Working with mothers affected by substance use: Keeping children in mind

Dan Moss, Ruth Crooke, Nicole Rollbusch & Jacquie Lee, Emerging Minds, Australia, September, 2019

Resource Summary

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Key messages

  • Mothers who are affected by substance use are often facing co-existing issues of mental illness, poverty, family and domestic violence and a history of trauma.
  • Engagement strategies which take into account all of the issues a mother is experiencing are vital for the improvement of children’s social and emotional wellbeing.
  • The high prevalence of substance use means practitioners are likely to work with mothers affected by substance use and co-existing issues which may impact on the child.
  • A mother’s relationship with her child is likely to be a strong motivational factor in her seeking professional help, even if she is not always parenting in safe or nurturing ways.

The language used in this resource aims to be strength-based and to avoid further stigmatising an already highly stigmatised population. Therefore, this resource will refer to ‘substance use’ as a broad descriptor of substance misuse, harmful or problematic use of substances, or dependence or addiction to substances.

Recent research has confirmed what many practitioners have long understood: that mothers who attend services often experience co-existing issues including substance use, child protection involvement, mental health difficulties, poverty, domestic and family violence, and a history of trauma (Bromfield, Lamont, Parker & Horsfall, 2010; Buchanan, 2018; Heward-Belle, 2017). Many of these mothers have had their first children at a young age, without the social structures or relationships with their own parents to support nurturing relationships with their children (EIRD, 2019).

More than ever, practitioners are tasked with engaging mothers with co-existing issues in conversations about the social and emotional wellbeing of their children. The ability to have these conversations in ways that focus on the child’s needs, while not further stigmatising disadvantaged mothers, is an increasingly necessary skill.

This paper will explore approaches to working with mothers who present to adult-focused services with substance use and co-existing issues, as well as exploring some of the challenges for practitioners.

Who is this resource for?
This resource is a reflective paper designed for practitioners who work in adult-focused services with mothers who use substances. It will benefit both professionals working in specialist AOD services, and those working in generalist settings.

This resource recognises the interrelated nature of substance use and mental health concerns, financial difficulties, family and domestic violence (FDV), homelessness, poverty and child protection issues, and the significant proportion of adults who present to services with multiple concerns.

It invites practitioners to think about their current interactions with mothers who use substances, the effectiveness of these interactions, and how they might more effectively conduct preventative conversations about children’s social and emotional wellbeing.

How common is maternal substance use and how does this affect children?

Generalist practitioners should screen for substance use as part of their practice. As well as gaining an understanding of the issues the mother and children are facing, this provides an opportunity to ensure the child’s safety, develop some alternative coping strategies and make sure the child is at the centre of practice. – Sarah Watson, Senior Manager, Uniting Communities

The Alcohol Consumption of Australian Parents study and 2016 National Drug Strategy Household Survey (NDSHS) found that:

  • 24% of mothers with partners engaged in risky drinking
  • 33% of single mothers drank at risky levels1
  • 32% of mothers aged 18-29 engaged in risky drinking, compared with 23% of those aged 30-54 years
  • 25% of women in their twenties had taken illicit drugs in the past twelve months
  • 24% of single parents had used illicit drugs in the past twelve months, increasing from 18% in 2007 (Laslett, et al., 2017; NDSHS, 2016).

Studies have shown that living with parents who use substances can have many negative effects on children, including unpredictable and chaotic home lives, feeling constantly vigilant, feeling like they need to keep the substance use secret, missing out on normal childhood opportunities, increased risk of harm, and not feeling prioritised in their parents’ lives (Tilbury, et al., 2016).

Given the increasing proportion of mothers using substances, generalist practitioners are required more and more to discuss the potential issues caused or exacerbated by alcohol and drug use. Practitioners’ ability to ask questions in ways that create a discussion about children, while also engaging and motivating mothers is critical. Openly inviting a mother to talk about the effects of her substance use on her children in normalising and non-judgmental ways can lead to preventative conversations. In turn, these conversations can make a significant difference to the outcomes for children.

Reflective questions

  • What do you currently do to screen for substance use in your practice?
  • How do you support clients to speak honestly, without fear of judgment, about their substance use?
  • How do you prioritise the safety and social and emotional wellbeing of children when mothers are initially assessed?
  • How do you encourage mothers to discuss concerns that they might have for their children or for their parenting?

1 Although this is significantly lower than the figure for both fathers in couples and single male parents (49%) the rates continue to rise.

The coexistence of substance use with other presenting issues

It’s not for fun. You use the drugs and alcohol to get through each day… it’s a coping mechanism. It’s self-medication to mask the pain or the feelings that you’re dealing with. – Phoebe, mother

Less than a third of people seeking support for issues around substance use are women (NADA, 2016). Social barriers, including gendered stigma and fear of judgement, complications around past or current child protection involvement, trauma history and experiences of FDV can all get in the way of women seeking treatment. Women who do seek support for substance use report being exposed to more severe and ongoing trauma experiences (including interpersonal trauma and family violence) than the general population and their male counterparts (Marsh et al., 2012). The collective challenges faced by many women affected by substance use can impact on a mother’s ability to parent and support her child’s social and emotional wellbeing and cannot be treated in isolation.

A lot of the women who come through our program have come from intergenerational patterns of substance misuse, and grew up in environments that were not able to meet their emotional needs. They often haven’t learnt the skills to manage their own emotions, and then they’re presented with the job of parenting, which… requires us to, where possible, be emotionally available for our children. So, we’re talking about women who struggle to do that with their own emotions trying to manage and assist their children with their big feelings, and often it can be quite problematic. – Lisa Hofman, Social Worker, Jarrah House

Traditional substance abuse therapy has often emphasised personal responsibility as the most important aspect of recovery (Covington, 2008). Often this has involved clients ‘standing up’ to the consequences of their substance use and making amends for their poor behaviour. Traditional responsibility therapies might involve practitioners working in more directive ways, and strongly encouraging clients not to overlook past wrongdoings. But these therapies were mainly developed for men, with the assumption that substance use was the sole causal factor for subsequent issues (Covington, 2008). Women who have experienced past or current trauma are more likely to be overly critical of themselves, reducing their agency to change. In these cases, it may be inappropriate for practitioners to work in directive ways without first establishing trust.

Trauma-informed practice is key to working with mothers to improve their children’s wellbeing. It takes the impact of trauma into consideration, regardless of the traumatic experience itself. Historically, practitioners have been concerned about their capacity to respond to traumatised clients or disclosures (Gruenert & Tsantefski, 2012). However, within a trauma-informed approach, the client does not need to disclose the traumatic experience for the support to be beneficial (The Jean Tweed Centre, 2013).

By working in trauma-informed ways with mothers, practitioners can interrupt the cycle of intergenerational trauma and substance use. Working with mothers to develop a shared narrative that separates the current generation and their experiences from those of the previous or future generations can also help to break the cycle (Isobel et al., 2018). Encouraging mothers to talk about their children’s experiences and the hopes they have for their children’s future can help them to see that these experiences will be different from their own.

It was easy to jump to judgment and to start labeling mothers because they ‘obviously’ preferred substances over their children. These women often brought other mental health and trauma responses (with them) which could be interpreted as mischievous, histrionic or manipulative, when really these were survival responses. Once we got to understand them through compassionate responses, they began to feel safe and work with the practitioner on making changes for the sake of their children. But the only way to help the child – in my experience – was to create safety. – Gill Munro, Social Worker and former Alcohol and Drug Service Manager

Research suggests that female substance users also face greater stigmatisation than their male counterparts as they violate gender role expectations (Lee & Boeri, 2017). Women, especially mothers, are seen by society as ‘caregivers’ and are expected to be more family oriented and active in the role of raising children. They are placed under considerable pressure as they work to balance childcare, household and work responsibilities, and often face social and economic adversity as a result (Marsh et al., 2012). The caregiver stereotype can also create psychological barriers to intervention and treatment as mothers, aware of society’s double standards, seek to hide their substance use (Lee & Boeri, 2017).

The stigma is that you’re a low-life person that’s just a druggo and you’re probably a bad mother and you think drugs are your priority over your kids… The truth is, for me, I was a great mother. My mortgage was paid, my fridge was full, my kids were at school on time and happy and healthy and if there was any money left over at the end of the week, yeah, I would go and buy some drugs with it… that was part of my self-medication, but it didn’t mean that I neglected my kids at all. – Phoebe, mother

Mothers can often feel intense shame and devastation when realising they may have treated their children in a neglectful or abusive way or failed to protect them from abuse or neglect at the hands of others (Marsh et al., 2012). Low self-esteem, painful feelings of insecurity and inferiority, and lack of belief in their own self-worth often accompany these feelings of shame (Marsh et al., 2012). When combined, these feelings can prevent mothers from freely discussing their parenting role and make them reluctant to seek the assistance needed to overcome challenges. Understanding the thoughts and experiences behind a mother’s shame can help practitioners to respond in sensitive and effective ways, whilst keeping the needs of the child in focus.

What we need to be doing is really around acknowledging that experience of judgment, and accepting that when people are coming to us they’ve probably had multiple experiences of judgment and stigma against them… signaling to the [client] that there is no judgment, that we are encouraging of them, and we recognise the courage that it took for them to reach out for that help. That’s really what the strengths-based perspective is about – really reaching in and trying to grow the strengths that person brings with them to every session. Children can be extremely powerful for that; the desire and the values mothers hold around wanting to connect with their children and be the best parent they can be. – Suzie Hudson, clinical director, NADA

Practitioners today are more understanding of the multiple reasons which lead to mothers’ substance use. However, despite these understandings, the effects on children are no less real or dangerous. It is this balance between acknowledging the multiple traumas that many mothers have or may continue to experience, while not minimising the effects of unsafe parenting on children that remains one of the most challenging aspects of modern practice.

Reflective questions

  • How do you meet the challenge of creating safety and trust for mothers, while maintaining a focus on the social and emotional wellbeing of children?
  • Are there questions you regularly ask mothers about their children?
  • How do you avoid making moral judgments about mothers whose substance use affects their children’s social and emotional wellbeing?
  • How do you proactively assist women and mothers to discuss their substance use in your service?

Children as a motivating factor for change

Even though I was afraid to tell my whole story because I was afraid of losing the kids, if I had been able to tell my whole story and someone could have seen that ‘Wow, her kids are actually the motivating factor for why she wants to quit and she’s here asking for help’… then it would have been good. But I was too scared to tell anyone because I was scared of losing them [the kids]. So it was a catch 22. – Phoebe, mother

Sometimes practitioners may be reluctant to raise the issue of children, for fear that the mother is involved in child protection, or that her substance use means that a difficult conversation will ensue. However, the most common message from Emerging Minds’ child and family partners is that they want questions about their children to be asked in practice. These questions can be asked regardless of the mothers’ relationship with her child or children.

The mother presenting to your service may view her substance use as a primary concern, or she may not. She may also immediately recognise the impacts of her substance use on her children, or she may be unaware of them. She may have children living with her, or they may be in care. Depending on the context of your service, there will be many variations in mothers’ stories. Regardless of these, a mother’s relationship with her children is likely to be/become a prime motivational factor for her wanting to change her patterns of use and/or engage in treatment (NADA, 2016).

The removal of children from their mother’s care is often correlated with maternal substance use and needs to be part of the conversation. Mothers with a history of child protection involvement may have difficulty discussing their children or parenting role, for fear of having their children removed from their care (Marsh et al., 2012). Even when a mother doesn’t currently have supervision access with her child, there is a chance that this may change, or that she will have more children in the future.

For most women, stories of connection and protective factors in their relationship with their child will become apparent, where the practitioner maintains a position of curiosity. Sometimes a mother’s substance use will suppress her own sense of hope that things can be different for her child. In other cases, people in a mother’s life, such as partners who have subjected her to violence or abuse, will use substance use and mental health as ‘proof’ that she cannot parent responsibly (Heward-Belle, 2017).

Many mothers who have experienced trauma, social disadvantage and substance use have long histories of resilience, which may not be obvious to others or even the mother herself. In many cases, curious conversations will support them to describe what they have done to protect and nurture their child, as well as the stories of times where their children have been at risk of harm (Buchanan, 2018). By encouraging mothers to describe and reflect on these events, practitioners can increase confidence in replicating parenting which provides safety, consistency and reliability for their children.

Reflective questions

  • What difference does it make to your practice when you assume that all mothers are motivated to change in order to improve their child’s mental health?
  • How can you maintain curiosity in your practice, even where a mother is not parenting in safe or consistent ways?
  • How can you establish relationships with mothers which include an expectation of conversations focusing on the needs of the child?

Summary

Every practitioner who works with mothers engaged in substance use can apply the principles outlined above to explore and support trauma, stigma and shame without losing sight of the child’s experience. This does not require any special training in family therapy (NADA, 2016). Instead, it asks practitioners to use their knowledge of child-focused and trauma-informed practice to conduct sensitive, non-judgemental and hopeful conversations with mothers about their parenting strengths and hopes for their children’s future.

This paper has examined many of the challenges mothers face in describing the effects of their substance use, as well as other coexisting issues on their children. Mothers continue to bear the burden of judgment in most layers of our society, and this stigma is a significant obstacle to child-focused conversations. It is important that practitioners, supported by organisational implementation drivers such as assessment, practice policy, supervision and training, demonstrate a commitment to overcoming these barriers.

The need to continue these conversations is crucial, as are consistent organisational responses to substance use that achieve safe outcomes for children. The intention of this paper is to continue that conversation and to encourage organisations and individual practitioners to reflect on their practice policies, assessment tools, supervision and professional processes with the view to providing child-focused service delivery.

I would trust a practitioner if they pointed out my strengths and kept praising me for them. If they took more notice of that than my mistakes, acknowledged that I was a good mother regardless of some of the issues that were going on, and were understanding of me. – Phoebe, mother

Resources

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Bromfield, L., Lamont, A., Parker, R. & Horsfall, B. (2010) Issues for the safety and wellbeing of children in families with multiple and complex problems: The co-occurrence of domestic violence, parental substance misuse, and mental health problems. NCPC Issues 33, 1-24.

Buchanan, F. (2018). Mothering babies in domestic violence: beyond attachment theory. Abingdon: Routledge.

Council of Australian Governments (COAG) (2009). ‘Protecting children is everyone’s business’: The National Framework for Protecting Australia’s Children 2009-2020. Canberra: Commonwealth of Australia.

Covington, S. (2008) Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, 40(5), 377-385. doi: 10.1080/02791072.2008.10400665

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Heward-Belle, S. (2017) Exploiting the ‘good mother’ as a tactic of control: Domestically violent men’s assaults on women as mothers. Journal of Women and Social Work, 32(3), 374-389.

Isobel, S., Goodyear, M., Furness, T., & Foster, K. (2018). Preventing intergenerational trauma transmission: A critical interpretive synthesis. Journal of Clinical Nursing, 28, 1100-1113.

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