An Exploration of Mothers’ Successful Completion of Family-Centered Residential Substance Use Treatment

Abstract

Behavioral health and substance use centers have started focusing efforts on creating, adopting, and implementing evidence-based practices and programs that effectively address the needs of women and, particularly, mothers entering treatment with children. However, women with substance use disorders (SUDs) remain an underserved and understudied population; even less studied are the complexities and unique SUD treatment needs of women who have children. Family therapists’ systemic training is a valued approach in conceptualizing and implementing treatment for mothers with SUDs and their families. This study explored the construct of mothering children during family-centered substance use treatment using a transcendental phenomenological approach. Analysis revealed themes related to motherhood, parenting, and support for mothers and children. Two themes emerged from the data: (a) grappling with motherhood and addiction leading to the decision for treatment and (b) specific aspects of the treatment program conducive to motherhood. Results indicated the positive impact of mothers’ experiences in family-centered substance use treatment, aligning with previous literature that suggests mothers are more engaged in treatment when their children remain in their care. The insights gleaned from the participants in this study provide suggestions for further improving programming that supports mothers and their children during the recovery process. Treatment considerations are offered for family therapists working with mothers with SUDs and their families.

In response to the opioid epidemic, working with women and their families to overcome addiction has become a topic of growing interest across disciplines. For example, a recent report in The Lancet (a weekly peer-reviewed medical journal) called for researchers, clinicians, and policymakers to account for different ways in which women encounter addiction and treatment (Yale University, 2018). Notably, the topical feature in the July/August 2018 issue of the American Association for Marriage and Family Therapy’s (AAMFT) magazine focused on helping families overcome opioid addiction (AAMFT, 2018). This recent attention underscores the need for systemically trained family therapists who understand the interplay of multiple systems involved in the development, maintenance, and recovery of substance use disorders (SUDs) among women and their families. Behavioral health and substance use centers have started focusing efforts on creating, adopting, and implementing evidence-based practices and programs that effectively address the needs of women and, particularly, mothers entering treatment with children (NIDA, 2017). However, women with substance use problems, and their children, remain an underserved and understudied population (Brakenhoff & Slesnick, 2015).

Mothers with substance use problems have reported a lack of parenting knowledge and understanding of the emotional and developmental needs of their children (Brakenhoff & Slesnick, 2015). The opportunity for parenting education classes and other therapeutic modalities stands to fill those parenting gaps; however, little is known about mothers’ parenting experiences during treatment. Ultimately, the role motherhood plays during treatment and the family’s perception of treatment experiences are phenomena that warrant deeper exploration. The present study used a transcendental phenomenological approach to explore the construct of mothering children during family-centered substance use treatment.

MOTHERHOOD DURING TREATMENT

Family-centered substance use treatment, endorsed by the Substance Abuse and Mental Health Services Administration (SAMHSA), is a framework that considers families in the context of treatment and the various systems that need to be addressed in order to support the whole family in recovery (Werner, Young, Dennis, & Amatetti, 2007). Specifically, the model prioritizes the need for gender-specific treatment that considers women’s roles in families and society. Key principles of family-centered substance use treatment emphasize comprehensive, gender-specific treatment that requires collaboration and coordination across service delivery systems, focusing on the context in which families reside (Werner et al., 2007). Services are made available to women and mothers with SUDs as well as their children, partners, and other family members. The inclusion of treatment services for women, mothers, and their children along with the family system including fathers, partners, and other caregivers is a priority of family-centered treatment. Family-centered substance use treatment emerged as a response to women’s needs being unmet by programs that used male-dominated models. The family-centered substance use treatment model emphasizes parenting support for caregivers and bonding time with children as well as providing childcare while women attend treatment (Werner et al., 2007).

Literature continues to emerge highlighting the critical need to examine the impact of gender-specific substance use treatment for women and, more specifically, for mothers (Chou, Beeler-Stinn, Diamond, & Cooper-Sadlo, 2014). This body of literature recognizes gender-specific treatment as critical for women because women’s development of dependency and resulting drug use patterns are different from those of men (Litzke, 2005). The National Institute on Drug Abuse (NIDA, 2017, p. 5) recently reported that “women often use drugs differently, respond to drugs differently, and can have unique obstacles to effective treatment as simple as not being able to find child care or being prescribed treatment that has not been adequately tested on women.”

Litzke (2005) found that while fathers were more likely than mothers to use and/or become dependent on drugs, mothers were more prone to experience social and psychological issues from substance use. Though the prevalence and impact of shame and stigma among mothers seeking substance use treatment have been established (Chou et al., 2014), historically, shame and punishment have not been effective deterrents for reducing maternal substance use. The societal expectation that mothers assume the role of primary caretakers places an extra pressure on mothers in choosing their options for treatment since treatment may impact their roles as mothers.

While existing literature examines treatment considerations for mothers (Berlin, Shanahan, & Carmody, 2014), children impacted by maternal substance use (Grant, Huggins, Graham, Ernst, Whitney, & Wilson, 2011), and the impact of the child welfare system on family reunification of mothers in treatment (Grant et al., 2011; Grella, Hser, & Huang, 2006), these topics have mainly been studied as separate entities. However, these topics within maternal substance use treatment are not mutually exclusive. For example, Milligan, Niccols, Sword, Thabane, Henderson, and Smith (2011) completed a systematic review of 120 studies examining the length of stay and treatment completion in integrated vs. nonintegrated programs for mothers in substance use treatment. Integrated programs followed the same principles as family-centered substance use treatment, while nonintegrated programs lacked parenting, pregnancy, or children’s services. The authors found that allowing children to stay with mothers and providing ancillary support through prenatal, child, and parenting programs effectively increased mothers’ lengths of stay in treatment. A meta-synthesis explored 12 qualitative or mixed-method studies conducted across Canada and the United States to examine treatment processes and outcomes for mothers with SUDs in family-centered substance use treatment facilities (Sword, Jack, Niccols, Milligan, Henderson, & Thabane, 2009). Results indicated that mothers reported a developed sense of self as well as an enlarged capacity for parenting skills and improved relationships with their children. Likewise, children remained a strong motivating factor for treatment engagement. Traditionally, mothers with substance use problems underwent treatment as a singular process separated from their children. However, these reviews support the idea that conceptualizing and treating addiction within the framework of the family rather than on an individual basis may in fact improve treatment engagement. Further work in this area can help us better understand how having children remain with their mothers during substance use treatment can benefit the family recovery process.

A more recent trend in gender-specific substance use treatment is mother and child (ren) participating in treatment together. This integrated model of treatment provides support and resources for mothers to parent while on the path to recovery. Often, parenting while abstinent is uncharted territory for mothers (and their children), and everyone in the family needs adequate support. Further research has indicated that mothers stay engaged longer in treatment, in both residential and outpatient settings, when they are able to keep their children with them (Grella et al., 2006), ultimately increasing the likelihood they remain abstinent.

MOTHER–CHILD RELATIONSHIP DURING TREATMENT

Recent shifts in the social service field have favored treatment of children with their mothers (Berlin et al., 2014), and research by Fowler et al. (2015) highlights the positive impact of mothering while in treatment. The authors conducted qualitative interviews with four mothers in an integrated substance use treatment program to understand what mothers learned from participating in the program. The mothers reported positive benefits for both themselves and their child(ren). For example, mothers viewed their role of mothering with confidence and reported increased maternal capacity and competence, as well as displaying greater responsiveness, reducing unwanted child behaviors. A systematic review of 13 studies examining pregnant or parenting women enrolled in substance use treatment with at least one parenting or child service found further support for children’s participation in treatment (Niccols, Milligan, Smith, Sword, Thabane, & Henderson, 2012). Results indicated a small, but important, effect size indicator for improvement in children’s emotional or behavioral functioning in treatment programs with parenting or child services components as compared to programs without these services. Thus, the potential benefits of integrating services for children into maternal SUD treatment approaches may positively impact both mothers and their children.

Current Study

The present study seeks to fill the gaps in existing literature on family-centered substance use treatment for maternal substance use by employing a qualitative approach to explore the experiences of mothers with SUDs who had their children living with them in treatment. Specifically, this study seeks to add to the extant literature exploring the nuances of the treatment processes experienced by mothers with SUDs and identify specific components of treatment experiences of mothers working toward recovery. By exploring treatment experiences of mothers through a family therapy context, we can better understand the unique treatment needs of mothers with SUDs and the potential impact on the family system.

METHODOLOGY

This study used a transcendental phenomenological approach to examine the experiences of mothers as they reflected upon having children with them during family-centered residential substance use treatment. Moustakas’s (1994) transcendental phenomenological method focuses on the description of the phenomenon to develop a deeper understanding rather than interpret findings, as is the case with hermeneutic phenomenology (Creswell, 2007). In the present study, the transcendental phenomenological method helped provide a full description of women’s experiences mothering children during family-centered residential substance use treatment. The aim of this study was to expand upon the extant research, which has primarily focused on studying the effectiveness of programming for women by describing mothers’ perceptions of their parenting experiences during residential treatment.

Recruitment

Upon IRB approval, the researchers recruited participants from a family-centered treatment facility in the Midwest for women who have experienced SUDs and mental illness. To be included in the study, participants were required to meet the following criteria: (1) be over the age of 18, (2) be enrolled in residential substance use treatment, (3) have child(ren) 12 years old or younger living residentially with them, and (4) complete the 21-day stay in residential treatment with child(ren) in care.

Participants

Mothers in this study were participating in substance use treatment from a family-centered treatment facility. The treatment center is a voluntary, family-centered behavioral healthcare provider for women with addiction, their children, and their families. The center offers a variety of evidence-based individual and family-based treatment options for addictions, co-occurring disorders, and trauma to best meet the needs of women and children.

In total, recruitment resulted in ten participating mothers; 80% were African American (n = 8) and 20% (n = 2) were Caucasian. The average age of the sample was 38.4 years. Seven women reported being single/never married, one woman reported being married, and two women reported “not applicable.” A majority of the mothers reported living with family (n = 6) prior to treatment. The primary substances participating mothers used included cocaine (n = 5), opioids (n = 3), alcohol (n = 1), and other (n = 1). Five women reported having completed a high school diploma or some college. On average, the women had 2.5 previous treatment episodes. The average number of children in treatment with each participant was 2.4 (range: 1–4 children; see Table 1).

Table 1.

Participant Demographics

Participant	Age	Race/Ethnicity	Children in Care	Treatment Episodes
Judy	32	African American	4	1
Anne	43	African American	3	7
August	36	African American	2	3
Carol	47	African American	1	1
Beckalina	48	African American	4	1
Cheryl	35	African American	3	1
Allie	25	Caucasian	1	3
Cathy	55	African American	2	3
Latoya	30	African American	3	2
Princess	34	Caucasian	1	3

In order to successfully complete the 21-day residential treatment stay, each mother participated in treatment services comprised of group therapy, individual therapy, parenting classes, community support services, and random urine analyses. The program assigned each mother a treatment team of a master’s-level therapist (e.g., LPC) and a bachelor’s-level community support worker who helped determine client readiness to complete level 1 treatment (30 days). Children (12 years and younger) entering the treatment center with their mothers had a treatment team consisting of a master’s-level child therapist and a bachelor’s-level case manager and could participate in day care five days each week. The mothers and their children also had access to a family therapist and a parenting educator.

Data Collection

The principal investigator (PI) and group facilitator recruited participants at the beginning of group meetings by providing details of the study to women who met eligibility criteria and directing them to notify their treatment team if they were interested in participation. The researchers also sent recruitment emails to the treatment center staff to provide information about the research and contact information. The PI and co-PI conducted each of the ten semistructured interviews in a private setting at the agency. Interviews ranged from 30 to 60 minutes, and the researchers recorded and transcribed audio of each one. Participants responded to the following prompts: (1) Tell me about your experiences of motherhood and addiction; (2) Tell me about your experiences of motherhood and treatment; and (3) What advice would you give treatment providers about how to help mothers in treatment?

Analysis

The purpose of transcendental phenomenology is to find details that are consistent across interviews, thereby identifying overarching themes within the experiences of the interviewees (Creswell, 2007). The research team consisted of the principal investigator (PI) and a co-investigator (co-PI) with expertise conducting transcendental phenomenological research. The research team followed Creswell and Poth’s (2018) adapted version of Moustakas’s (1994) structured method of analysis. First, the PI and co-PI read each transcript for significant statements and created a list of nonrepeating statements. Second, the investigators grouped the statements into codes that they used to form broader themes. Third, the research team analyzed each transcript to assess the fit of themes and to propose any necessary changes. This process consisted of extracting participant quotes verbatim from the transcripts, formulating and assigning meaning units, clustering meaning units into organized themes, and using rich descriptions to support these units (Creswell, 2007; Moustakas, 1994). Fourth, upon completion of the initial coding process, a second cycle of coding began, consisting of reading each transcript again and separating the possible themes into distinct, nonrepeating categories that included the setting and context of the phenomenon. Consistent with transcendental phenomenology, the researchers completed analysis both within each case and across all the cases to identify the overarching themes.

Methodological Rigor

To ensure methodological rigor, researchers applied five strategies recommended by Creswell (2007). First, to avoid bias from their own personal experiences, the researchers bracketed experiences similar to their own, allowing them to focus more on the unique details of participants’ experiences (Creswell, 2007). Bracketing consisted of researchers taking memos of their biases and personal experiences regarding maternal substance use that came up during the coding process and then discussing these at the research meetings to help maintain objectivity. Further, as a majority of the women (n = 8) were African American, researchers wanted to be mindful to not impose values or biases onto the women’s experiences. Although racial and contextual factors may impact the experiences of the women in this study, when coding the interviews the researchers did not discuss race in the context of motherhood and recovery, since the target population of this study was not African American mothers but mothers in general. Second, the researchers determined that they had reached saturation following the completion of interviews when the data failed to provide more new insights. Third, the PI and research team independently analyzed the same data to ensure consistency across themes and codes. Fourth, the research team discussed and clarified data codes and themes during monthly meetings. Finally, the team determined and adopted rich descriptions of the phenomena so that this study may be transferable to other populations for replicability (Creswell, 2007).

It is integral to the use of qualitative methodologies that researchers acknowledge and speculate how their own knowledge, values, and beliefs about maternal substance use might influence the research process. The PI is a biracial female who worked at the treatment facility in which the participants had obtained treatment, and all members of the research team had different levels of experience working with families affected by SUDs. While the PI’s relationship with the treatment facility was essential in building trust with clients and staff, the research team was cognizant of the potential conflict of the existing relationship. In addition to bracketing, the researchers adopted procedures to ensure that mothers would not feel coerced into participating in the study. Recruitment occurred through the PI and treatment staff informing potential participants to contact the PI if they were interested in participating. The researchers notified potential participants that their participation was voluntary and that their treatment experience would not be impacted either way. Once eligible participants contacted the PI, they received information about the study, and the researchers set the interview for a later date in order to provide time for the participants to consider the study components.

RESULTS

Analysis revealed themes related to motherhood, parenting, and support for mothers and children. Generally, two themes emerged from the data: (1) grappling with motherhood and addiction leading to the decision for treatment and (2) specific aspects of the treatment program conducive to motherhood. Below, we further describe each theme and corresponding subthemes and contextualize them with participant quotes to provide deeper insight into participants’ experiences mothering children during residential substance use treatment.

Theme One: Grappling with Motherhood and Addiction Leading to the Decision for Treatment

The first theme explored mothers’ struggles with SUDs and the decisions that led to entering treatment. Two subthemes emerged that focused on the participants’ difficult choices prior to treatment: (1) the relapse–recovery cycle and (2) children as a deciding factor for treatment entry and engagement.

Relapse–recovery cycle

The women described their experiences of relapse while parenting. Through their narratives, they recounted an ongoing battle to stay in recovery. Women additionally acknowledged that their children were impacted by the cycle of relapse–recovery, as Anne¹ exemplified: “I’m a chronic relapser so I relapse a lot. I go so far and then I relapse, but it made me and my children have ups and downs.” The relapse–recovery cycle tends to unfold quickly. Participants like August noted that one cycle can almost seamlessly progress into the next: “So, I’m going back and forth, back and forth, back and forth for the next couple of years and the next thing you know, I look up and it’s 2011.”

While some women may relapse back to using the same substance(s), others may try to remain abstinent from their drug(s) of choice but, in doing so, use one or more other substances and relapse nonetheless. Judy recounted how stopping one substance was a catalyst for starting another:

I would try to quit but well I would guess, now that I’ve learned about my disease and my addiction and what it does, I would try to quit one thing but I was always going to something else. Kept thinking, well I’m going to stop smoking weed and I’d pop some pills. Or, I’m going to stop popping pills and I’m going to do this. I’m going to stop snorting powder and go back to weed and then … turned to crack cocaine.

Children as a deciding factor for treatment entry and engagement

Women described attending treatment because they could bring their children with them. Specifically, women reported that their decision to enter treatment hinged on their ability to have their children reside with them during their treatment stay. All of the women (n = 10) discussed either wanting their children in treatment with them or recognizing the benefits of having their children in treatment. Mothers described both the benefits of having their children with them and the worry over potentially not being able to bring their children. Princess explained, “I based my treatment on if I could bring her, number one … I needed to.” Similarly, Judy based her decision to seek treatment on her ability to remain with her children in recovery:

I was so shocked [that they let me come] because when I called, I said, so I want y’all to know I have five kids. … So I have four with me, will they be able to come, I said because I want to be honest with you, if they can’t come, I won’t come.

Judy also went on to explain the necessity of having treatment for the whole family, providing insight into the notion that the whole family experienced the addiction; thus, the whole family needed the support of treatment services.

It’s wonderful, it’s good to me because if I can take them to all the dope spots and find drugs and do all this, I can—they can go through this with me, this was—you know, we all needed a readjustment, we all need to—I can’t even say it, we all needed this.

Likewise, mothers highlighted concern around services that did not support their children. They worried that being separated from their children would impact their ability to initiate and continue treatment. According to Cathy,

[Treatment] drew us closer, and if I hadn’t had them with me, I probably wouldn’t have stayed. I probably would have rather been in a car, but have my kids with me, because I couldn’t—I would always be afraid that somebody is mistreating them or something, or they’re not getting fed, or where are they sleeping?

Indeed, it is not surprising to hear from the mothers that their engagement in treatment would have suffered if they had been separated from their children. Carol echoed this same sentiment and discussed the impact for other women who have children and need treatment but may not have access to family-centered substance use treatment services:

I really believe in kids coming to treatment because a lot of us, … I don’t—even though my son was there, my son didn’t have nowhere to go when I lost my house, and he ended up having to go stay with somebody, and I probably wouldn’t have been able to come and ever get help if they didn’t let me bring my kid.

While the women discussed the ongoing struggle of being a mother and having an addiction, they all felt strongly about the opportunity to bring their children into treatment. The mothers also shared the need to continue to be a parent throughout treatment while taking ownership of parental responsibilities. Likewise, it became evident that not having their children with them could lead to decreased engagement in treatment. They cannot turn off their roles as mothers while in treatment; thus, having their children with them allows them to integrate motherhood into their recovery efforts while simultaneously increasing treatment retention and engagement.

Theme 2: Specific Aspects of the Treatment Program Conducive to Motherhood

The second theme explored specific aspects of the family-centered substance use treatment program the mothers in this study reported were beneficial to their recovery. More specifically, three subthemes emerged, focusing on the perceived beneficial components for the mothers: (1) support from other mothers and staff, (2) parenting in treatment, and (3) benefits for children. Due to the integrated fashion of the care provided in the treatment center and the complexity of treatment needs for families affected by maternal SUDs, these subthemes should be thought of not as mutually exclusive but instead as overlapping and influencing one another.

Support from other mothers and staff

Six of the women reported that treatment staff and other mothers were an integral part of their recovery. While each woman was assigned a treatment team, she likely encountered additional clinical and support staff during her residential treatment stay, such as parenting educators, family therapists, child therapists, and child case managers. For Anne, she felt her counselor was a key support, remarking, “My counselor [XXX], she empowered me. She showed me how to stand on my own two feet and grow up.” Judy highlighted her appreciation for the way that the staff focused on not just her needs but also those of her children: “The staff are real understanding, they know that just like you, we’re going through things, the kids are going through things.”

In treatment, having staff members who provide empathy and support is essential; Beckalina reported, “Our staff was off the chain, they loved us, they wanted us to live.” In addition to the staff support, the opportunity for mothers to bond with one another provided a unique environment of peer support that in some instances extended beyond the scope of treatment. Family-centered treatment also provided children the opportunity to bond with each other. Cathy explained, “We kind of became a family, the kids would play with each other, we would have a movie night, a taco night or something [the staff tried to] encourage others because we couldn’t go out, and we met so many people.”

Forming peer relationships may reduce the risk of isolation as women recognize similar struggles among one another—as mothers with SUDs—while also providing a sense of belonging and support for one another. Latoya described how this support from the other mothers extended beyond the residential setting once treatment was completed: “We always exchanged numbers when we get out of here, you know, I keep them clean, they keep me clean. It’s a support system.” Cheryl felt similarly:

You have to have somebody to relate to, because if it was just me and my kids, I would probably feel odd because it was all single women, but there was other women with kids and I actually met some really nice women that we’re still friends and we’ve been friends.

The bonds that participants forged with staff members, other mothers, and their children created a community, whereas outside of treatment, being a mother with SUDs can be marginalizing. The sense of community developed in a family-centered substance use treatment center seemed to provide a safe space for the women to work together to gain an understanding of their addiction in the context of their roles as mothers and to empower each other on the journey toward recovery. Ultimately, this appeared to support not only their recovery but their family too.

Parenting in treatment

Many women agreed that having assistance while parenting in residential treatment was beneficial. As the mother–child(ren) relationship changed during the treatment stay, having staff who could assist with parenting in the moment became a common thread among the women. For example, the treatment program offered mothers the opportunity to engage in parent–child groups and activities with their children that led to bonding moments. Princess reflected on how much she enjoyed having her children participate in class:

They had a class where you interact with your child, you do activities with your child. So, it kind of teaches you how to be creative, you know, that was helpful on the parenting aspect and it allows you to, you know, have some time like a class with your child. And they enjoy that, oh, mom’s painting with me, this is cool.

In addition to structured activities with children, mothers reported learning different parenting techniques in treatment, which helped guide their changing roles and responsibilities as mothers. They identified the value of learning to parent while sober, which, in turn, supported their recovery. Allie reported, “I learned to not spank and stuff like that and different ways to, I guess different ways to discipline, learning different ways to discipline.” Judy also expressed appreciation for learning alternate ways to discipline her children:

It’s been wonderful to me, I learned how to not just—not even about my addiction, but how to deal with my kids without yelling at them, how to deal with them without always whooping them or how to deal with them as far as—like we’ll name things that we like about each other now, you know, name three things that you like about each other, stuff about my kids that I didn’t even know.

During treatment, subsequent to engaging in parent–child activities and parental skill-building, some women reported a shift in power in the parent–child hierarchy. Mothers described experiences prior to treatment in which, while they were actively using substances, they gave their children more autonomy and less structure. During treatment, children were expected to follow rules put in place by the treatment center as well as new boundaries set by their mother. Thus, the women came to see the value of the healthy communication skills that they learned in parenting classes to reshape roles in the family. Cheryl described her experience with her children as they adjusted to this type of power shift:

So, when we did come to treatment and they started seeing me like actually trying to be a mother, it was kind of hard at first because they weren’t used to me like telling them, oh, you’re not going to do this. Or, we can’t do this because there’s rules and there’s certain stuff we can do and there’s certain stuff we can’t.

One place in which the families could discuss these difficulties as well as their successes was in parenting classes. The participants commonly mentioned these classes during their interviews. The classes offered techniques for parenting as well as bonding with children during recovery. About her experience with parenting classes that included her family, August said, “They’ve got time where you play with the kids all together and stuff like that, they celebrate families.” The women discussed learning that better understanding the physical and emotional needs of their children was essential in building stronger connections and healthier relationships. Cheryl noted how the parenting classes helped her learn how to redirect her child, who was also having difficulty adjusting to being in residential treatment:

The parenting class, I really loved the parenting class because with my 11-year-old, he was like really trying me, really, really, really. So, but if you keep on doing it consistently, he’ll get it—eventually, he was like, not going to do that.

Mothers utilized parenting resources in treatment to support their recovery and build healthier relationships with their children. They spoke of the sense of comfort and calmness that being physically present with their child(ren) during treatment provided, allowing them to focus more fully on their recovery. One mother explained the comfort of being able to walk past the day care, smile at her child, and have her child smile back. This simple interaction allowed for continued bonding and put her at ease so she could focus on treatment. As Ann described, “I learned how to be a good mom by going through those parenting classes and then I took outside parenting. I got certificates and everything.” In addition to the assistance provided during treatment to build competencies as mothers, women discussed the direct benefits of treatment for their children.

Benefit for children

Mothers noted that in addition to getting help for themselves, additional benefits of family-centered substance use treatment were the services and support provided directly to their children. Children had access to the therapeutic day care in addition to individual therapy and case management services. The treatment center also provided other resources vital to daily functioning. As Latoya explained, “He gets therapy. If I need anything for my baby, if they have it they give pampers, socks, wipes, body wash. I got deodorant, he got deodorant, lotion, towels, wash cloths, everything.” Several of the mothers made positive mention of the availability of the on-site day care. Generally, the children attended the day care while their mothers attended treatment. The therapeutic day care offered children a chance to learn new skills. Allie reported,

She loved it here. She loved the staff. She started her manners her manners really lightened up cause she was two, please thank you, and I didn’t have to bribe her to say that—she learned that in daycare. The daycare was a really good program for her.

The day care also offered exposure to play with other age-appropriate children in a safe environment, as Princess discussed: “The fact that, you know, she did go into daycare, she was exposed to other kids versus she’s not with me all the time and there’s not really many little kids in our family no more.” Carol echoed the same sentiment: “Your kids get to meet other kids and let them—and that’s just like—like they say, you’re not alone, so them kids be thinking they be themselves, they’re not by themselves.”

In addition to free childcare, mothers identified that both the individual and family treatment programming directly benefited their children. For example, Cathy identified family sessions as a place “kids could go with you and talk about how they feel.” Latoya similarly reported that she noticed her “kids learned self-esteem, how to build their self-esteem” as a result of the inclusion of family components of treatment. From the mothers’ perspectives, their child(ren)’s self-esteem developed from being exposed to other children in the day care. Likewise, the mothers reported learning how to talk with their child(ren) more effectively through opportunities like practicing positive reinforcement throughout treatment. Because children were directly involved throughout the recovery process, they were positioned to receive the benefits offered from family therapy and treatment services.

DISCUSSION

This study documented and explored the lived experiences of ten mothers who participated in family-centered residential substance use treatment. The goal of this study was to collaborate with the participants to construct a deeper understanding of mothers’ parenting experiences while working toward recovery with their children in treatment together. The in-depth interviews provided an opportunity to use mothers’ own words to document their lived experiences of addiction and recovery while maintaining and, in many cases, enhancing their roles as mothers. Importantly, all the women in the study affirmed that because the facility allowed them to bring their children to treatment, they were motivated to enter and remain engaged in treatment. Clearly, family therapists must consider the barriers unique to mothers in not only obtaining services but also obtaining services that consider the contextual factors unique to mothers, especially those encompassing these women’s children. Indeed, the existing literature on women and substance use well documents that a primary barrier to engagement in treatment for mothers is the lack of adequate childcare (Werner et al., 2007). Women in the present study reported that they were concerned about the safety of their children and that separation from their children would be a deterrent to engaging in treatment. Initiating and participating in treatment was unlikely if women’s children could not attend. While some appropriate treatment settings for mothers surely exist, most programs restrict the number and/or age of children allowed to attend treatment with their mothers. Furthermore, fewer than half of women-only treatment programs provide family-centered services such as childcare (19%), transportation assistance (45%), housing assistance (40%), or domestic violence and employment counseling (44%) (Olmstead & Sindelar, 2004). The lack of comprehensive, mother-friendly treatment services often leads mothers to make the difficult decision to not engage in treatment during a potentially timely opportunity for intervention (Hanson et al., 2015). Once these barriers are removed, as in the case for the mothers in the present study, women have the ability to continue parenting while simultaneously focusing on recovery. Interestingly, along with the current evolution toward family-centered treatment for SUDs there is a growing body of evidence indicating that providing mothers with the opportunity to parent during recovery can, in fact, reinforce and motivate abstinence (Hanson et al., 2015). As mothers experience themselves as competent and sober parents, the quality of their parenting experiences continues to increase, thus further reinforcing sobriety. Indeed, the mothers in the present study discussed this enhanced sense of competency through the various parenting and peer support mechanisms in treatment that were instrumental in their recovery. Because the family-centered substance use treatment facility prioritized the addiction and recovery process in the context of women’s roles as mothers, the treatment was able to support the whole family through this lens.

Treatment Implications for Family Therapists

This exploratory study highlights the positive impact of mothers’ experiences in family-centered substance use treatment, aligning with previous literature that suggests mothers are more engaged in treatment when their children remain in their care (Chou et al., 2014; Grella et al., 2006). The insights gleaned from the participants in this study provide suggestions for further improving programming that supports mothers and their children during the recovery process. The most salient insights from the mothers focused on the importance of establishing treatment programming that supports the entire family. Family therapists’ systemic training is a valued approach in conceptualizing and implementing treatment for mothers with SUDs and their families. Family therapists must continue applying a broad perspective that allows for intervention across multiple systems and considers the context for families impacted by addiction. Below, we provide more specific suggestions to family therapists focused on enhancing family-centered treatment for women, and especially mothers, with SUDs.

Parenting programs

Consistent with extant literature (Fowler et al., 2015), participants in the present study placed great importance on treatment programming aimed at enhancing parenting skills. Indeed, this continues to be critically important as research demonstrates that mothers who abuse substances tend to have difficulty being emotionally available to their children and developing interactive skills, among other challenges (Belt, Flykt, Punamaki, Pajulo, Posa, & Tamminen, 2012). Women in this study discussed gaining helpful insights into the differences between parenting while in recovery and parenting during active drug use. Furthermore, they emphasized their need for supportive services, parenting education, and family therapy to assist during this recovery period. Mothering while in addiction is often a source of shame, and women in this situation may isolate themselves (Brakenhoff & Slesnick, 2015). The parenting groups in this treatment program served as an important space in which women could discuss with peers their difficulties and successes in order to access necessary support while working on their recovery. Other family-based models of recovery have also utilized peer support groups (e.g., Family-Based Recovery, Hanson et al, 2015) for drug-free peer recreation and support, a place to discuss the successes and challenges of recovery and parenting, a place to plan for relapse prevention, and a public venue in which to celebrate sobriety. The women who participated in this study noted that they developed not only a sober community but also, more specifically, a supportive mothering community during treatment that they also maintained upon completion of treatment. This is what treatment providers hope for our clients: that they can develop a sober, supportive network to help maintain their sobriety after the completion of treatment.

Support for children

Women in the present study reported appreciation for the direct support services aimed at meeting their children’s physical (e.g., personal hygiene) and emotional (e.g., therapy and peer groups) needs as well as for the extended benefits to their children as a result of their own learned parenting skills. Extant research highlights the wide-reaching benefits to children for enhancing parenting skills in treatment through the concrete demonstration of reduced child maltreatment (Chaffin et al., 2004). Treatment providers should consider the importance of directly addressing children’s needs because, while children can act as a motivator to mothers in recovery, they can also act as stressors that may contribute to relapse if not also considered during their mothers’ treatment (Werner et al., 2007). Thus, it is imperative for family therapists to develop “in sync” treatment plans for mothers and their children that consider the needs of the entire family system (Werner et al., 2007).

Support from treatment team

A number of women in the study commented that one of the most helpful components of their treatment was the care and support they received from treatment center staff. A compassionate approach to treatment encourages mothers to feel safe and cared for. While community mental health can be an area with high burnout, and because of the correspondingly high levels of stress experienced by treatment providers, it is important that providers not forget that their clients are people suffering from SUDs. Thus, the final point to emphasize is the importance of promoting and supporting the person, as clients are more than the label of “addiction.” The staff in this particular treatment setting prioritized working with the mothers person to person. The mothers who participated in the current study spoke often of the quality and care of the staff. As Beckalina put it, “[the staff] was just like mothers, it wasn’t like it was their job, it was like they took their job home when they took care of [us]—it was awesome.” August admired the staff’s ability to “believe in me when I didn’t believe in myself.” Often, motherhood and addiction are presented in ways that promote shame (Briggs & Pepperell, 2009), which prevents society from seeing mothers apart from their substance use. Thus, a critical part of recovery is to assist women to see themselves as separate from their addiction, which starts with the treatment team being able to model that behavior.

Limitations and Future Research

As is the case with qualitative studies with small sample sizes, the ability to generalize to the larger population of SUD treatment is limited. Because of the composition of the participant sample, it is possible that some of the findings that emerged here will differ from those experienced in other SUD treatment facilities. Additionally, the use of retrospective recall in this study limits the perspective of the women’s experiences over the duration of treatment. Further, while the participants in this study reported positive aspects of having children in family-centered substance use treatment, our focus only on the mother’s experiences here precludes insight into the lived experiences from their child (ren)’s perspectives. Future research is needed examining the children’s experience of treatment to fully understand how residential treatment with children influences the entire family system. Finally, as the sample consisted primarily of African American women, future research should examine contextual factors that impact motherhood and treatment.