This study will focus on describing and analyzing specialized outreach and low threshold program practices for women with problematic substance use. The research question is: How are relationships and engagement formed within an outreach and low threshold service for pregnant women? The themes for enhancing relationships and engagement within outreach and low threshold program will then be described (see Fig. 1).
The women’s backgrounds are very diverse when they connect with the services, since the women are at a different stage of pregnancy, they may be first-time mothers, or already have older children. They use different substances, drugs, alcohol or they misuse medications. Some suffer from psychological distress or depression, and others endure chronic physical illnesses. Women may be active users of substances, when meeting with them the first time. Not everybody is motivated to participate in the ETMA program.
When attending the program, the clients carry with them their memories and the stigma they experienced during encounters with previous service providers or within society. The health care professionals’ attitudes at childbirth may be memorized and feel painful, despite inner knowledge of their right to equal access to supportive services and their right to proper treatment (hyvä kohtelu), “It’s about human values,” not undermining or being arrogant about the women’s requests for help:
“Wishes a general change of attitudes in regard to substance abuse. Especially when a woman is pregnant, doctors and nursing staff in obstetrics and primary care may treat those with substance-use problems really badly. Experts-by-experience type of connections work the best.” (Client, 126)
If previous requests for help have been negative, many women prefer not to disclose in the future. It may be surprising for the woman to find out that people and staff at the ETMA program can be friendly, and in fact, kindness may in itself function positively in regard to the women’s previous experiences within the substance world involving threatening events and experiences. Many women will not disclose easily.
Acceptance And Attitude: A Sensitive Approach Of Approval
The staff has a specific attitude when connecting with women experiencing this special life situation with problematic substance use and motherhood. Staff has in-depth knowledge about substances within the contexts of addiction, illness, and the lifestyle that is threatened to be challenged when the women seek help. Because their backgrounds are versatile and their life situations are diverse, meeting with professionals entails individualization, flexibility, and adjustments to the staff’s perspectives and the working models employed. Staff members within ETMA need skills to assess the help-seeker within a larger societal and cultural frame or phenomenon — the very many diverse levels and forms of substances have an impact on women arriving at the services. The personal agency of a woman is contested when she seeks help for her pregnancy or with motherhood.
According to families and staff, the best results occur if staff can begin collaborating with families during pregnancy. Staff aim to create an atmosphere of acceptance to contrast the stigma the women may have experienced prior to ETMA. The women must feel as if they are welcomed; the saying “come as you are” is applicable in the overall theme of acceptance, and a tailored approach is favored. Furthermore, a sensitive approach of approval can create connection:
“A suitable environment and workers ..important to understand the human irrespective of their starting point.” (Client, 442)
The first encounter is described especially important from the staff perspective. In the beginning, the mother, child, and the healthcare professional need opportunities to become closer to each other. Trust can be built in an open atmosphere, and it benefits the woman and the staff in the event that a relapse occurs later, so that additional challenges can more easily be disclosed. Women want to be supported and encouraged in the process. They need positive feedback. The workers can have a positive impact by demonstrating that they believe in the mothers:
“It has been important that somebody believes in me, even though I do not always believe in myself. Even though we only chat a little bit, I might later feel that the discussion was useful.” (Client, 210)
Many staff members were perceived as warm. Women noted that after their rehabilitation phase, they had also received help within other areas that they had not thought of in advance. In situations when they feel tired, this fatigue may restrict their options to ask for and receive help. From a woman’s perspective, help-seeking requires honesty and openness, and emotions arising during staff encounters may feel good, bad, irritating, or even anxiety-provoking. When the women felt physically ill, they sometimes felt they had to constantly repeat themselves and explain their situation to be taken seriously:
“As a tip to other clients, openness is the most important. You cannot be helped, if you do not share anything about yourself.” (Client, 384)
The clients admitted that their own attitudes could impact their help-seeking efforts. Moreover, the timing of their access could impact their ability to adhere to treatment, or how they interpreted staff attitudes. Treatment also felt like an ambiguous period because they were living and learning about their emotions.
The clients noted the importance of not blaming them. The clients considered that it was most important to find their motivation themselves and to pursue progress even though it did not always feel useful. Many women come from well-baby clinics after a positive substance use screening, or if they shared information on their close family’s substance use. The staff perspective is decidedly oriented toward the well-being of the fetus and developing “baby in the mind” thinking:
“Working throughout the pregnancy to ensure the growth and development of the fetus, so the baby would be born healthy, in spite of exposure. Fathers, if known, and if they want to be involved in the family, should have access to rehabilitation at the same time as the mother.” (Worker)
Staff considers the baby, pregnancy, and the effects related to expectancy every time they are able to meet with the woman, or soon-to-be mother. Staff try to answer any questions the mothers have, and they discuss how the baby is doing. The pregnancy period gives a woman the chance to focus on her own life, because self-centeredness will be more difficult after the child has been born. She might have difficult experiences in her life that have not yet been addressed and require attention. It may take a long time until motivation emerges. During the phase when a connection is being formed with staff, many women may experience difficulty accepting care. To make a trusting relationship work, staff need their own personality, while still maintaining a professional distance.
Flexibility Within Strictness To Allow For Diversity And Individuality
Women may feel afraid or ambivalent by the time they arrive at the service encounter, partly because of the risk of their children being taken into care unless their substance abuse issues are resolved:
“Child protection feels scary, but it is important they are strict by start…staff wants to support, provide feedback that it is going well, and that keeping their child is possible.” (Client, 476)
The openness in communication includes explaining why urine tests are taken and using screens with the aim of assessing for possible continuing substance use. Staff also discuss the child’s wellbeing and the impact of substances on the child’s development.
When working with these women, enhancing the development of trust and attempt to enhance the collaborative relationship between staff and clients is continuous. From the staff perspective, supporting and encouraging the parenting agency of the women in situations while also setting necessary boundaries requires a combination of flexibility and strictness. Flexibility helps when a woman forgets to tell staff that she cannot make it to her scheduled meeting, cancellations occur, and meeting hours or the number of meetings are changed. The situation can be reviewed and re-evaluated even quickly, such as in the event of physical health conditions. The reason for this flexibility stems from the raison d’être of HTTS:
“To hold tight to the clients and try to make them engage in some form of support.. if a mother cancels a meeting, I try to reach out to her and clarify, why the meeting did not occur; if I cannot reach her, I’ll go and visit the mother at her house if necessary. I only make home visits to clients I already know. On the other hand, the need to approve, if the mother does not want to accept support.” (Worker)
Flexibility and alertness to the possibility of making changes is needed in the event of a relapse. If a collaborative relationship has commenced, a relapse may mean that the woman will need additional support for a while. More testing and screening are occasionally administered. The respondents believed that an individualized flexible approach was possible if a worker is more knowledgeable about the special family questions. Respecting the woman’s choice and agency means that it remains the mother’s right is to decide how to set boundaries in the event of challenges. During these times, it is not possible to strictly follow plans, and flexibility may be needed:
“It is important to go through failures to have an experience that overall, it is possible to move forward, and failures do not ruin it all.” (Client, 369)
The process also involves disappointment if a relapse causes a client to stop attending her meetings or a relationship cannot be formed with a specific client. For workers, understanding that a relationship cannot be formed with every client may be a frustrating emotional journey to process. Workers know that non-interrupted intensive help has been shown to be the most effective. Beginning collaboration is a long-time effort, and it is important to also hold tight during difficult moments. Clients assert that individuality gives them the opportunity to recover. As humane people, staff challenge the stereotypes of addicts; the individuality that is necessary to connect with the mothers involves respect and is woman-centered. The clients emphasize the individuality of each event and of each woman and mother in relation to their own personal goals, as these need to be the women’s goals, not the workers’.
Because trust was developed in person-to-person connections, a contrast can be seen in whether it is possible for the women to speak out groups. This may not be possible due to sensitive questions and issues related to the culture residing in communities within addictions, such as inter-personal violence in the drug world. If a close person such as the baby’s father continues using substances, it will be challenging for the mother to continue toward her goal of recovery.
A family-centered approach supports the individualized perspective. Under Finnish law, workers must report living conditions that would challenge or harm the child’s well-being to social care. On the other hand, work at HTTS is baby-centred. Therefore staff utilize an honest, direct, and friendly approach to cope with such situations while developing a relationship. While there is a risk that the woman will leave and not commit to treatment in the outreach and low threshold phase, many clients giving feed-back were in favor of coercion:
“Perhaps when I hid things and in a certain way you knew, you could have faced me with the truth and asked, ‘What the shit are you doing?’” (Client, 185981)
Because other clients were against coercion and felt that the focus on the baby was oppressive, many questions required negotiations between the clients. Staff needed to confirm the mother, since the aim at ETMA is to make the mother understand the viewpoint of her child. In the beginning in the outreach and low threshold program, there is more flexibility and less confrontation than in future recovery steps. According to clients and workers, strict boundaries do not work in outreach. The challenge is how individualized boundaries are perceived by the peers, who may insist upon the exact same rules for everyone in the rehabilitation communes. Because speaking openly is important, workers choose the point of confrontation with sensitivity not to interfere with the development of trust.
“You should be able to talk openly about things without sanctions or fear. Speaking honestly is very important. It is difficult to be honest—for example, about stealing or other problems—because of fear of children being taken into custody.” (Client, 362)
Insensitive confrontations may lead the individual to choose to be silent or be offended if trust has not yet been developed. The goal in ETMA outreach and low threshold program is to establish connections and create a collaborative relationship.
Availability And Space To Ensure Calmness In A Trustful Atmosphere
Low threshold staff are available in easily accessible locations. Outreach services can meet the women anywhere, and when some level of connection has been established, home-based low threshold care can also become an option. Being available to the woman’s needs utilizes calmness within a specific space:
“Meeting, hearing the other human, respect, calmness in the situation—you must not hurry the other—and verbalizing and bringing up difficult issues with respect.” (Worker)
The women may feel vulnerable (rikki) if they have not yet attended preventive care. Their diverse background and experiences impact the manner in which workers can connect with them. Workers and staff emphasize the need for easily accessible care:
“It is important that it would be easy to seek care and to be given the chance and understanding of the enabling change involved in motherhood.” (Client, 134)
Availability is a space that contains a sense of freedom, because the person seeking help is fully entitled to speak within a trustful atmosphere. Again, staff utilize sensitivity to create the feeling of non-pressure and availability. Since each human has their uniqueness and background, they also will require unique solutions. A woman’s specific situation may necessitate changes in their personal manner of connecting with other humans within the services or when creating trust. Developing trust, starting to discuss her own problems, and asking questions about her life situation emerge in stepwise co-creative processes. Staffing changes may interrupt building a connection and may lead to setbacks. Situations where the child’s well-being requires action, may not be pleasant experiences for the woman.
Many families positively mentioned home-based outreach, their everyday lives, and rhythm with children as possibility for learning mothering and fathering in the context of their own home. The service can develop into a trusted safe space that women can contact by choice. Clients said they could trust the ETMA-built trust, which ensured that someone would always connect with them. Home-based support in their everyday lives was favored as easy access to care for families with children or when a client had a bad day. The goal of recovery and everyday situations could function as a frame for discussion and availability.
Negotiating Via Doing To Build Connections
The experiences of being heard and of receiving positive feedback can strengthen a woman’s ability to function. Because the meetings between humans occur in specific times and spaces, several negotiations are needed regarding different common rules of collaboration. After connection between the woman and workers has been co-created, a question may arise as to who is responsible for the recovery. The woman’s agency may grow when she makes decisions and has the freedom of choice, such as what to do within the spaces, where connections occur:
“A family-cafe would be great, so that parents could meet freely, exchange views, discuss bothering matters and children could play. There could be workers, if something acute and worrying would occur and the workers role would mainly be an enabling bystander, she should no way intervene, unless the clients want.” (Client, 225)
Clients said that meeting with peers was considered an ideal empowering option that would allow for the exchange of views from the inside and would shift the workers from an advisory role to consulting when they were needed. While some women required more encouragement when participating in peer groups, others clients refused participation, because not everyone has the energy to be involved. If a woman was sensitive to criticism, workers negotiated with them with the aim of respectful counseling or feed-back:
“Sometimes, the workers had too much advice and hints in motherhood and less would have been sufficient, considering that a new mother may be sensitive to too much counselling. I missed receiving more positive feed-back.” (Client, 168584)
Negotiations and interactions between clients and workers are intertwined with details and impressions and involve taking directions when communicating during different shared actions. Many interactions in the outreach and low threshold programs occur by doing: sitting together to have coffee, visiting different places such as parks, going for walks or engaging in sports activities, relaxing, going out on day excursions, engaging in the arts or photography work, baking or beginning a new hobby, and finding additional recreation activities. Supporting motherhood by engaging in activities together may further enhance the creation of a connection and participating in the program. Because verbal expression may be difficult for some women, doing provides more opportunities for building connections.
Doing together and commencing activities may lead to the development of interest in living everyday life and in devising solutions such as learning how to manage money. Furthermore, the positive emotional component of engagement yields new experiences. It was suggested that the women need connecting with others, having fun together, and finding everyday activities that give them a sense of meaningfulness. These activities can be seen as empowering, and help them to enjoy their everyday life. One of the clients suggested that connecting with peers might be helped by participating in activities:
“These would be easier at the start, to be with others and meet them.” (Client, 137)
Aiming to establish a rhythm in their everyday lives also benefitted by doing together with a worker. Concrete everyday skills and seeking solutions, could be elaborated by using a pregnancy diary:
“In every meeting we go through the mother’s pregnancy diary together, and we reflect on how the baby is doing and what the mother should know and remember in relation to the pregnancy. The mother has a task to ponder during every week of the pregnancy. I use cards and assignments.” (Worker)
While there were suggestions that the whole family would be included in treatment, also other formats were suggested: women-only peer support groups, groups for single mothers, fathers groups, as well as groups for both parents if they are together. Many felt that the relationship between the mother and father was also an issue that needed attention.
Everyday Life Changes: Imagining The Recovery
In early help-seeking efforts, clients connect with visions of what they perceive can become their future. Already during the first steps, it becomes necessary to view the future and discover potential goals. For recovery to occur, connections within HTTS are co-created. This process creates the option of stronger personal agency and yields insights into a woman’s everyday life:
“Accepting oneself the way you are, searching for own strengths.” (Client, 501)
The workers stated that women must be able to define their goals themselves, so that goals from outside the individual do not become overwhelming and impossible to implement at a practical level. A woman needs to elaborate upon her substance problems, her everyday life, and parenting at her own pace. Engagement and involvement may take a long time. Several clients expressed a need to hear the long recovery perspective and the possible phases of full recovery from the start, at the stage after the client connected with professionals:
“I would have wished more information of the whole process from start. Everything came so quickly that it was sometimes difficult to relate to things. Eg information on how long the rehabilitation takes, and what things help it to end. In the beginning it would be good to go through all details of rehabilitation. In the end, rehabilitation has felt really good and I have learnt much about myself and I have strengthened myself, even though it felt difficult at start.” (Client, 483)
Increased knowledge about recovery phases may enhance the vision of a future experience of being helped. Committing to and engaging with the forthcoming recovery process requires a certain level of preparedness for the necessary steps thereof:
“Rehabilitation should be long enough—at least a year—because changes do not occur quickly.” (Client, 338)
From the client viewpoint, the first steps involve being informed about their rights and the manner in which the overall helping system functions. The women need to know that self-directed reflections are part of the forth-coming recovery process. Women needed information about details such as the importance of reviewing their life histories as a whole, digging into problems with self-esteem, and how to maintain their individual point-of-view.
Timing is of interest, since coming for a visit to ETMA and increasing interest in recovery from problematic substance use during pregnancy is an opportunity for the mother to focus on her own care. The earlier a woman shifts the focus to herself and the baby about to be born, “the baby in the mind” knowledge promotes the family’s future steps. After the baby is born, learning to cope with the everyday routines in the family’s life will require significant energy. As such, the focus on the child involves understanding the child and becoming prepared to live with an infant. In the next step, children are involved in the recovery steps of the mother and her partner. New skills can be learned in everyday situations:
“The child at the center: children accompanying them in rehabilitation. The children’s joy and being together without drugs was rewarding and important.” (Client, 98)
The women received concrete guidance in childcare and knowledge about child growth and development. Rehabilitation focuses on the interaction between the child and the parent in the context of addictions, everyday skills, presence and engagement. The skills emerge stepwise. The knowledge of hardships ahead and perseverance is therefore helpful at the start. Workers considered it important that the parents’ own skills would awaken so they could see their own resources:
“The individual meetings usually include a discussion on the mother’s situation and how she is doing, and for every meeting, I have a theme related to the baby/motherhood/parenting planned.” (Worker)
An orientation to the future also exists in the knowledge that any future rehabilitation could be temporary, and the main aim for the women and their families would be to eventually live their everyday lives without using the service. If a bond has already formed between the mother and baby during pregnancy, the family can commit earlier to recovery-oriented communes and will start to hear about eg schedules and can imagine their way forward. They will learn basic skills according to their needs, such as food and eating habits within the family, maintaining a daily rhythm, and basic interactive and parenting skills.
A question about an orientation to the future emerged from the client responses, which suggested the need for increased visibility and the presence of the program within other services and in well-baby clinics:
“More visibility perhaps, survival stories, etc… Communicating more.” (Client, 259)
Clients use Google to create a pre-understanding and learn about early interventions, “points of entry,” and the different options available to them prior to accessing these services. In the current Finnish context, families can learn about suitable and available services, and they use peer recommendations.
Workers felt that awareness of HTTS and ETMA work with families in the early years was scarce. Other workers within health and social care fields may not know the client group, which may cause misunderstandings, misconceptions, and even stigma. As such, the workers networked among professionals that serve the same clientèle, and some provided open groups in well-baby clinics. They regularly meet with the network and release information in the form of leaflets and as digital materials, and they are also aware of online content strategies and a presence on the Internet, in social media platforms such as Twitter, Instagram and Facebook; where social media is accessible to the professional network and to the clients. Staff marketed their work; in this context, outreach utilizes networking and virtual channels.