Abstract
Children placed for adoption often face unique challenges and are at higher risk of mental health problems compared to the general population. Yet despite some important clinical developments, there is still a lack of evidence related to effective therapeutic interventions for this population. This study reports on the preliminary evaluation of a mentalization-based family therapy service, Adopting Minds, offered as part of a post-adoption support service. Thirty-six families who had adopted 42 children were referred to the service between September 2015 and December 2016. Demographic information was collected and assessments undertaken on the families at baseline and at the end of therapy, using a range of validated measures. Five families who had completed therapy were also interviewed about their experience of the approach. For those families on which data were available, positive outcomes in mental health and parental self-efficacy were identified, and adoptive parents reported high levels of satisfaction with the mentalization-based family therapy service. Analysis of the interviews revealed that the families found it a containing space that was supportive and non-judgemental. They felt able to express their fears and worries to a therapist who was friendly and knowledgeable and reported that the service helped them to deal with and link struggles they were facing to their own as well as their child's past experiences. However, some adoptive families felt that this short-term, six-session service alone was not enough to address all the difficulties that had brought the family to seek help, and would have preferred a longer-term intervention or therapy in combination with other types of support.
Introduction
Children who have been placed for adoption in the UK face unique challenges, often related to disrupted relationships in their past and the impact of these on their development. Many have been exposed to precarious physical and psychological conditions, such as inadequate prenatal and perinatal care, physical or sexual abuse and poor emotional support as well as multiple changes in foster care placements (Lewis, et al., 2007; Simmel, 2007). It is hardly surprising that they are at higher risk of mental health problems compared to the general population (Burns, et al., 2004; Ford, et al., 2007), as well as of difficulties with school adjustment, academic achievement, peer relationships (Pears, et al., 2010), cognitive delays (Judge, 2003) and struggles in developing a secure attachment to their caregivers (Hughes, 1999; Pace and Zavattini, 2011).
Adoptive parents can encounter significant challenges in developing a relationship with their children and in helping them adapt and develop their full potential. They may have insecurities and difficulties of their own, triggered by the situation they are experiencing. For instance, because of the potential rejection by their child, they may feel confused and frustrated, sometimes leading them to blame themselves or the child for what is happening.
There are many ways in which adoptive parents can be helped to build strong relationships with their children and one that has received recent attention is ‘parental reflective functioning’ (Slade, 2005) or ‘mentalization’. This term refers to the parents’ capacity to focus and understand mental states of self and their child, especially when trying to explain and predict behaviour. This process happens automatically much of the time and helps us regulate our emotions and develop self-awareness. It allows parents to see beyond the concrete behaviour of their child and imagine what may be motivating him or her. This capacity can help parents respond more sensitively to the children's behaviour and help manage their feelings more effectively, thus promoting their child's development and reflective functioning – an especially significant contribution when attachment relationships are disturbed by a child's lack of reflective capacity, as is the case for many adopted children who have experienced maltreatment (Jacobsen, Ha and Sharp, 2015).
The development of mentalization in adopted children can be facilitated by the new caregivers, but when the adoptive parents are struggling themselves, this can be difficult. An adaptation of mentalization-based treatment for families (MBT-F), Adopting Minds, has been fashioned to address some of these problems. It was originally developed as a trans-diagnostic intervention for use in generic child and adolescent mental health services (CAMHS) (Asen and Fonagy, 2012; Fearon, et al., 2008; Keaveny, et al., 2012) and works from the assumption that difficulties in mentalizing have an impact on family functioning, especially due to experiences of feeling misunderstood (Asen and Fonagy, 2012). Thus, its main goal is to improve the understanding of each family member's behaviour and feelings by promoting their capacity to mentalize, in everyday situations as well as stressful ones. A preliminary evaluation suggested that MBT-F reduced behavioural and emotional difficulties among children with a range of presenting problems (Keaveny, et al., 2012), although this was an uncontrolled study based on a small sample.
Although MBT-F has been used in work with adoptive families (Muller, Gerits and Sickler, 2012), no specific adaptations of the model for work with this population have been described and no formal evaluation has yet taken place to explore treatment outcomes or ascertain the views of the participating families. The Adopting Minds approach recognises the particular challenges faced by adoptive families: adopters and children coming together with no shared history and the possibility that both may have experienced significant difficulties in the past. Careful thought is given to who should participate in the sessions and although in some cases the work may only be with the parents, it is generally encouraged that the children should also be involved, either throughout or for some of the meetings. The significant relational risks that adopters and children face in working together to become a family are acknowledged, including the heightened danger of misunderstandings between adults and children. Given their past histories, adopted children may misinterpret their adoptive parents’ efforts and adults may have difficulty ‘reading’ the confusing signals that indicate their children's needs. In many cases, adopted children may not feel safe enough to explore the minds of their parents, so the Adopting Minds approach pays close attention to how past history may be affecting the ‘here and now’ and focuses on monitoring and managing arousal levels of all family members to provide a ‘safe enough’ experience of thinking together. Adoption may create a sense of ‘unsafe uncertainty’ for adoptive families (Tasker and Wood, 2016) and issues of suspicion and ‘epistemic vigilance’ (Fonagy and Allison, 2014) may be understandably challenging. With that in mind, Adopting Minds offers an integration of systemic and mentalization-based practice to adoptive families with the aim of helping to build trust, improve relationships and help parents and children understand one another better. Although there was no live supervisory team working directly with the therapist, arrangements were made to ensure that her own mentalizing capacity was continually monitored.
The study described in this article seeks to provide an initial evaluation of the Adopting Minds approach as described. It offers an opportunity to explore the experiences of the families who received the service, with a particular focus on whether the approach was suitably adapted to the specific needs of adoptive families.
Method
A mixed-methods design was used, comprising a pre/post evaluation for all families accessing the service and interviews with a sub-sample of those participating.
Setting
This study took place at Coram, an NGO in the UK committed to improving the lives of vulnerable young people, including those who have been fostered or adopted. The Adopting Minds approach was offered as a therapeutic intervention within a wider post-adoption support service.
Participants
An invitation to take part in the evaluation was given to all 36 families referred to Coram by adoption support workers between September 2015 and December 2016. The families were initially offered a short-term (six-session) intervention.
Procedure
Families were sent information about the evaluation prior to attending their first therapy session. A researcher then met them 30 minutes before their first session to discuss the project and seek consent. It was made clear that participation in the therapy was separate from taking part in the research. Families were then asked to fill out questionnaires prior to their first session (for the pre-evaluation) and after they finished the last one. If adopters did not complete all sessions, attempts were made to contact them by email.
For the second part of the project, families who had completed at least six sessions of therapy during the first six months of the project were invited to take part in an in-depth interview to explore their experience of attending the sessions. Eight families were contacted, one of whom did not wish to participate and two who were willing but not able to spare the time. This left five participating families. Although in three of these cases the therapy had involved both parents and child/ren, and the research team wanted all family members to be included, it was left to families to decide who should take part.
Consequently, three of the five interviews were with the mother only (Laura, Claire and Mary), one was with the father only (Paul) and one with a father and his daughter (John and Lucy, age 16). The presenting problems of these five families included attachment difficulties, challenging behaviour, relationship difficulties and problems for the child in adapting to a new home.
All families in both parts of the study were seen by the same therapist who was employed by Coram specifically to offer the new service and was experienced in systemic family work, well trained in MBT-F and knowledgeable about fostering and adoption services. She was part of the team who had developed the Adopting Minds approach but was not part of the research group.
Questionnaires
Five questionnaires were used. The first, the Demographic Questionnaire, is a bespoke form created to chart the backgrounds of the adopters and children accessing the service. All information was offered voluntarily.
The second, the Brief Assessment Checklist (BAC) (Tarren-Sweeny, 2013), is a 20-item caregiver-report rating scale having two versions: the BAC-C for children and the BAC-A for adolescents. Both are used for screening and monitoring mental health difficulties in children and adolescents in different care settings. Each question can be scored from zero to two, giving a range of total scores from zero to 40, with a total score of five or above indicating the need for a referral to a specialist mental health service for further assessment. Preliminary data suggest that the BAC-C/A total scores approximate the Child Behaviour Check List (CBCL) total problem score at least as well as the widely used Strengths and Difficulties Questionnaire (SDQ) total difficulties score.
The third was the Brief Parental Self Efficacy Scale (BPSES) (Woolgar, et al., 2013), a five-item measure of parental self-efficacy used to measure the parents' own perceptions of their efficacy and confidence as carers. Each item is rated from one to five, giving a total score of up to 25. The psychometric properties of the measure are yet to be established, although it has been used in a number of randomised clinical trials.
The fourth was the Experience of Service Questionnaire (ESQ) (Attridge-Stirling, 2002), a 12-item, self-report instrument that measures respondents’ experiences and satisfaction with the service. It is widely used by CAMHS in the UK and has demonstrated good inter-rater reliability and construct validity (Brown, et al., 2014). In a recent survey of UK CAMHS services (Wolpert, et al., 2016), ‘We were treated well’ and ‘Our views and worries were taken seriously’ scored most highly (91% and 89% respectively), while ‘Appointments were at a convenient time’ and ‘The location was convenient’ scored lowest (69% and 78%).
Finally, the second part of the study used an adaptation of the Experience of Therapy Interview (Midgley, Ansaldo and Parkinson, 2011), designed to ensure that the questions were focused on the experience of adoptive families and usable with parents alone or in a joint parent/child setting. The schedule explored six areas: difficulties that brought the child/family to the therapy; the parents' understanding of those difficulties; ideas about change; the story of therapy; evaluating therapy; and other therapies/resources.
Data analysis
In the first part of the project, descriptive statistics (mean and standard deviation) for the pre-measurements from the BAC and the BPSES were calculated for the whole sample. Later, descriptive statistics for the pre/post scores from the BAC and the BPSES were calculated for those families who had completed both before and after measurements. The pre- and post-measurements for both questionnaires were then compared and descriptive statistics calculated for each item in the ESQ. As there are not clinical cut-offs or norms for the ESQ, an average overall score could not be interpreted. Where appropriate, Student's t-test was used for analysis with a significance level of 95%.
For the second part of the study, analysis of the interviews was completed using interpretative phenomenological analysis (IPA) (Smith, Flowers and Larkin, 2009). This approach was chosen because it supports the aims of the project by examining how people make sense of, or give significance to, the experience of a particular life event and is valid with small samples. Each interview was transcribed and analysed separately and systematically.
Ethical considerations
Ethics permission for this project was granted by the University College London Ethics Committee (REF: 0389/009) and by Coram's own research ethics committee. All families gave informed consent to be part of the study and any identifiable information has been disguised and names changed in order to preserve anonymity.
Results
Demographics
The 36 families who were seen in the service included 59 parents and 42 children. Thirty of these had one adopted child and six had two. Of the 32 families on which demographic data were available, 81% reported parenting as a couple, with both parents attending sessions in most of those cases. Of the 33 participants on whom information was available, the majority (67%) described their ethnicity as ‘white British’, followed by ‘white other’ (24%). Of the 33 adopted children, the median age was nine years old and ages ranged from two to 17 years. Of the 29 children for whom these data were available, 15 were male and 14 female, with 60% of parents describing their child's ethnicity as ‘white British’, followed by 23% as ‘mixed’. Of the 22 children whose parents responded to a question about whether their child had a disability, four answered ‘yes’ but gave no further details.
Details about the length of time the adopted children had been placed with their adoptive parents were available for 23 children. Two had been placed with adopters for under one year, nine for between one and four years and eight for between five to ten years. Four children had lived with their adopters for over ten years.
Reasons for referral to the service were recorded for 22 children. Adoptive parents could select more than one reason from a list of five (relationship concerns, social and emotional concerns, behaviour problems such as attentional difficulties, emotional regulation and attachment with adoptive parents). Eighteen adoptive families had been referred because their children were displaying challenging behaviour in more than one area. Social and emotional concerns and emotional regulation were the most common reasons.
Baseline functioning and preliminary evaluation of the Adopting Minds service
All adopters were asked to complete the BPSES and BAC at the baseline stage. Forty-three did so for the former and 44 for the latter (relating to 33 children). The pre-therapy mean score on the BAC was 18.8 (and 21.7 for the 15 adopters with paired BAC pre- and post- questionnaires), which is significant as a score of five or above is considered an indicator that further mental health assessment is needed. Among the highest scoring items, and therefore the areas reported as most problematic, were the child ‘craves attention’ (mean 1.7), child ‘constantly seeks excitement’ (1.5) and the child is ‘too jealous’, ‘does not show affection’ and ‘feels misunderstood and victimised’ (all 1.3). The lowest scoring items were for ‘impulsive behaviour’ (mean 0.8) and ‘not sharing with friends’ (0.9).
The pre-therapy mean score on the BPSES was 18.7 (and 18.6 for the 18 adopters with paired BPSES pre- and post-questionnaires). While there are no guidelines for clinical cut-off ratings, the score is out of a possible 25, which suggests that before attending the Adopting Minds sessions parents were already reporting fairly high levels of parental efficacy. The highest mean-rated item on the BPSES was ‘I can make an important difference to my child’ (4.4) and the lowest were: ‘I am able to do things that will improve my child's behaviour’ (3.3) and ‘In most situations I know what I should do to ensure my child behaves’ (3.4).
Pre- and post-paired BAC and BPSES data were received from 15 and 18 adopters, respectively. Post-therapy data that was not paired has not been included in the subsequent analysis.
BAC scores improved for 11 out of the 15 adopters who completed pre- and post-questionnaires but in three cases it worsened and in two did not change. Using a Student's t-test, the change in mean BAC score for this group was statistically significant (p = 0.014) although there was large variation in responses within it. This suggests that most parents perceived that their children had less mental health difficulty after the intervention. However, the score was still higher than the optimal screening cut-point. Scores decreased in all areas of the 20-item scale apart from two, which were child ‘does not show affection’ and child ‘hides feelings’ (mean pre- and post-scores for both remained the same). The biggest mean decrease was found for the item child ‘craves affection’ – a fall from 1.7 to 1.0.
BPSES scores improved for 12 of the 18 respondents where both pre- and post-data were available (three worsened and two did not change) and the change in mean BPSES scores was also significant (p = 0.048). This increase suggests that adoptive parents felt more effective in their parenting roles after therapy. Scores increased in all five areas of the BPSES scale. The biggest mean increase (3.3 to 3.9) was for the item ‘I am able to do the things that will improve my child's behaviour’ and the smallest (4.4 to 4.6) was for ‘I can make an important difference to my child’.
Adopters reported high satisfaction with the service as measured on the ESQ. All the adopters reported that the help they received was good, their views were taken seriously, they were treated well, it was easy to talk to the people there, they were listened to and the help they received was beneficial. The two items that scored the lowest both referred to practical arrangements, the time and location of the sessions.
The experience of the Adopting Minds approach for families
Although the quantitative results gave some indication of the impact of the intervention on the families who took part, semi-structured interviews were conducted to gather more about the actual experience of the service. In these, four superordinate themes emerged: ‘receiving support and containment’; ‘a space where negative feelings are allowed and achievements praised’; ‘getting help to deal with past experiences’; and ‘short-term support is not always enough’. Each of these will be discussed in more detail.
Receiving support and containment
Families described how the therapeutic space acted as a supportive and containing environment. It was a place where they felt listened to, enabling them to talk about their anxieties, fears and worries. For instance, Laura stressed that it ‘felt like it held us’ and Claire referred to the therapy as ‘a sense of continuity and containment’. Likewise, Lucy (John's 16-year-old daughter) referred to the fact that she felt supported by the therapist during the sessions: [The therapist] was listening to everything I was saying, and taking me into consideration … I felt that I could talk to people here.
There were several factors associated with the therapist that participants saw as supportive, all of which referred to the importance of her personal and professional qualities. Four of the participants (all mothers) mentioned her personal attributes as the most valued and appreciated aspect of their experience, regarding her as being friendly, warm and easy to talk to. In terms of professional skills and expertise, they liked the way she formulated interventions during the sessions and the manner in which she talked to them. For instance, Paul found it helpful that the therapist tried to get him to question himself, making him think about what he did, why and to consider other options: …and then challenged myself about how I dealt with things, which was really useful because it helped me change my approach in dealing with the issues I had, in a good way. I have found it really helpful… to talk to somebody with amazing experience in child practice. [The therapist] … seemed very experienced, very aware of adoption and trauma and everything … so she is fantastic.' … so it was just knowing that I am not alone, that there is other people that are experiencing the same things.
A space where negative feelings are allowed and achievements praised
Alongside feeling supported, three of the participants (all mothers) spoke of the fact that the therapist did not judge them as parents. For instance, Laura found her encouraging, supportive and non-judgemental, which was something she had not expected. This helped reduce her feelings of guilt and anxiety about not being a perfect mother: … she really wasn't hard on me; she was very encouraging … [The therapist] never once said to me you shouldn't be doing this… you are not putting [your child] first… it was just that you know… just cut yourself some slack. … just about being allowed to talk about how you feel about your child and… particularly when it is not all positive […] just makes you feel supported. [The therapist] has been… just very good at reassuring me… just really helped… you know… somebody just saying to you, ‘You are actually not getting it wrong.’ [The therapist] was fantastic at just being understanding, accepting […] So she is fantastic and really flexible, open…I just felt we weren't judged or we weren't criticised… She was just being encouraging. She was just saying, ‘What you are doing is right.’ I think the way she talked to me… she didn't talk to me like I was a little kid, she didn't make me feel like what I've done is the worst thing in the world.
Getting help to deal with past experiences
All of the parents mentioned that their children (or themselves in the case of one mother) had experienced difficult times during their early years which had affected their current lives. Four of the families felt that it was the sessions that helped them to acknowledge and be more conscious of these experiences and of themselves in relation to them. Some families spoke of how their therapy helped them to be more conscious and accept their family (or their own) situation and difficulties. For instance, Mary said:
I have a busy life and I am quite good at sort of just ignoring things I shouldn't ignore… and I think with [the therapist] she kind of forced me to… just recognise a lot of things as not being the norm, because I think it's another thing when you have a difficult child… you start normalising behaviour that you shouldn't really normalise… I think Dad's always known why I put a wall up, but it is the fact that I haven't really thought about it…. In the past I've trusted people and all of a sudden they've hurt me so… to stop trusting them then they won't hurt me like they did in the past I think… Interviewer: It sounds like [the sessions] did help you to put things into perspective and understand. Lucy: Yeah, definitely.
Lucy's father, John, speaking directly to his daughter, also talked about how the sessions helped her to speak about her struggles linked to the past:
It also helped to give you the … confidence, courage to think a little bit more deeply and maybe assess and maybe repair all that from some of the things that have gone from the past, and to finally admit them to yourself as well. Part of dealing with it is admitting. We are conscious of what we are doing and that attachment is more present. Because sometimes thinking, ‘Oh, we are just parenting a normal child or a biological child who had not experienced trauma.’ And so to think and have that in our minds is, well, was really helpful […] and keeping all the things she said in mind about attachment and interaction. What he seeks, why he seeks and how early trauma may affect him. So we found out through adoption forums, online, and then looked it up, and my wife found a course that does it so she did a one-day workshop. I don't know if they do anything here, but they never told us about it.
Short-term support is not always enough
Despite the fact that for most families the therapy was an overall helpful experience, the majority of them also felt that the service on its own was not enough for achieving improvements or changes regarding the difficulties they or their children were facing. Some families felt that it was a combination of things, including the therapy, that influenced the positive outcomes and others questioned whether they could be sure that it was the therapy that had helped.
John talked during the interview about how the therapist ‘certainly gave you a kick in the right direction and made you think about things in a different way’, but felt overall that there were other factors more involved in improving things for his family. Likewise, Mary reflected on how the sessions did help her family to overcome the difficulties they were facing but that her daughter also benefited from attending music therapy. Additionally, she stated that the sessions were mainly helpful for her as a mother, for processing her own feelings.
Laura also talked about how she felt therapy helped her but was not enough, and emphasised the need for a longer-term therapy for her daughter and her family: It just helped stabilise […] it was accepted by everybody that actually six sessions with [the therapist] weren't going to solve the situation. It felt like it kept us safe over that period of time. It prevented it from getting even worse […] It helped give us a platform for, perhaps, building on, negotiating on […] but also just helped us get through a very difficult time […] To really help [my daughter] we need to get her to the point where there is some help available for her directly, preferably.
Discussion
The aim of the project was to offer a preliminary evaluation of the effectiveness of the new Adopting Minds service at Coram and to explore the experience of adoptive families who were referred to it. The study used a mixed-methods approach, analysing quantitative pre- and post-data from questionnaires, as well as a qualitative analysis of semi-structured interviews using IPA.
Although normative data is lacking for both the BAC and the BPES measures, families referred to Adopting Minds appeared to be reporting relatively high levels of parental efficacy, but also high levels of emotional and behavioural difficulties in the referred child. The mean baseline score of 18.8 (and a baseline score of 21.7 for those with both pre- and post-intervention ratings) can be compared to the mean BAC-C and BAC-A scores of 12.09 and 11.45 for a population of 219 Dutch children in full-time foster care (Goemans, et al., 2017), as well as to the clinical guidance that a score of five and above should be used as a screening cut-off to indicate a need for a mental health assessment.
The quantitative analysis of the pre/post outcome data indicated a reduction in emotional and behavioural problems in the children and increased levels of self-efficacy in adoptive parents. The mean reduction in BAC scores from 21.7 to 16.5 was statistically significant, even though the children were still scoring far above the screening cut-off score of five. Although self-reported parental efficacy was already relatively high for families at the point of referral, parents on whom pre- and post-intervention data were available also reported increased levels of confidence and feeling more effective in their role as parents by the end of therapy. However, as discussed below, high levels of missing data mean that these findings have to be treated with caution.
Findings from the ESQ and the interviews gave a better understanding of families' experiences of the service and in particular the Adopting Minds sessions. Service-level satisfaction among parents was generally very high, in line with recent evidence from a survey of CAMHS (Wolpert, et al., 2016). Lower satisfaction related to the location and timing of sessions, which in the case of Adopting Minds stemmed from the therapy being offered in one location and the therapist being employed part-time, making the service only available on one day per week.
The interviews indicated that families felt that the therapy acted as a space where they felt listened to and where they could talk freely about fears, anxieties and conflicted feelings. Most of the families experienced the therapy as somewhere where their and their children's past experiences were thought about, discussed and illuminated, thus helping them to understand their children's or their own struggles more clearly. Feeling contained and safe enabled them to engage better with the therapeutic process without feeling under scrutiny. Previous research has suggested that this sense of being judged is harmful (Howe, 1996) and attempts to address this anxiety and allow adopters to speak freely are now recognised as a key element of effective approaches (Henriksen, 2014; Merriman and Beail, 2009; Sheridan, Peterson and Rosen, 2010; Wimmer, Vonk and Reeves, 2010). Furthermore, these feelings of being listened to and supported are hugely important to children, especially as many adoptees struggle with trusting others and feeling safe in relationships (Pace and Zavattini, 2010).
This study also suggests that the specific characteristics of the therapist are important in getting adoptive families to acknowledge difficulties, question themselves and open up, which in turn can help them address their main struggles. These characteristics included personal as well as professional attributes which previous studies have suggested may be as important to families as the treatment itself (Blatt, et al., 1996; Sprenkle and Blow, 2004). The valued qualities were friendliness, a non-judgemental approach and encouragement. The importance of the therapist being experienced as well as caring and empathic was first emphasised by Carl Rogers (1965) and has been found to be important for service users in subsequent studies (Henriksen, 2014; Sheridan, Peterson and Rosen, 2010). It is also a key element of the ‘therapist stance’ in mentalization-based therapies (Keaveny, et al., 2012; Midgley, et al., 2017) as it can help some parents to reduce their feelings of being ‘bad’, as well as leading to high therapeutic satisfaction. For some of the parents in this study, this attitude of the therapist was a surprise as they expected to be criticised or told what or what not to do. This indicates the importance of addressing such anxieties in work with adoptive families where issues of guilt, failure and frustration can be especially acute.
As well as the overall qualities of the therapist, this study also identified specific therapeutic skills that adoptive families found helpful, such as the way that interventions were phrased or how questions were asked. They also spoke about the value of the therapist's ‘expertise’ and the importance of knowing that s/he had academic and personal knowledge about adoption. This helped them to question themselves as to why they were acting in certain ways and to consider other possibilities of action and thought, as well as helping them to open up and feel more able to trust others. This question of establishing trust is often mentioned by adolescents engaging in therapy, a process complicated by the fact that they tend to dislike being treated as children, a major obstacle to its success (Freake, Barley and Kent, 2007). While the fundamental importance of trust to the therapeutic relationship is acknowledged, more recent ideas in relation to mentalization-based therapy have suggested that overcoming ‘epistemic hypervigilance’ may also be core to effective therapy (Fonagy and Allison, 2014), a fact that has particular significance for adoptive families who are often suspicious about whether professionals can be trusted sources of social learning.
It is equally important to note that the families also highlighted service limitations. Previous studies have suggested that adopters attending group therapy, where experiences are shared, feel that interaction with other adopters provides different opportunities that individual interventions cannot give. These included social support, the development of lasting relationships and help from others with the challenges of parenting (Bonin, et al., 2014; MacMahon, et al., 2014).
Participants referred to the importance of having information about how trauma and early adversity can affect family interactions. Although some interviewees felt that the therapist provided such expertise, others spoke of wanting to receive more straightforward explanations and direct and precise expert advice. The latter is something noted in past studies where patients valued the therapist's teaching (Nevas and Farber, 2001); however, the literature on mentalization-based therapy speaks of the need for the therapist to take a ‘not knowing’ stance and to avoid taking on an ‘expert’ role, so it may be that this study has identified a potential tension between the core MBT model and the particular needs of some adoptive families. This needs to be considered in future developments of the Adopting Minds approach.
Finally, several participants in this study felt that the short-term service offered on its own, even when valuable, was not enough for achieving major improvements or changes regarding their or their children's difficulties. In some cases, the therapeutic intervention was effective in the context of a wider range of support services; but for others there was a frustration that it was too brief and ended at a point where the family could have benefited from a longer-term involvement. This echoes the quantitative evidence which showed a significant drop in mean scores on a measure of child emotional and behaviour difficulties following therapy, but with mean scores still well above the clinical cut-off point.
This raises important issues for funders and service commissioners. The initial Adopting Minds service was only able to offer a six-session programme; later this was adapted, following adoption support funding being made available, to allow up to 12 sessions for some families. Nevertheless, the realities of funding (such as the cap on resources in the UK's Adoption Support Fund) mean that therapeutic services may often be time-limited, even if some families identify a clear need for longer-term support. This may be especially important where issues of ‘epistemic hypervigilance’ are salient, and a short-term intervention may be experienced as simply another professional who comes into their lives and then disappears.
Where short-term, time-limited interventions are the only option available, it may be important to consider the family expectations before starting therapy. The ability of the therapist to clearly present the treatment in a way that is consistent with the client's expectations has been found to be an important element for successful outcomes (Howe, 1996; Johnson and Talitman, 1997). Furthermore, it could be that families are sometimes so overwhelmed that they engage with an intervention without considering the information offered or asking questions about it. Adoptive families faced with multiple difficulties may struggle to access appropriate services, so it would not be surprising if they engage in brief interventions that offer some help but are insufficient to address complex problems.
Practice implications
Even though these findings are initial and exploratory, they generate further ideas that can contribute to the development of mentalization-based interventions for adoptive families. Understanding more about families' expectations and motivations for engaging will help reduce misunderstandings. Assessing families' needs more clearly before referring to the Adopting Minds service may also lessen the risk of offering it when another type of intervention may be more useful. In line with the conceptual model of mentalizing, families appeared to welcome the opportunity to explore their own and others' experiences from different perspectives and to have their feelings – including more negative ones – accepted in a non-judgemental way by a therapist who takes a curious, non-expert stance. However, there are also some indications that a group-based approach could in some cases be more appropriate, either alongside or instead of Adopting Minds. Likewise it may be important to have some flexibility regarding the length of the intervention.
Limitations of the study
The effectiveness of the Adopting Minds service would benefit from further investigation. Although a significant difference between pre- and post-measures was identified, the evaluation was undertaken in an opportunistic way, the sample was small, there was no longer-term follow-up and pre- and post-data were only available for approximately 40% of the families who were assessed at baseline. Given these limitations, especially the high levels of missing data, there is a likelihood of response bias limiting the interpretation of the findings. Similarly with the interviews, only families who had completed six or more sessions within the first six months of the project were contacted.
Conclusion
Although the findings of this study are tentative, they nevertheless suggest that the Adopting Minds approach, as an adaptation of MBT-F in the context of post-adoption support, deserves further investigation as a therapeutic contribution to adoptive families presenting a range of difficulties. This is particularly important given the lack of research into effective interventions with this population.
Paired responses from BAC and BPSES.
Footnotes
Acknowledgements
This study was carried out without financial support. The second author was a student on an MSc programme at UCL at the time she worked on this study and took part in the research as part of her studies.