“The Whole Family Suffered, so the Whole Family Needs to Recover”: Thematic Analysis of Substance-Abusing Mothers’ Family Therapy Sessions

Abstract

Substance abusing mothers and their children are more likely to experience a range of social, behavioral, and psychological difficulties. Despite the significant challenges faced by these families, little is known about their experiences in treatment. The current study analyzed 12 sessions of family therapy using thematic analysis to identify common themes that arose during substance abusing mothers and their children’s discussion during family therapy. Mothers’ ages ranged from 28 to 35 years and the children’s ages ranged from 12 to 14 years. Four therapy sessions from three families were coded for a total of 12 therapy sessions. An ecological framework was used to classify themes, in which themes related to each level of the families’ ecological systems were identified. Thematic analysis of the therapy sessions indicated that mothers and their children primarily discussed topics related to their relational and emotional needs. The findings indicated that substance use disordered mothers and their children have unique treatment needs that should be addressed when the mother seeks treatment. More research is needed to further clarify and confirm the observations in this study. In particular, future research should include a larger sample and quantitative methodology.

Substance-abusing mothers and their children are a vulnerable, understudied, and underserved population. Maternal substance use is associated with parenting problems which may lead to poor mother-child relationships (Mayes & Truman, 2002; Gruber & Taylor, 2006). Further, children of substance-abusing mothers are at risk of experiencing several negative behavioral, social, and mental health-related outcomes (Gruber & Taylor, 2006; Johnson & Leff, 1999). While a number of previous studies have assessed the vulnerabilities experienced by these mothers and their children, less is known about mothers’ and their children’s experiences when the mother seeks help for her substance use disorder. Due to the complexity of problems faced by mothers and their children and the difficulties associated with treatment engagement and retention among substance-abusing mothers (Finkelstein, 1994), a better understanding of their discussions during family therapy may be beneficial. Since individuals often discuss issues they feel are salient in therapy (Farber, 2003), qualitative analysis of therapy sessions may be an important first step by providing insight on issues which may be important to target in the context of family therapy.

Many substance-abusing mothers grew up in substance-abusing and/or abusive family systems and may not have had good parenting role models (Davis, 1990; Gruber & Taylor, 2006; Mayes & Truman, 2002). Previous research has shown that these mothers often lack knowledge about appropriate parenting and may have problems understanding children’s developmental and emotional needs (Mayes & Truman, 2002; Seagull, et al., 1996; Velez, et al., 2004). Substance abuse is also associated with low levels of closeness and warmth in the mother-child relationship (Kandel, 1990). Qualitative studies have shown that mothers report past experiences of not being present to support their children both physically and emotionally (Baker & Carson, 1999; McKeganey, Barnard, & McIntosh, 2002). Furthermore, children often report feeling unloved and abandoned by their substance-abusing parent and are more likely to experience neglect and/or abuse than children without substance abusing parents (Gruber & Taylor, 2006; Kelleher et al., 1994; Kroll, 2004; Mayes & Truman, 2002). Additionally, mothers report feeling inadequate and insecure in their role as a mother (Gruber & Taylor, 2006; Mayes & Truman, 2002). Overall, substance abuse can have a negative impact on the relationship between mothers and their children and should be addressed when the mother seeks treatment.

Children of substance-abusing mothers are at an increased risk of experiencing a range of psychological, behavioral, and substance use problems of their own throughout their lives (Chatterji & Markowitz, 2001; Lynskey, Fergusso, & Harwood, 1994; Osborne & Berger, 2009; Weissman, et al., 1999). Osborne and Berger (2009) found that three-year-old children of substance users were more likely to exhibit aggressive behaviors, anxious/depressed behaviors, as well as behaviors related to attention deficit hyperactivity disorder and oppositional defiant disorder. Studies of older children also show similar results; by adolescence and young adulthood, children of substance abusing parents are more likely to be diagnosed with a psychiatric disorder and/or substance use disorder than children of non-substance abusing parents (Chassin, Pitts, Delucia, & Todd, 1999; Hill, Tessner, & McDermott, 2011; Stanger et al., 1999).

Qualitative Studies

While no previous study has assessed issues mothers and their children discuss during therapy, a modest number of qualitative studies have assessed issues mothers identify as challenging during their substance abuse treatment. Nardi (1998) used interviews, observations, and therapy case notes with 17 women in outpatient treatment to develop an understanding of pregnant and parenting women’s experiences with recovery from addiction. Many of the women in the study showed little understanding of the impact that their addiction had on their children (Nardi, 1998). Additionally, for most of the women it was their first experience of parenting while abstinent, so they had to adapt to their evolving parental role (Nardi, 1998). Coyer (2001) conducted interviews with 11 mothers of children in treatment for a cocaine addiction and found that the mothers struggled with developing a maternal identity. For example, many of the mothers had limited experience with parenting their children and tended to overlook their children’s emotional needs. Davis (1997) conducted interviews with 10 women who were recovering from alcohol dependence and many of the women noted that having children made focusing on their recovery more complicated. While these studies indicate that mothers often face challenges related to parenting during treatment, only mothers’ perspectives during individual-based treatment were assessed. Therefore, the findings do not offer insight on the challenges that children may identify or whether the identified challenges may be different from the child’s perspective.

Theoretical Formulation

Given the wide range of challenges associated with substance use disorders and treatment, recent research has begun to acknowledge the importance of the multiple systems beyond the family systems, in the initiation, maintenance, and treatment for substance use disorders (Rowe, 2012). Therefore efforts have been made to incorporate an ecological perspective and treatment approach. Bronfenbrenner’s ecological systems model (1994) can be applied to substance abusing mothers and their children to demonstrate the bi-directional influence between the mother’s substance use and the multiple systems in the family’s environment. The most influential system is the microsystem which consists of relationships and interactions that the individual has frequent and direct contact with, such as the mother and child’s relationship. The mesosystem links different systems together, for example the involvement that substance abusing mothers’ children may have with their mother’s substance abuse treatment center would be classified within the mesosystem because it illustrates how two of the mother’s microsystems (family and treatment) interact and influence one another. The exosystem consists of settings that individuals do not have direct contact with, but still influence the individual. For example, a mother’s involvement in the judicial system could be a possible component of a child’s exosystem because the mother’s involvement in the judicial system will have an impact on the child, but the child does not have direct involvement with judicial system. The macrosystem exerts overarching influence on the environment of an individual and consists of things such as societal beliefs and culture. The chronosystem is the final aspect of environment within ecological systems theory and focuses on aspects of individuals and their environment that remain constant or that change over time. Overall, the ecological systems model provides a framework for understanding how different relationships and environmental factors interact to influence individuals and families.

Current Study

Despite significant research documenting challenges faced by substance-abusing mothers and their children, little is known about issues that arise for families when the mother seeks help for her substance use disorder. Since individuals are likely to discuss issues they feel are salient during therapy (Farber, 2003), identifying issues discussed between these mothers and their children can provide insight on issues that are important to these families during treatment. Further, by utilizing a theoretical thematic analysis based on ecological systems theory, it will be possible to develop an understanding of how issues stemming from multiple systems in these families’ lives may influence mothers and their children during therapy. Therefore, the current study provides a thematic analysis of Ecologically-Based family therapy (EBFT) sessions with three substance-abusing mothers and their adolescent children.

Given the exploratory and qualitative nature of the current study, there are no hypotheses being tested. Rather this study seeks to generate information that can be used to develop hypotheses about substance-abusing mothers and their children’s challenges during treatment, as well as how their problems can be understood within an ecological systems framework. Therefore, the goals of the current study are: 1) to identify issues discussed by substance-abusing mothers and their children and 2) to identify the multiple systems influencing the issues discussed by these families as described by Bronfenbrenner’s (1994) ecological systems theory.

Methods

Participants

Participants in the current study were part of a larger, on-going clinical trial of Ecologically-Based Family Therapy (EBFT) with 183 single substance-abusing mothers and their adolescent children. The findings from the clinical trial are still being prepared and reviewed for later publication. Mothers were recruited to the clinical trial through a community substance abuse treatment center in a large Midwestern city. Mothers were eligible to participate if: 1) they had a child between the ages of 8–16 who lived with them at least 50% of the time for the past 2 years or 100% of the time in the past 6 months, 2) were seeking outpatient treatment for their substance use disorder, and 3) met diagnostic criteria for an alcohol or drug use disorder. Mother-child dyads who agreed to participate were then randomly assigned to receive: 1) in-home EBFT, 2) office-based EBFT, or 3) women’s health education intervention. These treatments were in addition to the outpatient treatment they received from the substance abuse treatment center. In the current study all mothers identified cocaine as their drug of choice. However, they also reported other drug and alcohol use including opiates, marijuana, and alcohol throughout the project. The mothers’ ages ranged from 28–35 years. Two of the mothers were African-American and one reported mixed ethnicity. Children reported the same ethnicity as their mothers. The target adolescents’ ages ranged from 12 to 14 years. None of the target adolescent children reported illicit drug or alcohol use in that past 90 days.

Three families who were assigned to receive in-home EBFT were included in the current study. Mothers who completed all 12 sessions of EBFT and had an adolescent child present at least 4 of the sessions were selected because it was necessary to use cases where both the mother and child were engaged in treatment. Pseudo-names were provided to all of the mothers to preserve confidentiality. Among the sessions coded for the current study (1 or 2, 4, 8, and 12), the number of children attending varied from session to session. “Alexia” had seven children, but began the first session with only one daughter, but later included two more of her daughters in the therapy session. She included four of her children and her mother in session four. Session eight began with only the mother, but her son later joined the session. Alexia attended the final session by herself. “Brooke” had two children, but had custody of only one child. Her son attended all of the therapy sessions. “Christina” had three children. She attended the first session by herself, but included her children in the rest of the sessions. During the second session her youngest son and daughter were present. All three of her children were present during the fourth session. The oldest son and daughter were present during the eighth session and the youngest son and daughter attended the twelfth session.

Procedure

The Ohio State University Institutional Review Board approved all study procedures. In the larger trial, mothers were informed about the clinical trial by a research assistant at the substance abuse treatment center. With permission, the mother’s child was then contacted. When mothers had more than one eligible child, the children were assessed for substance use and the child with more severe substance use was included. If neither child reported substance use, the children were given the Youth Self Report (Achenbach & Edelbrock, 1982) and the child with the highest total problem behavior score was included as the target child. However, all children were invited to participate in therapy sessions. Both the mother and target child completed an assessment battery that included several individual and family measures as well as a video recorded interaction task. Families were then randomly assigned to one of the 12-session therapy conditions. All therapy had to be completed within six months of the baseline assessment.

The current study focused on the family therapy sessions which were conducted by master’s level therapists who were currently in a doctoral couple and family therapy program. Each mother in the current study was selected to have a different therapist in order to ensure that the therapist did not influence themes that arose across cases. Therapy sessions were audio recorded and were later transcribed verbatim by a research assistant. To ensure that different time points in the therapy were represented, session 1 or 2, 4, 8, and 12 were coded. Furthermore, the case notes from all of the therapy sessions were reviewed to provide a general sense of each of the 12 sessions from each family.

Measures

The measures included in the current study include both the mother and child’s Form-90 and demographic questionnaire. The Form-90 is a structured interview that measures daily drug use for the past 90 days using a timeline follow back approach. (Miller,1996). Within the current study, information collected through the Form-90 was only used to identify mother’s drug of choice and to assess whether the child had used drugs or alcohol in the past 90 days. In order to characterize the sample, self-report demographic questionnaires were administered to mothers and children by research assistants. The current study utilizes this information to report mothers’ and children’s ages, education, income, and prior traumatic experiences.

Treatment

Mothers and their children participated in Ecologically-Based Family Therapy (EBFT; Author masked), identified as an evidence-based practice by the California Evidence Based Clearing House. EBFT is a family systems approach that incorporates concepts from ecological systems theory (Bronfenbrenner, 1979). It was originally developed for multi-risk families, specifically families with a runaway adolescent child. However, in the current study it was further developed for families in which the mother had a substance abuse problem.

One of the basic assumptions within EBFT is that individuals’ lives are influenced by multiple systems and the family is the primary system for individuals. All family members are assumed to contribute to the development, maintenance, and resolution of family problems, such as substance use. Therefore, EBFT does not focus on only one individual, but seeks to understand the entire family system. EBFT also considers how other systems, including larger societal systems, influence the family system and individuals. Overall, EBFT seeks to improve interactions within the family system as well as larger societal systems. Given that EBFT focuses on the family system as well as outside systems, it was expected that families participating in EBFT would discuss not only their concerns within their family relationships, but also their experiences with other social systems.

Data Analysis

Cross-case analysis was done to identify common themes that arose in all three families’ therapy sessions (Creswell, 2007). Themes consisted of common patterns of issues or concerns that were discussed throughout families’ therapy sessions. Braun and Clarke’s (2006) procedures for theoretical thematic analysis were followed to identify themes within and across cases. Audio recordings of therapy sessions were transcribed verbatim by a research assistant. The audio recordings of therapy sessions were then listened to and compared with the transcriptions to ensure accuracy and familiarize the researchers with the data. Next, initial coding was done to find patterns in the data. Following initial coding, codes were compared and combined to create preliminary themes and subthemes. After initial themes were developed, codes within each theme were reviewed to ensure they were consistent with the theme, and modifications were made when necessary. Finally, the themes were reviewed to ensure they represented the data from the therapy sessions.

Theme development was also guided by the goal of relating themes to an ecological systems theory framework. Since the mother-child microsystem was the basic unit of analysis, only themes directly related to the relationships involving mothers and their children were classified at the microsystem level within the current study. Themes were classified at the mesosystem level if they related to the mother’s and/or their children’s interaction or experience with other microsystems. Themes that related to systems that influenced mothers and their children, despite the fact they had no direct involvement with the system, were classified at the exosystem level. Themes that conveyed the larger societal influence on the families’ lives were coded at the macrosystem level. Since therapy occurred over a relatively short period of time (six months) themes related to chronosystems were not identified.

In order to ensure reliability of the analysis, the first author, as well as a research assistant, coded the data (Boyatzis, 1998). The first author coded all of the selected therapy sessions and the research assistant coded one session from each family. The first author and research assistant independently coded sessions and then met and compared findings. Discrepancies in their findings were discussed until an agreement was reached (Boyatzis, 1998). To further ensure reliability, themes were reviewed and discussed with the second author, who was the therapy supervisor and oversaw all therapists involved in the project.

Given the sensitive nature of the topics discussed in therapy, several efforts to protect participants’ identity were made. Each mother was given a pseudonym and children were not referred to by name. Any potential identifying information was not included in the study. Furthermore, issues discussed in therapy were only developed into themes if more than one family discussed that issue. This helped ensure that all of the information discussed by each family in therapy was not revealed in order to prevent the possibility of the families being identified.

Results

Microsystems

As would be expected given the primacy of microsystem interactions, several themes related to the family microsystem were discussed throughout therapy. Issues related to the mother-child relationships were discussed extensively. Therefore, an overarching theme of mother-child relationships was identified, which was composed of several sub-themes.

Mother-child relationships

All three families identified goals related to improving their relationships. As a result, a substantial amount of time was spent discussing mother-child relationships. While each family had different experiences, several common sub-themes emerged throughout the families’ discussions, which are presented in more detail below.

Children expressing their feelings

Each of the three mothers expressed hope that therapy would help their children express their feelings. Mothers seemed to sense that their children tended to withhold their feelings and tried to encourage their children to express their thoughts and feelings throughout therapy sessions. One mother, Christina, expressed concern that her children withheld their thoughts and feelings. She tried to encourage them to be more open by stating, “Everybody this is a time to let things out…I worry about you because I feel like you hold things in.” Another mother, Alexia, expressed joy when she saw her daughter cry and noted that she had never seen her daughter express feelings about the mother’s addiction. Alexia responded by saying, “Tell the truth, honey. It’s okay if you cry. See that’s what she [therapist] is here for.” A different mother, Brooke, also expressed concern that her son was not being expressive and encouraged him to be more open with her about what he wanted her to do differently in their relationship. The concern these mothers had regarding their children withholding their feelings seemed to relate to their belief that withholding feelings would negatively affect their children later in life. For example, Alexia said, “I teach my kids to allow yourself to feel what you’re feeling because if you don’t, one day you’re gonna explode.”

Two of the mothers also shared their belief that their children’s resistance to share their feelings and thoughts was related to their children’s concern about their mother’s reaction. Alexia acknowledged that during her drug use she would get angry easily and suspected her children may be afraid of her, she commented:

I guess with my addiction and the anger that I had…they was walking on eggshells. Like, is she going to go off… you know, if I say this? Or I want to say this to her, but I better not.

Similarly, Christina conveyed her belief that her children may not be sharing their feelings because they did not want to hurt her. She commented, “I feel like you hold things in…because you’re scared you’re going to hurt your mom or you’re going to hurt someone else’s feelings.” Christina’s daughter agreed that she often withheld her feelings because she was afraid of hurting other people, she commented, “I should share my opinions. I just get scared it would hurt other people’s feelings.” While the children did not engage in a significant amount of discussion about their comfort expressing their thoughts and feelings, the children who did contribute to the conversation tended to agree that they struggled with communicating openly.

Mother’s desire for her children to understand her experiences

Discussions from the three families indicated the importance the mothers placed on having their children understand and appreciate their struggles and experiences. Christina explained that she was writing a book about her experience, so her children could understand her life, “I think it’ll [her book] make…things that aren’t clear a little more clear for you to understand mom.” Brooke expressed frustration because she perceived that her son did not understand her struggles. During one session, she discussed her disappointment that her son would not go with her to her appointments. She perceived he would have gained a better understanding of her everyday struggles if he went with her. She explained that he would have thought to himself:

To have my mom go through all this and she still maintaining and she still paying the bills…and she got the house. Dang my mom really goes through. My mom really tries.

The therapist responded by acknowledging that Brooke may feel like people do not understand the challenges she faces. The mother responded by saying “No, it is not people, [it is] my son.” Alexia communicated the belief that her negative behaviors in the past were due to her addiction, thus she expressed the desire for her children to understand that her past behaviors were a result of her addiction. Overall, throughout therapy it appeared that the mothers hoped their children would gain a better understanding of their struggle.

Support from one another

The three families all reported receiving different levels of support from within their family. While two families discussed receiving support from one another, one family was disappointed with the amount of support they were receiving from one another. However, all the families indicated the importance of having support from their family members. Both mothers and their children shared their perspectives of the support they received from one another.

The children discussed support in broad terms by indicating they wanted to be closer or spend more time with their mother. Brooke’s son stated he wanted to be closer to his mom and noted his ideal close relationship would include “sitting down and talking” with his mother. Alexia’s children indicated their relationship with their mother had improved since Alexia stopped using drugs because they spent more time together, one child noted, “I’m happy for her that she decided to…get better and stuff. So it’s been good, we been doing stuff together as a family more.” Christina’s children also discussed how his mother would help them settle conflict. He happily noted, “My mom always has our back.” Throughout therapy, at least one of the children in all of the families indicated that they valued/would value having support from their mother.

The mothers were able to identify specific examples of the support their children provided or how they wanted their children to support them. Brooke described several expectations about the support she hoped her son would provide. However, he was not meeting her expectations, thus, she often discussed how she wanted him to behave. For example, when the therapist asked Brooke what her son needed help with, the mother responded, “He needs help with helping his mother, helping around the house.” In contrast to Brooke, the other two mothers acknowledged that their children were a source of support. Alexia noted that when she was struggling with her addiction her children took on some of her responsibilities. In fact, she discussed her current effort to have her children take on fewer responsibilities since she was no longer using drugs, she stated:

When I was delivered from this I told my kids…I am giving ya’ll permission to be children again. You don’t have to cook…of course help out. But as far as taking on mommy’s role, they don’t have to do that no more.

Christina also described her children as a source of support. She indicated that she liked therapy because it gave her family a chance to spend time with one another. She also noted that she did not like to leave the house because it felt unsafe, so her children were the only people she interacted with regularly. Overall, the mothers tended to indicate that their children were a source of support or hoped that they would provide support.

Children’s behavior problems impact on mother

Alexia and Christina conveyed that their children’s behavior problems were a source of stress. Brooke mentioned once that her son was doing poorly in school, but did not specifically identify his problem behaviors as a stressor. Alexia and Christina reported that their sons were not coming home, were getting in trouble at school, and were struggling academically. Through various points in therapy both mothers would direct discussions to their son’s problems. For example, at one point when the therapist tried to focus the conversation on Alexia, she responded by saying, “I’m fine…But I just want to know what’s going on with [son’s name].” Christina also expressed concern about both of her sons’ behavior. The youngest son was temporarily placed in foster care because of his behavior problems. The entire family appeared to blame him for the stress within the family and discussed their concern that his return would negatively impact the family. The mother noted:

With [son’s name] gone, a lot of the stress has alleviated, and I hate saying that, and I feel guilty as a mother saying that, but it’s the truth…I want him to be a part of the family, but…if he’s going to come back the same way that he was when he left…It’s like we’re just going backwards again.

Similarly, the older son expressed concern that his brother’s return would negatively impact his mother and the family:

I never want to be stuck in that position again where my mom’s going to be going through a lot more stress…She’s calmed down a lot and then if that goes back on her shoulders then I think everything in the house is really going to have a lot of tension.

Overall, children’s problem behaviors were a major source of concern for two of the mothers. And, it appeared as if they were able to use therapy to address some of these concerns.

Mothers’ beliefs about children’s behaviors

The mothers also discussed their beliefs about the innate and environmental causes of their children’s behavior. All three mothers conveyed a belief that some aspects of their children’s behaviors were often inherent to the child. Alexia noted that her son’s ethnic background contributed to his “anger problem.” Both Christina and Brooke indicated that their son’s zodiac signs contributed to their attitudes. Brooke explained “A Capricorn is stubborn and cheap. That’s him.” Christina also indicated that she believed her child had a mental illness that caused him to act out. She said, “I believe honestly and truly that he has some kind of mental illness.” Christina’s therapist tried to reframe the family’s perception of the son by suggesting that there may also be environmental reasons the child was acting out. Christina acknowledged her son had experienced previous trauma, but continued to assert that the main cause of his behavior was due to an innate condition. In contrast, Alexia acknowledged environmental factors may have contributed to her son’s problem behaviors. She expressed that her son’s problems were related to her behaviors, saying “It was my fault because mommy wasn’t home. He was starting to steal stuff because he probably felt he just didn’t have what he needed.” Brooke also noted that their impoverished living conditions may be contributing to her son’s attitude towards her. Initially, many of the mothers identified innate attributes of their children’s behaviors. However, throughout the process of therapy two of the mothers were able to also acknowledge environmental influences on their children’s behavior.

Mothers’ behaviors influence on children

All the mothers acknowledged the possible influence their behaviors may have on their children. Alexia discussed how her addiction had negatively impacted her children, stating, “Its [addiction] contagious. I hurt all of my children around me.” She also acknowledged the importance of her children participating in therapy saying, “The whole family had to suffer, so the whole family needs to recover.” However, she also indicated that her experience with addiction may benefit her as a mother in the future, saying “Now I can teach my children, I can educate my children…I can see the signs of drugs and alcohol in teenagers.” Christina discussed how her mental health problems impacted her relationship with her children. She noted that she had a personality disorder and that it may be difficult for her children to know what to expect from her. However, she asserted that she tries to maintain a positive attitude around her children even when she is upset. For example, she said:

I know that no matter how I feel inside, however I choose to react to things or whatever… affects them, [it] affects the whole family. So no matter how I may be feeling…I want to greet them when they get home from school with a positive attitude.

Possibly because of her own experiences with mental health problems, Christina appeared very concerned that her children had mental health problems. She noted that she tried to watch for symptoms in her children, saying, “I study a lot…I want to know what’s going on in here and what things I should look for.” Brooke did not extensively discuss the impact of her behaviors on her son, but she conveyed the belief that her mental health problems may impact her son. She acknowledged that having the right medication improved their relationship. She also noted that many of his behaviors she disliked, such as being “anti-social”, he likely learned from her. Overall, each mother revealed insight regarding how her struggle with mental health or addiction influenced her children.

Mesosystem

The mothers and children discussed several microsystems that that they had joint interaction and influence over. Many of these systems also appeared to have an influence on the relationship between mothers and their children. These systems included their relationships with their mother/grandmother, mothers’ involvement with men, children’s school, children’s friends, and community agencies.

Relationship with mom/grandma

All three mothers identified their own moms as an important person in their life. Alexia lived with her mom and Brooke lived across the street from her mom. Christina talked about the influence her mother had on her, but her mother had passed away so she was no longer an active part of her life. In the two families in which the mother’s mom was still living, the mothers relied on their moms for some financial support and help with parenting. Brooke described her relationship by saying, “I lean on my mom…I rely on my mom.” Both mothers discussed the closeness of their relationship with their mother. Alexia included her mother in some of the therapy sessions and indicated that she believed her addiction had also hurt her mother. However, Alexia also identified her mother as a source of stress. She described her mother as “clingy” and indicated she wanted space from her. Brooke also discussed her mother’s involvement in her life and described her mother as “controlling.” However, she conveyed that she accepted her mother’s controlling behavior because she was dependent on her mom. She explained “If she [her mother] did less… she would have less to say, but…I rely on mommy.” Overall, mothers conveyed that their mothers played an influential role in their lives.

The children also had a close relationship with their maternal grandmother. Even though Christina’s mom had passed away years ago, her children still identified their grandmother as an influential person in their life and discussed their sadness surrounding her death. Brooke’s child discussed spending time at his grandmother’s house when his mother was gone. He expressed being content with his close relationship with his grandmother saying, “While my grandma’s still living she’s going to be involved in everything.” However, at times his mother indicated his relationship with his grandmother was a source of frustration because it appeared her son was closer with his grandmother than he was to her. Brooke expressed anger that she needed her mother’s help with parenting her son, saying:

It’s messed up that he won’t listen to me, but he listens to my mom. That’s crazy. I’m the one that had him. I’m the one that carried him for nine months.

Alexia’s son, who was experiencing behavior problems, also identified his grandma as a source of support. Further, his grandmother mentioned that she tried working with the son to help him with his anger problems. Overall, in the families in which the grandmother was living, she provided an extra source of support for the children as well as their mothers.

Relationship with men

Two of the mothers and their children discussed the mother’s involvement with men. Both families discussed past involvement with men that negatively impacted them. Brooke reported that her last boyfriend had left without paying bills and had molested her daughter. Alexia discussed her experience with a previous boyfriend who introduced her to crack. She explained that she began using crack in order to stay with him, saying “[I would] just do anything to keep him around, so I started getting high with him and it just started going downhill from there.” Alexia’s daughter expressed that her mother’s involvement with a previous boyfriend was a source of frustration. The mother understood the child’s feelings and validated the child’s perspective, by saying, “Yeah, cause I did a lot for him and I should’ve been doing for my children. When the addiction came it was just like me and him, me and him, me and him.” Indeed, both of these mothers identified previous negative experiences with men that had an impact on their children and on themselves.

Throughout the course of therapy two of the mothers reported that they began new relationships and discussed their relationship with their boyfriend during therapy. In both families, mothers perceived that their children and their mothers were unhappy about their new relationships. Despite her suspicion that her son did not like her boyfriend, she still expressed a desire for them to have a relationship with one another. Her son expressed ambivalence about having a relationship with Brooke’s boyfriend, but the mother stated that it was important to her, saying, “I don’t care what you say…If I’m involved with somebody, they have to be involved with you also.” Similarly, Alexia conveyed that her mother and children were reluctant to accept her relationship with her boyfriend. The mother described her daughter’s perception of the situation by noted that her daughter had said, “Mom, what are you doing?…You leaving me out and… you leave out the rest of the kids out.” However, Alexia noted she was trying to develop a personal life outside of her family, saying “I told them I have to have a personal life. I never have. A boyfriend that I’m so close with.” She also discussed her boyfriend’s involvement with her children and indicated that her children should not feel abandoned since her boyfriend spent time with them as well. Throughout therapy both of these mothers discussed their struggle with balancing their relationship between their family and their boyfriend.

Children’s school

Children’s involvement and progress in school was discussed by two of the mothers and their children. A portion of Brooke and her son participation in therapy was during the summer months, which may have contributed to their lack of discussion concerning school. The other two mothers tended to use their children’s performance in school as an indicator of their children’s well-being. For example, when talking about their children, mothers often mentioned how their children were doing in school. When Alexia first discussed her children, she noted, “They’re all in school, no truancies. I have one son that’s suspended now.” If their children were doing well in school the mother would use it as a source of pride by acknowledging their success. Children who were doing well in school also discussed their school and related activities. Christina’s daughter frequently discussed her activities in school. Similarly, the eldest son discussed his improvement in school. One of Alexia’s daughters also discussed her achievements at school. However, when children were doing poorly in school or getting in trouble at school it was a source of stress for the family because it indicated that their child was struggling. In summary, the mothers seemed to use their children’s progress in school as a way to assess their child’s well-being.

Community support systems

In addition to their involvement with their family and romantic relationships, mothers also reported involvement with various community support systems. Brooke discussed her involvement with several community support providers to help with her physical disability and her addiction. She also mentioned her involvement in parenting classes, and discussed her attempts at utilizing those techniques with her son. She even indicated that she currently limited her interactions to professionals and family. Christina also noted that she tried to limit her relationships to family members and service providers.

Church was a community support discussed by Alexia and Christina. Christina briefly discussed her family attending church, while Alexia frequently discussed her family’s church attendance and how her faith in God had improved her life. She credited her newfound religious devotion for her recent sobriety. She explained:

I just appreciate, by the grace of God to be able to go through that [her addiction] and get out of it and still have my family. And we are just closer now more than ever.

She noted that she stopped attending her outpatient treatment and twelve-step meetings because she believed that God and her faith were her main support for sobriety. For example she stated, “I know what is working for me and that is God.” In sum, each of the families appeared to receive some level of support from community agencies; however the mothers differed in the services they chose to utilize.

Exosystem

As previously discussed, an individual’s exosystem consists of systems that influence individuals, but the individual is not able to influence because they do not have direct access to the system (Bronfenbrenner, 1994). Therefore, it would be expected that mothers and their children would not discuss issues related to their exosystems as frequently as issues related to their microsystem and mesosystem. Consistent with this proposition, only one theme related to exosystems was identified.

Compliance with Children Protective Services

Each of the three families mentioned children protective services. Alexia noted as a point of pride that she had always retained custody of her children, saying “By the grace of God, I was able to keep them all, even thru my addiction. [I] never had children services in my life.” The other two families were involved with children services. Brooke reported that she was trying to regain custody of her daughter through the court system. The daughter had recently been removed from the home and placed in her father’s custody. Brooke’s son expressed concern regarding his sister’s removal from the home saying, “I love my little sister too. I don’t want her to be over there. I don’t know where she is at.” Christina was also involved with children services, but she utilized the family court system as a parenting support. She noted that she filed charges against her sons to prevent them from misbehaving. She further, utilized the system by having one son placed in foster care based on the belief he would get help with his behavior problems. However, she learned that he was not receiving the help she thought he needed and expressed frustration she was not getting the support she wanted for her son. Christina explained, “I’m very concerned with the fact that he has been gone for a month and he’s not getting any help. So there’s no point in him leaving the home.” Overall, all mothers seemed aware of the possible influence children protective services could have on their lives whether or not they were currently involved with children services.

Macrosystem

Macrosystems consist of the larger societal and cultural context of an individual’s environment (Bronfenbrenner, 1994). Mothers and their children did not directly discuss aspects of their macrosystems, however the influence of societal beliefs and structures were transmitted in their discussions. Thus, themes related to their macrosystems were identified in their discussions.

Beliefs about male gender

As previously mentioned, mothers in the current study identified and discussed challenges they were having with their sons’ behavior problems. However, their beliefs about gender seemed to influence how they handled the situation with their son. Two of the mothers expressed concern that they were not able to understand or help their son because they were women. For example, one mother asserted “He’s a young man and goes through things that…I won’t understand as a woman.” They also felt that their sons may withhold information from them because they were women. Therefore, the mothers mentioned the importance of their children having a male role model. Alexia wanted her son to receive additional counseling, but wanted it to be from a male counselor. She expressed concern that it may be difficult for her son to live in a house with so many females. She asserted that his father could not be in his life because of physical distance. Christina, on the other hand, indicated that she wished her son’s father would “step up” and be involved in their son’s life and act as male role model. Brooke’s son’s gender also influenced their relationship. However, she did not discuss the belief that he may need a male role model and instead conveyed her perception that he should take on more responsibilities, since there were no other men in their life. She explained to her son, “[Boyfriend’s name] is gone, so I need you to help around the house. Be more of the man, you know, since you’re the man of the house.” In sum, mothers’ beliefs about gender influenced their relationship with their sons by creating the perception that they would not be able to understand their son’s experiences and by creating different expectations from their children based on their gender.

Maintaining a positive maternal image

Substance-abusing mothers face social stigma in regards to their addiction (Finkelstein, 1994). While their experiences of social stigma were not directly discussed by these families, the mothers appeared to act defensively and made frequent statements to justify or minimize the impact their addiction had on their children. For example, Alexia commented, “I always knew I was a good mother. I always got compliments, but of course through my addiction…[it was] kinda going downhill.” Despite some awareness that their previous behaviors may have impacted their children, these mothers would often minimize the negative impact of their behaviors. When discussing her drug use, Alexia explained, “The crack that was only, like the last two years…It never distanced me and my family to point where my kids started to hate me.” Further, mothers would often focus on discussing the positive things they had done. When the therapist suggested that Christina’s children may have been negatively impacted by their previous placement in foster care, Christina responded, by saying “I wrote them every week.” Similarly, Brooke expressed sadness and cried when she reported that her mother blamed her for her son’s dropping grades. She asserted, “It’s just me and him. It’s not all those other people coming in and coming out. You know, so I don’t have that. I guess I’m the chaos.” She then proceeded to discuss all she was doing to maintain the house for her son. Throughout their discussions these mothers attempted to maintain a positive maternal image, it is possible that societal expectations and perceptions of mothers may be one factor that influenced these mothers’ desire to maintain this image.

Discussion

The current study sought to identify themes that emerged during mothers’ and their children’s discussions during family therapy sessions. An ecological systems framework was used as a guide to classify themes. Several themes and sub-themes related to microsystem interactions were identified, as well as themes related to their mesosystems. Issues related to their exosystems were not discussed as frequently, which may be attributed to the lack of direct involvement and influence families have on exosystems. Themes related to the families’ macrosystems were also identified through the societal beliefs conveyed during the families’ discussions. In sum, substance abusing mothers and their children’s discussions in therapy appeared to incorporate their interactions with multiple systems.

To our knowledge this is the only study to provide a qualitative analysis of substance abusing mothers and their children’s discussions during therapy. This information can provide clinicians working with this population an awareness of concerns these families may experience. While the current sample is limited in size, many of the findings are consistent with previous self-reported quantitative research. However, the in-depth nature of the current analysis provides further insight about the interactions and relationships between substance abusing mothers and their children, as well as their interactions with other social systems.

The mothers in the current study expressed concern about their children’s well-being. One concern expressed by the mothers was the belief that their children were withholding their feelings. Similarly, previous studies have noted that children of substance abusing parents have difficulty expressing their feelings (Black, 1982; Kroll, 2004). The current study adds to this knowledge by providing insight on mothers’ perspective of their children’s withdrawn behavior. Two mothers acknowledged that their children’s resistance to share their feelings may be related to the children’s concerns about their mother’s reaction. Further, while mothers actively encouraged their children to be more expressive, they unintentionally engaged in behaviors that inhibited their children’s expressiveness, possibly resulting in confusion associated with mixed messages experienced by children.

Also consistent with previous studies focused on children of substance abusing parents (Chatterji & Markowitz, 2001; Johnson & Leff, 1999; Lynskey, Fergusso, & Harwood, 1994), some of the children in the current study appeared to have behavioral problems. Two of the mothers expressed concern about their children’s problem behaviors. The findings from the current study exemplify how substance abusing mothers understand and address their children’s behaviors. Mothers in the current study differed in their understanding and reaction to their children’s behavioral problems. One mother recognized how her own behaviors and other environmental factors were influencing her son’s negative behaviors, while a different mother seemed to attribute her son’s behavioral problems to an inherent trait of the child. Both mothers expressed frustration about their sons’ behaviors, but differed in the strategies they used to help their children. The mother who believed the problem was inherent to the child appeared to feel helpless and temporarily gave her child to children’s services, while the other mother attempted to talk her son, so she could understand his behavior. While no definitive conclusions can be made from the current study, future research may benefit from examining how mother’s perception of the source of their child’s problems influences their perceived self-efficacy in managing their child’s behavior, and the association to relinquishing custody of children. Furthermore, clinicians working with these families may benefit from addressing mothers’ potentially distorted beliefs regarding the source of their children’s behaviors.

The findings also highlight the importance mothers place on receiving support from their children. Previous studies have found that children often play an important role in substance abusing mothers’ support systems (Tracy & Martin, 2007). In fact, Tracy and Martin (2007) found that during recovery, substance abusing women reported that they received an equal amount of support from children as they did from other adults. While children can play an important role in providing support to their mothers during recovery, children may be negatively impacted if they are given an inappropriate amount of responsibility.

Parentification refers to the parent-child role reversal that occurs when children are given adult responsibilities and/or expectations (Boszormenyi-Nagy & Krasner, 1986). Previous research has found that parental addiction is associated with parentification of children (Burnett, Jones, Bliwise, & Ross, 2006; Goglia, Jurkovic, Burt, & Burge-callaway, 1992). Similarly, the descriptions provided by two of the mothers indicated the possibility that their children were parentified. Children can undoubtedly play an essential role in their mother’s support network. However, it may be beneficial for clinicians to help mothers identify other adult supports to alleviate some of the children’s responsibilities and help ensure children are not subjugated to adult responsibilities.

Several limitations should be acknowledged. The sample was limited to three families in order to provide an in-depth understanding of the families’ discussions in therapy. The mothers and children included in the current study were purposively selected, thus, they are not representative of the larger population of substance abusing mothers and their children. Mothers and their children were successfully engaged in treatment as evidenced by their completion of all the available therapy sessions. Issues discussed by mothers in the current study may be different than issues faced by mothers who are more difficult to engage in treatment. Further, while each mother in the current study discussed issues related to improving their relationship with their children, this may have been due to sampling bias, since only mothers with children who attended therapy sessions were included. Overall, the results from the current study were drawn from a small, non-representative sample, thus caution should be used when interpreting the findings.

The current study relied on audio recordings and written transcriptions of the therapy sessions, thus non-verbal communication was not assessed. Non-verbal communication would have likely provided further insight on the families’ experiences in therapy. This information may have been particularly beneficial to understanding the children’s experiences since they did not engage in dialogue as often as their mothers. Future studies may benefit from utilizing video recordings of therapy sessions rather than audio recordings.

While the current study provides an in-depth overview of these families’ discussion in therapy, it does not provide an exhaustive list of themes discussed by these families. Only four sessions from each family were coded, consequently additional themes may have been identified if more sessions were coded. However, efforts were made to ensure different time points of therapy were represented. Case notes from each session were also reviewed, which provided a general sense of each session. In sum, the current study provides an overview of themes discussed in therapy sessions, but other important issues may not have been identified.

Despite its limitations, the current study has significant strengths. To our knowledge, this is the first study that analyzed mothers and their children’s discussions during therapy sessions. This methodology allowed mothers and their children’s conversations to be examined as they naturally unfolded in therapy rather than being guided by a structured or semi-structured interview or questionnaire. It also provided rich information about their relationship with one another as well as with other systems in their lives. Further, by analyzing mothers and their children’s discussions using an ecological systems framework, it was possible to identify themes related to systems outside of their relationship.

Substance abusing mothers’ initiation into treatment is a unique opportunity to intervene with their children as well. However, substance abuse treatment programs often fail to include children in treatment partially due to the belief that children will improve as a result of their parent’s improvement (Conners et al., 2004; Coppello et al., 2006). However, children may have unique treatment needs as a result of their experiences with their mothers’ challenges, as one mother noted, “Its [addiction] contagious. I hurt all of my children around me.” In fact, families in the current study spent a significant amount of time discussing concerns related to the children’s own struggles, such as their behavioral problems. Furthermore, children often withheld their feelings and required encouragement from the therapist to discuss their feelings. It is likely that if these children were not given the opportunity to express their feelings in a safe environment, they would have continued to withhold many of their negative feelings. Overall, children of substance abusing mothers appear to have their own treatment needs which may require special attention; efforts should be made to incorporate children’s unique needs into interventions designed for substance abusing mothers.

Interventions for substance abusing mothers often focus on parenting skills and overlook the emotional and relational needs of mothers and their children (Suchman et al., 2004). In fact, research indicates that parenting skills interventions do not lead to improvements in mother-child relationship quality (Catalano, Gainey, Fleming, Haggerty, & Johnson, 2002; Kumpfer, 1998). In the current study, mothers and their children discussed several pertinent emotional and relational concerns emphasizing the importance of targeting these areas in treatment. For example, mothers and children each discussed the importance of having support from one another. Specifically, children indicated that they wanted to have closer relationships with their moms. Future interventions may benefit from continuing to explore and target substance abusing mothers’ and their children’s relational and emotional needs.

In addition to the mother-child relationship, mothers and children discussed interactions with multiple systems. In fact, it appeared that mothers and their children received support from both familial and social systems. Mothers and their children also appeared to be negatively impacted by relationships with other systems. In summary, there appeared to be multiple systems beyond the mother-child relationship that impacted these families throughout treatment. Further research of the ecological context of these families’ lives may provide valuable insight for multi-systemic interventions targeting substance abusing mothers and their children.

The current study addresses an understudied and underserved population. While the small sample size limits the conclusions that can be drawn, the findings provide rich insight into mothers’ and their children’s experiences in treatment which should be explored further. Overall, the findings revealed that both mothers and their children had several concerns to discuss in therapy that related to their relationship with one another and their relationships with other social systems. Future qualitative research should assess children’s and mother’s unique needs and experiences through qualitative interviews. Given mothers’ tendency to guide conversations and children’s difficulty communicating openly with their mothers, interviewing children separately may provide a better understanding of their perspectives. Additionally, many of the findings presented in the current study may be further explored and substantiated utilizing quantitative methods. Quantitative methods using a larger sample may lead to more conclusive findings. In conclusion, while the current study provides a glimpse into these mothers and their children’s discussions during therapy, future research should continue to explore their treatment needs and experiences in order to further develop interventions targeting mothers’ and their children’s unique needs.