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. Author manuscript; available in PMC: 2025 Sep 23.
Published in final edited form as: J Fam Ther. 2017 Jul 20;40(4):557–583. doi: 10.1111/1467-6427.12187

Effects of Ecologically-Based Family Therapy with Substance Using, Prostituting Mothers

Aaron Murnan 1, Qiong Wu 1, Natasha Slesnick 1
PMCID: PMC12453060  NIHMSID: NIHMS2109432  PMID: 40989915

Abstract

Studies report that high rates of prostituting women seek substance use treatment, and that most of these women have children in their care. However, compared to non-prostituting women, they show poorer treatment outcomes. Effective intervention for this population is needed, and the current study is the first to test family therapy with mothers seeking substance use treatment, who also reported prostitution. Sixty-eight treatment-seeking women with children in their care were randomly assigned to receive 12 sessions of Ecologically-Based Family Therapy or 12 sessions of individual treatment. Results showed that women who received family therapy reported greater reductions in substance use and depressive symptoms as well as greater improvements in their mother-child interactions. Findings underscore the importance of offering family therapy as a treatment option when prostituting women with children seek substance use treatment.

Keywords: prostituting women, substance use, family therapy

An estimated two million women work as prostitutes in the United States (Murphy, 2010; Priscilla, 1987), but only two studies have examined treatment outcomes with these women (Burnette et al., 2009; Yahne et al., 2002). This is of concern because prostituting women have higher vulnerabilities than other women, including higher rates of substance use and depressive symptoms (Dalla, 2002; El-Bassel et al., 1997; Nuttbrock et al., 2004), physical health problems, and premature mortality (Bagley & Young, 1987; Ward et al., 1999). Furthermore, a large number of prostituting women report having children in their care who are unlikely to receive intervention themselves. These women report high rates of stress associated with parenting and low quality parent-child relationship, which can exacerbate substance use and depressive symptoms (Sloss & Harper, 2004). The current study addresses several gaps in the literature by examining the impact of Ecologically-Based Family Therapy (EBFT) on substance use, depressive symptoms and parent-child interaction for substance using mothers who also report engaging in prostitution.

Among women seeking substance use treatment, studies rarely report the number of women who engage in prostitution, which is defined as the exchange of sex for drugs, money, or needed resources (Murphy, 2010). Researchers note that women infrequently self-report sex work possibly because they do not recognize themselves as prostituting, or they fear the removal of their children from their care (Burnette et al., 2009). However, Burnette et al. (2009) found that approximately 40% of women seeking substance use treatment reported engagement in prostitution. Further, these women reported more severe substance use, and were four times more likely to meet criteria for a major depressive episode, compared to non-prostituting women (MacMillan, 2001). Substance use treatment facilities offer an opportunity to intervene, as a high percentage of prostituting women (66%) report prior substance use treatment (Arnold et al., 2000; Nuttbrock et al., 2004).

Substance Use Treatment

Despite high rates of women who engage in prostitution receiving substance use treatment, research on the efficacy of intervention with this population is limited. Burnette et al. (2009) reported that substance use treatment predicted reductions in substance use and prostitution among a sample of prostituting women. However, these women reported higher rates of substance use and mental health symptoms compared to their non-prostituting counterparts following treatment (Burnette et al., 2009). While findings from Burnette et al. (2009) suggest that prostituting women can benefit from substance use treatment, no information regarding the differential effectiveness of specific treatment modalities (e.g., individual, family, group) was provided.

Only one study to date has reported the effectiveness of a specific substance use treatment with prostituting women. Yahne et al. (2002) conducted a pilot study to test the efficacy and feasibility of Motivational Interviewing (MI) in reducing substance use among a sample of 27 prostituting women. Each client received one MI session at baseline and then completed a follow-up assessment four months post-baseline. Similar to Burnette et al. (2009), Yahne and colleagues (2002) found that prostituting women reported less substance use following treatment. While these findings support the feasibility of engaging these women in treatment, more research is needed to identify treatments that effectively address the range of their needs using randomized, controlled longitudinal designs.

Parenting

Interpersonal stress associated with parenting has been linked to greater risk of relapse and poorer substance use outcomes among women (Denton et al., 2014; Hodgkinson et al., 2014). The majority of women (91%) engaging in prostitution have children in their care (Sloss, 2002). These women are typically single mothers who report high rates of removal of their children from their custody and poor mother-child relationship quality (Dalla, 2004; Dodsworth, 2014). As a result, mothers engaged in prostitution report higher rates of stress associated with parenting compared to non-prostituting women (Sloss & Harper, 2004). Therefore, interventions that address parenting and family relationships, while also improving substance use outcomes, could be especially effective.

Family Therapy

Family therapy intervenes in mothers’ substance use while also positively impacting family relationships that contribute to substance use behaviours. Studies show family therapy to be an effective treatment modality for substance use disorders (Rowe, 2012). In particular, some studies indicate that family therapy is more effective in reducing substance use than individual-based treatments because it addresses family processes (Horigian et al., 2015).

Family processes, such as autonomy and relatedness, are a focus of most family therapies because family therapists consider problems as occurring between individuals more so than within individuals. Autonomy refers to an individual’s ability to think independently and be self-reliant, whereas relatedness refers to one’s ability to maintain emotional connectedness and relationships with family members (Allen et al., 1994; Sessa & Steinberg, 1991). Autonomy and relatedness behaviours have been linked with lower levels of mental health symptoms and substance use among parents, as well as reduced rates of experimentation with substance use and criminal behavior among children (Allen et al., 1996; Hall et al., 1985; Kuperminc et al., 1996). Therefore, family therapy should be associated with improved autonomy and relatedness behaviours in both mothers and their children.

Current Study

Ecologically-Based Family Therapy (EBFT) is a family therapy that has been shown effective for improving family interaction patterns and reducing substance use among adolescents (Guo & Slesnick, 2013; Slesnick & Prestopnik, 2005). Originally developed for substance-using runaway adolescents and their families, EBFT has been rated as a promising evidence-based practice by the U.S. National Institute of Justice and as a supported evidence-based practice by the California Evidence-Based Clearinghouse. The current study utilizes a larger dataset that resulted from a randomized controlled design testing EBFT with substance-using mothers and their children. Evidence for the effectiveness of EBFT for adult substance users was shown in that mothers receiving EBFT exhibited better substance use outcomes compared to those assigned to the comparison condition (Slesnick & Zhang, 2016), and mother-child dyads participating in EBFT displayed greater improvements in mother-child interactions (Zhang & Slesnick, 2016). Given the gap in understanding of the effects of family therapy on prostituting mothers, the impact of EBFT on substance use, depressive symptoms and mother-child interaction among prostituting women was of particular interest.

Therefore, in the current study, prostituting women who received family therapy in the larger clinical trial were expected to exhibit greater reductions in frequency of substance use, greater improvements in depressive symptoms and improved mother-child interactions compared to prostituting women who received a psycho-educational comparison intervention. Further, outcomes for family therapy offered in the home and the office were compared given that little information on the differential effectiveness of home- versus office-based family therapy is available. This information can be useful to practitioners as it has cost implications. Specifically, it was hypothesized that prostituting women receiving EBFT would show an increase in autonomy and relatedness promoting behaviours and a decrease in autonomy and relatedness inhibiting behaviours.

Methods

Participants

This study utilized data from a larger randomized controlled trial testing EBFT with women seeking treatment for a substance use disorder (N=183) (Slesnick & Zhang, 2016). Women were recruited from a large substance use treatment facility in Columbus, Ohio. To be eligible for the study, mothers had to meet criteria for a substance use disorder (SUD) as defined by the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000), be seeking outpatient treatment for their SUD, and have a biological child between the age of 8–16 years in their custody. The larger clinical trial was funded by the U.S. National Institute on Drug Abuse (NIDA). The Ohio State University Institutional Review Board approved all study procedures.

A sub-sample of prostituting women (n=68) was identified from the larger sample using self-report data and therapist report. Mothers who reported prostitution ranged in age from 22-54 years (M = 33.8 years) and reported having between 1-8 children (M = 3.29). Majority of these women were white (60.3%). Most women reported unemployment at baseline (63.2%) and many women reported less than a high school education (45.6%). All women within the sub-sample reported the use of multiple illicit drugs or alcohol within the 90 days prior to the baseline assessment. Specifically, 53 women reported alcohol use (77.9%), 40 reported opioid use (58.8%), 38 reported marijuana use (55.8%), and 32 reported cocaine use (47.1%).

Procedures

Women were engaged and screened in a private office by a study research assistant (RA). Following the initial screening, the informed consent was signed, parental permission for children’s participation was obtained, and baseline assessment was completed. Participating mother-child dyads completed baseline assessments including several individual and family measures, as well as a mother-child interaction task. Dyads were then randomly assigned to one of three intervention conditions: 1) home-based family therapy, 2) office-based family therapy, or 3) Women’s Health Education (WHE, mothers only). Follow-up assessments were administered at 3, 6, 12, and 18-months post-baseline. Participating mothers received a $75 gift card to Walmart and their children received a $40 gift card to Walmart upon completion of the baseline and each follow-up assessment interview.

Measures

A demographic questionnaire that assessed core variables necessary to characterize and compare samples was administered. Motivation for change was evaluated using the Stages of Change Readiness and Eagerness Scale (SOCRATES; Miller & Tonigan, 1996). The SOCRATES is a 38-item measure that assesses three subscales of motivation for change including: readiness, ambivalence, and taking steps (Isenhart, 1994; Miller & Tonigan, 1996). SOCRATES has demonstrated high test-retest reliability and internal consistency across its three sub-scales. Research shows these variables influence an individual’s drug use, depressive symptoms, and interactions with their children; therefore these variables were controlled when analyzing treatment effects (Bosquet Enlow et al., 2016; Chaplin & Aldao, 2013; DiClemente et al., 1999).

Mother’s substance use was measured using the Form-90 (Miller, 1996). The Form-90 is a structured interview that measures daily drug and alcohol use for the past 90 days using a timeline follow-back approach (Sobell & Sobell, 1992). Thus, a comprehensive report of women’s alcohol and drug use was generated that included the types of drugs used as well as the daily severity of use for each substance. Specifically, reported days of substance use were categorized as severe, moderate, or light. The Form-90 defines severe use as at least five standard drink units or three doses of an illicit substance and moderate use as two to four standard drink units or two doses of an illicit substance. Additionally, light use is defined as a single standard drink unit or dose of an illicit substance. A composite score was created by summing the moderate and severe use subscales for alcohol, marijuana, cocaine, and opiates to indicate problematic use of substances. The Form-90 has demonstrated high test-retest reliability for indices of drug use in the major drug classes for adults (Tonigan et al., 1997; Westerberg et al., 1998) and runaway adolescents (Slesnick & Tonigan, 2004) with kappas for drug classes ranging from .74 to .95.

Mothers’ depressive symptoms were measured using the Beck Depression Inventory II (BDI-II; Beck et al., 1996). The BDI-II is the most frequently used self-report instrument for the assessment of mood, cognitive and somatic aspects of depression, and has been used with adults and youth (Miner, 1991; Maxwell, 1992). It has shown good psychometric properties. Specifically, estimates of internal consistency and test-retest reliability are high, and the measure appears sensitive to depression severity across community and clinical populations (Al-Musawi, 2001; Huprich et al., 2012; Wiebe & Penley, 2005).

Mother-child dyads participated in a 10-minute interaction task at baseline, 6-, and 18-months post-baseline. First, a topic associated with disagreement between mother and child was identified using the Parent-Child Areas of Change Questionnaire (PC-ACQ; Jacob & Seilhamer, 1985). Then, mother-child dyads were asked to discuss the topic of disagreement with the goal to work towards a resolution. The interaction task was video-recorded and later coded using the Autonomy and Relatedness (A&R) Coding System (Allen et al., 2000). The A&R coding system yields 10 behavioral scores that assess the promotion and undermining of autonomy and relatedness within mother-child dyads. These 10 scores were grouped into three dimensions: 1) Behaviours promoting autonomy (justifying one’s position and making statements with confidence) and relatedness (querying, showing genuine interest in other’s viewpoint, validating, and displaying empathy), 2) Behaviours undermining autonomy (blurring boundaries between the other person and their character, pressuring others to agree, and recanting positions of other family members), and 3) Behaviours undermining relatedness (interrupting or ignoring the other person and using hostile or devaluing statements). Mother’s and child’s interactive behaviours were coded separately which generated ten relationship scores. In order to assess inter-rater reliability, 20% of all interaction tasks were double coded. Intra-class correlations (ICCs) were good-to-excellent at baseline (ICC= .84), 6-months post baseline (ICC= .86), and 18-months post baseline (ICC= .89).

Intervention Groups

Ecologically-Based Family Therapy (EBFT; Slesnick & Prestopnik, 2005) is a 12-session family therapy that targets specific dysfunctional interactions that contribute to the development of problem behaviours such as substance use. In this study, the identical intervention was offered in the home or in the office. Appointments were flexibly scheduled to meet clients’ needs with evening and weekend sessions offered. Additionally, therapists were available 24 hours a day, 7 days a week for crises. EBFT therapists were licensed therapists or clinical graduate students who received training that included manual review, role-playing exercises and discussions on the underlying theoretical framework and practical application of EBFT techniques. Two graduate student coders completed treatment fidelity coding on 20% of tapes to ensure that implementation of EBFT adhered to the intervention protocol.

EBFT is based on the Social Ecological Systems Framework (Bronfenbrenner, 1979) and assumes that all family members contribute to the development, maintenance, and resolution of problems. Therefore, the intervention does not focus solely on the individual, but on the social interactions among all members that impact successful interactions within the family. Therapists facilitate improved communication and problem-solving skills among family members through the use of reframes, interpretations, interrupting problem behaviours, and assisting families in connecting with other needed services. Specifically, therapists assist parents and children in becoming more confident and competent in their ability to communicate needs and address their responsibilities. Additionally, this approach is designed to assist families in obtaining connection to other services such as medical care, job training, governmental assistance, or 12-step programs (Murnan, Zhang, & Slesnick, in press).

Women’s Health Education (WHE; Miller et al., 1998) is a 12-session psycho-educational intervention that focuses on topics such as female anatomy, human sexual behavior, pregnancy and childbirth, and sexually transmitted infections (STIs). WHE also includes sessions focused on risk behaviours associated with sexually transmitted infections, particularly HIV. Fifty minute sessions were offered by master’s level therapists. WHE therapists completed a two-day training that included a review of the manualized intervention, session observations, and role-plays. Additionally, weekly supervision was provided to WHE therapists and sessions were coded for fidelity. WHE has been used as an attention control and has been shown to improve maternal outcomes, including substance use, in high-risk populations of women (Hein et al., 2009).

In summary, while EBFT and WHE were matched in number of sessions (12 sessions, 50 minutes each) and duration (completed in a 6 month timeframe), EBFT incorporated a family systems approach that engaged women’s children into treatment, whereas WHE did not engage family members in the treatment. Significant differences in treatment attendance were observed in which those who received EBFT attended more sessions (M = 7.77, SD = 4.43) than those assigned to WHE (M = 2.89, SD = 4.47); t(43) = 3.63, p =.001. Additionally, higher treatment attendance was observed in the office-based EBFT group (M = 5.83, SD = 4.69) compared to the WHE group (M = 2.89, SD = 4.47); t(40) = 2.06, p = .046. No significant differences were detected for treatment attendance between home-based and office-based EBFT; t(47) = 1.49, p = .143.

Statistical Analysis plan

Preliminary analyses were run to explore differences between the intervention and WHE groups at baseline. Specifically, ANOVA and chi-square tests were conducted to compare treatment groups on demographic characteristics of the participants (i.e., age, race, employment status), mother's substance use, depressive symptoms, and autonomous and relatedness behaviours at pre-treatment. The SPSS program (version 20) was utilized for the preliminary analysis.

Analyses were conducted using the Mplus program (Version 7; Muthén & Muthén, 2012). Percentages of missing data ranged from 17.65%-35.29% on the substance use variables, from 8.82% - 10.29% on the depressive symptoms variables, and from 35.29% to 45.59% on autonomy-relatedness behaviours variables. Little’s MCAR test (Little, 1988) revealed that data were missing completely at random, χ2 (784) = 768.76, p = .65. Full information maximum likelihood (FIML) algorithm was thus employed for missing data estimation as recommended for data missing completely at random (Enders & Bandalos, 2001). The data were then analysed using intent-to-treat analyses, where participants were considered to be compliant to the therapy group that they were assigned (Armijo-Olivo et al., 2009; Little, & Yau, 1996). This strategy is recommended for randomized clinical trials (Armijo-Olivo et al., 2009). Moreover, a parametric bootstrapping approach was used to improve the estimation of standard errors, as recommended for small sample sizes (Efron & Gong, 1983). Bootstrapping is a resampling technique that can improve estimation of the population, as it is likely to be biased in small sample sizes. We estimated the coefficients based on 5000 bootstrap samples.

Treatment effects of mother's frequency of moderate and severe substance use and depressive symptoms were investigated using two multilevel models, because the data are structured with repeated measures nested in individuals. First, an unconditional model was tested and intraclass correlation coefficients (ICC) were estimated. Second, a random coefficient model was run to test the linear change of data after the baseline assessment. The within-subject level (level-1) tested time effects, exploring the change in outcome variables from the 3-month to the 18-month follow-ups. Here, follow-ups of 3-, 6-, 12-, and 18-months were coded as 1, 2, 4, 6, respectively, in order to account for the different time intervals between follow-ups. The random effects in level-2 were set as free to vary. The random coefficient model was then compared with the unconditional model on the model fit. Finally, a conditional model was estimated. Two dummy variables representing two treatment conditions (EBFT home and EBFT office) were entered as level-2 predictors for the level-1 intercept and the slope of time effects, with WHE as the reference group. The baseline levels of study variables were also entered at the between-subject level (level-2) predicting both the intercept and slope of time effects, since the baseline was not supposed to be affected by the treatment. Mother’s education and race were also entered as between-subject (level-2) control variables in the analysis. Mother’s motivation for change was used as a between-subject control variable in the model estimating mother’s substance use. The following formulas represent the full mixed effects model for the HLM analyses:

Outcometi=π0i+π1i∗timeti+eti Level 1:
π0i=β00+β01∗baselinei+β02∗EBFThomei+β03∗EBFTofficei+β04∗controli+γ0iπ1i=β10+β11∗baselinei+β12∗EBFThomei+β13∗EBFTofficei+β04∗controli+γ1i Level 2:

Treatment effects on dyad autonomy-relatedness behaviours were investigated using autoregressive cross-lagged models. This model was adopted because it could reveal both the change in family interaction over time and the transactional influence between mother’s and child’s behaviours. An autoregressive model can provide the stability of individual differences from one time point to the next. The cross-lagged loadings provide information about the mutual influence between mother’s and child’s behaviours, which were observed in the same interaction. Maternal behaviours at an earlier time point could influence child behavior at a later time point, and vice versa. The three types of mother’s and child’s autonomy and relatedness behaviours were estimated in three separate models, with all the auto-regressive paths, and the cross-lagged paths between mother and child estimated. Treatment effects were estimated at the 6-month and 18-month follow-ups. Child sex, age and maternal education were included as covariates in these models. Errors between treatment conditions and baseline variables were correlated to avoid estimation bias, in case that participants differed across groups at baseline assessment. The root mean squared error of approximation (RMSEA) and comparative fit index (CFI) were used to evaluate the model fit, with a RMSEA of .05 and below and CFI of .95 and above indicating good fit. (Hu & Bentler, 1995; Little, 2013).

Results

Mothers did not differ in age (F(2,67) = 0.42, p = 0.66), sex (χ2(4) = 0.82, p = 0.94), relationship status (χ2(12) = 14.47, p = 0.27), years of education (F(2,67) = 0.90, p = 0.41) or income (χ2(12) = 6.28, p = 0.90). In addition, one-way ANOVA tests were conducted on the baseline variables to test the group differences. Mother’s undermining autonomy behaviours yielded a significant difference among groups (F(2,67) = 4.75, p = 0.01); post hoc tests revealed that the WHE group had higher baseline maternal undermining autonomy behaviours than the EBFT-home group, mean difference = 1.47, s.e. = 0.49, p < 0.01; the EBFT-office group also had higher baseline maternal undermining autonomy behaviours than the EBFT-home group at a marginally significant level, mean difference = 0.90, s.e. = 0.46, p = 0.05. The baseline group difference was not found for frequency of moderate and severe substance use (F(2,67) = 0.17, p = 0.85), or depressive symptoms (F(2,67)=2.49, p = 0.09) at baseline. Table 1 presents means and standard deviations of study variables. Figure 1, 2, and 3 present the main outcomes over time, graphically. Error bars indicated 90% confidence intervals for the sample means, calculated based on procedures recommended by Gardner and Altman (1986).

Table 1.

Descriptive statistics for study variables.

Variable EBFT home EBFT office WHE
N Mean SD Lower
CI0.95 		Upper
CI0.95 		N Mean SD Lower
CI0.95 		Upper
CI0.95 		N Mean SD Lower
CI0.95 		Upper
CI0.95
Substance use
     Baseline 25 0.91 0.65 0.64 1.17 24 0.82 0.57 0.58 1.05 19 0.83 0.53 0.58 1.09
     3-month 22 0.67 0.68 0.37 0.98 20 0.45 0.48 0.22 0.68 14 0.64 0.44 0.39 0.89
     6-month 19 0.57 0.55 0.30 0.83 20 0.46 0.44 0.26 0.67 13 0.67 0.37 0.45 0.89
     12-month 20 0.50 0.63 0.20 0.79 18 0.41 0.46 0.18 0.64 13 0.54 0.39 0.31 0.78
     18-month 19 0.66 0.59 0.38 0.95 15 0.80 0.82 0.34 1.25 10 0.66 0.67 0.18 1.13
Depressive symptoms
     Baseline 25 28.70 13.58 23.10 34.31 24 22.38 14.53 16.24 28.51 19 20.47 10.09 15.61 25.33
     3-month 23 26.18 12.02 20.98 31.38 22 19.13 14.79 12.57 25.68 16 24.75 16.34 16.04 33.46
     6-month 22 25.55 16.72 18.13 32.96 24 18.96 12.62 13.63 24.29 16 21.50 14.92 13.55 29.45
     12-month 21 18.38 16.62 10.81 25.95 21 17.71 15.48 10.67 24.76 15 19.27 11.13 13.10 25.43
     18-month 23 20.43 13.66 14.53 26.34 22 18.59 15.47 11.73 25.45 16 15.50 11.71 9.26 21.74
Mother autonomy-relatedness
     Baseline 25 6.14 2.71 5.02 7.26 24 6.75 2.13 5.85 7.65 19 7.16 2.32 6.04 8.27
     6-month 17 6.82 2.89 0.92 2.24 17 6.85 2.02 1.91 3.04 10 7.80 1.80 2.13 3.97
     18-month 12 7.92 2.37 0.44 1.48 15 7.73 2.12 0.63 1.66 10 6.45 2.30 0.62 1.69
Mother undermining autonomy
     Baseline 25 1.58 1.59 5.34 8.31 24 2.48 1.34 5.81 7.89 19 3.05 1.91 6.51 9.09
     6-month 17 1.74 1.32 1.05 2.42 17 2.12 1.67 1.26 2.98 10 2.05 1.46 1.00 3.10
     18-month 12 0.88 0.98 0.12 1.05 15 1.67 1.53 −0.04 0.86 10 2.15 1.63 0.00 2.80
Mother undermining relatedness
     Baseline 25 0.96 1.25 0.25 1.50 24 1.15 1.21 0.82 2.51 19 1.16 1.11 0.98 3.32
     6-month 17 0.59 0.91 0.13 1.12 17 0.41 0.87 0.19 1.21 10 1.40 1.96 −0.10 1.40
     18-month 12 0.63 0.77 2.10 3.94 15 0.70 0.92 3.29 5.54 10 0.65 1.06 2.92 5.03
Child autonomy-relatedness
     Baseline 25 3.02 2.22 0.64 2.12 24 4.42 2.66 0.64 1.86 19 3.97 2.20 0.79 1.90
     6-month 17 4.38 2.93 2.88 5.89 17 4.44 2.67 3.07 5.81 10 4.10 2.82 2.09 6.11
     18-month 12 5.08 2.42 0.61 1.56 15 5.07 2.57 0.40 1.66 10 2.90 2.02 −0.06 2.16
Child undermining autonomy
     Baseline 25 0.98 1.02 3.55 6.62 24 1.67 1.30 3.64 6.49 19 2.00 1.63 1.45 4.35
     6-month 17 1.09 0.92 −0.06 1.23 17 1.03 1.23 0.43 1.51 10 1.05 1.55 −0.02 2.12
     18-month 12 0.58 1.02 0.29 1.79 15 0.97 0.97 0.58 1.68 10 1.05 1.50 −0.21 1.51
Child undermining relatedness
     Baseline 25 1.38 1.78 0.92 2.24 24 1.25 1.44 1.91 3.04 19 1.34 1.16 2.13 3.97
     6-month 17 1.21 1.21 0.44 1.48 17 1.41 1.41 0.63 1.66 10 0.95 0.72 0.62 1.69
     18-month 12 1.04 1.18 1.19 1.61 15 1.13 0.99 1.28 1.72 10 0.65 1.20 1.23 1.72
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Figure 1.

Figure 1.

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Means of maternal moderate and severe substance use over time.

Note. Error bars indicate 90% confidence intervals for the sample mean.

Figure 2.

Figure 2.

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Means of maternal depressive symptoms over time.

Note. Error bars indicate 90% confidence intervals for the sample mean.

Figure 3.

Figure 3.

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Means of autonomy-relatedness behaviors over time.

Note. Error bars indicate 90% confidence intervals for the sample mean.

Substance use

Multilevel modeling was used to estimate changes in percentage of days of moderate and severe substance use among the mothers. The unconditional model suggested significant variability in the random effect with ICC = 0.36. The random coefficient model showed a significantly better fit (χ2 (3) = 29.35, p < .001) than the unconditional model. The average use of alcohol/drugs was 0.53 post-treatment, and the slope was not significantly different from zero, indicating no significant change in time. The random effects of the linear slope were significant, indicating significant variance between individuals in their trajectories. The conditional effect model showed a better fit than the random effects model (χ2 (12) = 22.66, p = .03), with level-2 predictors added. There was a significant treatment effect in the EBFT home group on the intercept, in that this group showed less moderate and severe substance use than the WHE group on average (b = −0.39, s.e. = 0.19, t = −2.03, p = 0.04). Maternal motivation for change also yielded a significant negative impact on the slope of maternal substance use (b = −0.002, s.e. = 0.001, t = −2.28, p = 0.02), in that higher motivation was related to faster reduction in substance use (see Table 2).

Table 2.

Mixed effects modeling testing change in substance use over time across treatment conditions

Unconditional means model Random-coefficient model Conditional model
b se t b se t b se t
Fixed effects
Intercept 0.560 0.053 10.616*** 0.525 0.080 6.525*** 0.850 0.696 1.220
 EBFT home −0.386 0.190 −2.027*
 EBFT office −0.130 0.176 −0.740
 Baseline substance use 0.091 0.185 0.493
 Education −0.051 0.052 −0.975
 Motivation 0.005 0.003 1.483
 Ethnicity −0.064 0.152 −0.423
Linear slope 0.008 0.021 0.388 −0.205 0.182 −1.126
 EBFT home 0.077 0.054 1.425
 EBFT office 0.023 0.045 0.512
 Baseline substance use 0.053 0.055 0.970
 Education 0.025 0.014 1.759†
 Motivation −0.002 0.001 −2.280*
 Ethnicity −0.030 0.038 −0.791
Random effects
 Intercept 0.110 0.037 2.942** 0.265 0.067 3.927*** 0.227 0.058 3.923***
 Linear slope 0.017 0.008 2.052* 0.014 0.005 2.665**
 Level 1 error 0.194 0.042 4.593*** 0.117 0.019 6.236*** 0.115 0.018 6.336***
 Estimated parameters 3 6 18
 Loglikelihood −153.805 −143.564 −133.464
 χ2 29.352*** 22.664*
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Note. Ethnicity 1= black, 0 = non-black. † p < 0.09, * p < 0.05, ** p < 0.01, *** p < 0.001.

Depressive symptoms

Multilevel modeling was also used to estimate changes in depressive symptoms among the mothers. The unconditional model suggested significant variability at baseline with ICC = 0.46. The random coefficient model showed a significantly better model fit than the unconditional model (χ2 (3) = 16.64, p < .001). The average depression score was 23.9 post-treatment, and there was a significant reduction in time in the random coefficient model (b = −0.99, s.e. = 0.41, t = −2.41, p = 0.02). The random effects of the linear slope were again significant, indicating significant variance between individuals in their trajectories. The conditional effect model fit the data even better (χ2 (10) = 56.59, p < .001). There was a significant treatment effect in the EBFT home group on the intercept, in that this group showed less depressive symptoms than the WHE group on average (b = −7.97, s.e. = 3.60, t = −2.21, p = 0.03). Maternal race also yielded a significant negative impact on the intercept of maternal depressive symptoms (b = −7.81, s.e. = 3.56, t = −2.20, p = 0.03), in that being African American was related to increased depressive symptoms compared to other races (predominantly white) (Table 3).

Table 3.

Mixed effects modeling testing change in depressive symptoms over time across treatment conditions

Unconditional means model Random-coefficient model Conditional model
b se t b se t b se t
Fixed effects
Intercept 20.735 1.369 15.146*** 23.893 2.002 11.932*** 7.462 8.661 0.862
 EBFT home −7.966 3.601 −2.212*
 EBFT office −2.840 4.347 −0.653
 Baseline depressive symptoms 0.613 0.143 4.299***
 Education 0.738 0.855 0.863
 Ethnicity −7.810 3.556 −2.196*
Linear Slope −0.985 0.409 −2.410* −0.188 2.272 −0.083
 EBFT home 1.525 0.991 1.538
 EBFT office 0.323 1.076 0.300
 Baseline depressive symptoms −0.025 0.035 −0.724
 Education −0.108 0.214 −0.503
 Ethnicity 0.933 0.933 1.000
Random effects
 Intercept 93.442 17.817 5.245*** 167.141 41.683 4.010*** 47.826 27.765 1.723 †
 Linear slope 3.973 1.910 2.081* 3.036 1.776 1.709 †
 Level 1 error 111.790 16.505 6.773*** 88.179 14.199 6.210*** 88.365 14.594 6.055***
 Estimated parameters 3 6 16
 Loglikelihood −956.259 −949.766 −919.564
 χ2 16.640*** 56.594***
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Note. Ethnicity 1= black, 0 = non-black. † p < 0.09, * p < 0.05, ** p < 0.01, *** p < 0.001.

Autonomy-relatedness behaviours

Autoregressive cross-lagged models were used to investigate mother’s and child’s autonomy-relatedness behaviours. The model estimating the dyads’ autonomy-relatedness promoting behaviours showed a good fit (RMSEA = 0.038, CI0.95 =[0.000, 0.114], CFI = 0.974; Figure 4). The EBFT office group showed significant improvements in child autonomy-relatedness promoting behavior at the 18-month follow-up, compared to the WHE group (b = 2.08, s.e. =0.84, t = 2.48, p =0.01).

Figure 4.

Figure 4.

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Mother and child autonomy-relatedness behaviors.

Note. M = mother, C = child, AR = autonomy-relatedness behaviors. Control variables: Child age, child gender, maternal education.

† p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001.

The model estimating the dyads’ undermining autonomy behaviours also revealed a decent fit (RMSEA = 0.059, CI0.95 =[0.000,0.129], CFI = 0.955; Figure 5). Mothers showed more undermining autonomy behaviours to girls than to boys at the 18-month follow up (b = 1.20, s.e. = 0.55, t = 2.21, p = 0.03). No treatment effect was found in this model. The model estimating the dyads’ undermining relatedness behaviours also had a good model fit (RMSEA = 0.000, CI0.95 =[0.000,0.033], CFI = 1.000; Figure 6). However, no treatment effect was found for undermining relatedness behaviours.

Figure 5.

Figure 5.

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Mother and child undermining autonomy behaviors.

Note. M = mother, C = child, UA = undermining autonomy behaviors. Control variables: child age, child gender, maternal education.

† p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001.

Figure 6.

Figure 6.

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Mother and child undermining relatedness behaviors.

Note. M = mother, C = child, UR = undermining relatedness behaviors. Control variables: child age, child gender, maternal education.

† p < 0.10, * p < 0.05, ** p < 0.01, *** p < 0.001.

Discussion

Similar to findings in other studies, African American women experienced more depressive symptoms than their White counterparts (Bromberger et al., 2004; Haralson et al., 2002; Myers et al., 2002; Oquendo et al., 2001). To our knowledge, this is the first study to identify a relationship between race and depressive symptoms among prostituting women. Researchers have suggested racial differences in depressive symptoms may be attributed to other individual factors (e.g. socio-economic status, education, and marital status) or environmental factors such as racial discrimination (Bromberger et al., 2004). While depressive symptoms are likely influenced by individual and environmental factors, the mechanisms underlying higher depressive symptoms among African American women are not well understood, and more research is warranted to better specify group differences.

Reports indicate that many women seeking substance use treatment engage in prostitution (40%), and the majority (91%) have children in their care (Burnette et al., 2009; Sloss, 2002). Compared to non-prostituting women, these women report higher rates of substance use and depressive symptoms, but few efforts to document effective intervention with this population are available. In an effort to identify interventions that may be effective with this high needs group of mothers and children, this is the first study to compare the effects of EBFT (office- versus home-based) to a psycho-educational intervention (WHE). As expected, mothers assigned to EBFT reported greater reductions in substance use and depressive symptoms, as well as greater improvements in mother and child autonomy-relatedness behaviours, compared to those assigned to WHE. These findings suggest that individual problem behaviours (substance use and depressive symptoms) can be better addressed by including children in their mother’s therapy than by working with the mother alone. This finding has practical implications for prostituting women seeking substance use treatment. That is, the findings suggest that substance use treatment facilities should offer family therapy as an adjunct treatment for mothers seeking assistance in order to optimize outcomes.

The superior outcomes for family therapy compared to individual treatment may be due to the focus of family therapy on helping mothers cope with the stress associated with parenting, as well as its focus on improving mother-child interactions. Research has linked parenting stress with a greater risk of relapse and worse substance use outcomes (Denton et al., 2014). Further, negative mother-child interaction patterns are associated with maternal substance use and depressive symptoms (Denton et al., 2014; Hodgkinson et al., 2014; Pelham et al., 1997). In the current study, positive changes in mother-child interactions (autonomy and relatedness behaviours) may have reduced maternal stress associated with parenting, thereby promoting reductions in substance use and depressive symptoms. However, this study was underpowered to test mediating effects, but the differential improvement in these variables in family therapy compared to individual treatment suggests a promising line of inquiry for future research.

Although EBFT showed superior outcomes to WHE, the context of family therapy – home or office – influenced treatment response. For mother’s depressive symptoms and substance use, home-based family therapy resulted in more improvements. This finding is consonant with a small number of studies indicating that in-home family therapy is more effective at engaging and retaining families in treatment than office-based therapy (Slechta, 2012; Slesnick & Prestopnik, 2009). However, for autonomy-relatedness behaviours, office-based therapy was superior. While no evidence of the superiority of office- versus home-based therapy on client outcomes was found in the literature, possibly, office-based therapy offers a less chaotic environment than the home environment, better facilitating clients’ focus on communication with one another without interruptions in the home. Office-based therapy has lower cost associated with transportation and therapist time, and the findings here suggest that the context of service delivery impacts outcomes differently.

Limitations

This study is limited by a relatively small sample of women who reported prostitution. A larger sample would provide greater power to detect treatment effects and would allow exploration of the mediating and moderating effects. Uncovering mediating and moderating relationships associated with treatment could improve our understanding of how and for whom family therapy is most effective. Finally, findings from this study might not generalize to all prostituting women, especially those not seeking substance use treatment who might have different levels of motivation.

Conclusions

Following substance use treatment, prostituting women have shown poorer substance use and related outcomes compared to non-prostituting women. As most women have a child in their care, this study compared EBFT to a psycho-educational intervention delivered to individuals on substance use, depressive symptoms and mother-child interaction behaviours. Women seeking substance use treatment through a local treatment facility and who also received family therapy with their child reported greater reductions in substance use and depressive symptoms compared to women that received individual treatment. Additionally, women and children who received EBFT were observed to exhibit greater improvements in autonomy-relatedness behaviours. Overall, the current study provides evidence that family therapy outperforms individual treatment for prostituting women with children. However, studies with larger samples are needed to better assess the comprehensive benefits family therapy offers to prostituting mothers and their children.

Practitioner Points.

  • It has proven difficult to meet the unique needs of prostituting women, and this paper offers practical assistance to practitioners serving this population.

  • Ecologically-Based Family Therapy (EBFT) shows promise, having some superior outcomes compared to an individual therapy with prostituting mothers.

  • Substance use treatment facilities should strongly consider including EBFT for these women and their children as an adjunct to treatment.

Acknowledgments

This work has been supported by NIDA grant R01DA023062, N. Slesnick, PI.

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