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Abstract

The review assessed literature on interventions for alcohol and drug dependent mothers. Alcohol

and drug dependence of mothers comprise a persistent problem. A number of interventions have

emerged. However, there is need to assess the relative effectiveness of these interventions for the

group of alcohol and drug dependent mothers to support responsive social work practice. The

assessment of effectiveness is in terms of theoretical basis and empirical evidence.

The review proceeds by tracing the chronological development or emergence of interventions,

presenting the different models together with the theoretical basis and empirical evidence, and

assessing effectiveness. A summary of the results follows together with the implications on

social work practice. The discussion ends with conclusions on the effectiveness assessment

together with the research gap for further investigation.

Introduction
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Alcohol and drug dependence of parents, particularly mothers remain a pressing family

social problem. Statistics do not provide data on the prevalence of alcohol and illicit drug

dependence of mothers but the situation can be gleaned from statistics for the adult age group

and adult females. Alcohol abuse is a problem with the percentage of adults 18 years and older

dependent on alcohol reported at 7.9 percent for both 2005 and 2006. Drug dependence is also a

problem with the percentage of drug dependent adults 18 years and older increasing from 2.6 to

2.7 percent between 2005 and 2006. Alcohol and drug dependence is lower for female adults 18

years and older but the prevalence still indicates a problem. Alcohol dependence remained at 5.1

percent in 2005 and 2006. Drug dependence decreased from 1.9 to 1.7 percent between 2005 and

2006. (Department of Health and Human Services, 2009) These percentages reflect on the

alcohol and drug dependence of female adults including mothers.

Various intervention and treatment models with varying scopes and targets emerged

(Suchman, 2004) but these faced challenges on effectiveness from lack of continuity or failure to

achieve long-term results. With the recognized impact of alcohol and drug dependence of

mothers on the health, safety and welfare of children and the family, assessing the range of

family practice models is an important step in determining effective intervention models and

ways of improving applied models. The result has implications on the focus and direction of

family practice intervention for alcohol and drug dependence.

The literature review considers empirical studies on family intervention for alcohol and

drug dependence to identify the different models applied and to assess the relative effectiveness

of these models in addressing the problem of alcohol and drug dependence of mother. The

discussion proceeds with a presentation and critique of these models.

Results
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The empirical studies on intervention for alcohol and drug dependent mothers shows the

shifts in the focus of intervention discourse as well as the bifurcations or deviations in the

perspective over effective interventions.

Lundgren, Schilling and Peloquin (2005) studied methadone as a treatment for drug-

dependent parents. This treatment is a neurobiological intervention. Through reviews of

empirical studies, welfare policies of various states, and articles the results showed no strong

policy support or application of methadone as a treatment option for drug-dependent parents.

While this treatment is a general treatment for alcohol and drug abuse, there are not studies

indicating its acceptance and effectiveness for substance-dependent parents, particularly mothers.

Moreover, this only focuses on neurobiological aspects and requires integration with other

approaches to achieve a comprehensive intervention program.

Loneck, Garrett and Banks (1997) studied high and low intensity groups in an outpatient

alcohol and drug treatment program for women. This approach is based on the concept of social

networking with members of the network providing support in completing the outpatient

program. High intensity referral includes the Johnson Intervention with members of the social

network directly confronting the alcohol or drug dependent woman over her addiction and the

negative effects of the addition together with coerced referral with an ultimatum comprising the

motivation. Low intensity referrals include unrehearsed intervention with a counselor facilitating

the confrontation, unsupervised intervention with the members of the social network conducting

the confrontation on their own, and non-coerced referral. The results from data on 109 women

showed that high-intensity referrals had better impact on engagement and completion. However,

high intensity referrals have varied effect on engagement and completion across age groups,

educational level, employment, and marital status, favoring women in the older age groups,
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lower educational achievement, part time employment, and unmarried status. This indicates the

limitation of the applicability and effectiveness of high intensity referral for different groups of

women.

Salmon et al. (2000) also studied outpatient drug treatment programs for pregnant women

and mothers with substance abuse problems in terms of the effectiveness of support given by

providers and other sources of social support. The study also considered the aspects of the

program that helped them in maintaining abstinence. The program was based on the social stress

model that explains substance abuse as the effect of the offsetting of stress level and its modifiers

such as social support and resources. The survey of women participating in the program showed

that majority expressed satisfaction towards the support they received relative to their

engagement in the program. The helpful aspects of the program are education, coping

techniques, 12-step guide, resource assistance, and spiritual direction. However, two-thirds of the

women expressed lack of information coming from medical providers over the risk of substance

abuse on their pregnancy. An implication is the need to widen the scope of social support to

include information dissemination by medical workers to further mitigate stress. The

effectiveness of outpatient programs strongly depend not only on the existence but also of the

sufficiency and quality of the support provided.

Marques and Formigoni (2001) evaluated an individual and group cognitive-behavioral

psychotherapy that employed rational behavior therapy by appealing to the rationality of

participants over the difficulties and problems caused by substance abuse to influence change in

attitudes and behavior. The clinical trial of 150 patients showed no significant difference in the

level of alcohol consumption, degree of dependence, and problems encountered before and after

the test for those undergoing individual and group psychotherapy. The study recommended
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adoption of group psychotherapy as a cost-benefit measure. Although, there was no significant

difference between the level of alcohol consumption and problems encountered in the pre and

post test of the two groups, the study did not determine whether the level of alcohol consumption

and problems after the psychotherapy indicated significant success of the program. Moreover,

the lack of difference means the possible failure of the program to optimize the benefits of

individual and group interventions.

Fiorentine and Hillhouse (2003) compared two cognitive-behavioral programs, the

Relapse Prevention Approach and the Addicted-Self Model in terms of relative effectiveness in

achieving long-term abstinence. The difference between these two programs is the relationship

between self-efficacy and recovery. The Relapse Prevention Approach associates recovery

positively with self-efficacy while the Addicted-Self Model propounds a negative relationship.

The study of 356 outpatients showed that there is higher abstinence with the Addicted-Self

Model because the acceptance of loss of control over the addiction supports the stronger resolve

for long-term abstinence. The study recommended shift to the Addicted-Self Model. However,

the Addicted-Self Model does not predict the levels of relapse or continued use as well as the

factors that reinforce life-long abstinence. This significantly bears down on the effectiveness of

the approach.

Suchman et al. (2004) studied parenting interventions for mothers with drug dependence

problems. This integrated cognitive-behavioral approach with parenting elements as an

intervention for drug dependent mothers. This shifted the intervention process from behavior

management to emotional quality of parent-child relations. This emerged from the failure of

behavioral training programs to influence continued abstinence and support children adjustment.

Data from an outpatient treatment program showed that parenting intervention based on parent-
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child emotional attachment improved successes in abstinence based on quality parent-child

relations. This comprises a promising intervention program specifically for alcohol and drug

dependent mothers albeit there is need to test this intervention in various intervention scenarios

and participants.

Suchman et al. (2006) recommended the relational approach as an improvement in

parenting interventions integrated into alcohol and drug abuse treatment programs. This

approach improves the quality of the parent-child emotional attachment by training parents to be

emotionally open to the messages from their children, to accurately interpret these messages, and

sensitively responds to the emotional needs of their children. By strengthening parent-child

relations, this encourages and enables mothers to manage their behavior and ensure successes in

child rearing. While this contributes a way of improving cognitive-behavioral outcomes, this

requires highly trained clinicians to assess progress and prevent overwhelming mothers that

could cause relapse. The effectiveness varies according to the situation and cases to imply the

use of this approach on a case-by-case basis.

Joanning et al. (2007) compared the effectiveness of three drug dependence treatment

programs targeting young people, which are Family Systems Therapy, Adolescent Group

Therapy and Family Drug Education through controlled outcome experiment. The results

showed that highest level of success of Family Systems Therapy by having two times more

patients abstaining from substance abuse. The success is due to improved communication

between parents and children. However, the intervention showed no difference in influencing

family functioning, which if unimproved could cause relapse.

Sun (2004) studied case management as an intervention focused on the role of service

providers in supporting mothers with alcohol and substance dependence. This is a

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comprehensive approach based on the principle of inter-agency mediation that incorporates

prenatal care, psychiatric treatment, legal advice, social welfare advice on matters such as

housing, nutrition, and training. A comparison with the non-integrative program showed that

case management led to higher levels of completion and lower dropout rates. This comprises an

effective program by targeting multi-dimensional issues causing alcohol and drug dependence

and hindering lifelong abstinence. However, this is beset with challenges in inter-agency

mediation. Social workers are in the best position to negotiate inter-agency collaboration by

covering a wide range of issues.

Lundgren, Amaro and Ben-Ami (2005) studied the engagement in treatment of Hispanic

women with drug dependence problems. The results showed differences in engagement,

treatment selection, and treatment maintenance. Puerto Rican participants showed preference for

methadone in combination with other detoxification programs. A strong influence on

engagement and treatment preferences is health insurance. Continuance of treatment was

influenced by mental health service use and criminal justice system involvement. An implication

of this study is the effectiveness of treatment programs that focus on specific needs and the role

of social workers in informing women from different ethnic minority background about drug

abuse treatment options and maintain cooperation relations with mental health and criminal

justice workers. This supports the importance of inclusive treatment programs that accommodate

various needs and conditions.

Greenfield et al. (2007) tested the difference between a Women’s Recovery Group

(WRG) and a mixed-gender Group Drug Counseling to assess the importance of interventions

specifically designed for women. After the 12-week treatment, there was no difference in

outcomes. However, the 6-month follow up showed continued reduction in substance use by
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those in the WRG. There were also higher levels of satisfaction with the WRG. Women-focused

interventions could lead to more long-term results. This is an effective approach that requires

further investigation. The focus on women’s needs would consider comprehensive factors that

determine the success of intervention for alcohol and drug dependent mothers.

Discussion

A number of interventions for alcohol and drug dependence of mothers emerged from the

literature. These can be categorized into a number of classifications. One classification is based

on the underlying principles and operations to include neurobiological (Lundgren, Schilling and

Peloquin, 2005), cognitive-behavioral (Marques & Formigoni, 2001; Fiorentine & Hillhouse,

2003, Suchman et al., 2004; Suchman et al., 2006) and social models (Loneck et al., 1997;

Salmon et al., 2000; Sun, 2004; Lundgren et al., 2005; Greenfield et al., 2007; Joanning et al.,

2007). The second classification is interactive comprised of the interventions based on social

principles or didactic comprised of some of the cognitive-behavioral interventions. The third

classification is mono or mixed interventions based on the application of models singly or

combined with other models that determine the scope of the intervention. Some of the models

were singular approaches such as methadone (Lundgren, Schilling & Peloquin, 2005) and

Addicted-Self Model (Fiorentine & Hillhouse, 2003). Other models involved combination

approaches by emerging from general interventions for alcohol and drug abuse but integrated

with parental substance to incorporate the maternal element such as high and low intensity

groups (Loneck et al, 1997), rational behavior therapy (Marques & Formigoni, 2001), and case

management (Sun, 2004). The remaining combination models emerged particularly for women,

pregnant women, and mothers such as the Relational Approach (Suchman et al., 2006) and

Women’s Recovery Group (Greenfield et al., 2007). From these emerging thematic
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classifications, the trend is towards combined or mixed principles, services and application that

cater to women’s groups.

Methadone as a singular method that generally apply to different treatment groups

(Lundgren, Schilling & Peloquin, 2005) but there are limited studies showing the effectiveness

of this method as an intervention for alcohol and drug dependent mothers. Moreover, this only

addresses one aspect of intervention that limits its effectiveness. The limited focus of this

intervention together with lack of empirical support for its application to alcohol and drug

dependent mothers limits the effectiveness of this model.

Some of the cognitive-behavioral and social methods that generally apply to different

groups created broader intervention approaches by integrating the parental substance to address

the particular needs of mothers with alcohol and drug dependence problems. There is empirical

evidence over the effectiveness of these interventions in terms of engagement and abstinence.

However, these also have limitations including focus on only a certain phase of the treatment,

dependence on the fit with the circumstances of target groups, reliance on the role of

interventionists or providers, and need for further testing in different and wider groups. These

interventions apply to mothers with alcohol and drug dependence problems but the effectiveness

depends on the achievement of requisite elements.

The comprehensive models such as case management and Women’s Recovery Group

cover various areas of need and adopted or created for women. Case management is generally

applicable to different groups but it is adaptable to alcohol and drug dependent mothers because

of its wide scope. The Women’s Recovery Group fits the needs of mother with alcohol and drug

dependence problems and targets various areas of concern and accommodates diverse sub-
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groups. These are the most effective programs. However, these require high skills from social

workers and coordination with other practitioners involved.

Implications

The review of literature gave rise to a number of implications for family practice. One

implication is the importance of skills and training of social workers in managing the

requirements of comprehensive intervention models. The comprehensive models are the most

effective interventions because these address multi-dimensional issues that contributed to alcohol

and drug dependence and determine the success of interventional models. However, these are

also the most demanding on practitioners. Practitioners need to adapt the intervention according

to the particular needs of mothers with alcohol and drug dependence problems and sub-

groupings such as according to age and ethnic background, monitor the progress to prevent any

negative intervening factors, and implement adjustments as necessary. Social workers also need

to establish and maintain strong working ties with practitioners in other disciplines to achieve the

targeted encompassing and long-term outcomes of comprehensive interventions.

The greater weight of comprehensive intervention models finds support from empirical

evidence on positive changes in engagement and continuity of abstinence when tested on their

own or in comparison with traditional or single interventions. The studies employed a number of

methods in investigating the application of these intervention models from which the

implications on effectiveness emerged including cohort study, experiments, participant

observation, and analysis of secondary empirical data. This implies directing practice towards

more comprehensive treatments adapted to the needs of mothers with alcohol and drug

dependence problems. However, there is need to draw further evidence on the application and

use of the interventions towards the group of alcohol and drug dependent mothers and the
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subgroups to further strengthen effectiveness. Moreover, further studies on the empirical

application of interventions would lead to guidelines for practice or best practices.

Conclusion

The effectiveness of interventions depends on their theoretical underpinnings and

supporting empirical evidence. The developments or shifts in interventions for alcohol and drug

dependent mothers occurred alongside shifts in theories over effective interventions. Theories on

interventions shifted from the singular concepts or ideas targeting specific aspects of alcohol and

drug dependence treatment to a more comprehensive, integrative, flexible, and accommodating

concepts that cover multi-dimensional aspects of alcohol and drug abuse interventions.

Neurobiological, cognitive-behavioral and social concepts are no longer considered as theoretical

options but complementary ideas that could be combined to achieve encompassing applications.

Due to this shift, more comprehensive interventions received recognition for better effectiveness

in actual practice. The results of empirical studies support the theoretical shift. An integrative

theoretical basis also results to interventions that accommodate different treatment groups with

varying needs and conditions.

Comprehensive interventions such as case management and Women’s Recovery Group

are the recommended approaches for social workers in addressing the intervention needs of

alcohol and drug dependent mothers. These are comprehensive in scope and adjustable to

different sub-groups of mothers. Social workers should assess existing practices to determine

ways of adopting more comprehensive interventions to achieve engagement and life-long

abstinence for more women participating in the intervention program.

The review of empirical studies identified the evidence on interventions for alcohol and

drug dependent mothers and supported the greater effectiveness of more comprehensive
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interventions. However, the limitations of the interventions comprise the research gap that merits

further investigation.

References
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