(p. 365) Intervention with Mothers Who Abuse Alcohol and Drugs: How Relationship and Motivation Affect the Process of Change in an Evidence-Based Model
“There were times when I felt like I was going to relapse and my case manager would be there for me, and she’d keep checking on me and I’d get through it. I’ve learned so much about myself and being responsible again and being a good mother.”
In the mid-1980s, cocaine was at the height of popularity in the United States, and our research team at the University of Washington was awarded a federal grant to study the effects of prenatal cocaine exposure on young children. The research protocol involved enrolling 500 high-risk cocaine-using pregnant mothers, interviewing them, and bringing their babies into our laboratory for periodic neuropsychological testing. Study findings confirmed our hypothesis that prenatal cocaine exposure is not a good thing, but in many ways the most important lessons were those we learned directly from the mothers themselves. We listened carefully as we spent time with them in their cramped apartments, listening to stories of family dysfunction that seemed horrific to young researchers, but were “just the way it is” to the mothers. They wanted to be “good mothers” but were instead giving their babies the same kind of upbringing they had experienced as children. They didn’t know any other way.
As the cocaine study came to an end, it seemed to us that a more compelling challenge than studying effects of prenatal substance exposure would be to work in a meaningful way with the high-risk mothers who delivered these babies—to help them take care of the children they already had, and avoid future births of exposed and affected children. Thus began the Parent-Child Assistance Program (PCAP).
Parent-Child Assistance Program (PCAP)
PCAP began (in 1991 at the University of Washington, Seattle) as a federally funded research demonstration project designed to test the efficacy of a three-year (p. 366) intensive home visitation and case management intervention among substance-abusing pregnant and parenting women, and their children (Ernst et al., 1999; Grant et al., 2003; Grant et al., 2005). PCAP’s primary aims are: to help mothers obtain alcohol and drug treatment, stay in recovery, and resolve the myriad of complex problems related to their substance abuse; to assure that the children are in safe, stable home environments and receiving appropriate health care; to link mothers to community resources that will help them build and maintain healthy, independent family lives; and to prevent the births of future alcohol- and drug-affected children.
In their study of outpatient and home visitation parenting interventions for substance-abusing women and their children, Suchman et al. (2006) reviewed published evaluations of quasi-experimental and experimental studies with regard to their impact on drug abuse, maternal adjustment, parent–child interactions, and child outcomes. PCAP (formerly known as the “Seattle Birth to Three Program”) was one of six studies that met criteria for the review. Suchman and her colleagues highlighted two fundamental characteristics of PCAP that may account for its high retention and positive outcomes among high-risk mothers: the emphasis on relationship quality between mothers and their case managers/home visitors; and the use of motivational interviewing (MI) strategies that encourage mothers to examine conflicting emotions as they struggle in the process of replacing risky behaviors with healthy, adaptive ones. A third fundamental characteristic of PCAP that may also account for its success is its emphasis on professional supervisory support for the paraprofessionals who deliver the intervention.
Critical Objectives and Components
The PCAP model has been widely replicated in the United States and Canada, and a question often asked is, “What makes the model work?” The purpose of this chapter is to describe the defining principles and key clinical practices that distinguish PCAP. We will explain how PCAP integrates MI strategies into the relational work we do with the clients while taking into account their roles and experiences as mothers. We will also describe PCAP’s approach to supporting the paraprofessional case managers in this work that is so often characterized by frustration and burnout. Our intent is to inform interventionists working with this special population of substance-abusing mothers and their children, and to provide guidance to researchers interested in studying this hard-to-reach population.
Mothers who enroll in PCAP exemplify the intergenerational nature of familial substance abuse and dysfunction; they were often themselves the neglected and abused children in our communities just a decade or two ago. As children, of the 753 women currently enrolled at nine PCAP sites in Washington State, 90% had substance abusing parents, 68% were physically and/or sexually abused, 64% ran away from home, and 31% had had child welfare services involvement (Grant & Ernst, 2011).
(p. 367) Children who have experienced these kinds of traumatic events are at risk for long-term biological, developmental, and behavioral problems (Atchison 2007; Casanueva et al., 2008; Conners et al., 2003). Their early devaluing experiences can impair the emotional foundations for development by inhibiting self-expression and self-directed action, thus limiting autonomy and intimacy and increasing the risk for future victimization (Jack, 1991; Jack & Dill, 1992; van der Kolk, 2005).
Characteristics of PCAP clients at enrollment reflect the consequences of early trauma on their adult development. At intake, clients are typically in their late twenties, and their life circumstances are almost always grim: most are unmarried (92%), beaten by their partners (77%), have a history of incarceration (76%), and are on public assistance (71%); approximately 69% are homeless or living in temporary housing, including treatment or transitional housing (Grant & Ernst, 2011). All have a history of substance abuse during the most recent pregnancy, and many use alcohol or drugs to self-medicate and cope with the psychological and sometimes physical pain of a lifetime of traumatic events (Gentilello et al., 2000; Kilpatrick et al., 1997; Kilpatrick et al., 1998; Martin et al., 2003; Najavits et al., 1997).
Mothers with co-occurring substance use disorders and trauma symptomatology have been shown to have significant parenting problems (Cohen et al., 2008). Mothers in PCAP, for example, have on average 2.7 biological children, over half of whom are not in their custody. Loss of custody is usually not related to the mother’s direct abuse of her child. Instead, it is her substance abuse, involvement in the drug culture, lack of attention to the family, and poor judgment with regard to who she allows to come into contact with her children that lead to potentially dangerous situations and removal of the children from the home. A mother may have provided adequate basic care in the home, but her children are removed because she is arrested and incarcerated for drug use, possession, or sales. In other cases, a mother may continue to be involved in an extremely abusive relationship with a man, placing her and her child at serious risk. Circumstances are complicated by the fact that in either of these situations the mother may lose her subsidized housing, but her housing must be in place in order to regain care of her children.
Paradox of High Risk and Insufficient Treatment
Poor parenting in high-risk mothers with co-occurring disorders contributes to the intergenerational transmission of increased risk for substance use and mental health disorders in their children (Dube et al., 2003). These mothers are often labeled as unmotivated and difficult to reach, and many professionals view them as a hopeless population (Greenhouse, 2000; Nelson & Marshall, 1998; Paltrow et al., 2000; Will, 1999). Consequently, they often become distrustful of and alienated from community resources. This disenfranchising process results in mothers who are at greatest risk for having children with serious developmental and psychosocial problems being the least likely to seek and receive assistance from community resources.
(p. 368) Snapshot of Retention and Promising Outcomes
PCAP’s retention rate is nearly 70%. A recent analysis of PCAP outcomes (Grant et al., 2011) found that among 739 mothers who enrolled from January 1998 through December 2004 at five PCAP sites in Washington (King, Pierce, Yakima, Spokane, and Grant counties), 132 (18%) did not complete the program because they disengaged or disappeared (n = 45), moved out of area (n = 37), withdrew (n = 35), died (n = 10), or went into prison long-term (n = 5). An additional 108 (14.6%) participated in PCAP but did not complete the exit interview (reasons include no-shows, could not be located, were too busy, and did not want to end PCAP). A total of 499 (67.5%) participated in PCAP and completed valid intake and exit interviews. In comparison with our approximately 30% attrition rate, Gomby and colleagues (1999) reviewed six home visiting programs and reported attrition rates ranging from 20% to 67%. Katz et al. (2001) reported 41% attrition in a research study including lay home visitation.
Final analyses of this cohort included data from 458 mothers. A total of 41 were excluded for these reasons: had a fetal alcohol spectrum disorder and were enrolled in a separate study, n = 22; exited the program early (< 30 months of PCAP involvement), n = 11; and the index child died or was miscarried, n = 8. Among these 458, 24.9% had a subsequent birth during the three-year PCAP intervention (10.5% were alcohol- or drug-exposed, and 14.4% were alcohol- and drug-free pregnancies). By way of comparison, Ryan and colleagues (2008) found that among 931 substance-abusing women enrolled in a demonstration project, after only 1.5 years of follow-up, 15% of the intervention group and 21% of the control group had a subsequent alcohol- or drug-exposed birth.
At PCAP exit, 71.2% of the mothers were at reduced risk for delivering another exposed child, either because they had been abstinent from alcohol/drugs for at least six months or because they were using a family planning method consistently. Most of the clients had completed inpatient (62.5%) or outpatient (83.2%) treatment (prior to PCAP, 81.4% had attempted inpatient treatment, an average of 3.2 times); at exit, 40% were currently abstinent from alcohol and drugs for at least six months; during PCAP, 77.1% had been abstinent from alcohol and drugs for a period of at least six months. At PCAP exit, 62.8% were using a method of family planning regularly (vs. 12.2% using contraception prior to the target pregnancy), and of these 77.8% were using more reliable methods such as Depo-Provera injections, IUD, or tubal ligation; 30.6% were receiving any income from employment (vs. 4.6% at intake); and 71.8% were in permanent, stable housing (vs. 37.8% at intake).
Our analyses explored the complicated interplay of how maternal risk and protective characteristics and service elements are associated with disrupted parenting and reunification. At PCAP exit, 60% of the mothers were caring for their index child (the child they had been pregnant with at intake). During the intervention, these mothers had more treatment and mental health service needs met, more time abstinent from alcohol and drugs, secure housing, higher income, and support for staying clean and sober. Among women who had multiple psychiatric diagnoses, (p. 369) the odds of regaining custody were increased when they completed substance abuse treatment and also had a supportive partner. Mothers who lost and did not regain custody had more serious psychiatric problems and had fewer service needs met. Their untreated mental health problems may have limited their ability to access mental health services, anticipate and resolve serious problems, and utilize available community services to build a stable home environment and maintain child custody (see Grant et al., 2011, for a full account of study details and findings).
Universal Principles: The Intervention Backdrop
Before describing the distinguishing aspects of the intervention, we briefly summarize here the important but more universal principles that provide the intervention’s foundation: case management, structured implementation, long-term intervention, developmental perspective, and parallel process.
The PCAP model incorporates fundamental and well-known components of effective case management (Case Management Society of America, 2010). It is individually tailored, promotes the competence of the client, is community-based and multidisciplinary, and considers the dynamics of the family.
The intervention has a well-defined, structured, and manualized protocol for implementation (available at http://depts.washington.edu/pcapuw/) but also involves the practice of continually examining and reflecting on what works and what does not. The manual and structure insure that the principles of the intervention are delivered in practice at a “dose level” that is sufficiently strong.
As a three-year intervention, PCAP offers a realistic length of time during which a woman can form a therapeutic alliance with her case manager and undergo the developmental process of making gradual behavioral changes. The beginning of this process is naturally slow and tentative for most clients, who have never known the steady presence of a trusted parent or other individual in their lives (in fact, many clients state that their own mother first introduced them to drugs). The three-year duration also provides a clear time frame during which clients know they will have assistance; in this way it serves as an external motivator to completing their goals.
The model embraces a developmental approach at multiple levels: the development of the mother as an individual and as a parent; the development of the child; and (p. 370) the professional development of the PCAP case manager. Mothers who grew up with substance-abusing parents experienced insensitive and unreliable caregiving, at best. They knew the emotional pain of having a mother and/or father who did not respond to their distress, and this childhood environment contributes to their fundamental, persistent beliefs that relationships cannot be trusted. Their ability to recognize healthy relationships continues to be compromised. As mothers, this trajectory is evident in their difficulty responding in a developmentally appropriate manner to their own child’s emotional cues and distress signals, and in their difficulty in identifying and connecting with healthy individuals who will not pose a threat to the family. PCAP offers these mothers, perhaps for the first time, the opportunity to develop a different kind of relationship. Over the three years, as the case manager works closely with the mother and implements intervention strategies, the woman begins to make positive strides and gradually recognizes that this relationship is a healthy one that allows her to grow. As she trusts the case manager and experiences the reliability of the relationship, she becomes more capable of offering consistent attention and care to her child.
The attention, care, and support that case managers give to their clients is expected to be reflected in the way the mothers interact with their children. Accepting and supporting the mother in her troubled (and often painful) physical, emotional, and social domains not only helps the mother engage in treatment and avoid relapse, but may also gradually enhance her capacity to care for her child physically, emotionally, and socially. Similarly, the PCAP case managers receive close attention, care, and support from their clinical supervisors, as described below.
Defining Principles and Key Clinical Practices
In this section, we review the constellation of principles that define PCAP, distinguish it from other programs for high-risk substance-using parents, and are believed to explain its clinical efficacy. These principles place special emphasis on relationship, motivation, paraprofessional role modeling, attending to neurological deficits associated with chronic drug use, harm reduction, preventing harm to the child, being realistic about parenting potential, and developmental supervision. We also explain how each principle is translated into practice, and provide research findings when available.
Two relational constructs inform the therapeutic approach with clients and shape the day-to-day case management practices. Relational theory underscores the importance of interpersonal relationships to women as they grow, develop, and (p. 371) define themselves (Miller, 1991; Surrey, 1991). Therapeutic alliance—the process through which a mental health professional builds rapport and engages with a patient in order to help the person achieve desired change (Orlinsky et al., 2004)—is also considered vital. Therapeutic alliance has been well studied by addiction researchers and practitioners and found to be critical to successful outcomes among women with substance-abuse disorders who are in intervention, treatment, and recovery settings (Amaro & Hardy-Fanta, 1995; Finkelstein, 1993). Therapeutic alliance has also been shown to determine the extent of patient compliance and retention in an intervention (Barnard et al., 1988), and it may be more important to treatment outcomes than concrete services received (Pharis & Levin, 1991).
The PCAP model puts concepts of relational theory and therapeutic alliance into practice by offering personalized, knowledgeable, and compassionate support from a single case manager who works consistently with her clients for three years. We prioritize hiring paraprofessional case managers who have successfully overcome difficult personal, family, or community life circumstances similar to those experienced by their clients (e. g., substance abuse, single parenting, poverty). Case managers who have undergone difficult change processes and achieved successes (e.g., in education, employment, and relationships) are realistic role models who share their experience of recovery with clients and inspire the hope that it is possible to overcome obstacles.
PCAP clients often present defensively at the start of the intervention; most are ashamed of their substance use in pregnancy and know they have poor parenting skills. The case managers’ shared history allows them to literally “get in the door” on home visits—because they are more easily perceived as understanding and empathetic with the client’s situation, allowing them to more easily build rapport with those who might be unapproachable. The case managers’ sustained empathetic peer guidance, offered in the context of teaching and role modeling, promotes the client’s social and emotional development as she learns to trust others, build practical skills, and gradually trust in herself.
PCAP case managers spend an average of approximately two hours of face-to-face time with each client every other week, and an additional 40 minutes per week working with the client’s family or service providers. The amount of time spent undoubtedly reflects the complexity of the mother’s problems and the personalities involved, but “time spent” may also reflect the extent to which the case manager has developed a successful relationship with her client.
We surmised that more time and more positive and therapeutic relationships with the case managers contribute to clinically relevant maternal outcomes, and data among 458 recent PCAP graduates indicate a moderate “dose–response” effect. When we compared outcomes among clients who spent an average of 30 minutes (p. 372) per week or more with their case managers versus those who spent less time together, we found that those who spent more time were more likely to complete inpatient or outpatient treatment (87% vs. 81%, respectively); to be abstinent from alcohol and drugs for at least six months at PCAP exit (40% vs. 34%); to have had any six-month or longer period of alcohol/drug abstinence during PCAP (85% vs. 70%); and to be using a reliable family planning method (58% vs. 48%) (Grant & Ernst, 2011).
At exit from PCAP, clients are asked to assess the relationship with their case manager using the Advocate-Client Relationship Inventory, a 27-item instrument, adapted with permission from Kathryn Barnard (Barnard, 1998; Sikma & Barnard, 1992). The inventory’s four constructs are based on Barnard’s conceptualization of the home visitor’s role, and PCAP uses the instrument because these constructs reflect PCAP’s central principles and the case managers’ role. The four constructs include: 1) coach (seven items on the supportive role of a coach, who helps someone reach her potential; 2) ongoing developmental (six items on the role of assisting the mother in her role as an adult, a mother, and a family member); 3) caring (ten items on being emotionally involved, being present, doing for, giving hope); and 4) harmony (four items on harmony among the mother, her family and the case manager).
Among 754 PCAP clients who have completed the inventory, at least 85% agreed or strongly agreed with nine of the ten “caring” constructs, five of the seven “coaching” constructs, and three of the six “developmental” constructs. Fewer clients (68% to 83%) agreed with items in the “harmony” construct, which is perhaps not surprising, because the case managers help clients make major behavioral changes that may create disruption in dysfunctional family systems (Grant & Ernst, 2011).
Stages of Change and Motivational Interviewing
“Stages of Change” theory recognizes that people will be at different stages of readiness for change at different times, and that ambivalence about changing addictive and other behaviors (e.g., parenting) is normal and should be expected (Prochaska & DiClemente, 1986). Motivational interviewing is a corresponding counseling style developed by Miller and colleagues (1991) that helps clients examine and resolve ambivalence about change and increase intrinsic motivation to change.
MI strategies are based on four basic principles: expressing empathy, developing discrepancy, accommodating to resistance, and supporting self-efficacy (Miller & Rollnick, 1991; Prochaska & DiClemente, 1986; Rollnick & Bell, 1991). The principles embodied in MI naturally complement relational theory, because they call for clinicians to be empathetic and nonjudgmental, to listen closely and respectfully to the client, and to accept and trust in the client’s perception and judgment about her own life. The self-efficacy principle of MI complements PCAP clinical practices because a person’s self-efficacy (i.e., her belief in her ability to behave in ways that will lead to desired outcomes) will be influenced most powerfully by her own history of accomplishment (Bandura, 1977).
(p. 373) Clinical Practice
PCAP case managers are trained and reinforced in the use of MI strategies. In practice, the most important way in which a PCAP case manager has a positive effect on her client’s self-efficacy is by listening carefully to her about what is important and how she thinks about her problems, and valuing this self-expression. Case managers then promote self-directed action by helping clients define and accomplish explicit goals toward behavioral change, and then recognize and celebrate the positive steps they have taken.
PCAP case managers use the “Difference Game” periodically throughout the intervention (Grant et al., 1997) to teach and reinforce the practice of setting and achieving goals. Adapted from a scale developed by Dunst et al. (1988), the game is a card-sort instrument consisting of 31 cards, each of which names a possible client need (e.g., “housing,” “safe daycare,” “drug or alcohol treatment”). The client sorts the cards into two piles, items that would “make a difference” and those that “would not make a difference.” The client selects the five items that represent her most important needs. The case manager then engages the client in a conversation about each card selected (“Tell me about this …).
For example, one client in PCAP selected the seemingly benign card “Time to get enough sleep.” As her story slowly emerged, the case manager learned that the mother did not sleep well because she was (appropriately) worried that someone in her temporary household might sexually abuse her child. After they completed the Difference Game, and using motivational strategies, the case manager worked with her client to identify a few specific, meaningful goals she would like to work on in the next two to four months. Together they agreed on realistic, incremental steps they would each take toward meeting the goals, and who would be responsible for accomplishing each task.
It is critical that some steps, no matter how small, be attainable by the client within the designated period, because it is as she observes herself accomplishing desired behavior that her sense of self-efficacy develops. In the example above, the larger goal was to move into a permanent, safe home, given limited affordable options. The first step was for the case manager to identify two acceptable temporary options and arrange visits so the client could see the spaces, make her own informed choice, and retain a sense of agency.
At the same time, the case manager worked with the client to complete lengthy and detailed applications required for more permanent housing. As they dealt pragmatically with the housing issues, and using strategies of MI (expressing empathy, rolling with the client’s resistance to addressing past painful memories of her own abuse), the case manager helped the client understand the value of talking with her mental health therapist about the situation and its relationship to her own past, and the opportunities she had now to respond differently to the potential threat to her own child.
The PCAP goal-setting activity is designed to be dynamic, and is repeated every four months throughout the intervention. This ongoing process allows for the client’s gradual development: from initial dependence on the case manager’s assistance and support, to interdependence as they work together to accomplish steps (p. 374) toward goals, to independence as the client begins to trust in herself as a worthwhile and capable person, and learns (to the extent she is able) the skills necessary to improve the quality of life for her and her children.
Role-Modeling and Teaching Basic Life Skills
Our clients simply do not have the skills “their mothers should have taught them.” They rarely have a mental template for what healthy adult life or parenting might look like, and their bleak backgrounds have done little to prepare them for these responsibilities. In addition, they typically have poor emotional regulation and interpersonal skills, and may respond to problems and disappointments with other adults and with their own children with poorly controlled anger, or withdrawal. The simple approach of consistent support and modeling is a powerful one that has the potential to help women change entrenched family patterns. The comments of a PCAP mother with two children under the age of two illustrate this point: “I really liked working with [case manager]. She was very supportive and taught me to be more observant of my kids. If they do something now, I know they are trying to tell me something so I try to respond. I am trying to reverse the chain. I got beat up as a kid. I didn’t get anyone who sang to me or played with me. I am trying to do these things with my kids. [Case manager] taught me how to do this.”
PCAP case managers model positive interpersonal behaviors in order to teach the clients how to improve and maintain relationships so they will eventually be able to manage competently on their own. PCAP mothers and their children are typically highly dependent on community providers for a range of comprehensive services. One of the case manager’s responsibilities is to meet periodically with members of the client’s service provider network with the client present, in order to develop service plans that meet the client’s needs while addressing providers’ concerns. In preparation for these meetings, the case manager helps the client identify her feelings and organize her thoughts. She then works with the client to practice articulating her views. Over time, the client can learn to speak up in a way that demonstrates self-respect and regard for others, and indicates that she understands how to work more effectively with others.
Attending to Neurological Deficits
It is essential that case managers consider the impact of alcohol and drug use on neurocognitive functioning among clients, including impairments in attention and concentration, learning, impulsivity, abstraction, and executive functioning (Nordahl et al., 2003; Scott et al., 2007; Vocci, 2008). These problems may not only decrease treatment effectiveness, but they also complicate the client’s ability to participate in the goal-setting process, and they impede everyday life functioning in areas such as planning, paying attention to and responding to one’s children, and managing a household (Aharonovich et al., 2006; Dean et al., 2009; Henry et al., 2010; Sadek et al., 2007).
(p. 375) Clinical Practice
At PCAP intake, the clinical supervisor administers the Addiction Severity Index (ASI) interview (McLellan et al., 1992), supplemented with additional questions about pregnancy substance abuse, use of community services, and childhood history. Questions include items about the mother’s own prenatal alcohol exposure, as well as other indicators of possible neurocognitive impairment (for example, couldn’t complete school, difficulty keeping a job, serious head injury). The clinical supervisor conducts the intake interview in a conversational manner in order to elicit the most comprehensive picture of the mother’s history, including the ways in which the mother views her problems and copes with them. The supervisor and case manager use this information to identify potential deficits, outline an initial approach to interacting with the client, and develop realistic expectations.
Clients who have neurocognitive limitations may not respond fully to the subtleties of MI counseling. When necessary, case managers modify MI approaches with concrete and explicit activities. They help clients explore choices visually if possible; they accept the client’s ideas for solutions, but also offer a few alternative options for the client to consider; they discuss events as soon as possible after they occur in order to maximize the woman’s ability to learn from them; they ask more close-ended vs. open-ended questions.
Harm reduction is based on the premise that alcohol and drug addiction and the associated risks can be placed on a continuum, with the goal being to help a client move along this continuum from excess to moderation, and ultimately to abstinence, in order to reduce the harmful consequences of the habit (Marlatt & Tapert, 1993). In this view, “any steps toward decreased risk are steps in the right direction” (Marlatt et al., 1993).
Relapse is a well-recognized characteristic of substance-abuse disorders, and PCAP clients are not asked to leave the program because of relapse, noncompliance, or setbacks. Instead, these problems are used as opportunities for clients to learn from their mistakes. This policy is straightforward in theory, but challenging to implement. It requires the case manager to manage her own discouragement (and sometimes anger) about a client’s setbacks, renew her commitment to the client’s potential, and think creatively about how to re-engage the client. Case managers use clients’ relapse experiences to help them examine triggering emotions and events, consider more functional ways of responding to these triggers, and make decisions about how to manage these kinds of situations in the future. When a client is able to successfully rebound from a relapse, she develops self-efficacy as she sees herself coping, repairing the damage done, overcoming a crisis, and moving on.
(p. 376) Preventing Harm to the Child
Case managers help the client focus her attention not only on reducing alcohol and drug use, but also on reducing other risky behaviors that impact her health and well-being and that of her children. In many cases, clients who are not fully abstinent from alcohol and drugs are parenting their children. When a client is still using substances or is at risk for a relapse, her case manager recognizes and accepts this current situation and at the same time challenges the client to take responsibility for her role as a mother. For example, if a woman has plans to go out with her boyfriend on the weekend, the case manager uses MI to develop discrepancy by asking if she has weekend safety plans for the children. She helps the client think ahead about possible consequences of her weekend activities, and how to plan in order to reduce potential harm. This means they may discuss who will baby-sit, the food and diaper situation, and her birth control plan.
Being Realistic About the Potential to Parent
The issue of child custody is a recurrent theme in clients’ lives because a majority of the women have had children removed from their care by the state. PCAP case managers routinely teach clients about behaviors that are normal and appropriate for their children of different ages, and they model alternative ways of responding to their child’s behavior. Clients are often mandated to attend parenting classes (which can vary widely in content and quality) but are reluctant because they have found previous classes to be unhelpful, or because of apprehension about being judged. Case managers talk with their clients about how to conduct themselves in a class, what they might expect, and how they might extract a positive benefit. In some cases, the case manager will accompany her client in the beginning to help her get oriented to the routine and feel more comfortable.
Regaining custody is a common goal stated by clients in their first year in the program, although case managers may not necessarily concur that reunification is in the best interests of the child or children. The turning point for successful resolution of child custody issues occurs when the mother comes to terms with her ability to parent and is willing to consider the best interests of the child. For some mothers, this means deciding to relinquish custody to a foster family who has bonded with the child and would like to adopt. For others, it means staying in recovery and doing whatever is necessary to resume or maintain custody of her child. Regardless of who has custody, case managers work on behalf of the child to secure a safe and stable home environment.
As regular home visitors, PCAP case managers are in the unique position to identify problems that may put children at risk in families that would otherwise (p. 377) escape the notice of health and social service providers. PCAP staff members are mandated to report child abuse and neglect. Whenever possible, if case managers believe the child welfare system should be alerted, they let a mother know ahead of time. In many cases, we successfully encourage the mother to call Child Welfare herself to talk about warning signs and difficulties, and to ask for help getting back on track. In this way, the mother conveys to the child welfare worker that she is self-aware and is trying to take responsibility as a parent who wants to improve. Mothers do not generally drop out of PCAP after Child Welfare is called. While they may at first feel angry or betrayed, we challenge them to think about the reality of their behavior and the resulting consequences, always within the context of helping them take responsibility for becoming better parents.
As advocates, PCAP case managers help clients comply with their individual Child Welfare contracts and act as liaisons between the agency and the client. In general, PCAP and child welfare social workers work well together. PCAP case managers keep careful documentation and releases of information so that they can communicate with all parties, verify both client and social worker compliance or non-compliance, and advocate accordingly for the upholding of agreements made in the contract. However, it is not uncommon for a mother to comply with all of her contract stipulations in order to regain custody of her child, only to learn that her social worker plans to recommend that the child be removed for a variety of reasons that can include social worker inexperience and biased attitudes. In these cases, a client may seriously question her own worth and abilities, feel humiliated, and manifest symptoms of depression and anxiety while at the same time suspecting that she has been double-crossed. The PCAP case manager’s role is to help her client cope with these complex feelings, and continue to advocate for her by providing documentation, negotiating with child welfare, and helping the client meet demands required as she tries to prove herself again within the system.
Using Supervision to Promote the Paraprofessional Case Manager’s Development
Closely aligned with the intervention principles described above is the overarching principle emphasizing the personal and professional development of the case manager through intensive and ongoing clinical supervision. Below, we elaborate on this principle and how it is put into practice.
PCAP supervisors expect that case managers will progress along a personal developmental trajectory as they work intensively with high-risk families undergoing change. Supervisors support this process by working with the case manager to untangle the intense feelings generated during the work, to help her reflect on her emotional reactions to the client and child, and to examine and understand how these feelings relate to the choices the case manager makes about day-to-day activities with the client (Bertacchi & Norman-Murch, 1999). With ongoing support and training, the case (p. 378) managers can mature in their ability to avoid overreacting, to fully assess situations, and to respond effectively with a balance of honesty, objectivity, and care.
A critical element of PCAP has been the development and institutionalization of excellent supervision practices. PCAP supervisors are bachelor’s or master’s level female clinicians who meet individually with case managers for at least an hour, ideally every week, and at a minimum twice each month. They are available for consultation throughout the week either by phone or in person.
Management of Multiple Roles
The supervisor has diverse roles. As an administrator, she discusses each client’s status and reviews paperwork, case notes, and how the case manager allocates her time. As a teacher, she explores with the case manager how case activities are related to client goals and helps her differentiate between crises that need the case manager’s intervention and those the client may be ready to handle by herself. As a mentor, the supervisor discusses areas of growth the case manager would like to see for herself and opportunities for additional training.
The supervisor is also in a leadership position that allows her to create a positive, healthy work environment in which case managers can deliver sustained attention and care to their clients. When the parallel process functions well, the supervisor’s support of the case manager is reflected in the case manager’s attention to the mother, which is in turn reflected in the mother’s care for her child. The words of Jeree Pawl come to mind: “Do unto others as you would have others do unto others” (Pawl & St. John, 1998).
Managing Difficult Emotions and Preventing Burnout
Disappointment and frustration are common among service providers who work with high-risk, unpredictable populations. It is critical for the PCAP clinical supervisor to assist case managers in recognizing and understanding these normal responses, rather than reacting to clients in counterproductive ways or ignoring the feelings and increasing the risk of burnout. In a model like PCAP that is based on maintaining long-term trusting relationships between case managers and clients, staff turnover must be kept to a minimum. If burnout results in a case manager leaving, the transfer of a caseload to different staff disrupts the relationship not only with the case manager but also in some cases with the program, and can lead to setbacks for the client.
Monitoring Contact Balance
Supervisors are alert to the particular challenges that arise when case managers work very closely with high-risk women and children in home-based settings. For example, dividing one’s time among a caseload of 16 high-risk women can be (p. 379) extremely difficult. (The amount of time spent with clients depends on many factors, and will naturally vary.) What is important is that the case manager be persistent in trying to find ways to connect and build a relationship with every client. This is particularly challenging if a client is rude and angry with the case manager, dismissive and harsh with her children, continually misses appointments, or has poor hygiene. On the other hand, clients who are doing well are easier to be with, and it is a natural tendency for case managers to schedule more time with these women.
The supervisor’s role is to help the case manager examine and avoid extremes. PCAP case managers complete a form weekly that documents time spent in direct contact with and on behalf of each client. Using this data, the supervisor is able to objectively monitor the time the case manager spends with each client on her caseload. She also provides ongoing training on the key tenets of PCAP—that every mother who has agreed to be in PCAP hopes on some level for a better life, and for some it will take a great deal of time and persistence before a therapeutic alliance can be established and progress can be observed.
Fostering Timely Independence
Supervisors must be attuned to the potential problem of case manager’s task-oriented efficiency interfering with the model’s goal of helping women achieve healthy independence within the context of a supportive mentoring relationship. For example, a case manager may become frustrated with a struggling client and do the client’s work for her, instead of guiding the client in a process that will result in her developing competence and self-efficacy. Alternatively, a case manager may be tempted to leave a “star” client to her own devices, failing to remember the importance of her continued support in helping the client sustain her progress.
Maintaining Healthy Boundaries
Healthy relationships between case managers and clients require that boundaries be articulated and maintained. Early in the development of the PCAP model, we used a focus-group process with case managers to identify essential home visitor boundaries, and we continue to refine these standards based on case managers’ field experiences, both good and bad. At present, PCAP has twenty boundaries that case managers review and discuss annually. The boundaries touch, not only on the content of conversations (e.g., “Case managers will role model/discuss aspects of their personal lives they believe are beneficial/relevant to a client’s progress and well-being, but will not discuss other aspects of their own personal lives. Ask yourself, ‘Whose needs are being met?’”), but also on realistic situations that arise in the course of the work (e.g., “Case managers will not buy goods or services from clients. PCAP staff will not hire clients for any service”).
Ongoing Training and Staffing
Comprehensive and ongoing training is essential to building strong staff skills and to helping case managers maintain confidence. PCAP training includes: Initial (p. 380) 80-hour intensive training on program protocols and working with clients; formal training as necessary on topics relevant to the issues case managers encounter; periodic meetings with community agencies to brainstorm about how to work together most effectively and prevent service barriers; annual three-day refresher training on the PCAP model and protocols; annual one-day statewide retreat where PCAP staff members share success stories, problem-solve challenges, and are honored individually for their work.
PCAP sites have weekly, two-hour group staffing/problem-solving meetings where case managers share the highlights of the prior week, examine challenging cases, share community resources, and mentally prepare for the week ahead. This is the only time case managers come together as a group during the week, and the clinical supervisor uses this valuable time to best advantage by gleaning common themes, problems, or service barriers from her individual supervision meetings with the case managers. She then asks case managers to staff specific clients or situations as case study illustrations at the group meeting in order to stimulate brainstorming and discussion. Case managers offer ideas and support, and reflect on experiences with their own clients. Subsequent staffing meetings provide continuity when case managers give updates on client status and on how others’ suggestions have worked. A continuing challenge faced by supervisors is maintaining a balance between spontaneity (keeping meetings flexible and interesting) and structure (covering essential business items within time limitations).
From a day-to-day perspective, it can be difficult for case managers to see the effect they are having on clients’ lives. PCAP has created a dynamic evaluation feedback loop that gives staff the opportunity to examine the data, to see specifically how they are helping clients make gains, and to identify areas for improvement. PCAP staff are trained in data collection methods to assure quality control: The clinical supervisor administers intake interviews using the ASI; the case managers collect data monthly and every six months to track client progress; a research assistant administers exit interviews using the ASI. The program evaluator compiles data and reports trends to staff every six months. This feedback and the accompanying discussion about the meaning of the data give case managers an active role in the evaluation process and help them better understand their work.
Conducting Research with Substance-Abusing Parents and Children
Research with high-risk populations can be challenging, and may include problems with sample recruitment and maintenance, suspicion of researchers’ intent, self-report biases, scheduling difficulties and no-shows, transportation and childcare considerations, mandates to report abuse and neglect, and the potential for research records to be subpoenaed. Some of these problems are unavoidable, but none are insurmountable. The most effective way to avoid frustration and failure (p. 381) is to anticipate these issues while writing a grant, and plan realistically for them in the study procedures, the timeline, and the budget.
Taking Time and Showing Interest
To improve the accuracy of data collected and help mothers feel comfortable about revealing personal and sensitive information, it is critical that researchers respect subjects and that subjects trust researchers. This requires taking time from the outset to demonstrate sincere interest, to explain the research and how their personal contribution may benefit other mothers and children, and to thank them for being a part of the work. While a consent form may convey some of this information, it is not a substitute for a conversation that conveys honesty, concern, and care. We have found that, for most mothers in PCAP, participating in a university-based research study is a source of pride.
Mandated Reporting and Confidentiality
Researchers must inform clients clearly, both in writing and verbally, that they are mandated reporters. It is advisable to obtain a federal Certificate of Confidentiality in order to protect research records from subpoena (note that this does not necessarily protect case notes or preclude personal testimony). If researchers release confidential data inappropriately, faith in the study or the institution will be undermined, and serious legal consequences can ensue. PCAP has developed an extensive protocol for managing subpoenas that is available to researchers and interventionists. Institutions should additionally seek guidance from their own legal counsel.
Conclusions and Future Directions
At present, the PCAP model is being fully implemented and evaluated as designed at ten sites in Washington State. Ongoing funding, through state legislative appropriation, is a result of PCAP’s positive, sustained outcomes and the state’s commitment to serving pregnant and parenting women. SAMHSA has funded three PCAP replication sites that are currently being evaluated, and HRSA has recently funded another. Adaptations of the model are being implemented at over forty sites in provinces throughout Canada, including sites in a number of First Nations communities. The Canadian sites have not yet incorporated a formal evaluation component, which limits our ability to understand the impact of the intervention there and whether cultural adaptations have been effective.
The PCAP model serves as a platform from which to examine research questions regarding prevention and intervention with high-risk substance-abusing pregnant women and their families. For example, we are currently completing a federally funded study exploring the integration of infant mental health (IMH) therapy among PCAP mothers who abused methamphetamine during pregnancy, and their infants. This approach blended individual work with the mother along with IMH dyadic therapy delivered in the home. We recently received a grant that will provide trauma-informed therapy to mothers while they are in long-term (p. 382) residential substance-abuse treatment with their children, and at the same time provide them with specialized training on how to respond to their child’s cues and sensory-based needs.
Substance-abuse professionals recently developed a working definition of “recovery” that resonates with PCAP values because it recognizes that, for a substance-abusing mother, the process of becoming a whole person means far more than achieving sobriety: “Recovery from substance dependence is a voluntarily maintained lifestyle characterized by sobriety (abstinence from alcohol and non-prescribed drugs), personal health (improved quality of personal life), and citizenship (living with regard and respect for those around you)” (Betty Ford Institute Consensus Panel, 2007). PCAP creates an environment in which vulnerable substance-abusing women can achieve recovery and offer their children the possibility of having a better life.
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