Assignment: Writing a Treatment Plan

Everything that social workers do is an intervention; therefore, social workers develop treatment plans so that they can outline the purpose of treatment, assist in giving the client direction in the treatment process, allow the social worker to collaborate with the client, and help social workers and clients mark progress toward goals. Depending on where you work as a social worker, your funding source may be dependent upon your treatment plan. 

In this Assignment, you develop a treatment plan for a client. In real practice, you should never create a treatment plan without conducting a more thorough assessment and then collaborating with the client to mutually agree on goals and steps to implement the plan. For the purpose of this Assignment, however, you explain how you might go about this process.

To prepare: Watch the video case study found in the Learning Resources. Then, go to the Walden Library and review literature related to interventions for this type of client or problem. Use this information to help develop an individual or family treatment plan for the identified client (Amy, Mrs. Bargas, or Bargas family) with whom you have chosen to work from the case study.

By Day 7

Submit a 3- to 4-page paper in which you:

• Identify the client.

• Describe the problems that need to be addressed.

• Explain how you would work with the client to identify and prioritize problems.

• Identify the related needs based on the identified problems.

• Describe how you would utilize client strengths when selecting a strategy for intervention.

• Identify at least two treatment plan goals.

• Create at least one measurable objective to meet each goal.

• Explain the specific action steps to achieve objectives.

• Discuss evidence from the research literature that supports your intervention choices.

• Describe what information is important to document in a treatment plan and explain why.

Social support available for substance‐dependent mothers from families with parental substance abuse

Eli Marie Wiig*†, Astrid Halsa‡ and Bente Storm Mowatt Haugland§ *Institute of Clinical Medicine, SERAF, University of Oslo, Oslo, Norway, †Borgestadklinikken, KoRus Sør, Skien, Norway,

‡Lillehammer University College, Pedagogical and Social Studies, Lillehammer, Norway, and §Uni Health, Uni Research,

Regional Centre for Child and Youth Mental Health and Child Welfare (RKBU West), Bergen, Norway

Correspondence: Eli Marie Wiig, Institute of Clinical Medicine, SERAF University of Oslo P.O. Box 1039 Blindern, Oslo, NO 0315, Norway Email: eli.marie. wiig@borgestadklinikken.no

Accepted for publication: November 2016

ABSTRACT

Substance‐dependent mothers, who have grown up with parental substance abuse, struggle during and after treatment to abstain from substances while trying to process traumatic experiences and integrate their family into society. The aim of this study was to explore the social support available for these mothers to help them stay abstinent and cre- ate safe family environments for themselves and their children. Using purposeful sampling, we approached nine mothers admitted for 1 year to a family ward at a substance abuse clinic and their significant others. Through in‐depth, qualitative interviews, first with the mothers, later with their significant others, we investigated characteristics of the avail- able social support. The findings indicated that the significant others had limited resources and were themselves exposed to adverse and cumula- tive psychosocial and socioeconomic risk factors. Their relationships with the mothers were, nevertheless, close, consistent and reliable. Supporting the existing social network should be an integrated part of the work of family welfare services aiming to help substance‐ dependentmothers from families with parental substance abuse to reha- bilitate and to integrate successfully into local communities.

INTRODUCTION

Substance‐dependent women who have grown up in families with substance abusing parents have major challenges to solve when they themselves become mothers, such as heightened risk for transferring sub- stance abuse or psychiatric problems to their offspring (Belsky et al., 2009) and establishing a safe and predict- able environment for their child without substance abusing caregivers or family members. We approached nine women admitted to a family ward at a substance abuse clinic to learn about the challenges these women face and how they understand their own situation. All mothers received inpatient treatment together with their child during the first year after giving birth. The aim of the treatment was twofold: learning to lead an abstinent life and becoming able to care for a child. The first paper from this study showed how these women’s life courses had so far been filled with experiences with substance abuse, traumatic events and insufficient developmental

support (Wiig et al., 2014). These findings are in line with Young et al. (2007) who described the adverse childhood experiences that may follow from parental substance use disorders (SUDs). Lindgaard (2011) and Haugland (2005) also show how these women’s ex- periences in childhood and adult life may have fostered feelings of shame, guilt, low self‐esteem and a chaotic lifestyle. Growing up with substance abusing parents may leave the offspring with serious deficits when it comes to parenting (Suchman et al., 2005). As the inter- nal working model of parenthood develops through childhood (Kanami et al., 2002), these women may need extra help with the parenting role. Becoming a par- ent is a big responsibility for any woman. The marginal- ization experienced by these women throughout childhood and adult life, as well as their own adverse childhood experiences, is likely to increase the chal- lenges they face in motherhood (Wiig et al., 2014). As many substance abusing mothers have partners who

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doi:10.1111/cfs.12341

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are also substance dependent, they may lack an absti- nent partner to assist them in their parenting role and are left alone with the responsibility of caring for and raising their child (Banwell & Bammer, 2006).

A marginalized life without structure or abstinent friends may be a consequence of having been a harmful substance user and growing up in a family disrupted by parental substance abuse (Wiig et al., 2014). Byqvist (2011) and Dawe et al. (2008) claim that female sub- stance abuse is often accompanied by social isolation. The social isolationmay be lessened during the inpatient treatment where the women receive support from pro- fessionals and fellow patients but may represent a chal- lenge in the rehabilitation of the mothers when they try to build a home for themselves and their child in a com- munity. Being discharged from an institution is a critical transition for substance abusers in general (Dahle & Iversen, 2011; Ilgen et al., 2008). Leaving a safe and controlled environment to establish an independent adult life in society may be particularly challenging for those who have never had a normal family life.

The mothers in our study had aspirations to lead an abstinent life, to establish a secure and stable life with a loving environment for their children and to integrate their family into society (Wiig et al., 2014). To manage these goals, they would need support. However, substance‐dependent women from substance abusing families may have partners and family members who struggle with substance dependence themselves, being unable to support the mother‐and‐child dyads.

Social support is defined as emotional (loving, car- ing), informational (advising, counselling) or practical assistance (financial help, babysitting) from significant others, such as family members, friends or work colleagues (Thoits, 2010). Perceived social support is influential for healthy psychological functioning (Thompson et al., 2006) and a key factor in creating nurturing and predictable environments for children (Mathiesen et al., 1999).

Suchman et al. (2005) found that the necessary growth and development may be possible for substance‐dependent women if they receive sufficient support, so their caregiving may be influenced by their perceived social support. Belonging to a family or having a network of friends or supportive neighboursmay act as protective factors (Suchman et al., 2005). The care- giver’s social support influences the development of children, directly through providing social control, role models and social bridging to other people and indi- rectly through making mothers feel better (Boe & Schiefloe, 2007; Olstad et al., 2001). Social support is especially important for the offspring of parents at

risk from socio‐economic factors and stressful life situations (Kendler et al., 2005), like substance‐ dependent mothers with substance abuse in their family of origin (Banwell & Bammer, 2006; Dawe et al., 2008).

Even though research confirms that social support in general is beneficial, it may be of importance to evaluate the reciprocity of the relationship. Gouldner’s (1960) reciprocity norm dictates that one in the end is not sup- posed to gain at the expense of others’ beneficial acts. In- dividualswhoreceivemore support than they reciprocate may experience feelings of dependence, low self‐efficacy or low self‐esteem (Nurullah, 2012; Shrout et al., 2006).

Cohen (2004) suggests that isolated individuals inpar- ticularmaybenefit fromestablishingnewsocial contacts, but there is also the possibility that thosewith strong feel- ings of isolation or relationships filled with ambivalence and conflict will be unable to expand their social net- works. Thus, Cohen (2004) underlines that services should facilitate and strengthen the bonds between the mothers and individuals in their natural social networks.

Substance‐dependent women with substance abuse in their family of origin may experience dilemmas with regard to their social network. They need support to stay abstinent and to take care of their child – at the same time they may need to distance themselves from their social network and family. Maintaining contact with parents, siblings, friends and former partners who continue to abuse substances may imply a substantial relapse risk in a rehabilitation process (Marlatt & Witkiewitz, 2009). Substance‐dependent mothers may also need to protect their children from exposure to the unpredictability and violence that close contact with friends and families with SUDs may imply (Dube et al., 2003; Perry, 2010; Wiig et al., 2014).

Increased knowledge of the social support available to substance‐dependent mothers from families with sub- stance abuse is important in understanding how the community can help these women stay abstinent and create safe family environments for themselves and their children. The aim of the present study was to explore the relationship between mothers with SUDs from families with parental substance abuse and their signifi- cant others. In particular, we wanted to investigate what kind of social support the significant others provided, and what additional social support was available for these mother‐and‐child dyads?

METHODS

We interviewed substance‐dependent mothers with a history of SUDs in their families of origin. All mothers

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were hospitalized in a family ward, and the first results from this study were published in Wiig et al. (2014). In the current paper, we wanted to expand on these find- ings. As a first step, we re‐examined the transcripts from the original interviews with the mothers, collected dur- ing the mothers’ hospitalizations. The transcripts were re‐analysed focusing on the mothers’ expectations re- garding social support after the inpatient stay. The next step involved interviewing the mothers’ significant others – designated by the mothers when interviewed during the treatment – focusing on what social support they perceived to be available for the mothers. Individ- ual semi‐structured in‐depth interviews with the mothers’ significant others were conducted, after the mothers and their children had been discharged from the family ward.

The significant other interviews were conducted in the interviewees’ private homes, with the exception of one, conducted at the familyward.The interviews lasted for 1–1.5 hours and took place between April and November 2014, between 2weeks and 29months (mean 15months) after the mothers’ hospitalizations were terminated.

Participants

All mothers with a history of parental substance abuse who were hospitalized in a specific family ward for sub- stance abusers betweenNovember 2011 and April 2013 agreed to participate in the study (n=9). The mothers were between 20 and 37years of age (mean 25, median 23) and were admitted together with an infant. The hos- pitalization lasted for 12months.

All mothers were diagnosed as substance dependent (ICD‐10, F10‐F19) and had been using a mixture of substances, but were abstinent during the interviews. One mother had been using alcohol and cannabis, but the others had also been using amphetamines. Many had used additional substances like prescription drugs (benzodiazepines etc.) and some opiates.

Themothers were asked to select an individual whom they expected to be the most important supportive per- son for them in their everyday life after discharge from inpatient treatment. Around half of these significant others had recovered from SUD’s, with the rest never having had addiction problems. None of the significant others were currently suffering from SUDs.

Two fathers were hospitalized together with the mother and the child. Six of the mother‐and‐child dyads had minimal contact with the child’s father. According to the mothers, all nine fathers were substance‐dependent, with most of them still engaged

in harmful substance use at the time of the mother’s hospitalization.

Having moved out from the clinic, the mothers were contacted again for the purpose of the present study, and asked to share contact information for their signifi- cant other. Eight of themothers consented that their sig- nificant others could be contacted. The ninth mother remained in the study, although she withdrew her con- sent to interview her significant other. All significant others of the 8 consenting mothers agreed to participate in the study. One mother reported two grandparents to be her significant others. This resulted in a sample of 9 mothers and 9 significant others (i.e. partners, older sis- ters, close friends, mothers, and grandparents).

Around half of the significant others reported them- selves having had SUDs. However, they had all recov- ered and stayed abstinent between 2 and 12years. One was currently medicated with an opiate‐substitution, but on a reduction schedule, and prepared to quit medication.

All interviews were individual, except for one (the grandparent couple was interviewed together). The mothers were interviewed twice, the significant others once. A total of 26 interviews from 18 interviewees were included in the analysis.

Interview guide

The guide for the interviews with the significant others was divided into four parts, comprising the interviewee’s perspective on: a) his/her prior history with the mother, b) his/her current relationship with the mother, c) his/her future relationship with themother‐and‐child, and d) the total psychosocial network of the mother‐ and‐child dyad.

The interviews with the mothers focused on their parenting role in a past, present and future tense. For details about these interviews, see Wiig et al. (2014).

Analysis

The transcribed interviews were analysed using a Giorgi‐inspired analysis: Systematic Text Condensation (Malterud, 2012). This is a systematic, thematic, cross‐cutting analysis suitable for analysing transcribed in‐depth interviews. The first step of the process provides an overview of the texts and selects themes that are relevant to the research questions. In the interviews with the mothers the following themes emerged: a) Returning to a life outside the clinic – fear and hope. b) Characteristics of the relationship between the mother and her significant other. This second theme also surfaced in the interviews with the significant others,

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where two additional themes were identified, resulting in the following three themes: a) Characteristics of the relationship between the significant other and the mother, b) The significant others are supporting, but also struggling with their own problems, c) Poor social resources.

The next step was to identify meaningful units in the texts and sort these units into different codes across the interviews, e.g. frequency and duration, giving advice. The third step was to condensate the codes in terms of their significance and meaning, e.g. building a social net- work, a complementary relationship. The final step of anal- ysis was to synthesize the significance of the condensates into new concepts and descriptions, i.e. categories. This process of analysis resulted in the following categories: a)

Returning to a life outside the clinic – hopeful but insecure

, b)

Close and long lasting relationships – offering many‐ faceted support

, c)

Three types of relationships

, and d)

A thin and brittle network

. Each step of the analysis was thor- oughly discussed between the first and at least one of the coauthors.

Ethical considerations

The research was approved by the Norwegian Ethics Committee (REK number 2011/879b) and followed the guidelines from the Helsinki Declaration. Both the mothers and the significant others received oral and written information about the study before informed consent was signed. Studying human beings in vulnera- ble situations demands ethical sensitivity. The inter- viewer was supposed to refer the participants to treatment if necessary, or alert child welfare services if child abuse/neglect had been suspected. Neither was actualized. The respondents are referred to by using pseudonyms.

FINDINGS

Returning to a life outside the clinic – hopeful but insecure

The mothers both worried about and were looking for- ward to an abstinent and stable life after discharge from the clinic. They felt proud that they had been able to quit using substances and start inpatient treatment before their babies were born. Anne described that; ‘being pregnant and giving birth, it gave me a new kind of strength.’ She had been heavily intoxicated over many years, so this was an awakening for her; ‘I am growing together with my child. I feel we are discovering the world together.’ However, Anne and the others still

feared losing custody and cooperated anxiously with child protection services.

The mothers all suffered from adverse childhood ex- periences, and were determined to avoid making the same mistakes as they experienced that their parents had done, but they were uncertain what parenting strat- egies to use instead. Some considered that just being there for the child and always being supportive was im- portant. However, the lack of good parental role models from their own childhood made the women feel inse- cure and doubtful about their own parenting role.

I knowwhat parenting strategies to avoid, but not what to replace

them with. .. When my child does something wrong, it’s difficult

to knowhow to correct himwithout using the same spanking and

shouting that my parents used. (Emma)

Social connectionwith others today were described as challenging for some mothers because of negative and traumatic childhood experiences. Emma described her feelings in this way: ‘I don’t have confidence in people. The people around me have been unpredictable, and I haven’t felt safe.’

The fact that most fathers were continuing their harmful use of substances presented a twofold difficulty; the mothers were left to take care of and raise their children alone. In addition, they worried about their children’s relationships with their fathers. Diana stated that the father would not be allowed to see his child unless he became abstinent.

Themothers described awish to be perceived as a reg- ular family. Having livedmany yearsmarginalized on the edge of society made this important for them. They saw financial independence as a necessary ingredient in becoming a regular family. To be able to support their own family, they wanted to complete an education and obtain a job, but few had concrete plans on how to ac- complish these goals. Some had done well in school ear- lier and believed they were able to finish an education; others had experienced failure andwere afraid to goback to school. All had received financial support from their local municipality to arrange for an apartment to move into once discharged from hospital. They expected that a regular life would include structure and stability and acknowledged that their life so far had been more char- acterized by chaos and instability. Diana expected that ‘the new life sometimes would be boring’, whereas Claire, on the other hand, felt that to stay home alone every night would be uncomplicated. Anne expressed concerns that her childmight experience difficultieswith other children, because of her own adverse life history. She worried that her child would have to face questions fromother children about her previous substance abuse.

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The mothers expressed hopes for the future, but they were at the same time unsecure and afraid. Their signif- icant others also worried that the mothers avoided to make contact with others because of feelings of shame. Fay’smother expressed that this was a barrier for Fay to- wards building social relations with other parents in the child’s kindergarten. She described how Fay excused herself when other parents invited her: ‘They know my SUD‐history. I don’t know what we could talk about.’

Close and long lasting relationships – offering many‐ faceted support

Most mothers designated close relatives as their signifi- cant others. These included grandparents, mothers and older sisters. The mothers, who were cohabitants with a partner, described them as their significant other, whereas one mother picked out a long lasting friend (Table 1). According to the significant others, they pro- vided a wide range of practical help and emotional sup- port in everyday life. They helped with transportation for mothers who did not have a driving licence or a car, assisted as babysitters and caregivers for the chil- dren and offered financial support by helping the mothers pay for accommodation and food. The help of- fered was sometimes extensive; ‘I took over responsibil- ity for her mortgage as I moved back home, when we sold our own apartment’ (Beth’s sister).

The significant others described how they offered ad- vice, coached themothers inhowtocontinue living absti- nently andacted as rolemodels in takingcare of children. For example, Beth’s sister offered to attend evening clas- ses togetherwithBeth tohelpher complete aneducation; Anne’s friend advised her to avoid contact with her

family of origin; and Diana’s parents supplied financial advice and help.According to the significant others, they were available and offered advice about everything.

I asked her:Why did you stop paying the rent?Why did you stop

paying for kindergarten? No, she didn’t know… Well, how did

you spend the money? No, she didn’t know the answer to that,

either… She is paying for kindergarten now…We tried to calcu-

late her finances when we were in a meeting with child welfare

services. They suggested that we should try to get control of

her finances together… She might be able to finish an education

if I accompany her. I do believe that. (Beth’s sister)

The significant others assisted the mothers in various ways in their everyday lives. They were concerned about the single mothers becoming worn out from vigil nights with infants and noticed every sign of discomfort. They worried about the mothers managing their tasks as care- givers and tried to support abstinence by looking out for potential relapse risks. They described how they strug- gled to balance monitoring, supporting and offering guidance, without limiting the mothers’ freedom or conveying distrust.

But I amworried when we go downtown, and it seems as though

she is looking for old friends… The last times I have suggested:

‘We can drive downtown together, and then you can feel free

to walk back home with the kid in the stroller by yourself.’ We

have to show her confidence. I try to show her that I trust her.

We cannot babysit such a grown up girl. I have to give her some

space even though I am afraid. (Emma’s grandfather)

All significant others provided emotional support. The grandparent and mother significant others, how- ever, seemed to be most focused on offering practical support, such as transportation and help when moving into a new apartment. The sisters and close friends tended to focus on helping the mothers getting an edu- cation, establishing a social network and giving advice regarding motherhood and financial management. In addition to both emotional and informational assis- tance, the partners also provided support by partaking in household chores in the everyday life of the family. Overall, from the description given by the significant others, the relationships between themothers and them- selves were close, consistent and reliable. ‘She tells me everything and knows that I will never abandon her’ (Diana’s mother). ‘She means a lot to me, just as much as my husband and my children’ (Grace’s sister).

The mothers, likewise, described their significant others as someone they could trust, someone who had always been there for them and someone they could rely upon 100%. ‘She is going to be there. I know because she has always stood by me, despite everything that I have been through’ (Anne).

Table 1 Demographic information on the mothers and their significant other

Mother Significant other

Pseudonym Age

(years) No. of children

Type of relationship

Age (years)

Anne 25–29 1 Friend 25–29 Beth 20–24 >1 Sister 30–34 Claire 20–24 1 ‐/‐ Diana 35–39 >1 Mother 55–59 Emma 25–29 1 Grandmother 65–69

Grandfather 70–74 Fay 20–24 >1 Mother 50–54 Grace 20–24 1 Sister 30–34 Helen 25–29 >1 Partner 25–29 Ingrid 20–24 1 Partner 25–29

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Three types of relationships

The relationships between the mothers and the signifi- cant others were categorized in three groups: (i) rela- tionships with close family members from previous generations; (ii) relationships with sisters or close friends; and (iii) relationships with partners.

The first type comprised the mothers’ own mother or grandparent. These relations were to a large degree complementary, i.e. the mothers received, and the fam- ily members provided support and help. Diana’s par- ents, for instance, assisted her when Diana moved into her own apartment. They helped with transportation and provided furniture and other equipment necessary for the household. Diana and her mother talked on the phone almost every day, with the mother trying to support and monitor Diana’s rehabilitation process through the phone calls. ‘If more than 2–3days passes, or if she doesn’t answer my calls, then we start to worry’ (Diana’s mother).

The mothers typically described these significant others as someone they spent much time with and who were closely connected to the everyday lives of their chil- dren.Themothers stated that the significant others were the ones who knew them the best, although these rela- tionships also included challenges. Some mothers expe- rienced difficulties being emotionally open towards their significant others. They feared that the family members were ashamed over their SUDs and expected to be judged by others for having a substance‐dependent child or grandchild. ‘She seems to be concerned about ap- pearances. That everything must look proper from the outside. So it hasn’t always been easy to come and talk with her’ (Emma).

The second type of relationship comprised the mothers’ older sisters or close friends. Also in this cate- gory, the significant others offered extensive help and support to the mothers.

I told her, even when I came looking for her – the godforsaken

places I found her – I still care about her. Even though she was

using, I will continue to love her. Though it hurt to see that the

abuse affected her child, she is still my sister. I have to be there

for her. (Beth’s sister)

The sisters and friends had been actively engaged in the mother’s treatment and rehabilitation process. They were closely connected and had daily contact. The sig- nificant others felt they had been available for the mother and endured even through the most difficult years when she was deeply embedded in substance abuse. They had tried to take care of their friend/sister with personal costs, like arguments with own partners. In these periods, the relationships had been more one‐

sided. Beth’s sister stated a lack of reciprocity; ‘It is probably mostly I who have supported her.’

However, these relationships were also somewhat more reciprocal, with the mothers and the significant others to a larger degree mutually supporting each other. For example, the significant others could ask the mother for advice concerning their own children, and both parties helped each other with household chores. ‘Just the other day she was here and helped me make my child accept the bottle’ (Anne’s friend).

The third type of relationship comprised themothers’ partners. Two partners were both cohabitants and fa- thers of the children. According to the mothers, they had stayed together in difficult times and thereby gained confidence in eachother.These relationships seemed re- ciprocal,where themothers and theirpartners, to a larger degree than the two previous types of relationships, were offering mutual help and support to each other. Ingrid’s partner exemplified how they shared the childrearing re- sponsibilities: ‘What works best for us is that we get up early with the child every secondmorning.’

In these relationships, both parts had substance abuse problems and tried to overcome their challenges together. These fathers had taken on equal responsibil- ity as their female partners and chosen to join them into substance treatment when the baby was announced, although they dreaded it. They were determined to be- come well‐functioning parents together with the mothers. ‘I do believe that we went through the detox and rehab together…We are going to continue like this, supporting each other and listening to each other’ (Helen’s partner).

There were, nevertheless, challenges in these relation- ships, as well. They were both facing the challenge of liv- ing with substance dependence, traumatic experiences and being unemployed with limited education.

The three different types of relationships seemed to imply different kinds of reciprocity and somewhat differ- ent challenges, with the partner relationships being the most reciprocal, the relationships with the mothers or grandparents the least reciprocal and the relationships with sisters and close friends somewhere in between.

A thin and brittle network

Most significant others had been next of kin to other substance abusers besides the mothers. They had expe- rienced similar traumatic events as the mothers (e.g. physical violence, emotional abuse and unpredictability) when living with substance abusers, and some had themselves suffered from mental illness and substance dependence. Most of the significant others had few

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individuals in their own social networks. ‘It’s hard with- out a social network, but we have each other and can build a new one together’ (Ingrid’s partner).

And some had no persons to turn to themselves for support.

I don’t really have a supporting person myself. Our friends from

before, they are not our friends any longer. It was destroyed by

my husband’s alcohol problems… I am what you call a ‘next of

kin’. Now I have no less than 4 individuals inmy familywho have

been in treatment here at the drug‐clinic. I can’t take any

more…. (Diana’s mother)

The significant others had heavy burdens and worries in their everyday lives. They had several loved ones who they worried about, because of substance abuse, psychiatric problems, insufficient social networks or other disadvantages such as lack of education or limited job experience.

I have had the feeling of sitting on top of a volcanomy whole life.

It beganwithmy husband abusing alcohol.He died young. Then

my son started using illegal drugs and killed himself in a car ac-

cident. We also believe that my daughter committed suicide…

So over the years, life has made it difficult for me to smile and

be happy. I just can’t accomplish it. (Emma’s grandmother)

Some described being troubled by guilt because of their previous SUD or the feeling of having neglected the mothers for other reasons. ‘It wasn’t easy to see her doing drugs once I had become abstinent myself. I felt guilty remembering all the things she hadwitnessed over the years’ (Grace’s sister).

Some significant others had financial worries of their own. They had not been able to finish a proper educa- tion or had limited work possibilities for other reasons. For Fay’s mother, this meant living away fromher home town. She had not managed to build a new social net- work and felt like an outsider.

I can’tmake itfinancially. I have to get a steady job. I don’t have a

regular income…This house is the only alternative that I can af-

ford, so it’s impossible for me tomove back home, even though I

would like to.

The resources the significant others had to offer in the relationships with the mothers appeared limited, psy- chologically, practically and economically. In spite of this, they described being available and offering support and help to the mothers the best way they saw possible.

DISCUSSION

The support available to substance‐dependent mothers from families with parental substance abuse seemed to

be emotionally close, consistent and reliable, although their networks can also be described as thin and brittle. These close and long‐lasting supporting relationships are important considering the many challenges these women face when trying to establish a life in sobriety for themselves and their children after hospitalization. The mothers’ significant others described the social support they offered as many‐faceted comprising emotional, informational and practical assistance. However, the relationships were characterized by lack of reciprocity, especially when the significant other was a close relative (e.g. mother or grandparent).

Research suggests that networks of care usually rely on reciprocity (Hansen, 2005; Gouldner, 1960). Reci- procity describes the practice of exchanging things or services between individuals for mutual benefit. Jaeckela et al. (2012) report that women who receive more sup- port than they provide feel less self‐efficacy. Therefore, the insufficiencies in reciprocity found between some mothers and their significant others might threaten the mothers’ trust in their own coping skills or the relation- ship itself. However, the sustainable support that was documented might be understood by the close familial relations between the mothers and most of the signifi- cant others. Farmer & Moyers (2008) indicated that kinship might contribute to a strong obligation to offer support, and Hansen (2005) suggested that one seems to a larger degree to be granted care, in spite of lack of reciprocity, from individuals in family networks. This concurs with findings from the highly burdened families participating in the present study. Shrout et al. (2006) suggested that receiving social support might threaten one’s self‐esteem and contribute to a feeling of ineffi- cacy, or being indebted, but this did not surface in the mothers’ descriptions, possibly because of the close fa- milial relations.

Although the mothers’ close relationships with their significant others had proven sustainable, their support networks still seemed vulnerable. Many significant others struggled with heavy burdens themselves, which might limit their resources and abilities to offer support to the mothers. Close familial relations may indicate a strong obligation to offer support, but also that the significant others have faced many of the same challenges as the mothers, e.g. prior traumatic experi- ences,marginalization and few abstinent friends and rel- atives. Boe & Schiefloe (2007) found that the networks of marginalized people are often characterized by low frequency, lack of reciprocity, imbalance in power and resources and little exchange of services. This partly concurs with findings in our studywhere themothers re- ceived more practical and informational support than

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they provided. However, because of familial bonding, the significant others might, in line with Farmer & Moyers (2008), have felt good about helping themother and child doing well and having them present in their everyday lives. In addition, the marginalization and lack of support in their own lives may have made their rela- tionships with the mothers important and partly explain why these relationships were perceived as close, consis- tent and reliable.

Some significant others indicated that shame repre- sented a barrier for the mothers against expanding their social networks. The mothers may have internalized a stigma experienced growing up in amarginalized family. Guilt and shame may also be a consequence of discrep- ancies between the mothers’ ideal selves and their per- ceived actual selves (Chou et al., 2013). Substance abuse has been associated with being a dysfunctional parent (Dube et al., 2003), which seems to be particu- larly stigmatizing for women (Green et al., 2002). Liss et al. (2013) found that fear of negative evaluation by others may enhance mothers’ feelings of shame. Feel- ings of shame, guilt and stigmatization may therefore represent barriers against making contact with others and building new social support networks. Hence, the relationships already established with the significant others may be crucial for substance‐dependent mothers in remission.

Strengths and limitations of the study

The participants were strategically elected (see the re- cruitment procedure), so this study is explorative and the findings must be interpreted as examples of under- standings and descriptions. The descriptions may, nev- ertheless, also have relevance to other vulnerable and stigmatized families.

Themothers in this study representahighlyvulnerable group, who usually is difficult for researchers to access. This studywas, however,made possible through thefirst author’s employment in a research unit linked to the in- patient clinicwhere themotherswere treated.This repre- sented a unique research opportunity where both the women and their significant others could be reassured that the interviews would be conducted by a researcher whohadknowledgeandunderstandingof their situation.

Implications

The relationships between the mothers and their signif- icant others in our study seemed to help the mothers re- main sober and supported them towards a less marginalized lifestyle. In line with Barnard (2007), it may be worthwhile for professionals to support the

mothers’ significant others themselves, as well as their relationships with the mothers, as this strengthens what is already established. The mothers could be encour- aged to invite their supporting friends and family members to network meetings in the clinic during the inpatient stay. These meetings should include service providers from the local community and focus on how each member of the network might help, what support the significant others would need for themselves and how the support from the network and professionals to- gether could make a difference for the mothers and their children.

The mothers may have had insufficient role models onhow to enter into and behave in different social arenas for families with children, e.g. visiting playgrounds, at- tending parents’ meetings at school or kindergarten or joining voluntary organizations. To overcome shame and fear of being rejected, and get acquainted with other parents, they might benefit from having someone ac- companying them. This could be a task for voluntary or- ganizations (i.e. Red Cross), as well as a responsibility for social services. The family group conference model (Levine, 2000), which is a method for trying to resolve family issues concerning child protection, has proven to increase social support and decrease marginalization and might also be a relevant intervention recognizing and taking advantage of the importance of the significant others for these families (Malmberg‐Heimonen, 2011; De Jong & Schout, 2013).

The mothers’ challenges in participating in social networksmay partly be a result of difficulties connecting with others who have not themselves experienced mar- ginalization. Hence, health workers and social services, in cooperation with therapists at treatment institutions, should invest resources into facilitating meeting places where marginalized families may come together for mu- tual support and social activities.

In addition to helping the mothers increase their so- cial networks, an important aim is to help these women into education and employment. Attending school or a workplace will facilitate social networking as well as con- tributing to the integration of the mothers into society, whereas the ability to support the children financially also will benefit the mothers’ self‐esteem.

Summing up, these mothers are in need of a social support network to copewith the challenges they face af- ter being discharged from treatment. Their significant others offer support and continuity in their lives and are essential for both themothers and their children. At- tending to, involving and supporting these significant others might therefore be an important issue for profes- sionals during these women’s rehabilitation processes.

Substance‐dependent mothers and social support EM Wiig, A Halsa and BSM Haugland

Child and Family Social Work 2017, 22, pp 1246–1254 © 2016 John Wiley & Sons Ltd1253

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Southside Community Services: Mrs. Bargas Case History

© 2018 Laureate Education, Inc. 1

Southside Community Services: Mrs. Bargas Case History Program Transcript

[MUSIC PLAYING]

LINDA FORTE: Hi, Mrs. Bargas, I’m Linda Forte, the social worker assigned to your case. It’s nice to meet you. So what brings you in, today?

MRS. BARGAS: Well– I’ve been out of work about 3 months. And 2 weeks ago, my husband had a stroke. He’s still in the hospital. So it’s been– a lot, all at once. And the money– I don’t know how going to pay the bills, or the rent. We cannot lose our home. We have five children.

LINDA FORTE: Has this been hard on them? It sounds like you’ve been going through a lot since losing your job and your husband being in the hospital. I can understand how you can feel stressed and concerned.

MRS. BARGAS: My daughter Amy– she’s my oldest– she’s been having the hardest time. She’s cutting classes at school and she’s failing two of her courses.

LINDA FORTE: So how did you hear about our agency and how can I help?

MRS. BARGAS: Well, my pastor said that you could help me find a job and maybe help with the rent money. And maybe Amy could– speak to somebody.

LINDA FORTE: OK. Has your daughter, Amy, has she ever expressed any interest in hoping to speak to somebody about her problems?

MRS. BARGAS: Maybe. I don’t know. I haven’t really mentioned it to her. But my pastor thinks it’s a good idea.

LINDA FORTE: Has Amy ever spoken to the social worker at her school, before?

MRS. BARGAS: No, I don’t think so.

LINDA FORTE: OK. That’s fine. We can definitely talk about getting Amy some help. But first, why don’t we talk a little bit about work experience. What kind of job are you hoping to find?

MRS. BARGAS: Well, before I married my husband, I worked as a nanny.

LINDA FORTE: OK. So why don’t we talk a little bit more about that, about who you worked for, and what kind of job duties you had.

MRS. BARGAS: Well, I was much younger when I was a nanny. Let me see, it was– more than 12 years ago. But I don’t think I could do that work, now. Maybe

Southside Community Services: Mrs. Bargas Case History

© 2018 Laureate Education, Inc. 2

I could work in an office. You know, I’m really good at working with people. Can you find me a job in an office?

LINDA FORTE: I don’t know. I work with a career counselor, here. She might be able to help you.

MRS. BARGAS: I don’t know how I’m going to pay the rent.

LINDA FORTE: I know right now is really tough for you.

MRS. BARGAS: I just don’t know what to do. Nothing has turned out the way I hoped it would. My whole life. I’m really worried about my daughter, Amy. She’s afraid to go to school. She loses her temper all the time. She yells at me and then locks herself in a room and she won’t speak. I am so confused. I don’t know what to do with her. I just– I don’t know.

LINDA FORTE: It’s OK to be upset. Mrs. Bargas? Are you OK?

MRS. BARGAS: I’m sorry, what?

LINDA FORTE: Are you all right?

[MUSIC PLAYING]

LINDA FORTE: Good news. I spoke with the career counselor and she has an available opening for you, tomorrow. She thinks she can help you find a job.

MRS. BARGAS: That’s great! Thank you so much. I was wondering, actually, there’s something else that you could help me with. I told you that my husband had a stroke. He’s going to need speech therapy. But it’s– we can’t afford it. And we don’t have any insurance. Is there any chance that you could call his doctor and see if my husband can get this therapy? He really needs it.

LINDA FORTE: I may be able to help. But I’m going to need to understand your husband’s situation a little bit better. Is there any way your husband would be willing to sign a release form, so I could talk to the doctor?

MRS. BARGAS: You can’t just call his doctor? I give you permission.

LINDA FORTE: I’m afraid not. According to HIPAA regulations, the doctor is not allowed to discuss your husband’s condition with me without his consent. Your husband could sign a release of information form, which would then make it possible for me to talk to his doctor. I recommend you go home and talk to your husband about whether he’d want to give his consent.

MRS. BARGAS: OK. I will. Thank you so much. You’ve been so helpful.

Southside Community Services: Mrs. Bargas Case History

© 2018 Laureate Education, Inc. 3

LINDA FORTE: Absolutely. And I look forward to seeing Amy next week.

MRS. BARGAS: Bye.

LINDA FORTE: Bye.

[MUSIC PLAYING]