Jody Todd Manly, Clinical Director of Mt. Hope Family Centre shares more about her work at University of Rochester’s Mt. Hope Family Centre. With 40 years of experience, Jody provides an overview of the TRANSFORM National Center Grant and the research studies that it funds at Mt. Hope. She highlights important study findings and provides insights into the value of clinical work informing evidence-based research and how this contributes to contextually relevant interventions.
Getting to know Jody and Mt. Hope Family Centre
Salisha Maharaj: Please share more about yourself and the work you’re involved in at Mt. Hope Family Centre.
Jody Todd Manly: OK well I am a Clinical Psychologist by training. I am the clinical director at Mt. Hope Family Center. It’s affiliated with the University of Rochester, but it’s located in a separate building off campus. Mt. Hope is a pretty unique place in that we have clinical services to support children and families, and we conduct research which includes treatment evaluation studies that inform our clinical practice. We do translational research where we’ll investigate a treatment modality, see if it’s efficacious and then bring it into our clinical service delivery. Our clinical work informs our research questions and helps us, I think, to provide a richer evaluation as well as some basic research where we’re trying to find out some information that can inform the treatment and vice versa. And then we’re training not only students, but also other professionals around the country. We’re part of the National Child Traumatic Stress Network (NCTSN) in the US which is a grant funded network of people who are doing work in the area of trauma across the country. We also have a federally funded grant that supports our Transform Center, which is a National Center devoted to child abuse and neglect prevention. We are one of three national centers that focuses on child abuse and neglect, the prevention and treatment and research, and also translating research so that it can be disseminated to different people in different disciplines, different fields, whether that’s family court, judges and attorneys, whether it’s teachers or child care providers or medical professionals and law enforcement. We’re trying to get the information out and disseminate it as broadly as possible.
Salisha: That’s incredible, Jody. How long have you been at Mt. Hope?
Jody: I’m coming up on 40 years actually. I started here as a graduate student and I thought that I would, you know, finish my graduate work and move on. But I found this to be such a unique setting, particularly with that integration…A real true integration of clinical service provision and research that I ended up staying and I’ve continued to be here. I remark on it often that I have a fabulous team here and our clinical service providers, some of them have been here 5, 10, 15, 20 years, so it’s pretty unusual, especially given how challenging the work in the trauma field is, to not have more staff turnover. And we do have more staff turnover in our research staff because a lot of our research assistants who are working full time with us have graduated from their universities and they’re getting some experience before they go on for their graduate work.
Salisha: I am wondering about the history of Mt. Hope… is it part of the University of Rochester from the get go or was that something specifically set up for this kind of purpose?
Jody: It was part of the university from the beginning. In the beginning we had a therapeutic preschool program and so a lot of the emphasis was on supporting the kids in the preschool as well as doing some parenting programs. And we worked a lot with special education and kids with special needs, particularly because of trauma. So even from the beginning, we were doing a lot of work in child abuse and neglect, which actually was one of the things that attracted me to Rochester and to the University of Rochester for my graduate work because Mt. Hope was already a center that was working in the area that I was interested in. That was even before Dante Cicchetti came on board as our director, and he was my mentor for most of my graduate work. It’s interesting because we’ve had some people who have read our research in journals, and I can think of one person who started working with us after she learned about our work in South Korea. And she came from South Korea to the US and worked with us for a number of years before she went into a faculty position at Virginia Tech and now she’s partnering with us again. So sometimes people leave and then cycle back even after they’ve left us and they come back. One of our current clinical staff members worked in our therapeutic preschool left for a while and then came back and our current research director was a research assistant with us before she went to Graduate School and now she’s come back and is working with us as our research director so that I think also speaks to how once you’re part of our Mt. Hope family, people remain part of the family. And even if they’re off doing other work, we stay connected and we have partnerships with them. It’s a special place with a lot of special people who work here and I could not do the work by myself. I think having that very, very dedicated team supporting my work and inspiring me is one of the reasons I’ve stuck around here for so long.
Salisha: It sounds like a real home base…people go grow and go off and come back, but there’s always connection. It sounds very special.
TRANSFORM: National Centre on Child Abuse and Neglect Prevention
Salisha: Can you share more about the TRANSFORM treatment evaluation study?
Jody: Well, I would say that TRANSFORM is a center grant. So, it’s a National Center on child abuse and neglect prevention. In our current iteration our current grant funding has three different studies that are part of it as well as a dissemination and community engagement arm. So, two of those studies involve some basic research, but it’s longitudinal follow up.
We used to have a summer camp program where about 250 kids participated every year. That actually was the basis of my dissertation… starting that summer camp program back in the day. We had over 2000 children who came through our summer camp programs over the years and now we’re following those families up and they’re in adulthood. We have extensive information about them when they were children. Now we’re trying to get back in touch with them, see how they’re doing as adults and the newest piece is looking into the next generation. We’re going to also be following the children of those former summer camp participants…So that’s a really cool piece. It does make me feel kind of old when I’m looking at the children of our participants and we already have some preliminary information. First of all, about a lot of the challenges and risks that these individuals have had in their lives. By design, half of those kids attending the summer camp had experienced child abuse and neglect. The other half as best as we could tell, had not, but had some of the similar challenges of coming from economically challenged families. Looking across time then at the impact of those early experiences, we’re finding some significant physiological changes as well as psychological changes from some of that chronic stress and that early adversity.
Key research findings
Salisha: Jody, can you share some of the key research findings from the studies that are underway?
Jody: I’ll talk about two different treatment evaluation studies. One is wrapping up and the other one is going to get started this year. The one that’s wrapping up is the one that’s most relevant to the infant mental health work, and that is what we called our Promise Project. So, in that study, we started working with women during their pregnancy and kind of related to some of the other challenges that we found in our other studies. We found that 44% of those women who were participating had experienced sexual abuse during their childhood. So that’s a really high rate in my way of looking at things. But we’re looking at the impact of that in our family health study, the effect of sexual abuse on reproductive health outcomes. But in our Promise Project, we started working with women during their pregnancy and we followed them up until their child was fifteen months of age. We were able to follow them over time and look at not only what were their expectations of their babies before they were born, and then how did that play out in their relationships with their children after they were born? We were specifically evaluating an intervention that is child-parent psychotherapy. Child-parent psychotherapy is typically delivered as a 12-month intervention, but there are a lot of requests to see whether you could have the same kind of outcomes with a shorter duration of treatment. A lot of policymakers and funders, and sometimes the families themselves are looking for a shorter intervention. So, we were comparing the typical 12-month intervention with a 6-month version and we were also asking the question of the pregnancy and birth period as a ripe opportunity to support families. But is it better to try and begin that support during pregnancy or to wait until after the baby is born and work on the parent-child relationship when the baby has actually arrived? So those are some of the research questions that we are now on the brink of being able to address because we’ve just finished up our pre-post time sets and now we’re just left with finishing up the remaining follow-up after the intervention is concluded.
The Promise Project that is some of what I presented at the WAIMH Congress in Dublin and one of the preliminary findings, the early findings that really was exciting for me is even during pregnancy, even before we’d started entering intervention…and we’re just looking at baseline data…We thought that things like a parent’s own history of child abuse or neglect in their childhoods and the presence or absence of intimate partner violence with their partner would influence the way that they viewed their baby. And that, uh, we had a scale of maternal fetal attachment to look at just their perceptions of the baby, how they’re viewing that relationship even before birth. What we found is that instead of those adversities having the biggest role in how they were perceiving their babies, it was actually benevolent, childhood experiences and social support that played the biggest role in influencing those perceptions. In our child parent psychotherapy work, we talk about angels in the nursery and, you know, certainly ghosts in the nursery is a concept, but also angels (Lieberman, Ippen & Van Horn, 2015). And it was like evidence for the important role that angels and positive experiences can play. And that’s what we hope to then harness when we’re intervening with families to build on that support and build on those positive memories in hopes of having more positive outcomes.
Salisha: That’s so interesting because what you are saying is that if you can hold on to those benevolent experiences and carry them with you through pregnancy and birth that has more of an influence than the negative experiences. There is a lot of hard work that goes into the patient and clinicians in terms of looking at those ghosts and unpacking them and processing them. The research evidence perhaps supports an intervention that’s not as intense, not fraught with a lot of unpacking of deeper material and one that’s more about a fostering of resilience and growth and support and holding on to that.
Jody: I think you’re right that so many of our systems, especially our medical models, are built on this, umm, pathologizing and diagnosing and looking for the problems. In some cases, not intervening until the problem is big enough or severe enough…and I think we do really need to look at how to change that up and have a real strength-based approach. How do we really harness those positive experiences to build on to say, “what is the relationship you want to create with your baby?”. “How can you look back on those experiences of feeling safe and protected and cared for, and create that with your baby?”. Or if you didn’t have those experiences, how can you build new memories with your baby?
Salisha: I’m remembering the paper Ghosts in the Nursery and you know, it’s not just the memory, but it’s the affects, the feeling of those memories that creates a shift in the patient. As you’re talking, I’m just thinking, wow, how powerful is it to not just to be able to talk about the positive, benign, supportive experiences but to be able to remember the feeling of them.
Jody: And I think we still need to acknowledge the impact of trauma. We still need to speak the unspeakable and help families to process that trauma, but one of the ways of fostering healing can be also bringing in that benevolence, bringing in those feelings of relationships that did elicit care and concern and love and compassion.
Salisha: Jody can you share how you measured these experiences in your research? What you are saying has been a part of psychoanalytic thinking for a long time but this is something that has been evaluated using standardized measures.
Jody: Well, we have a lot of different things that we’ve incorporated. One of which is the maternal fetal attachment scale (Cranley, 1981) to look at mother’s perceptions and Angela Narayan (Narayan, Rivera, Bernstein, Harris & Lieberman, 2018) developed a benevolent childhood experiences scale that we incorporated, but we have a host of measures that we’re still tapping into. For example, we asked mothers to describe some of their relationships and a 5-minute speech sample to assess their expressed emotions. We asked them to talk about their babies even before birth and their own caregivers, and to talk about themselves in these different 5-minute speech samples. We’re currently coding right now especially that 5-minute speech sample about the unborn baby, not only to code that in a quantitative way, but we also want to look at it from a qualitative research standpoint and try and look at what the themes are that the mothers are sharing. And we also have some things built in. For some of our follow up, we didn’t get this at baseline, obviously because the baby wasn’t born. But when the babies were 15 months old, we have Strange Situations (Ainsworth & Wittig, 1969) where we’re going to be able to capture that attachment relationship and code that. Because we had a pandemic in the midst of our data collection, we had to switch to some of the things that maybe don’t require the families to come in, in person. Although as soon as they were able to we got back to those, some of the things like the Strange Situations were shut down for a while, but we resumed.
But we also built in some things like a Parent Development Interview (Slade, Aber, Berger, Bresgi, & Kaplan, 2020) to be able to capture some of that information in a different way as well as we added some COVID assessments to say, you know, how was the family impacted by COVID, the stress of maybe not being able to have your partner in the delivery room with you, in addition to how it impacted medical care and whether they had lost a job, lost a family member, had more financial stress or more loss and grief, or general stress with the anxiety of the pandemic. We’re also looking at the effect that that had because we have some families that we had already done some assessment with before the pandemic and then we had some, that didn’t start with us until after the pandemic shutdown. So, there we have many layers of things that we’re going to be evaluating and I’m sure it will take us some time to process all of that.
Salisha: What a huge amount of important data. It is very rich…
Jody: Yes, we also have maternal cortisol. So, we were looking at maternal stress regulation and we had a paradigm where we had an infant cry and we were assessing mom’s cortisol before and after hearing that during pregnancy and then before and after the Strange Situation. We are looking at a physiological change as well as psychological changes. I’ll also highlight some of the findings from that Adult Family Health study in TRANSFORM, including the impact of early child maltreatment on things like cellular aging. We’re studying telomere lengths and we’re looking at epigenetic changes and already seeing some cognitive decline in the participants who experienced chronic stress and early maltreatment histories, even though they’re only in their 30s. But there’s already several domains of functioning that are impacted by that early history of adversity and how that plays out as people develop over time. So, I think having that ability to do that longitudinal work, because there are a lot of consequences that you know conceptually, theoretically we would assume would be the case and there are a few other studies that have been able to do longitudinal follow-ups. But really, being able to do the deep dive so we understand those processes and if we understand those processes of how those things can play out, then we can really look at what are the optimal windows for intervening or what are the ways that we can implement preventive strategies. I think the deeper our understanding is the more we can use that to target intervention and prevention efforts.
Salisha: That’s so important. It becomes so much more effective, for patients and cost of the intervention especially in resource limited settings. It also allows prevention to take focus with an evidence base.
Jody: And that’s such an important point too, because the prevention piece is sometimes hard to document, to say what didn’t happen. But the more we have this data and the evidence to support it and I think your point about resources is so important, that so often the larger systems put their resources where it’s going to make the most difference understandably… But sometimes it’s hard to make the case for prevention and I firmly believe that prevention is really the way to go, especially if you’re talking about trauma and you’re talking about maltreatment. And obviously we want to prevent the suffering that goes along with those, but making the case to funders or policymakers sometimes is hard without having that data. So, we are trying to compile the data in a way that we can use it not only for our treatment and our intervention, but also for those policy pieces.
Insights on developing evidence-based research that is influenced by clinical work
Salisha: Jody, can you share some of your insights on the research process in developing evidence-based research interventions that are influenced by clinical work?
Jody: Yes, everybody should incorporate both clinical work and research into their work, but I will say when you’re trying to do it all, you don’t get much sleep! So, it’s yes, so it’s hard for a lot of places to do both. I’ve certainly done work partnering with clinical agencies that just don’t have either the bandwidth or the expertise to do the research piece and similarly a lot of research institutions are not set up to have the clinical piece. That’s one of the reasons that I feel so fortunate to be at a place like Mt. Hope, because I think even our research, is more likely to be successful because we’re seen in the community as not just a research ivory tower, that is only using people as Guinea pigs. We are actually doing the work to support families. I think that’s helped us with our research being able to get off the ground and being able to recruit participants in all of that. And I also think that in our research work, we’ve never done the very limited treatment evaluation studies where the inclusion criteria are so restrictive that it’s like a pure sample that’s not representative of the larger community. Our research has always been very real world and understanding the challenges in the community, and we’ve tried to be as open as we can with our inclusion criteria so that we capture some of those real world dimensions and challenges and then it’s easier to translate that work into a clinical setting because it’s not saying “ohh you, you can’t participate if you have XY or Z or like comorbidity, if you have more than one diagnosis or more than one challenge going on then you know we can’t take you”. We’re much more aware that it’s the majority of people that have more than one thing going on, so we want be inclusive of that. If we’re doing the work because that is the reality.
Salisha: It sounds like it is not about going out there to find people to answer a research question. It seems much more sort of a keen eye on the community and what some of the challenges are and using those to really inform some of the questions. What are the attrition rates like? I would imagine that they may be low since the research harnesses the needs of the community?
Jody: Yes, I don’t want to minimize the challenges because it’s very hard to track people down over time. Some of them have moved away or they’re incarcerated or they have died, unfortunately. When we’re following a group of people over time or they’re like, “I don’t wanna be bothered”. During the work and even our treatment evaluation studies, we’re offering free treatment and not everybody takes us up on that. Even if you know you’re assigned to a treatment group, that doesn’t mean you’re going to follow through and actually participate in counseling. So, it’s hard work and there are a lot of challenges there and yet I feel like the quality of the work overall is improved and what we’re learning is improved. I’ll give an example that doesn’t have to do with our Transform center, but one of the treatment evaluation studies because we keep doing this cycle of we need to intervene earlier and earlier and earlier. When we were working with older parents, then we’re looking at what about teen parents? Maybe we intervene there and then we’re like, well, what if we intervene with the teens before they get pregnant? And can we look at that and we keep going around the cycle and cycling around and around. In a study that we did a few years ago, we were looking at treating depression in teenage girls and hoping that if we addressed some of the depressive symptoms then they might have better outcomes over time. And you know, perhaps even prevent pregnancy. But that wasn’t our main goal. When we started recruiting for that study and we were saying we want to find, girls who were 13 to 15 year olds who are experiencing depression and we started working with youth programs and going out and doing depression screenings, and we found so many girls who not only experienced symptoms of depression, that they may or may not have told anybody about, but they also told us about a lot of suicidal thoughts and sometimes suicide attempts that they’ve never shared with anybody before. So, it’s like if you’re aware of what some of the challenges are and you go out and you ask, you find that a lot of people are struggling in a way that you wouldn’t know if you didn’t bother asking.
Salisha: I think perhaps what you’re saying is that the flexibility of the research and allowing the participants to sometimes lead the process is the real power of evidence based-research that leads clinical intervention. We are coming up to the last question which is about speaking to the global applicability of the project and the work that you’re doing. How can this fit in elsewhere?
Jody: Well, I think that an important consideration that I know you’re very aware of, because we’ve talked about it before, but is looking at the cultural context of the work that we’re doing. And so it’s very important to be mindful of that context, because there are a lot of contextual factors that do influence the work, and I’m going take a side tangent and then hopefully I’ll get myself back. But the tangent is the other new project that’s coming up for Transform that I haven’t mentioned yet. We are looking at,, trying to improve treatment for youth who are African-American or identify as Black, who may have experienced child abuse and neglect as well as racial discrimination and oppression, and asking how we can infuse our ongoing treatment with more sensitivity to racial socialization and positive racial identity for Black youth who in the US, unfortunately we have this long history of slavery and discrimination, particularly against Black families and Black individuals. We are trying to see how our treatment can change to be more sensitive to the needs of that cultural group. To loop back to the global applicability… That project may or may not have a more global recommendations for treatment of how to do that in other places, but it does really underscore how important it is in my belief to really look at the cultural context…And then how can we continue to ask ourselves how to improve treatment so that we’re more responsive to the needs of the people that we’re trying to serve? And I think there are some things that we can learn from different treatment approaches that could be extended into other countries or other places. But we always have to ask ourselves what adaptation might be needed, and I think assuming that Western approaches are automatically going to be useful in other places may have some limitations in our thinking…and there are some things that we need to think about from within a group. You know, maybe you start with asking the community what they need and listen to that and trying to map our services onto those needs rather than the other way around. It is very difficult to do cross-cultural work that involves not only interpretation of the language, but it also means looking at what are the goals and the priorities and the assumptions that the treatment is trying to bring. And are those assumptions valid, so one of the things that I like about our child-parent psychotherapy work, building off the work of Alicia Lieberman, who started evaluating the studies with Latina moms who had immigrated to the US and that was the beginning of the treatment evaluation and the evidence base for child-parent psychotherapy (Lieberman, Ghosh Ippen, & Van Horn, 2015). And we have done the work also with minoritized people who are struggling with multiple challenges. So that intervention wasn’t developed with a kind of Westernized top down approach. It was developed from looking at the needs of that community and I think we need to do more of that. Umm, although there are some things that we look at, like the pandemic effect at all of us across the globe and some things like one of my colleagues here, Christie Petrenko does work in a fetal alcohol spectrum disorder. So prenatal exposure to alcohol has similar consequences on the developing fetus, no matter where that fetus is living. However, there are also a lot of contextual pieces of what services are available, what supports are available, and how is that viewed and different countries etc…there’s both and there are some things that we need to support children and families with globally, especially in the midst of wars and other things that are catastrophic for children and families’ development…And at the same time, we need to be very sensitive to where the child and family are located and what are the external environmental factors that are impacting them.
Salisha: Jody, that is such a brilliant description of holding in mind both the context and the people that you’re working with as well as considering global factors that influence them.
Jody: Well, and it’s one of the things I love about WAIMH too, because I think WAIMH has a way that we can look at a global perspective and we can find both the commonalities that are similar in our human development with people who have babies across the world…and we also can look at our differences and how we need to be very mindful of place and time and that influence on development as well.
Salisha: In wrapping up Jody, is there anything else that you would like to share?
Jody: Well, I guess I will just wrap up with the fact that a lot of people are doing this work across the globe and that I get so inspired by seeing what everyone is working so hard to do to support especially babies. I think our youngest global citizens are so important to protect and to give voice to, since they may not be able to speak or have language for themselves and that makes advocacy so important too. I think coming together, sharing ideas, all of us, knowing that there is a big picture, we are all working together and despite all of the challenges and how hard the work can be for me, organizations like WAIMH and other ways that we come together. It was so delightful for me to be in Dublin at the WAIMH Congress this year…and to say it feels so good to be together, to be able to be in person that gives me hope that gives me inspiration. Those relationships are so important too, and that gives me strength. I just give a lot of credit to WAIMH and to our global efforts to support kids and families and to make sure that our youngest world citizens aren’t overlooked, that we are working on their behalf.
Contact
For correspondence Jody can be contacted on jody_manly@urmc.rochester.edu
Further information about Mt. Hope Family Centre, clinical services, community projects, research and training can be found at https://www.psych.rochester.edu/MHFC/about/.
Mt Hope Family Centre project descriptions can be found at https://www.psych.rochester.edu/MHFC/community-services/study-participation/.
More information on the TRANSFORM Research Centre can be found at https://www.psych.rochester.edu/MHFC/transform/
References
Aber, J. L., Slade, A., Berger, B., Bresgi, I., & Kaplan, M. (1985). The Parent Development Interview [Unpublished manuscript]
Ainsworth, M. D., & Wittig, B. A. (1969). Attachment and exploratory behavior of one-year-olds in a strange situation. In B. M. Foss (Ed.), Determinants of infant behavior (Vol. 4, pp. 113-136). London: Methuen
Narayan, A.J, Rivera, L.M, Bernstein, R.E, Harris, W.W, Lieberman, A.F. (2018). Positive childhood experiences predict less psychopathology and stress in pregnant women with childhood adversity: A pilot study of the benevolent childhood experiences (BCEs) scale. Child Abuse & Neglect. (Vol. 78, pp. 19-30). ISSN 0145-2134.
Cranley, M.S. (1981). Development of a tool for the measurement of maternal attachment during pregnancy. Nursing Research. (Vol. 30(5), pp. 281-284). PMID: 6912989
Lieberman, A. F., Ghosh Ippen, C., & Van Horn, P. (2015). Don’t hit my mommy: A manual for child-parent psychotherapy with young witnesses of family violence (2nd ed.). Washington, DC: Zero to Three Press.
Authors
Maharaj, Salisha,
Assistant Editor, WAIMH Perspectives in Infant Mental Health,
South Africa
Todd Manly, Jody,
Clinical Director, Mt. Hope Family Centre,
United States
