Coercion and Drug Treatment for Postpartum Women

Coercion and Drug Treatment for Postpartum Women Based upon the work of Amelia C. Roberts, Ph.D. Professor at the University of North Carolina, Chapel Hill School of Social Work Developed by Ashlie D. West, MSW Student copyright 2001 1

Coercion Controversy Coercion defined: external conditions that drive people to seek treatment [that] do not necessarily reflect inner reasons for changing oneself (DeLeon & Jainchill,, 1986) Raises legal, ethical, clinical, and service delivery issues But, external pressures from family, friends, and courts are necessary for successful treatment, especially for women with children and parenting responsibilities involved in the welfare system (Looney & Metcalf, 1974; Andrews & Patterson, 1995). copyright 2001 2

Coercion, Substance Abuse, and Women Child protective cases involving substance abuse: 21.2% - 80% (Young & Gardner, 1998; Strawn, 1997; Tracy & Farkas,, 1994; Curtis, 1993) Number of child abuse and neglect cases involving parental use of drugs/alcohol has increased over time (Curtis, 1993) Treatments for pregnant and postpartum women abusing substances treatment in lieu of prosecution, involuntary civil commitment, removing child custody, and denial of public benefits (Garcia, 1992) copyright 2001 3

Findings from other coercion studies Statistically significant relationships with treatment seeking (Rounsaville( & Kleber,, 1981), length of time in treatment (Collins & Allison, 1983; Simpson, 1993; Mark, 1988), and program completion (Grella( et al., 1994; Siddall & Conway, 1988). Those who were coerced into treatment did as well as, if not better than, voluntary treatment (Collins & Allison, 1983; Brizer, Maslansky,, & Galanter,1990; Brecht, Anglin, & Wang, 1993; DeLeon,, 1988; Maddux,, 1988). Legal pressures negatively correlate, with outcomes across different drug abuse treatment modalities (Harford, Ungerer,, & Kinsella,, 1976) Have no predictive power regarding treatment retention (DeLeon & Jainchill,, 1986; Fagan & Fagan, 1982). copyright 2001 4

Methods for this study: Participants 292 Participants 83.1% referred by the local child protective services agency 8.0% referred by local hospitals 6.0% referred by other social service agencies 2.8% self-referral copyright 2001 5

Methods for this study: Procedure Psychiatric social worker assessed participants appropriateness for outpatient services; Participants were randomly assigned to a treatment program (after informed consent); Structured interviews (lasting approximately 2.5 hours) were conducted prior to treatment, and at 3, 6, and 12 months post discharge. Additional information considered included length of time in treatment, discharge status, and child custody (obtained from various case records). copyright 2001 6

Intensive Day Treatment vs. Traditional Outpatient Treatment Based on gender-specific Male-based philosophy, philosophy in meeting the needs with added gender of women specific components Required participation 7 days Required 1.5 hours per day, at least once weekly per week, for 5.5 hours a day Less structured, less Same services as traditional intensive, and less outpatient comprehensive Unique services: family therapy, Individual and group childcare arrangements, counseling, women s transportation, and infant support groups, psycho- assessment and tracking educational groups, provided by pediatric nurse medical assessment, case management specialist 6 month duration 6 month duration copyright 2001 7

Instrumentation Coercion: a) prompted by criminal justice system, b) subject on probation or parole, c) subject awaiting trial, d) subjective rating of the seriousness of the subject s legal problems, e) subject s s custody of infant (obtained from local child protective service agencies) Addiction Severity Index (ASI): basic demographic information; assess seven life areas associated with drug use Beck Depression Inventory (BDI): 21-item instrument to assess the severity of depression in adolescents and adults (Beck, Ward, Mendelson, Mock, & Erbaugh,, 1961) copyright 2001 8

Instrumentation continued Brief Symptom Inventory (BSI): subscale used to measure anxiety; self-report inventory to measure nine psychological symptom patterns (Derogatis( & Spencer, 1982) Hudson (1982) index of self-esteem: esteem: 25-item scale measuring individual s s problem with self- esteem Nowicki-Strickland Locus of Control: : 40-item scale to assess the construct of locus of control of reinforcement (Nowicki( & Duke, 1974) copyright 2001 9

Findings - Demographics 94% African American women, 4.0% Hispanic,1.2% White, 0.8% Other Average age: 30.6 years, ranging from 16 to 45 years Average number of children: three, ranging from 0 to 12 88% fell in the lower two socioeconomic strata 71% unemployed during the previous 2 years 58.7% had at least a high school education copyright 2001 10

Findings Drug Use and Treatment History Choice of drug: cocaine (51.6%), combination of cocaine and other substance (32.1%) 81% polydrug users 91% had no previous treatment, remaining 9% had an average of 1 prior treatment episode 35.3% reported no family member with a substance abuse problem ASI drug use composite score was 0.13 (scores range from 0 to 1, higher scores indicate greater problem severity). 85% rated their need for treatment as either considerable or extreme; only 5.2% said that treatment was not important now About half reported being abstinent at entry copyright 2001 11

Findings Psychological Status Depression: : 46% scored in the normal range, 30% scored mild to moderate, 17.9% in the moderate to severe, and 6% in the severe to extreme range; average score was in the normal range Anxiety: : average score in the very low anxiety range, which was lower than that reported by pregnant women who reported some degree of substance use and slightly higher than non-patient population (McLellan( et al., 1994) Self-esteem esteem: : 40.2% had a clinically significant problem with self-esteem; esteem; 1.2% had scores indicating a severe level of problems with self-esteem esteem copyright 2001 12

Findings Coercion 9.9% reported being on probation or parole; 10.3% awaiting trial; About half reported treatment prompted by the criminal justice system mandated by the Dependency Court and child welfare system; 42.5% responded that their legal problems were considerable or extreme copyright 2001 13

Findings Child Custody 48.8% had custody of their infant Women who had custody of their infant remained in treatment longer than non-custodial mothers For women in day treatment, almost 60% of those who had custody of their infant successfully completed the program; 32.4% of non-custodial mothers completed the day treatment program For women in the outpatient program, non- custodial mothers reported more severe legal and social problems copyright 2001 14

Support in favor of coercion Women who were coerced by the criminal justice system AND had custody of their children remained in treatment longer. Women who had custody and were in the more intensive day treatment program completed treatment at substantially higher rates than those in the other, more traditional outpatient program. This study supports the previous empirical evidence that demonstrates that more services equal better outcomes (McLellan et al., 1994) and that gender sensitive treatment programs have greater success with women in recovery (Roberts & Nishimoto,, 1996; Dahlgren & Willander,, 1989; Stevens & Arbiter, 1995). copyright 2001 15

Implications for Social Work Practice Child welfare workers must be able to competently assess the family s s risk and protective factors concerning both child protection and substance abuse issues. Identifies the need for education and coordination between systems of care (medical, child welfare, and criminal justice system) to accurately assess and provide services that would ensure successful recovery Treatment programs need to be able to treat the addiction of the mother, and support the needs of the children. copyright 2001 16

Implications for Social Work Practice - continued Additionally, treatment programs need to be gender- sensitive and provide ample space for children. Policy-makers must allocate funds for intensive outpatient gender-sensitive programs for pregnant and postpartum women Policy decisions regarding mandated treatment must acknowledge discrimination toward minority women. Practioners need to be aware of mediators toward treatment success, including child custody, psychological health, social support, and internal motivation copyright 2001 17

Future Research Longitudinal studies to determine the long-term impact of coercion and custody; Culturally competent treatment programs, with specific components needed for successful outcomes; client s perception of coercion at intake, discharge, and follow- up (Monahan et al., 1995); Examination of coercion across diverse cultures of women, socioeconomic levels, and treatment methods (therapeutic communities, intensive outpatient, outpatient, etc.) and how they intervene with coercion and treatment success. This will impact the development of individualized treatment programs, based on the individual s s specific needs and value systems. copyright 2001 18

Reference Nishimoto,, R.H. & Roberts, A.C. (2001). Coercion and drug treatment for postpartum women. American Journal of Drug and Alcohol Abuse, 27 (1), 161-181. 181. References from information cited in article and slideshow: Rounsaville,, B.J., & Kleber,, H.D. (1981). Untreated opiate addicts: How do they differ from those seeking treatment? Arch. Gen. Psychiatry, 38, 875-880. 880. Looney, M. & Metcalf, S. (1974). The Fatigue Factor in drug addiction: Insufficient motivation for treatment. Hospital and Community Psychiatry, 25 (8), 528-530. 530. Andrews, A.B. & Patterson, E.G. (1995). Searching for solutions to alcohol and other drug abuse during pregnancy: Ethics, values, and a constitutional principles. Social Work, 40 (1), 55-64. Collins, J.J., & Allison, M. (1983). Legal coercion and retention n in drug abuse treatment. Hospital and Community Psychiatry, 34 (12), 1145-1149. copyright 2001 19

References continued DeLeon,, G., & Jainchill,, N. (1986). Circumstance, motivation, readiness, and suitability as correlates of treatment tenure. Journal of Psychoactive Drugs, 18 (3), 203-208. 208. Young, N.K., & Gardner, S.L. (1998). Children at the crossroads. Journal of the American Public Welfare Association, Winter, 3-10. 3 Strawn, J. (1997). Substance abuse and welfare reform policy. Welfare Information Network. http://www.welfarewatch.org www.welfarewatch.org. Tracy, E.M., & Farkas,, K.J. (1994). Preparing practitioners for child welfare practices with substance-abusing abusing families. Child Welfare, 73 (1), 57-68. Curtis, P.A., & McCullough, C. The impact of alcohol and other drugs d on the child welfare system. Child Welfare, 72 (6), 533-542. 542. Garcia, S. (1992). Drug abuse in America: Medical and socio-legal dilemmas. Med. Law, 11,, 323-335. 335. English, A., & Henry, M. Legal issues affecting drug-exposed infants. Youth Law News, 11 (1), 1-14. 1 14. Simpson, D.D., & Joe, G.W. (1993). Motivation as a predictor of early dropout from drug abuse treatment. Psychotherapy, 30 (2), 357-368. 368. copyright 2001 20

References continued Garcia, S. (1993). Maternal drug abuse: Laws and ethics as agents s of just balances and therapeutic interventions. Int. J. Addict., 28 (13), 1311-1339. 1339. Harrison, M. (1991). Drug addiction in pregnancy: The interface of science, emotion, and social policy. Journal of Substance Abuse Treatment, 8, 261-268. 268. McNulty, M. (1990). Pregnancy police: Implications of criminalizing ing fetal abuse. Youth Law News, 11 (1), 33-36. 36. Schottenfeld,, R.S. (1989). Involuntary treatment of substance abuse disorders - Impediments to success. Psychiatry, 52, 164-177. 177. Harford, R.J., Ungerer,, J.C., & Kinsella,, J.K. (1976). Effects of legal pressure on prognosis for treatment of drug dependence. American Journal of Psychiatry, 133 (12), 1399-1404. 1404. Mark, F.O. (1988). Does coercion work? The role of referral source in motivating alcoholics in treatment. Alcoholism Treatment Quarterly, 5 (3/4), 5-22. 5 Brizer,, D.A., Maslansky,, R., & Galanter,, M.. (1990). Treatment retention of patients referred by public assistance to an alcoholism clinic. c. American Journal of Drug and Alcohol Abuse, 163 (3/4), 259-264. 264. copyright 2001 21

References continued Grella,, C.E., Anglin,, M.D., Wugalter,, S.E., Rawson, R., & Hasson,, A. (1994). Reasons for discharge from methadone maintenance for addicts at high risk of HIV infection or transmittion. Journal of Psychoactive Drugs, 26 (2), 223-232. 232. Brecht,, M.L., Anglin,, M.D., & Wang, J.C. (1993). Treatment effectiveness for legally coerced versus voluntary methadone maintenance clients. American Journal of Drug and Alcohol Abuse, 19 (1), 89-106. Siddall,, J.W., & Conway, G.L. (1988). Interactional variables associated with retention and success in residential drug treatment. International Journal of Addiction, 23 (12), 1241-1254. 1254. DeLeon,, G. (1988). Legal pressure in therapeutic communities. Journal of Drug Issues, 18 (4), 625-640. 640. Maddux,, J.F. (1988). Clinical experience with civil commitment. Journal of Drug Issues, 18 (4), 575-594. 594. Fagan, R.W., & Fagan, N.M. (1982). The impact of legal coercion on the treatment of alcoholism. Journal of Drug Issues, 12,, 103-114. 114. Beck, A.T., Ward, C.H., Mendelson,, M., Mock, J., & Erbaugh,, J. (1961). An inventory for measuring depression. Arch. Gen. Psychiatry, 4, 561-571. copyright 2001 22

References continued Derogatis,, L.R., & Spencer, P.M. (1982). The brief symptom inventory: administration, scoring, and procedures manual. Vol. 1. Baltimore: Clinical Psychometric Research. Hudson, W.W. (1982). The clinical measurement package: A field manual. Chicago: The Dorsey Press. Nowicki,S.. & Duke, M.P. (1974). A locus of control scale for college as well as non-college adults. Journal of Personality Assessments, 38, 136-137. McLellan,, T.A., Alterman,, A.I., Metzger, D.S., Grissom, G.R., Woody, G.E., Luborsky,, L., & O Brien, O C.P. (1994). Similarity of outcome predictors across opiate, cocaine, and alcohol treatments: Role of treatment services. Journal of Contemporary Clinical Psychology, 62, 1141-1158. 1158. Roberts, A., & Nishimoto,, R. (1996). Predicting treatment retention of women dependent on cocaine. American Journal of Drug and Alcohol Abuse, 22 (3), 313-333. 333. Dahlgren, L., & Willander,, A. (1989). Are special treatment facilities for female alcoholics needed? A controlled 2-year 2 follow-up study from a specialized female unit (EWA) versus a mixed male/female treatment facility. Alcohol. Clin.. Exp. Res., 13 (4), 499-504. copyright 2001 23

References continued Stevens, S.J., Arbiter, N. (1995). A therapeutic community for substance-abusing abusing pregnant women and women with children: Process and Outcome. Journal of Psychoactive Drugs, 27 (1), 49-56. Monahan, J., Steven, K.H., Lidz,, C., Roth, L.H., Bennett, N., Gardner, W., Mulvey,, E. (1995). Coercion and commitment: Understanding involuntary mental hospital admission. International Journal of Law Psychiatry, 18 (3), 249-263. 263. copyright 2001 24