ReConnect
Final Evaluation Report November 2015
Research Team:
Dr Michelle Sleed
The Anna Freud Centre/ University College London
Prof. Pasco Fearon
The Anna Freud Centre/ University College London
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ReConnect Service Evaluation
About ReConnect
‘ReConnect’ is a specialist service within Buckinghamshire CAMHS that aims to improve outcomes
for the most vulnerable children from 0-2 years who have been identified as at high risk of
developing a disorganised attachment. ReConnect is a manualised programme that aims to improve
the quality of the parent-child attachment relationship via three types of intensive treatments for
parents and infants: Individual Therapy, Group Therapy, and Video-Interaction Guidance.
The evaluation has been carried out by an independent team of researchers at University College
London/ The Anna Freud Centre.
Remit of this report
This report is based on the evaluation of the ReConnect service for the first two cohorts of families
who participated in the individual and group therapy and who agreed to participate in the
evaluation (n=16). It is only possible to report findings from families who engaged with the service
and evaluation (see the project report for details of all referrals to the service). Some families did not
complete all measures at pre- and post-intervention, so sample sizes may differ for different
measures.
Referrals
Parents were referred to the ReConnect Service by a range of professionals including: social workers,
GPs, midwives, health visitors, community paediatricians, children’s centre staff, and mental health
professionals. Essential referral criteria included: the child to be under the age of two, and the
parent to have had some acknowledgement of difficulties in their relationship with their child or in
previous relationship breakdowns. In addition, at least one of the following criteria was essential for
referral: current parental mental health problems; parental history of childhood trauma or neglect;
history of domestic violence; history of substance abuse; or history of severe parenting breakdown,
including permanent removal of previous children.
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Intervention
Once accepted into the service, ReConnect offered each family three types of intensive treatments:
1. Individual Therapy with the parent
Using a Mentalization-Based Therapy (MBT) treatment, parents were supported to develop greater
awareness of their own emotional states, to better manage their emotional arousal, and to develop
their skills in noticing and thinking about their child’s thoughts and feelings.
MBT is an evidence-based treatment originally developed for Borderline Personality Disorder to
improve emotional regulation. 1:1 sessions were offered fortnightly to each parent throughout the
duration of the Parenting Group. Additional sessions were offered according to clinical need.
2. Parenting Group
Parents were also offered a Mentalisation-Based Group Therapy course that ran for 20 sessions. This
group aimed to support parents to develop a greater insight into how they manage relationships.
The group covered topics on attachment, understanding children’s needs and how best to respond
to these needs, as well reflecting on how personal experiences of being parented can impact on
their parenting sensitivity towards their own child.
3. Video-Interaction Guidance (VIG)
Video-interaction Guidance (VIG) is a 6 session treatment that has been found to be very effective in
improving responsiveness and self-efficacy in parents. During this treatment, therapists film the
parent interacting with their child for 15 minutes. The video is then edited into three short clips that
highlight aspects of the interaction in which the infant seeks contact with their parent. These clips
are shown to the parent who is supported to consider how they can respond to their child’s
attachment cues and build upon their relationship with their child.
If required, additional treatments in individual Cognitive Behavioural Therapy and Couple Work were
offered to each family.
Participants
The description of the full sample of all eligible dyads (n = 16) can be found in Table 1. As can be
seen, this represents a relatively high risk cohort of families, with high levels of unemployment,
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single parenting, and previous removal of children into care.
Table 1. Description of participants in the Reconnect Project (n = 16)
N
(total N=16)
%
Child Gender
Male
Female
9
7
56%
44%
Parent Ethnic Status
White-British
Other
14
2
88%
12%
Parent Marital Status
Single
Cohabiting/Married
7
9
44%
56%
Parent highest level education
Did not finish school
GCSE/higher education
Did not answer
3
11
2
19%
69%
12%
Parents who have had other children taken into care
6
38%
Parents unemployed
13
81%
Treatment Input
All families were offered individual appointments and 20 sessions of the group programme and up to
6 VIG appointments (9 out of 16 families received some VIG sessions). The summary of treatment
taken up by each of the families is presented in Table 2 below.
Table 2. Treatment input for families in the ReConnect programme (N=16)
Mean (sd)
Range
Individual sessions
20 (6)
8 – 30
Group
17 (5)
4 – 20
VIG
2 (2)
0–6
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Outcome measures
Treatment outcomes were assessed on a number of measures at both pre- and post-intervention. All
evaluation measures were administered by the ReConnect clinicians and these were built into the
first few assessment visits and the end of treatment follow-up visits. The measures used were as
follows:
1. Patient Health Questionnaire- 9 (PHQ-9; Kroenke, Spitzer and Williams, 2001)
The PHQ-9 is a brief and widely used measure of depression. It assesses symptom frequency
for each of the nine DSM-IV criteria for depression. Higher scores indicate higher frequency
of depressive symptoms. Total scores for all nine items range from 0 to 27, with scores of 5,
10, 15, and 20 representing cut off points for mild, moderate, moderately severe and severe
depression, respectively.
2. Generalized Anxiety Disorder-7 (GAD-7; Spitzer, Kroenke,Williams & Löwe, 2006)
A brief measure for assessing generalized anxiety disorder. Total scores for all seven items
range from 0 to 21, with scores of 5, 10, and 15 representing cut off points for mild,
moderate, and severe anxiety, respectively. Although designed primarily as a measure for
assessing generalized anxiety disorder, the GAD-7 also has moderately good operating
characteristics for three other common anxiety disorders – panic disorder, social anxiety
disorder, and post-traumatic stress disorder.
3. Parenting Stress Inventory- Short Form (PSI:SF; Abidin, 1995)
A 36-item questionnaire that measures stress level experienced within the parenting role.
The measure contains three subscales related to parenting stress. The Difficult Child (DC)
subscale assesses the degree to which parents are bothered by behavioral characteristics of
their child that make them difficult to manage. The Parent-Child Dysfunctional Interaction
(P-CDI) subscale focuses on the degree to which parents are satisfied with their child’s
abilities to meet their expectations. The Parental Distress (PD) subscale determines the
distress parents feel as a function of personal factors directly related to parenting. There is
also a total Parenting Stress scale. Higher scores on each scale are indicative of higher levels
of difficulty.
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4. Clinical Outcomes in Routine Evaluation Scale (CORE; Evans, Meller−Clark, Margison,
Barkham, Audin, Connell, and McGrath, 2000)
A generic self-report measure of global distress which includes measures of subjective
wellbeing, commonly experienced problems or symptoms, social/life functioning (including
general functioning, functioning in close relationships and functioning in social
relationships), and risk to self and others. Higher scores on each subscale are indicative of
poorer functioning. For this study, a shortened, 18-item version of the CORE (CORE-18A) was
administered. A score of 10 is considered to be the clinical cut off.
5. Maternal Self Efficacy Questionnaire (MEQ; Teti & Gelfand, 1991)
The MEQ is a 20-item scale assessing maternal self-efficacy in relation to specific caregiving
activities. One variable, maternal self-efficacy, is derived from this measure. The scale was
developed for use with mothers of 3-13 month old infants. Scores are derived from the total
of either the even-numbered or the odd-numbered questions.
6. Reflective Functioning on the Parent Development Interview/Pregnancy Interview (PDI-R;
Slade, Aber, Bresgi, Berger & Kaplan, 2004)
The PDI is a semi-structured clinical interview intended to examine parents’ representations
of their child, themselves as a parent, and their relationship with their child. The PDI is
intended to assess internal working models of relationships. The parent is asked to describe
their child’s behaviour, thoughts, and feelings in various situations, as well as their responses
to their child in these situations.
Each interview is coded for Reflective Functioning (RF). The RF scale measures the parent’s
ability to reflect on their own and their child’s mental states, i.e. it measures the capacity for
mentalization in the parent-child relationship. This capacity has been shown to be a crucial
component of secure attachment relationships. Each passage in the interview is scored on
an 11-point scale ranging from negative RF (-1) to Full or Exceptional RF (9), based on
demonstration of various criteria. An overall interview score is given that takes into account
scores from each passage, as well as the quality of the entire interview.
Some parents were still pregnant at the start of treatment and in these cases a prenatal
version of the PDI was used instead. Similarly to the PDI, the Pregnancy Interview (PI) has
been shown to predict adult attachment classification. The PI is a semi-structured clinical
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interview that consists of 39 questions and probes, and assesses the quality of a mother’s
representation of her relationship with her unborn child. The interview is administered in
the mother’s third trimester and assesses the mother’s emotional experience of pregnancy,
and expectations of her future relationship with her child. This interview was coded on the
same RF coding system as was used for the PDI.
7. Maternal Sensitivity (NICHD Scales)
Maternal sensitivity was assessed via structured video-recordings of the parent interacting
with their child. Parents were asked to participate in a variety of tasks involving their child.
These were: free play (with and without toys), reading a book with their child, filling in a
questionnaire whilst minding their child, and changing their child’s clothes. Altogether, 30 to
45 minutes of video data was collected for each dyad at each time point. These interactions
were rated by experienced raters who are reliable in coding interactions on this measure.
For each task, sensitivity ratings were the sum of three four-point ratings for Sensitivity to
non-distress, intrusiveness (reversed), and Positive Regard. Scores can range from 3 to 12
with higher scores indicating more sensitive responsiveness.
Qualitative Interviews
All participants from the first two groups were contacted at the end of the programme by the clinical
team and asked if they would be willing to be contacted by the research team to be interviewed
about their experiences of the programme. Eight mothers agreed for their contact details to be
passed on, and of these six mothers could be contacted by the researcher. All interviews were
carried out over the telephone at the end of treatment. These were audio-recorded and transcribed
verbatim. A thematic analysis was carried out.
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Results
Scores for each measure were compared before and after treatment to determine change over the
course of the intervention. Results of the analyses can be found in Table 3 below. The table reports
results of paired samples t-tests to examine the statistical significance of change over time. Nonparametric tests were also carried out and the results were relatively stable.
Table 3. Scores and analysis for change over time of outcome measures
Mean (sd) Scores for Outcome Measures
PrePosttreatment
treatment
Mean (sd)
Paired Samples
t-test
p-value
Maternal Self Efficacy Scale (n=12)
25.8 (5.6)
31.2 (4.0)
.018**
GAD-7 (n=14)
8.5 (6.4)
6.5 (6.0)
.222
PHQ-9 (n=14)
9.4 (5.9)
7.4 (8.5)
.308
CORE-18 (n=12)
26.8 (17.6)
20.7 (19.9)
.266
PSI:SF (n=12)
Defensive Responding
Parental Distress
Parent-Child Dysfunctional Interaction
Difficult Child
Total Stress
23.4 (7.3)
38.2 (11.0)
24.8 (11.1)
27.4 (11.9)
90.3 (29.0)
16.5 (7.2)
27.9 (12.2)
21.3 (9.1)
23.3 (9.4)
72.5 (27.2)
.026**
.031**
.067*
.092*
.025**
Reflective Functioning on the PI/PDI (n=11)
3.3 (0.8)
3.5 (1.6)
.779
Sensitivity (n=6)
Free Play
Questionnaire
Book Read
Clothes Change
** Statistically significant change (at alpha < .05)
8.3 (1.8)
7.5 (1.4)
8.5 (2.3)
8.2 (1.7)
9.1 (1.8)
8.3 (1.6)
8.0 (1.8)
8.7 (2.2)
.045**
.185
.597
.646
* Trend towards statistically significant change (at alpha < .10)
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1. Maternal Self Efficacy
Parents reported higher levels of parental self-efficacy after the intervention than before it and this
improvement was statistically significant. In other words, the parents were feeling more confident in
their capacity to care for children at the end of the programme than they did before the treatment
started.
2. Anxiety and Depression
Parents reported lower scores of general anxiety (as measured by the GAD-7) after receiving
treatment than at baseline. However, this difference was not statistically significant and may be due
to chance. Similar results were found for depression scores on the PHQ9; parents were found to
experience fewer/less severe depressive symptoms at the end of treatment than pre-treatment but
this improvement was not statistically significant. It is worth noting that a large proportion of
parents were not reporting high levels of anxiety or depression at baseline and there was only a
small minority of parents for whom these symptoms were moderate or severe to begin with.
3. General Psychological Distress
The average total score on the CORE-18, which measures global distress, was also lower after
treatment than before it. However, this improvement was not statistically significant and, unlike the
GAD-7 and PHQ-9, after treatment the mean scores remained above the clinical cut off point at
baseline and follow-up. This indicates high levels of emotional distress in these parents, even at the
end of the programme.
4. Parenting Stress
There were significant improvements in the participants’ parenting stress levels over time, as
measured by the PSI. The severity of reported stress in relation to parenting was a great deal lower
post-intervention than at baseline. This was most pronounced in relation to the subscale of Parental
Distress (parents’ negative feelings associated with parenting). There were also marginal
improvements in how parents perceived their child to be difficult and in how positive they felt the
interactions between them and their child were. The PSI includes a subscale that is sensitive to
picking up on defensive responsiveness (i.e. overly positive/ idealised answers to the questions that
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will portray the parent in an unrealistically favourable way). There was less evidence of defensive
responding at the post-intervention assessment, suggesting that parents were more willing to reflect
on their difficulties in an honest and realistic manner. This may be indicative of improved trust in the
clinicians administering the measures over the course of the programme.
5. Reflective Functioning
The Parent Development Interview (and in a couple of cases, the Pregnancy Interview, which was
used when parents were still pregnant when referred) was carried out with parents before and after
the intervention. These interviews were “blind” rated by an independent researcher for the level of
reflective functioning (i.e. the researcher was not aware which interviews were pre- or postintervention). As can be seen in Table 3, there were no significant changes in parental reflective
functioning over time. At both time points, parents were generally scoring at the lower end of the
scale, suggesting a fairly limited capacity for “mentalising” about their child and themselves as
parents. Several recent and larger studies have similarly not found improvements on this measure,
despite treatment effects being found on other instruments. The non-significant results may be that
the coding system is not sensitive to treatment changes at the lower end of the scale. There is some
evidence of this from the qualitative interviews (see below). The mothers were clearly able to talk
about their improved understanding of how they and their child felt following the intervention, and
they spoke of how they could use these skills to parent in a more effective and regulating manner.
Thus, there is some qualitative evidence of improved mentalising capacity, but this could not be
confirmed by the RF coding.
6. Parental Sensitivity
Parents and their babies were video-recorded interacting in a number of tasks. These interactions
were blind rated by an experienced independent researcher who was not aware of pre- or postintervention status. Most tasks showed improved levels of behavioural sensitivity to the babies’
cues, apart from the Book Reading task. The only task that showed statistically significant change
was free-play between the parents and babies. In this task, parents were significantly more sensitive
post-treatment. It is important to note that virtually all the measures of parenting sensitivity showed
numerical trends indicating improvement. Because only a small number of participants completed
the observed parenting assessment there was very limited power to show statistically reliable
changes.
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Results of Qualitative Interviews
There were a number of themes that emerged from the interviews with the ReConnect participants.
These were:
1. A life changing experience
Subthemes: confidence, sensitivity, attachment, trust
2. Value of Group and Individual sessions
3. Content
4. Timing and Endings
5. Something that should be widely offered
1. A life-changing experience
The most striking theme was the very positive changes that mothers attributed to the programme.
This was the case for 5 out of the 6 mothers interviewed.
“It’s changed my life basically” (participant 6)
“Well, it’s the most amazing therapy I’ve ever had in my life, and I’ve had a little bit off and
on; nothing has been the way this is.” (participant 5)
“giving you tools and skills that are put in front of you in such a black and white way that you
could carry them with you when you weren’t in the classroom, as it were … it actually made a
difference, it made a massive, massive difference… It has literally changed how I parent and
changed my life” (participant 5)
“And the way I feel about ReConnect, if I didn’t join that session or have ReConnect in my life,
I probably wouldn’t be the person I am now.” (participant 3)
“Personally I thought it was invaluable.” (participant 2)
“I feel like if I could have done it 6 months before, I think that I would have my other 2
children with me here as well.” (participant 1, talking about older children in foster care)
There was only one exception to the overwhelmingly positive experiences that the mothers spoke
of. Participant 4 did not feel that the programme had been helpful to her:
“I didn’t find it useful at all, I’m sorry, it was completely useless actually.”
When probed about the reasons she felt it was not helpful, this mother said that it was:
“just once a week. And you know, it was only for two hours. So it just wasn’t enough”.
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This mother felt it difficult to open up and join in the group discussions and only started to be able to
do this by the end of the course. She did find some of the small group exercises and the individual
sessions with the Psychologist helpful, but working in the larger group seemed to be a barrier to her
feeling like she could fully participate. It is possible that a greater number of group sessions would
have enabled this mother to benefit from this part of the intervention as she began to feel more
comfortable in the group setting over time.
For the mothers who experienced such positive changes, these were seen in several areas of their
lives.
a) Confidence:
Several mothers commented that they felt more confident as a result of the programme.
“I was really too scared to leave the house, after coming out of a domestic violent relationship,
over 15 years. And Psychologist A…she’s really pushed me to go shopping, go out of the house,
meet new people. Really building my confidence up, so yeah, she was, she was amazing with me.
And she still is.” (participant 3)
“My confidence with my daughter has grown… the confidence I have to know what's right for my
daughter rather than second guessing myself” (participant 2)
The improved self-confidence often resulted from the mothers learning to not be so hard on
themselves. They felt that this had a knock-on effect on their parenting.
“That was a massive thing, being able to not be so hard on myself. To realise that you don’t
have to get it right, you don’t even have to get it right 50% of the time to not mess your child
up… Forgiving yourself teaches your child that it’s okay to forgive themselves, and that
really, really changes things because you realise that… And also that getting it wrong is
actually part of being a parent and being a child, and then repairing and making up for it;
and then moving forward from there. That if you can do that for yourself then you teach
them to do that.” (participant 5)
“And actually if I do lose my temper every now and again, not, not like to the extreme of
anything bad, but you lose your patience, it's okay for that to happen, because actually it's
hard being a mummy. So it's given me the confidence to know that I'm doing a good job.”
(participant 2)
“She helped me find that, you know, it wasn’t my fault, you know, and I am respected in the
world. And it’s okay to have respect for myself, you know? It’s okay to cry, it’s okay to let it
out, don’t bottle it up because then you get frustrated, and you get frustrated with yourself
and you end up taking it out on people that you love. Or you don’t recognize like the needs
your children have as well because you’re in so much turmoil yourself.” (participant 1)
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b) Sensitivity:
Most of the mothers talked about how ReConnect had helped them to be better attuned to their
children and to make sense of their communications and emotions. This is at the heart of a
mentalisation-based approach and the qualitative interviews confirm that the clinical aims are being
met for many of the participants.
“It’s made me realize that actually I did need the help… I started to realize that I was
actually… missing all of his cues” (participant 6)
“I didn’t really pick up on their feelings and their emotions, because of the domestic violence.
I didn’t, I just went into myself and focused on what was happening. But now I can see how
my children are feeling.” (participant 3)
“It helped me understand my daughter” (participant 2)
“But I feel very confident about moving on with my life, being able to control my emotions,
understand my daughter’s emotions, attuned to her needs, and put her needs above my
own.” (participant 1)
c) Positive Attachment
Some of the mothers talked about how they were now able to notice and understand their child’s
attachment behaviours in a positive light, or that they saw noticeable changes in how the child
responded to them over the course of the programme. Thus, there is some sense that the clinical
aim of improving attachment security is being met.
(talking about seeing a video of the parents and children greeting each other at the end of
the programme): “And he came straight to me. Just the way we looked at each other and
said how much we missed each other… Before he wouldn’t even do that. He wouldn’t be
bothered if I walked back into the room, he wouldn’t even notice I was gone. And he actually
noticed. It was just amazing that, you know, just the feeling, it’s amazing to actually know
and actually see that video.” (participant 6)
d) Trust
A powerful theme that emerged from several interviews was that the mothers felt that they learnt
how to trust through the relationship they developed with the clinical team.
“I was abused as a child, I suppressed a lot of memories because I didn’t want to remember.
And this group therapy, and then having the one-to-one therapy to reflect upon everything, it
brings back my memory. And I had nice memories come back, I also had some quite awful
memories come back. But I’ve been able to cope with them, because I feel confident. I trust
the people that are working with me. And I’m learning to deal with the way that affects me.”
(participant 1)
This trustworthy relationship with the therapist was seen by many mothers to be extremely
containing and even somewhat like another chance for them to be parented in a better way:
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“It’s almost like I needed parenting myself, it’s almost like I’ve been parented.” (participant 1)
Many of the mothers in this service have experienced traumatic and difficult childhoods. The
capacity to build their trust and give them a different sort of experience of “being parented” is
pivotal to interrupting intergenerational patterns of relational trauma.
Furthermore, the trust was important for engaging the parents in the ReConnect group and with
other supportive services.
“My psychologist had to see me three or four times before I felt like I could do this. And…but
she gained my trust. Which for me, is a very difficult thing to do. I’ve always had a big
problem with trusting people. But no, she gained my trust and she worked with me very well.
And I owe her so much.” (participant 1)
“And [Psychologist], for me, she became very parental in my relationship with her… She then
said that there is this course available so I could go on that if I wanted to. I didn’t really know
anything about it but she just sort of, said I should, so I did. I just took her word for it.”
(participant 5)
“And, you know, it also gives me faith, a lot more faith in professionals, you know? I don’t
know why, I think it might just be a general non-trust for anyone. Like, I’ve always had a
problem with trusting adults my whole life because it was adults that abused me and
mistreated me throughout my life. And you know, I’ve never had a problem with children, but
I’ve always had a problem with adults, and now that problem is breaking down and I’m able
to work with professionals. Maybe to go to the children’s centre with my daughter and make
friends with people, and not feel awkward, not feel like people are judging me.” (participant
1)
This finding relating to increased trust is theoretically and clinically important in this population for
whom attachment difficulties are so pervasive. Recent thinking in attachment theory highlights the
importance of “epistemic trust” (trust in the authenticity and personal relevance of interpersonally
transmitted knowledge) in attachment relationships (Fonagy and Allison, 2014). This is considered to
be the mechanism by which infants learn about the social world and themselves. These parents,
many of whom did not have the experience of safe and trustworthy attachment relationships when
they were infants themselves, made the links between their improved capacity to trust and the
experience of being “parented” by the therapists. This suggests that the therapeutic relationship
may have provided them with an opening up to learn new ways of thinking about themselves and
the social world. This could have important implications in breaking the cycle of attachment
difficulties.
2. Value of individual and group sessions
The combination of individual and group work was valued by most of the mothers as serving
different needs. As described above, some mothers needed the individual support to enable
them to build trust in the group as something that could be helpful. The personal relationship
that was built through the individual sessions was highly valued:
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“Psychologist A is there day or night, if I need to talk to her. She’s just on the end of the
phone, so if I do have problems or if I’m having a bad day, I can just phone her anytime. And
talk to her about my feelings, and how, what kind of mood I’m in. And a good thing as well,
Psychologist A would do is a home visit about behaviour as well, and attachment. So yes,
they do really put themselves out.” (participant 3)
“I really liked the way the one on one sessions ran alongside the group sessions because it
meant that if you, if something came up during a group session that you didn't maybe feel
you had the confidence to broach at the time, you had the opportunity to discuss it one on
one with your counsellor.” (participant 2)
One mother (participant 4) found the groups difficult to manage, but did appreciate the individual
support. For the other 5 mothers interviewed, the group became a powerful source of support.
“When one of us was really struggling, the rest of us really rallied around to her to help.”
(participant 2)
A subtheme relating to the impact of the group was that it helped parents feel that they were not
alone:
“what’s so lovely about this is you don’t feel judged, you don’t feel criticized, you don’t feel
alone. And that’s just really important to progressing in therapy. Whereas when you’re on
your own with just those professionals, you feel like your whole world is against you. I know
that can have a massive effect on how you deal with situations and manage your emotions,
which can then have an effect on your children.” (participant 1)
“You know, depression and all these problems I have with my child, like the bonding and
that. And it was nice to know that I’m not the only one out there that suffers with all those
problems.” (participant 6)
3. Timings and endings
The general consensus amongst the mothers interviewed was that even more input would have
been good, although some of them also acknowledged that it was probably time to end and that
the programme had equipped them to cope without the ongoing support.
“I do think that the actual length of the session possibly needed to be a bit longer because it
felt sometimes that we'd not been going very long and we were just getting involved in what
we were doing and it was time to stop and end for the week.” (participant 2)
“I didn’t want it to end but I knew that it had to end and, you know, it couldn’t have carried
on and on and on. Although, you know, because it became such a safe place where we were
really heard and where we could really sort of be open, that’s what we wanted, as it were,
but, yes, the course had to come to an end. So I can’t even really say for it to be longer,
because I think it was completely… it was right on the nose.” (participant 5)
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“But I do think the 20-week sessions, the group sessions, are a little bit short. I’d recommend
that they go on to, instead of say, 20-weeks, I’d recommend that they should go on to, say,
40 to 50 weeks.” (participant 3)
“I think the group therapy should be a bit longer. And to some people, when we left the
group, they didn’t seem…and they missed it as well, they weren’t ready to move on yet. They
needed a bit more group therapy. And I mean I moved on from it quite well, but, if it was
offered to me, I wouldn’t have said no.”
4. A service that should be widely available
Most of the mothers interviewed spontaneously said that this is a service that should be widely
available to all parents. This confirms that value that they believe the programme can provide.
“If just more people could have access to the kind of amazing service that I had, it could only
be a better thing.” (participant 5)
“I would advise to open up to the public as well, not just people in social services or having
trouble with their feelings, their emotions, stuff like that. I do recommend it should be more
advertised so if people do need a little bit of help, I’d recommend that there be posters up
about it and stuff like that.” (participant 3)
“A lot of the material that we covered would be useful for first time parents and it would be
fantastic if, obviously not opening the ReConnect program up, but some of that material was
perhaps shared with health visitors and like the Sure Start Centres.” (participant 2)
“I would recommend that this needs to be done on a wide scale.” (Participant 1)
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Example of mentalising in practice
In box 1 below, participant 5 tells a story about how she has been able to put her skills gained from
the ReConnect intervention into practice. At the heart of the theory of mentalisation is the concept
of affect regulation. Being able to maintain the capacity to understand the behaviour of others in
terms of their internal mental states (thoughts and feelings) can be inherently regulating for the
parent and, consequently, the child. When the parent becomes overwhelmed by negative affect, the
capacity to mentalise can be compromised. This mother has clearly learnt skills to be able to “switch
on” her mentalising in difficult situations, resulting in more regulated and adaptive interactions with
her child.
Box 1
“A couple of months ago, I was getting out of the car and it was raining, desperate,
desperate, desperate for a wee, and I’ve got no bladder control anymore, I was desperate,
and the dogs needed to go out for a wee. It was in a big mad rush to get in because the dogs
needed to come out for a wee, they’ve been in all day. I needed a wee, it was raining, and I
was trying to get [Child] out of the car.
And I got him out of the car and I put him on the ground and said come on walk, walk and he
just… he wouldn’t, he lay on the ground, just didn’t want to come in. I said, “come on we
have to go in now” and he wouldn’t, he lay on the ground. It’s raining, he’s getting wet, and
I just… I completely… I just said, “well, stay there then”. And I ran inside and I let the dogs
out, and I was having my wee and I was still triggered. I was thinking, just “what an idiot,
what an idiot, just out there in the damn rain, why didn’t you just come in when you were
meant to come in?”
And I went out to him and he was still lying on the ground. Now, it wasn’t raining hard but it
was raining; now he’s wet, and I picked him up under his arms and I’m carrying him into the
house. And I can feel I’m being rough, I can feel it, I’m not being a loving, wonderful mother,
I’m being rough. And then as I was carrying him into the house I just suddenly got: “You’re
doing this like your mum”, and then the whole mentalisation thing.
There is just little boy got out of the car, way too much in a rush, he might have wanted to
show me something, he might have wanted to do anything else. And he’s just all worried
because you’re not acting normal, and he’s just been out there worried, waiting for you, and
he doesn’t know any of this other stuff going on. And by the time I got through the kitchen
and into the front room and sat on the sofa I was completely with my little boy, and I wasn’t
my big, angry mum anymore.
That whole thing I just… I don’t think that… I don’t think I’d have got it. I’d have just been in
a grump, just “put yourself on the sofa then if you don’t want to walk” and, you know, carry
on like that. But because I could get the whole mentalisation… because I could get, I was
triggered, I could get I wasn’t being like… I didn’t have my lighthouse, my main beam on.
And I know I was triggered and all the things, and I knew I wasn’t seeing it from [Child’s]
point of view. And in the space of getting from the kitchen to the sofa I was completely… I
put on my lighthouse beam and I then I was just with my little boy who’s got wet and waited
for me out in the garden.”
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Summary
Key Findings
There were significant improvements over the course of the programme in relation to:
 Parents’ self-efficacy in caring for their babies
 Parents’ levels of stress in their parenting role
 Parents’ sensitivity in responding to their babies’ needs and communications when
playing with them
Although there were improvements on almost all measures, these changes were not
statistically significant in relation to:
 Parental depression and anxiety
 Parental reflective functioning (mentalizing capacity)
 Parental sensitivity on structured tasks (such as reading a book, or changing the
babies’ clothes)
There were several themes that emerged from the interviews with the mothers.
 The programme was seen by most as “a life changing experience” as it helped
them to improve their confidence, sensitivity, attachment relationship and
capacity to trust.
 The combination of individual and group therapy was seen as highly valuable
 The imagery (such as the lighthouse) used in the programme had a powerful
impact on the parents
 Most parents did not want the programme to end
 Most parents felt this was something that should be widely offered to all parents
There were three domains in which there were noticeable and significant improvements for the
ReConnect parents over time: self-efficacy, parenting stress and parental sensitivity during playful
interactions.
It is interesting to note that the measures tapping more general emotional wellbeing in the parents
(depression, anxiety, general distress) did not change significantly over time, but the two measures
relating to the parental role did (maternal self-efficacy and parenting stress). Thus, the parents were
clearly feeling more confident and relaxed in their ability to care for their baby, even if they may
have continued to have emotional difficulties themselves. The improved capacity to cope with the
demands of parenting a young baby may be an important protective factor for the children of these
parents, many of whom have experienced a great deal of trauma in their past and for whom
emotional difficulties are persistent. In the absence of a control group, it is not possible to attribute
with certainty any findings to the fact that these families took part in the ReConnect programme.
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However, in the qualitative interviews, the parents themselves spoke of their improved confidence
in themselves as parents and they clearly attributed these changes to the intervention. Furthermore,
the improvements that were found are certainly aligned with the aims of the programme which are
focused around improving the parent-child relationship. The positive reinforcement provided by
both the VIG and the therapeutic group may have all contributed to parents feeling more capable as
parents.
A potentially very important finding is the improvement seen in maternal sensitivity during free-play
interactions. Sensitivity, the capacity to recognise and respond appropriately to the infant’s
communications, has been repeatedly shown in large studies to be a key predictor of secure
attachment relationships. In turn, early attachment security is widely acknowledged as an important
predictor of a host of psychological, educational and social outcomes later on in life. Thus,
improvements on this measure may shift these young babies onto a much more positive
developmental trajectory. This outcome is particularly notable because it was statistically significant
even with a very small group – which in turn implies that the changes on that outcome were large.
The qualitative interviews provided a great deal of evidence for the value that parents felt the
programme provided. For most parents the intervention was literally life-changing. The
improvements they noticed following the intervention were all in important areas that contribute to
secure attachment and positive parent-child relationships (parental confidence, trust, sensitivity,
improved attachment).
In conclusion, the results of this evaluation suggest that there were several clear improvements in
the lives of the parents and children who participated in the ReConnect programme and these are
likely to foster more secure and protective parent-child relationships in the long-run.
Further research with a larger sample size and control group is needed to verify these promising
initial findings and to determine the effectiveness of the ReConnect programme.
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