**1.1 Seeking safety, trauma informed model of care**

Trauma has been described as the single most important public health challenge [1] that is too often silenced and unacknowledged for its significant prevalence and devastating impact in our public dialog [2]. In the United States drug overdose deaths rose from 38,329 in 2010 to 70,237 in 2017 followed by a decrease to 67,367 in 2018. Narcotics or opioids (mainly fentanyl or fentanyl analogs) are the main cause of drug overdose deaths followed by methamphetamine and cocaine psychostimulants. Additional overdose deaths involving benzodiazepines or antidepressants are mainly due to those ingested with synthetic opioids. Women account for 33% of these statistics (National Institute on Drug Abuse, 2020).

These alarming data override the importance of the 19.7 million American teenagers and adults, age 12 years and older, who battle daily with a substance use disorder, many of whom struggle with alcohol consumption and both a substance use and mental health disorder [3]. Nor do they account for the effects of the loss of a loved one or the consequences of intergenerational trauma as children inherit extreme stress that is passed on through the caregiving system. Such a predisposition interfaces with life's pressures that trigger emotional and psychological problems in future generations [4].

The purpose of this article is to report on an innovative in-patient residential recovery program that serves as a model for those who treat low-income women with substance use and psychiatric problems and their children. The majority are mothers who are pregnant, parenting infants in the first 3 years of life, or reunifying with older children who are in the foster care system. We find that long-term substance use or dependency is associated with mental health challenges, and no matter which came first, successful treatment demands that one addresses both simultaneously. The recovery program combines a *seeking safety, trauma-informed model of care* [5] to enable the women to meet their most urgent clinical need to establish safety and develop trusting relationships and secure attachments with their children, thereby, interrupting the intergenerational dynamics of early relational trauma.

There is a deepened understanding that infants and young children, who live in impoverished environments exacerbated by substance use and maternal psychopathology, are at risk for adverse developmental outcomes. Given their capacity for mutuality and reciprocal relationships, the form of psychotherapeutic treatment most compatible with this view is performed within the context of the dyad and the attachment relationship. Attention is focused on the complex interactions that occur between mother and child in a relational context [6–8]. This type of relationship-based clinical practice is appropriate when difficult circumstances such as parental substance use or depression, chronic stress, or child constitutional or developmental characteristics interfere with the formation of a secure attachment [9].

Clinical questions that are germane to this paper are: 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?

### **2. Theoretical perspectives**

#### **2.1 The psychoanalytic approach and attachment theory understanding**

Ainsworth's [10] characteristic of the attachment figure as a secure base from which to explore the protection of a therapeutic relationship and to develop new models of trust resonates with a seeking-safety, trauma-informed model of care. Developing a secure base in psychotherapy is as important as it is for children's development and humans' long-term need for safety. In the therapeutic process, protection includes social-emotional security through the therapist's ongoing regulation of the individual's affective state, often calming through emotional availability [7, 11]. Therapeutic co-regulation signifies regulation of co-adaptive processes at the level of behavior, physiology, and representation [12–14].

#### *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*

Bowlby [15] places a steady relationship between an individual and a familiar person on a level of biological importance secondary to the maintenance of physiological stable states. He proposes, "the regulatory systems that maintain a steady relationship between an individual and his familiar environment can be regarded as an outer ring of life-maintaining systems complementary to the inner ring of systems that maintain physiologic homeostasis" ([16], p. 150). Therapeutic co-regulation is a critical component of a homeostatic response to stress and is a treatment strategy that can be used to regulate the individual's internal state [12, 14].

The aim of a secure base model of psychotherapy is to facilitate the mother's understanding and reconstruction of a protected internal working model at a representational level [12]. Another purpose is to enable the mother to form a healthy bond with her offspring. Bowlby [12] recognized that when treating mothers with insecure states of mind with respect to internal working models of attachment, it is essential for the therapist to remain fully present and emotionally attuned to the mother so that a special kind of well-being can flow from the dependable emotional connection. That deep and loyal attachment with the mother is profoundly individually empowering and emotionally regulating. The mother now feels a special bond with the therapist emerge, assisting her to reciprocate emotionally attuned and regulated interactions with her child.

#### **2.2 The attachment relationship and its regulatory function**

The goal of the attachment system is for the infant to obtain proximity to the attachment figure, especially in time of stress, fear, or danger (real or perceived). A mutual goal of the caregiving system is to provide proximity, safety, and sensitive care for the child. Protection includes not only physical protection but social-emotional protection as well, through ongoing regulation of the infant's emotional state by way of emotional availability and attunement [7, 11].

Attachment research shows that mothers with unresolved trauma and who demonstrate fearful or dissociative behavior tend to have children with a disorganized attachment pattern [17, 18]. For these children the mother is a source of fear rather than a source of comfort. In situations where the children feel a threat to their own survival, they will have great difficulty regulating arousal. For these children the mother is a source of fear rather than a source of comfort. As a result, they lose the benefits of the attachment relationship and psychobiological attunement and homeostatic regulation that should serve to reduce their fear.

Schore [19] claims that attachment relationships are important beyond the provision of a sense of safety and protection. He goes on to say that prolonged psychobiological transactions associated with a stressful caregiving relationship impair the initial formation of the stress response system in enduring ways. His view supports the notion that poor psychobiological regulation is a traumatic stress that produces long-term changes in biological systems. Continuous suboptimal caregiving generates hormonal reactions that promote an impaired hypoactive or hyperactive stress response that is mediated through the hypothalamic-pituitaryadrenal (HPA) axis [20]. If the HPA axis is repeatedly activated, stress-response mechanisms are set a high level of reactivity that both stimulates the release of cortisol and is sustained by it [21, 22].

#### **2.3 Polyvagal theory**

Polyvagal theory offers another view of homeostatic regulation of the autonomic nervous system in which to understand and treat fear and arousal. Porges [13] coined the word neuroception to describe how the nervous system is genetically

wired to detect safety, danger, or threat, well below the level of conscious awareness, when it is challenged by the environment. At the point where fear activates biochemical changes in the autonomic nervous system, the brain reacts defensively to social challenges through either sympathetic hyperarousal or parasympathetic dissociation. The most usual response to a perceived threat is a fight or flight response as a form of self-protection. If the environment does not respond, the individual moves through a dissociative continuum, initially becoming compliant and immobile (freezing), followed by surrender and dissociation. This hypoarousal cool down on top of high arousal leads to a collapse in the parasympathetic nervous system.

Porges [13] asserts that a traumatic event can impair an individual's neuroception and leave in its wake misidentification with a sense of safety, danger or threat. In his view, prosody of voice and facial expressions are important features of safety that set-in motion the process of reducing stress and calming the limbic system, thereby, allowing an individual to participate in social engagement. Emotionally-attuned interactions that are presented face to face with kind gestures and a soothing tone rather than signs of disapproval more reliably mitigate fear and interrupt defensive behaviors [13]. These favorable exchanges have the potential to regulate autonomic state so that an individual can explore feeling safe within the protection of a therapeutic relationship and fully engage in therapy. At the same time, it is important to create added features of safety in the environment through predictable expectations and schedules.

## **2.4 Neurobehavioral descriptions of trauma**

Trauma has been described as the single most important public health challenge [1]. The neuroscientific world recognizes that trauma is imprinted on the body leaving the individual overaroused and fearful even after an event ceases to exist [1, 13]. When everyday occurrences activate intense fear, the fear becomes conditioned and deeply entrenched, biasing the nervous system towards overarousal. Fewer environmental stimuli are now required to reactivate early fear [23, 24]. 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 [23].

Living in fear distorts sensory perceptions and it gives rise to disproportionate, atypical development of the parts of the right brain associated with decoding facial expressions and reading threatening social cues. At the same time there is underdevelopment of the parts of the right brain governing self-control. In some cases, the brain seeks extreme sensory experiences and pursues incautious unsafe exploration. In other cases, brain function and behavior become rigidly organized around an aversion to stimulation and exploration.

Trauma produces high levels of the catecholamines epinephrine, norepinephrine, and dopamine. Activation of these neurotransmitters correlates with anxiety, hyperarousal, and hypervigilance [24]. As such, individuals have trouble inhibiting negative impulses and thus operate under the influence of the lower, impulsive brainstem, literally acting without thinking.

This same fear activates biochemical changes in the autonomic nervous system [19, 23–25]. It is not unusual for people to react neurobiologically and defensively to their fear with a constant fight or flight response or, worse, dissociation. If they stay in a continuous state of dissociation, the neuronal system mediating this response becomes sensitized thus increasing the risk of their developing psychiatric symptoms including depression, anxiety, helplessness, and withdrawal [23].

*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*

## **3. An integrated trauma informed model of care**

Those of us who work directly with families living in extraordinarily stressful circumstances confess to the many difficulties inherent in the process. Over the past 35 years our recovery program has treated low-income mothers with substance use and psychiatric problems and their young children in the San Francisco Bay Area. The majority of the women who come to the program have histories of trafficking, poverty, homelessness, incarceration, school failure, and are victims of domestic violence and child abuse.

#### **3.1 Relationship-based intervention**

There is a heightened understanding that comprehensive substance use and mental health treatment for the mother must include the young child in the cure [26]. Otherwise, little attention is paid to the adverse developmental threats to children who may be prenatally drug exposed or whose lives are negatively influenced by toxic stress. The trauma-informed in-patient residential recovery program for women and children that we are presenting is founded on the premise that a relationship-based approach acts as a secure source from which the women explore the protection of a therapeutic bond and environment.

This corrective method enables the women to realize safety and develop new models of trust, encourages them to express their ideas in an environment where they are valued, treats their substance use and mental health disorders simultaneously, facilitates emotionally attuned interactions between the mother and child to foster secure attachments, remedies the many deleterious effects that profound stress has on the mother's and the child's nervous system, and interrupts the intergenerational dynamics of early trauma.

A culturally competent and trauma informed recovery team of family therapists, clinical social worker, psychologist, psychiatrist, nurse practitioner, and medical doctor work collaboratively with intake clinicians, substance use counselors, parenting specialist, and child care providers to deliver ethically responsive in-patient substance use, mental health, physical health, onsite therapeutic childcare, and parenting education. This coordinated effort provides a singular opportunity to help the mothers to overcome their addiction and stabilize their mental health while promoting an emotionally healthy mother infant dyad.

The residential treatment program has resources and system-wide procedures in place to identify and treat the women and their children's needs. The assistant executive director oversees the management of treatment programs and recurrent multidisciplinary team meetings strengthen collaboration and coordination among all services and other community support systems. The women receive psychiatric consultation, clinical case management; substance use and mental health counseling; health screenings; nursing advice; and recovery groups plus life skills, seeking safety, and nurturing skills parenting classes; a 14-week Circle of Security attachment training; and interactive playgroups that accentuate dynamic exchanges between the mother and child.

The birth of a constitutionally-compromised prenatally-exposed infant to a mother in recovery is stressful and can overwhelm her. More often, the infants have experienced other complex traumatic stressors and have regulatory problems that plunder the mother's own ability to co-regulate her infant. All mothers admit that it is a struggle to care for an agitated, stressed infant. Even capable mothers may be unable to do so without proper help. The infants and young children at the recovery program get onsite pediatric health care, mother-child psychotherapy, and licensed therapeutic childcare with mental health consultation, developmental assessment, and early intervention that is focused on prenatal drug exposure and early childhood trauma.

#### **3.2 Toddler with a history of neglect and a disrupted attachment relationship**

The following example illustrates the program's therapeutic treatment of a mother with a known history of depression and substance use and her 18-month old male toddler with a noteworthy past of prenatal drug exposure, neglect, a disrupted attachment, and a foster home placement. Early experiences of neglect can create implicit memories that may trigger defensive behavioral reactions if adults try to console the child when feeling threatened [2]. A toddler who has been removed from the mother is likely to suffer from separation distress and problems with the attachment relationship. In turn, the mother may have difficulty regulating her child who is easily disorganized from the effects of the traumatic separation that endangers the attachment bond and that are exacerbated relative to her own mental health challenges. Additionally, it is not unusual for the mother to feel remorseful for failing to get help sooner.

At the early phase of treatment, the mother immediately meets with the psychiatrist to ensure psychiatric stabilization and medication management. The mother and child spend the first week together in the STAR (Services to Accelerate Resilience) program where they meet staff from the adult substance use and mental health recovery program, the family mental health and pediatric clinics, the therapeutic child care, and the family enrichment program. During this initial stage, the staff develops a relationship with the mother and child focusing on their strengths and informally observing their interactions while evaluating their needs. Afterwards, the team members gather at its weekly meeting and clinical supervision to recommend features of safety across all of its programs and to coordinate on-site child referrals to the pediatric clinic and the family mental health treatment program.

At the next phase, interventions are implemented to treat the mother's symptoms of mental distress through ongoing sessions with the substance use and mental health therapist and the clinical case manager. The mother attends daily in-patient recovery groups that focus on her own trauma and substance use history, as well as a Circle of Security attachment training and parenting classes where she is taught knowledge of child development versus child management, how to identify and respond to her child's trauma behaviors, and ways to use emotionally attuned interactions to re-regulate the child's distress.

By now, the child is enrolled in child care and is receiving trauma informed developmental care and assessment, medical and nutritional support, and mental health consultation. Given that the trauma coincides with the child's expectable developmental challenges, interventions focus on supporting new skills, identifying traumatic stress reactions, and recognizing traumatic triggers that lead to stress behaviors. These trauma-informed strategies are incorporated and reinforced in the residential living area by the parenting specialist and a 24-hour staff of substance use counselors. Additionally, the child is seen in the pediatric clinic and referred to the family mental health clinic for mother-child psychotherapy.

#### **4. Mother-child pyschotherapy**

Mother-child psychotherapy is a relationship-based clinical practice that is appropriate when the mother is depressed and battling substance use and the

#### *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*

child has a history of traumatic stress that jeopardizes a secure attachment [9]. The therapist's primary objective is to strengthen the attachment relationship between the child and mother and improve developmental outcomes. This clinical approach demonstrates the sensitive care that is needed when working with the dyad and the favorable ways that holding the mother in mind frees her to be emotionally available to the child.

In this kind of psychotherapy, the therapist attends to both the mother's and child's emotions, and to their relationship while considering the mother's mental health and substance use treatment. Essential to this practice is for the therapist to notice and reinforce positive interactions between the mother and child by remaining mindful and emotionally attuned to the mother. This support and attunement will help to alleviate the mother's symptoms of distress so she can be more present and available to help her child organize emotional and intellectual responses necessary to adjust to life stressors.

The psychotherapeutic treatment begins with a guided clinical interview performed by the child psychologist who is a team member of the therapeutic recovery program. The mother talked about her own psychiatric and drug history and how it prevented her from protecting and caring for her child. Now that she is in recovery the mother wanted to get well and attend to her child's needs. The mother disclosed that she was exhausted due to her depression and the child's night terrors that were keeping her awake at night. She discussed how the child is frequently tearful when he is dropped off at the childcare and her inability to comfort him. The mother wanted to know if the therapy could help her understand her son's behavior and whether he would be like other children in the program who seemed less upset. The therapist explained that her child appeared easily disorganized from the effects of early trauma, including separation from her while he was in foster care, but that he could adapt to these stressors with her support and therapeutic intervention.

The psychotherapeutic treatment included the therapist observing the dyad interacting during caregiving and child-centered play, focusing on how the mother engaged her child. The therapist looked for areas of synchronicity and difficulty in their interactions that were influencing their relationship. When the child cried and the mother raised her voice to get his attention and rushed to soothe him, he ran away and hid in a corner of the room, refusing her comfort. When the child did not accept her efforts to console him, the mother perceived this as rejection and became stiff and helpless. The therapist observed a mutually stressed mother-child system that was diminishing the mother's own regulation and ability to co-regulate her son's behavior.

In these moments, the therapist contained the mother's and son's distress by creating a quiet and supportive environment, and by modeling for the mother how to respond in a sensitive way. She encouraged the mother to approach her child more slowly at eye level and use a soothing voice to lower his arousal to an intensity he could tolerate before trying to comfort him. The therapist talked in a reassuring tone that helped to calm and regulate the mother's emotions before explaining that her son's rejection was his way of telling his story and asking for help. In this close context, the mother gained trust in the therapeutic process and revealed her own traumatic history of growing up in the foster care system.

The treatment also included periodic observations of the child in the childcare setting where the therapist worked with the teachers to identify his traumatic stress reactions. The teachers reported that the child was primarily tearful and subdued when he was dropped off in the mornings, that he often hid in the corner of the room and rejected interacting with the teachers or playing with his peers, and that the child was mostly silent except when he became highly aroused and protested if he had to wait his turn during meal times. At naptime, he would resist going to sleep or wake up crying.
