enough rest during nap time.

The therapist modeled for the teachers how to offer interactive regulatory support to the child when he became highly aroused during stressful periods. It was explained to the teachers that the therapeutic skill from this point of view is to gradually regulate levels of arousal through an interpersonal and emotionally attuned relationship within the context of a supportive environment [27]. The suggested curative aim is to minimize the stimulation of the neural pathways that communicate fear and stress in the hope that these pathways may eventually fade through lack of use [23].

The teachers were asked to create a consistent and predictable nap routine that prepared the child for sleep and to use comfort items for him to have during the transition that would calm and soothe him. They were reminded not to wake him up if he was crying out in his sleep, but rather use a reassuring and soothing voice that lets him know that you are there for him and to remain by his side until he settled. The teachers and parenting specialist recognized that "pressuring" the child to wait to eat during meal times increased his stress. They met with the mother to identify his favorite foods and arranged for small meals and snacks to be available at child care and in residence for him to eat throughout the day and evening.

#### **5.3 Support transition from the mother to child care**

The child was subdued and tearful each time the mother left him at the child care. The mother was conflicted over staying to comfort and meet his emotional needs and being late to the recovery program. Some of the time she would leave abruptly due to her own stress reactions, which increased both his and her distress levels. The therapist discussed with the mother that quick departures reinforced his sadness and worked with her and the teacher to implement a consistent and gradual transition plan during morning drop off.

The mother agreed to come to the child care earlier to participate in a pleasurable activity such as reading a book in a quiet area with her child and the teacher. Together, they looked for cues that he was relaxed and adjusted to the classroom before the

mother left for her program. At the time of departure, the teacher assured the child through close proximity and a reassuring voice that he would be cared for until his mother returned to pick him up.

As part of the transition plan, the mother brought his favorite items to the classroom to access during the day to calm and self-soothe. It was explained to the mother that his representational thinking of his attachment figure had not yet emerged and the comfort items, which represented a symbolic image of their relationship, were a form of self-soothing during difficult goodbyes. So, for the child, when his mother moved out of his sight, he felt scared as he perceived that she had vanished. His fear was triggered automatically by the stressful experience of his "mother's disappearance" when he was removed from her and placed in a foster home. It is of significance that traumatized young children are at a heightened risk of perpetuating a fearful state because their immature perceptual system interprets stimuli that even remotely resemble those associated with the trauma as dangerous.

#### **5.4 Create features of safety**

An important part of the therapeutic process was to create features of safety in the classroom and the residential environment that reduced the child's fear and protected him from exposure to reminders of past traumatic experiences. The child care teachers and the parenting specialist consulted with the therapist to identify strategies that worked to modulate the child's emotions and their own stress reactions when he would hide in the corner of the room and rejected interacting with them or playing with his peers. In these moments they learned to take deep breaths, practice being mindful and present by pausing and reflecting, and asking each other for support if feeling overwhelmed.

The therapist reinforced the teachers' efforts to implement consistent routines, a predictable daily schedule, visual aids, and an area that provided the child a sense of control. The teachers created a quiet area with pictures of the mother, books, comfort items, and sensory-regulating activities where they could quietly join the child and validate his strong emotions, while mediating pleasurable peer interactions. To reduce his fear response, the teachers were taught to approach the child slowly at eye level and to communicate with a soothing tone and kind face that affirmed his emotions and that guarded against signs of displeasure. They were educated in polyvagal theory, that prosody of voice and favorable face-to-face exchanges have the potential to regulate autonomic state so that young children can socially engage with their caregivers [13]. At the same time, the therapist worked with agency staff to integrate trauma informed practices and features of safety across all programs. The staff's deep affection for the child that grew over time, and was reinforced by the progress that he made, suggested he was feeling safe and trusted his needs were consistently being met.

#### **5.5 Alleviate the mother's symptoms of distress**

A mother with a substance use and a psychiatric disorder who is coping with unresolved trauma often cannot be emotionally attuned to her young child without therapeutic support**.** Notably, during the initial clinical sessions with the dyad, it was necessary for the therapist to alleviate the mother's symptoms of distress and free her to be emotionally available to her son. In these moments, the therapist's own attuned affective state helped organize the mother's mental processes and emotions so that her son could regulate his state through direct connection with the mother. This interactive regulatory process created a deep bond within the triad that reduced the mother's and child's intense arousal. In other words, the mother's

*From the Shadow to the Light: Navigating Life as a Mother with a History of Substance Use… DOI: http://dx.doi.org/10.5772/intechopen.94073*

emotions are regulated by the therapist's compassion and empathy. The child's emotions are now regulated through the mother. When the child calms down the mother also calms and is able to emotionally attune to her child.

In this close therapeutic context, the mother discussed her own trauma history with the therapist. The mother talked about her parents who used drugs and the loneliness she experienced living in a foster home. Now in recovery, she was reconciling the pain of both receiving and passing on the family suffering to her son. The therapist explained that psychological distress from a history of traumatic experiences predisposes individuals to inherit extreme stress and a misidentification with parental suffering [4]. Such a predisposition borders with life's pressures to trigger psychological disorders whose symptoms worsen overtime when healthy coping strategies break down under high stress. If untreated, stress is passed on through generations of children passing on this painful legacy. The therapist's shared affect and willingness to stay connected to the mother during these painful conversations created a safe space and affection between them and enabled the mother to gain trust and fully commit to the therapeutic process.

### **6. Summary and discussion**

The case discussed here details the psychotherapeutic treatment of a mother and child that was carried out within the protection of the residential recovery program's seeking safety, trauma informed model of care [5]. The mother-child psychotherapy demonstrated the sensitive care that was needed when working with a child with a history of neglect and a disrupted attachment relationship and the favorable ways that holding the mother in mind freed her to be emotionally available to her son. There existed evidence that the child's early traumatic experiences had created a sensitization where he did not trust that his basic needs would be met and a mother who was remorseful for not getting help sooner.

Early in the therapeutic process it was vital for the therapist to remain fully present and emotionally attuned to the mother so she could gain trust in the therapeutic relationship and fully engage in the therapy. The mother's attempts to soothe her child caused him to reject her and the mother to become overwhelmed and helpless. The therapist observed a mutually stressed mother-infant system that was diminishing the mother's own regulation and ability to co-regulate her son's behavior. The therapist created a protected therapeutic space and explained that the child's rejection was his way of telling his story and asking for help. The therapist's shared affect and willingness to stay emotionally connected to the mother alleviated her symptoms of distress so she could be emotionally available to her son even in moments when he was outwardly refusing her efforts to comfort him.

The primary questions that guided the therapeutic process asked: How does a psychoneurobiological approach, which draws from psychoanalytic, attachment, polyvagal, and neurobiological theories present an integrated way of interrupting the intergenerational effects of trauma that are passed on to future generations? How does our understanding of polyvagal theory enhance the clinical situation within the safety of a trauma informed model of care that emphasizes secure base therapeutic relationships?

To address these questions, the therapist explained to the mother that young children who experience early trauma see the world as a dangerous place. When your child is avoiding going to sleep and waking up screaming or running away from you, his nervous system is saying that he is scared. His fears are triggered automatically by something that reminded him of a stressful experience. He is saying, "I am scared, and I want you to support me even when I run away from you". The therapist clarified that his fear overwhelmed him and that he got relief and reduction of his stress through the protection of a secure attachment relationship with his mother. The therapist modeled for the mother how to approach her child slowly and gently at eye level, singing softly and telling him that he is safe and that I will stay and take care of you. According to polyvagal theory, prosody of voice and favorable face-to-face exchanges have the potential to regulate autonomic state so that children can relate to nurturing adults [13].

As part of the psychotherapeutic treatment it was necessary to apply the psychotherapeutic goals and to create features of safety in the classroom and in the residential treatment program. Inquiries that surfaced focused on the child's neurobiological reactions to stress. Does he create the same conditions of compromise in the program staff? Do they have the emotional self-awareness and interactive regulatory capacity to regulate their own behavior and ameliorate the child's distress? To address these questions, special care was taken to explain the child's behavior to the teachers in the classroom and the residential treatment staff.

The therapist clarified that the child's behaviors were a natural response to early traumatic stress and showed the child care teachers and parenting counselor how to regulate the child's distress and attune to his intense emotions using gentle movements, a calm voice, and face-to-face interactions [13]. They were supported for their efforts to stay connected to the child during heightened levels of arousal and for providing a safe and containing environment that affirmed the child's emotions and minimized his fear responses from becoming conditioned. According to Perry et al.'s [23] findings, the therapeutic aim is to reduce the stimulation of the neural pathways that communicate fear and stress in the hope that these pathways may eventually fade through lack of use.

The mother successfully completed the in-patient residential treatment program in 6 months and moved to the program's sober living environment where she and her child resided for one year. The mother recognized that during the transition, her child's separation distress had increased, and it was beginning to take an emotional toll on her. It was essential for the mother to receive individual community mental health and out-patient recovery services and for the child to continue the motherchild psychotherapy and the therapeutic child care. The therapist assured the mother of the progress that she and her child had made in the first 6 months of treatment and that the recent changes showed that they had regressed under the current stress and could adapt to these changes with ongoing therapeutic support.

In the next 6 months of mother-child psychotherapy the therapist worked with the mother and the child care teachers to continue with the strategies that were effective in assisting the child to develop new models of trust. During this phase of treatment, the mother revealed that her confidence to care for her son improved and she was better at regulating her own emotions and meeting his needs. She learned how to prepare nutritional meals in the recovery program and her son was no longer highly aroused around food. He was sleeping throughout the night in his own bed and had made substantial developmental gains, entering childcare ready to play. The mother brightens when talking about their close relationship and the sureness she has gained in caring for him. She believes that her childhood would have turned out differently if her parents had received substance use and therapeutic support.

### **7. Conclusion**

This article represents our clinical work with mothers and young children who suffer extraordinary stress from the effects of substance use and mental health

#### *From the Shadow to the Light: Navigating Life as a Mother with a History of Substance Use… DOI: http://dx.doi.org/10.5772/intechopen.94073*

illness. The mother-infant psychotherapeutic treatment and developmental guidance provided to the mother and the program staff helped to regulate and restructure the child's nervous system. Feeling affirmed and supported, the child developed an emerging reorganized protective structure from which to safely resolve his fears and explore social relationships.

We conclude the mother and young child can follow a course of recovery from early traumatic experiences within the context of favorable conditions, thereby, interrupting the intergenerational dynamics of early relational trauma. A critical variable is staff who serve as a secure base whom the mother and child can trust and who is available to provide interactive regulatory attunement. It was by virtue of the therapist's ability to regulate the mother's and child's dysregulated affective states that they seemed to endure the strain of recovering from substance use and mental health challenges within this particular therapeutic milieu.

### **Author details**

Linda M. Perez1 \*, Suzi E. Desmond1 and Cheryl J. Sundheim<sup>2</sup>

1 Epiphany Center, San Francisco, CA, United States

2 CS Consulting Services, San Francisco Bay Area, CA, United States

\*Address all correspondence to: lmperez@mills.edu

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
