From surviving to thriving: Understanding reuni!cation among African Americanmothers with histories of addiction

Joan M. BlakeyUniversity of Texas Arlington, School of Social Work, 211 S. Cooper Street, Suite 112C, Box 19129, Arlington, TX 76019-0129, United States

a b s t r a c ta r t i c l e i n f o

Article history:Received 23 June 2011Received in revised form 8 September 2011Accepted 9 September 2011Available online 17 September 2011

Keywords:Reuni!cationSubstance abuseAfrican American mothers

Child maltreatment cases involving substance abuse have increased. Estimates reveal that between 40% and80% of all families involved with child protection have substance-abuse issues. Only 12%–20% of substance-abusing families regain custody of their children. Little is known about the factors that contribute tosubstance-abusing women regaining or losing custody of their children. Using the Multiple Embedded CaseStudy method, this study illuminates the experiences and feelings of mothers struggling to overcome addictionand highlights the main differences between women who regained custody and those who permanently lostcustody of their children. In this study, 50% of thewomen lost custody and 50% regained custody of their children.The womenwho lost custody of their children tended to be in survivalmode, characterized as going through themotions, engaging in acting-out behaviors, and failing to follow treatment recommendations. The women whoregained custody of their children tended to thrive, characterized as having internal motivation, taking respon-sibility, and engaging the material. This study advances our knowledge of the factors contributing to reuni!ca-tion. Understanding these factors can lead to the development of practices that increase the likelihood ofreuni!cation for families struggling to overcome addiction.

© 2011 Elsevier Ltd. All rights reserved.

1. Introduction

Child maltreatment resulting from parental substance abuse hasbecome a major problem for child welfare agencies (Choi & Ryan,2006; Nishimoto & Roberts, 2001; Semidei, Radel, & Nolan, 2001). Par-ents with histories of addiction are at increased risk for maltreatmentassociated with substance abuse (Chaf!n, Kelleher, & Hollenberg,1996; Kelleher, Chaf!n, Hollenberg, & Fischer, 1994; Walsh, MacMillan,& Jamieson, 2003). Kelleher et al. (1994) found that parents with drughistories were !ve times more likely than non-substance-abusingparents to abuse their children and nine times more likely to neglecttheir children. Substance abuse is estimated to be a problem for 40%to 80% of families involved with the child protection system (Choi &Tittle, 2002; Hines, Lemon, Wyatt, & Merdinger, 2004; Semidei et al.,2001; Young, Boles, & Otero, 2007).

Substance-abusing parents are more likely to lose permanentcustody of their children (Frame, Berrick, & Brodowski, 2000;Jones, 2004). Marsh, Ryan, Choi, and Testa (2006) found thatnon-substance-abusing families achieved reuni!cation 42% of thetime, compared to substance-abusing families, which achievedreuni!cation 20% of the time. In addition, they found that only12% of substance-abusing families who had co-occurring problems(domestic violence; lack of housing; mental health) achievedreuni!cation. African American substance-abusing families were

found to be the most likely to lose permanent custody of theirchildren (Walker, Zangrillo, & Smith, 1994).

Using the Multiple Embedded Case Study method, this study illu-minates the experiences and feelings of African American mothersstruggling to overcome addiction and highlights the main differencesbetween women who regained custody and those who permanentlylost custody of their children. More research is needed to betterunderstand why the majority of parents with histories of addictionlose custody of their children (Sagatun-Edwards, Saylor, & Shif"ett,1995). This study explores factors that contributed to 50% of AfricanAmerican women losing custody of their children and highlightsservices and practices that potentially impact reuni!cation formothers who are struggling to overcome addiction.

2. Literature review

Children often are removed from their parents' custody whensubstance abuse is the precipitating reason for the child maltreatment(Brook & McDonald, 2009). When children are placed in out-of-homesettings, reuni!cation remains the primary permanency goal, unlessparents fail to demonstrate progress within the speci!ed permanencytimeframes (Miller, Fisher, Fetrow, & Jordan, 2006; Ryan, Marsh,Testa, & Louderman, 2006;Wulczyn, 2004). Over the years, numerousstudies have identi!ed factors that increase or decrease the likelihoodof reuni!cation. The majority of these factors fall into threecategories: child characteristics, practice-system related factors, andparent characteristics.

Children and Youth Services Review 34 (2012) 91–102

E-mail address: jblakey@uta.edu.

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2.1. Child characteristics

Research regarding the relationship between children's character-istics and reuni!cation has examined children's age, physical andmental capabilities, gender, and race. Results regarding the age ofchildren and its relationship to reuni!cation have been mixed. Sever-al studies found that children under one year of age and adolescentswere less likely to be reuni!ed with their parents (Connell, Katz,Saunders, & Tebes, 2006; Frame et al., 2000; Harris & Courtney,2003; Hindley, Ramchandani, & Jones, 2006; Shaw, 2006; Wulczyn,2004). However, Hines, Lee, Osterling, and Drabble (2007) foundthat younger children were more likely to be returned home.

Further, results regarding the role of gender in reuni!cation havebeen inconclusive. Wells and Guo (1999) found that children's gen-der was not related to reuni!cation, but Harris and Courtney (2003)found that males were less likely than females to be reuni!ed withtheir parents. The research related to children's disabilities has beenmore conclusive in that children with physical disabilities, mentalhealth and behavioral problems, and special needs were less likelyto be reuni!ed with their parents (Connell et al., 2006; Courtney,1994; Hindley et al., 2006).

Finally, several studies report that African American children wereless likely than White children to be reuni!ed (Cheng, 2010;Courtney, 1994; Harris & Courtney, 2003; Hayward & DePan!lis,2007; Lu et al., 2004; Shaw, 2006). Harris and Courtney (2003)concluded that “all else being equal, African American children gohome at a much slower rate than White children do” (p. 414).

2.2. Practice-system related factors

Some studies revealed caseworker practices or system-related fac-tors that contributed to low reuni!cation rates. Davis, Landsverk,Newton, and Ganger (1997) found that children who had multipleplacements while in foster care were less likely to be reuni!ed withtheir parents. Studies also have indicated that children placed withrelatives or in group homes were less likely to return home(Courtney, 1994; Hayward & DePan!lis, 2007; Smith, 2003; Wells &Guo, 1999). Ryan, Garnier, Zyphur, and Zhai (2006) found that casesinvolving multiple caseworkers were less likely to be reuni!ed withtheir families. They also reported that caseworkers with a Master ofSocial Work (MSW) degree more quickly reuni!ed children thannon-MSW-level caseworkers. Last, Cheng (2010) found thatcaseworkers' engagement promoted increased reuni!cation.

Another practice-system related problem that affects reuni!cationis the limited availability of effective services that assist parents inaddressing the conditions or problems that led to the abuse and ne-glect. Constrained child welfare budgets and resources, long waitinglists, and the lack of suf!cient substance-abuse treatment facilitiesfor women greatly impact family reuni!cation efforts (Marsh,D'Aunno, & Smith, 2000; Resnik, Gardner, & Rogers, 1998). Thetypes of services received by families that become involved withchild protection also seem to in"uence reuni!cation. Studies havefound that reuni!cation was more likely when services were tailoredto the needs of the family (Cheng, 2010; Choi & Ryan, 2006).

Moreover, substance-abusing parents who receive comprehensiveservices (i.e., employment, educational, parenting, and individual andfamily counseling) along with treatment are more likely to be reuni-!ed with their children (Marsh et al., 2000). Brooks and McDonald,(2009), however, found that receiving comprehensive services ledto slower reuni!cation rates.

2.3. Parent characteristics

Parental characteristics are the most common cause of low reuni-!cation rates. Single parents and parents who are poor are less likelyto be reuni!ed with their children (Courtney, 1994; Davis et al., 1997;

Harris & Courtney, 2003; Miller et al., 2006; Smith, 2003). Parentswho do not visit their children while they are in out-of-home settingsalso tend to lose custody of their children permanently (Leathers,2002). Mothers who face challenges with employment and psychiat-ric diagnoses are less likely to be reuni!ed with their children (Grella,Needell, Shi, & Hser, 2009). Finally, parents who enter the child wel-fare system because of neglect are less likely to be reuni!ed withtheir children (Courtney, 1994; Davis et al., 1997; Hindley et al.,2006; Wells & Guo, 1999).

Further, parents who have histories of addiction were more like-ly to lost custody of their children (Brook & McDonald, 2009; Choi& Ryan, 2006; Frame et al., 2000; Grella, Hser, & Huang, 2006;Maluccio & Ainsworth, 2003; Miller et al., 2006; Smith, 2003).Marsh et al. (2006) found that non-substance-abusing familiesachieved reuni!cation 42% of the time, compared to substance-abusing families, which achieved reuni!cation 20% of the time. Inaddition, they reported that only 12% of substance-abusing familiesthat had co-occurring problems (domestic violence; lack of hous-ing; mental health) achieved reuni!cation.

Walker et al. (1994) reported that African American substance-abusing families achieved reuni!cation only 28% of the time—incontrast to 51% of non-substance-abusing African American families.Several studies have concluded that the mere indication that drugsand alcohol might be a part of the problem dramatically reduces thelikelihood of reuni!cation (Miller et al., 2006; Shaw, 2006; Smith &Testa, 2002).

Another important parent characteristic related to low reuni!cationrates is substance-abusing parents' failure to comply with conditions oftheir case plan. Even though completion of substance-abuse treatmentis a base-level expectation for parents who want to retain or regaincustody of their children (Karroll & Poertner, 2002; Rittner & Dozier,2000; Smith, 2003; Stromwall et al., 2008), between 50% and 75% ofwomen addicted to drugs and alcohol did not comply with or droppedout of treatment during the !rst few months (Green!eld et al., 2007;Zlotnick, Franchino, St. Claire, Cox, & St. John, 1996).

Smith (2003) found that substance-abusing parents who complet-ed drug treatment were more likely to achieve reuni!cation than par-ents who did not complete treatment. According to Huang and Ryan(2011), parents who completed treatment were assumed to be absti-nent, compliant, and as a result were often recommended for reuni!-cation. Green!eld et al. (2007) found that women who enteredtreatment right away, remained in treatment longer, and completedat least one treatment episode were reuni!ed more quickly withtheir children. The research shows a correlation between treatmentcompletion and reuni!cation (Grella et al., 2009; Marsh et al., 2006).

Within the reuni!cation literature, the vast majority of child wel-fare research focuses on children's experiences within the child wel-fare system. Rarely do studies privilege mothers' voices or explorereuni!cation from their perspective (Gregoire & Schultz, 1995; Sun,2000). A lot can be learned from parents who are successful or unsuc-cessful in regaining custody of their children. Of the studies focusingon the parents, most identify parents who are the least likely to losecustody of their children or factors that lead to loss of custody. Under-standing the “who” and “what” is a signi!cant !rst step. Still, little isknown about why some substance-abusing parents retain or regaincustody while others lose custody of their children. This study seeksto !ll these gaps in the literature by illuminating the experiences ofwomen struggling to overcome addiction and highlight the main dif-ferences between women who regained custody and those who per-manently lost custody of their children.

3. Methods

This article presents !ndings from a Multiple Embedded CaseStudy of 26 African American mothers who become involved withthe child protection system because of their histories of addiction.

92 J.M. Blakey / Children and Youth Services Review 34 (2012) 91–102

Using in-depth interviews and information from the women's case!les, this study explored the women's histories of addiction; theirexperiences in substance-abuse treatment; their previous and currentinvolvement with child protection; as well as their relationship withtheir substance-abuse treatment counselors and child protectioncaseworkers.

Embedded within each of the mothers' cases was a substance-abuse treatment counselor and child protection caseworker whoworked with and assessed these mothers' abilities to parent theirchildren effectively. Sixteen of those professionals (10 substance-abuse treatment counselor and 6 child welfare caseworkers) com-pleted in-depth interviews that explored their assessment of theirclients' ability to recover, regain custody and parent their children,the factors that could impede their ability to regain custody of theirchildren, their relationship with the women, as well as their role inhelping the women accomplish their goals.

The Multiple Embedded Case Study method brings multiple van-tage points (e.g., participants and methods) to bear on a speci!c phe-nomenon of interest. This type of study design is ideal for a holisticand in-depth investigation into the differences between womenwho regained custody and those who lost custody of their children(Fisher & Ziviani, 2004; Padgett, 2008; Scholz & Tietje, 2002; Stake,2006; Yin, 2009). Embedded Case Study designs involve explorationwithin cases, as well as examination of similarities and differences be-tween cases. Overall, this type of case study is considered robust andreliable because multiple units of analysis (e.g. participants andmethods) are used to investigate a problem (Yin, 2003).

3.1. Data collection

The data were collected at a women-only, comprehensive residen-tial substance-abuse treatment program that allows women to bringtheir children into treatment with them. This type of treatment pro-gram has been found to be most effective in treating mothers withhistories of addiction (Covington, 2002). Data collection methods in-cluded semi-structured interviews and review of the women's case!les. The 1- to 2-hour, in-depth, interviews were conducted over14 months (April 2007–June 2008). All of the interviews were audio-taped and professionally transcribed verbatim. The interviews wereuploaded into NVIVO, a qualitative software program that allowstranscribed interviews to be stored, coded, and categorized.

A purposive sample of 26 African American women was recruitedfor the study. Participation was limited to African American womenwho at that time were involved with child protection because oftheir substance abuse. The study focused on African Americanwomen because African American families have the worst outcomesin terms of their involvement with child protection (Harris &Courtney, 2003). Further, African American families are least likelyto regain custody of their children, compared to White families(Walker et al., 1994).

For substance-abuse treatment counselors and child welfarecaseworkers to participate in the study, the women had to provideconsent for their counselor and their caseworker to be interviewed.Once consent was obtained, the professionals also had to agree to par-ticipate in the study. A total of 16 professionals (10 substance-abusetreatment counselors and six child protection caseworkers) agreed toparticipate in the study. The 10 counselors were interviewed concern-ing 24 of the women. Two substance-abuse treatment counselors didnot participate in the study for unknown reasons.

Six child protection caseworkers were interviewed concerning six ofthe women. Only six child protection caseworkers agreed to participatein the study. I spoke with several of the child welfare caseworkers whoshared the outcome of the women's cases but refused to participate inthe study because the cases had been closed for a long time. Otherworkers failed to respond to my repeated attempts to contact them.After !ve phone calls over a 2-month period and no return phone

calls, I decided that the other caseworkers were not interested orwere willing to participate in the study.

3.2. About the participants

The womenwho participated in this study were 19 to 43 years old.The majority (22 women) became involved with child protectionafter giving birth to a substance-exposed infant; three becameinvolved because of child neglect, and one became involved whenher child was injured during a domestic altercation. Twenty-onewomen had anywhere from one to !ve previous involvements withchild protection, with an average of three involvements. Theseprevious involvements were mostly for neglect. Three women had aprevious history with child protection because of physical abuse.Five women had no prior history with child protection. Fifteen ofthe women in this study received Intact Family Recovery services(IFR), an alternative child protection program. Eleven womenreceived traditional child protection services.

The women had between one to 10 children, with an average of!ve children. Twelve women lost custody of all of their children,except for the current child (ren) for whom they were working to re-tain or regain custody. The women's primary drug of choice was crackcocaine (11 women), followed by heroin (9 women). Poly-substanceabuse was common. Nineteen of the 26 women used three or moredrugs, not including nicotine and methadone. The women startedusing illicit drugs (e.g., marijuana, heroin, or crack cocaine) whenthey were from 5 to 37 years old. On average, the women startedusing when they were 14 years old. The women remained in treatmentfrom 14 days to 1 year and 10 months. On average, the women in thestudy remained in treatment 99 consecutive days. During my study,the majority of women (18 women) completed treatment. Fivewomen left against medical advice, and three women were dischargedfrom the program because of constant rule-breaking (see Table 1).

Of the professionals who participated in the study, two were maleand 14 were female. Eleven of the professionals were AfricanAmerican, four were White and one was biracial (African Americanand White). One of the professionals had an Associate's degree, fourhad a Bachelor's degree, nine had a Master's degree, and two had aDoctorate. The counselors and caseworkers had anywhere from9 months to 35 years of experience, with an average of almost14 years of experience. Two of the child welfare caseworkers workedin the IFR program, and four worked in the traditional child protec-tion system. Three of the child protection caseworkers worked forthe state, and the other three were employed by non-pro!t agenciesthat contracted with the state to provide services to clients involvedwith child protection (see Table 2).

3.3. Analysis

The analysis process began by open-coding (e.g. allowing thecodes to emerge from the data versus starting with a list of codes)the transcripts from in-depth interviews, information from thewomen's !les, and my !eld notes (Charmaz, 2000; Miles & Huberman,1994; Padgett, 2008). I read through the data multiple times and gen-erated a list of in vivo (i.e., codes that used the study participants'words) and descriptive codes (Miles & Huberman, 1994). I reviewedmy initial codes with a qualitative research group. The codes werechallenged, re!ned, combined, and deleted. Together, we developeda !nal coding scheme.

Coding all of the data revealed codes pertaining to the women,their families, and support system, as well as worker/system-levelfactors. Many of these codes seemed to be ecologically nested. As aresult, I decided to use an ecological framework. Once I identi!ed aconceptual framework, I used the Case Study analytic technique oflooking within and between cases to con!rm and substantiate theconceptual framework and identify emergent themes (Yin, 2009).

93J.M. Blakey / Children and Youth Services Review 34 (2012) 91–102

Looking within and between cases also involved repeatedly checkingfor discon!rming and corroborating evidence, as well as alternativeexplanations (Yin, 2009).

Multiple reviews of the codes and data generated themes. The-matic analyses involve searching for patterns that emerge from thedata that help the researcher begin to answer the research questions(Fereday & Muir-Cochrane, 2006). Yin (2009) refers to this process aspattern matching, a way of dissecting the data to understand “the pat-terns, the recurrences, the plausible whys” of individual instances, aswell as the aggregation of instances (Miles & Huberman, 1994, p. 69).Pattern matching is the most desirable technique for case study anal-ysis (Yin, 2003).

The larger study had three research questions that focused on theindividual, family, and worker/system levels. Here I reported on theindividual differences between the women who regained and thosewho lost custody of their children. The primary research questionguiding this study was: What in"uences whether African Americanmothers who are addicted to drugs and alcohol regain or permanent-ly lose custody of their children?

To answer this research question, I asked questions of the data toexpose patterns that highlighted the main differences between thesetwo groups of women. For example, what do the women whoretained or regained custody of their children have in common?What do the women who lost custody of their children have incommon? Once I identi!ed the factors that seemed to in"uence theoutcome that women in this study experienced, I begin to ask myselfwhat these factors had in common or represented. The analysisrevealed that the women approached substance-abuse treatmentand child protection differently and that these differences tended toaffect the outcomes of the women's child protection cases.

To enhance the rigor and credibility of the analysis, I created anaudit trail through memos and !eld notes (Gillham, 2000; Lincoln &Guba, 1985; Yin, 2009). I also conducted member checks and follow-up interviews with participants whose experiences challenged oradded complexity to the study's !ndings (Lincoln & Guba, 1985;Padgett, 2008).

4. Results

Based on reports from the child protection caseworkers andfollow-up calls by the substance-abuse treatment center, I was ableto determine that 50% percent of the women (13 women) lostcustody1 and 50% regained custody of their children. The main differ-ence between the women who regained custody and those who lostcustody of their children was how they approached their involvementwith substance-abuse treatment and child protection. Most of thewomen who lost custody of their children exhibited behaviors thatwere characteristic of surviving or being primarily in survival mode,whereas the majority of women who regained custody of their chil-dren exhibited behaviors that were characteristic of thriving.

Women in survival mode super!cially complied with the condi-tions of their child protective service case plan in an attempt to regaincustody of their children, but without making any real changes orbeing changed by what they were learning in substance-abusetreatment. They often engaged in behaviors that met their immediateneeds and desires without thinking about the long-term conse-quences of their behavior. Their actions tended to be rote and habitu-al, often lacking insight into why they did certain things or engaged incounterproductive behaviors. In addition, these women often wereunwilling to listen to feedback or suggestions, instead believing thatthey knew how to remain sober and that there were no valid reasonsfor their involvement with child protection. Overall, women in sur-vival mode were just biding their time long enough to regain custodyof their children and get child protection out of their lives.

Women in thriving mode approached their involvement withchild protection as an opportunity to change their lives. They

Table 1Demographics of the women.

Name ofmother

Age # Years usingalcohol/drugs

# of previousTX episodes

Length of timein TX (1)

# ofkids

Previous # of DCFSinvolvements

Type of currentDCFS involvement

# of children lostcustody prior to study

Outcome

Barbara — 4 38 27 6 95 days 10 5 TRAD 8 Reuni!cationDallas — 2 42 30 7 84 days 2 2 TRAD 0 Reuni!cationBelinda — 1 26 13 2 661 days 2 0 TRAD 0 Reuni!cationDarcy — 3 20 6 1 86 days 1 0 IFR 0 Reuni!cationDawn — 2 39 24 3 102 days 7 2 IFR 0 Reuni!cationLashaun — 3 41 21 5 86 days 6 3 IFR 0 Reuni!cationLisa — 3 37 30 13 101 days 5 3 IFR 4 Reuni!cationMackenzie — 3 39 22 4 90 days 8 1 IFR 0 Reuni!cationNatalie — 3 31 18 1 85 days 4 1 IFR 0 Reuni!cationTabitha — 3 37 18 1 96 days 5 1 IFR 2 Reuni!cationTahlia — 3 37 19 1 96 days 4 0 IFR 0 Reuni!cationTonia — 3 34 21 3 71 days 4 2 IFR 0 Reuni!cationVivian — 4 33 19 1 122 days 10 4 IFR 6 Reuni!cationDana — 3 19 3 0 82 days 1 0 IFR 0 UnknownBailey — 3 32 15 3 25 days 3 1 IFR 2 Lost CustodyDarla — 4 43 29 3 95 days 10 2 TRAD 9 Lost CustodyEdith — 1 42 26 9 85 days 8 4 TRAD 7 Lost CustodyEvelyn — 2 33 17 1 14 days 4 3 TRAD 4 Lost CustodyHarriet — 2 39 25 3 90 days 8 3 TRAD 7 Lost CustodyKai — 3 40 35 4 39 days 7 2 IFR 6 Lost CustodyTasha — 2 30 16 0 36 days 1 0 IFR 0 Lost CustodyVictoria — 4 37 23 3 111 days 4 2 TRAD 0 Lost CustodyCandace — 4 39 26 5 91 days 4 4 TRAD 3 Lost CustodyTammy — 4 43 25 4 33 days 7 2 IFR 5 Lost CustodyVanessa — 3 40 26 4 105 days 6 4 TRAD 5 Lost CustodyVickie — 3 26 15 2 110 days 2 1 TRAD 1 Lost Custody

4 = four sources — SATC, PP, DCFS, and !le; 3 = three sources — SATC, PP and !le; 2 = two sources — SATC and !le, 1 = one source SATC interview or !le only.Sources = Interviews with substance-abuse treatment counselor (SATC), parenting professional (PP), child protection caseworker (DCFS) and !le review.

1 The outcome of one woman's case remains unknown. I put her in the loss of custo-dy group because she was only 19 years old at the time, struggling to care for herdaughter and had several hotline calls made against her while in treatment, expresseda desire to have her stepmother raise her daughter, left treatment against medical ad-vice and disappeared. Based on these circumstances, I determined that she most likelylost custody of her daughter and put her in the loss of custody group.

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perceived their involvement with child protection as a wake-up callfor them to get their lives together. They moved beyond participatingin treatment because child protection mandated them to and, rather,were driven internally by their desire to live a drug-free life and be agood parent to their remaining child or children. Women in thrivingmode took responsibility for their decisions and mistakes that led totheir involvement with child protection. They took charge of theirlives and no longer blamed other people. The womenwhowere thriv-ing engaged the material and used what they learned in treatment tomake lasting changes. Ultimately, they wanted more out of life, andthey believed that they could have the life they desired if they wereto remain committed to this goal.

4.1. Characteristics of surviving

Three characteristics of surviving contributed to the women notcompleting treatment, returning to drug use, and losing custodyof their children: (1) going through the motions, (2) acting-outbehaviors, and (3) not following treatment recommendations. Ofthe 13 women who lost custody of their children, 12 went throughthe motions, 10 engaged in acting-out behaviors, and 13 did notfollow treatment recommendations. Of the 13 women who regainedcustody of their children, two went through the motions, three en-gaged in acting-out behaviors, and two did not follow treatmentrecommendations.

4.1.1. Going through the motionsThe womenwhowent through the motions often focused on com-

pleting the required number of days stated in their child protectionservice plans and bided their time until they were discharged fromsubstance-abuse treatment for disruptive behavior, decided to leavethe program against medical advice (AMA), or completed the re-quired amount of time. Candace, a 39-year-old mother of four, stated:

DCFS said I have to do 60 days, and that's all I'm doing. When60 days hit, I'm walking out that door, and I don't care whatnobody says. I done got all I can out of treatment. What morecan I get out of 90 days than 60 days? Nothing! Let me moveon… I might not make it through 90 days. I made it through the60. The 60 might save my life. Let me go to recovery.

Child protection required Candace to remain in substance-abusetreatment for 90 days at her counselor's request. Candace reluctantlycomplied with this request and remained in treatment exactly90 days. Three days after Candace left treatment, she relapsed.Candace never reengaged in services, and she lost custody of her son.

The women who went through the motions tended to engagesuper!cially in treatment. These women often did not share deeper-

level issues and concerns. They showed little openness or personalexploration while in treatment, instead remaining surface-level ingroups and in their individual sessions with counselors.

In self-disclosure group, the women are asked to share their lifestories and tell the group members how they got to this point. Ms.Francis,2 Tasha's treatment counselor, re"ected on Tasha's disclosuresession:

After Tasha shared her story, I didn't understand any more aboutTasha than when she started. It reminded me of that James Brownsong-“talking loud but ain't saying nothing.” That's what it waslike… Even in our one-to-one sessions, I still can't !gure her out,and I can usually get through to my clients. She's a hard one to peg.

Most of the women in this characteristic of surviving lost custodyof their children. Two women were the exception. The reason theydid not lose custody is that the IFR child welfare case workers didnot bring them to court. Families that are court-involved have a spec-i!ed amount of time to address the conditions that led to the abuse.Once children have been in foster care 15 of the most recent22 months and the parents have made little or no progress on theircase plans, a petition is !led to initiate termination of parental rights.

Tabitha is an example of one of the women in survival mode whodid not lose custody of her children. Ms. Kathy stated that “the onlyreason that Tabitha hasn't lost custody of her children is that herIFR caseworker didn't have the heart to bring her into court.” Tabitharelapsed numerous times. While in an outpatient treatment program,she tested positive for crack cocaine three times, and this is why shewas required to participate in residential treatment. Tabitha left resi-dential treatment after 90 days. Within a month she relapsed andreturned to treatment a second time. She completed another90 days and relapsed again. Ms. Linda related:

Tabitha's second time around was pretty much like her !rst. Shecame here, did her time, and left. Not much about Tabitha haschanged.

All of Tabitha's progress notes indicated that she was unwilling tolook at the deeper issues that kept her stuck in this cycle of addiction.

In contrast to the women in the group labeled as surviving, thosewho were moving toward thriving knew that 90 days did not consti-tute enough time to understand their addiction and learn alternative

Table 2Demographics of all professionals.

Name Role Gender Race Education level Years of experience # of clients in the study

Mr. David DCFS Male African American Bachelors 17 years 1Mr. Edward DCFS Male White Masters 15 years 1Ms. Connie DCFS Female African American Masters 7 years 1Ms. Fran DCFS Female White Masters 14 years 1Ms. Layla DCFS Female African American Masters 20 years 1Ms. Uma DCFS Female White Masters 2 years 1Ms. Beatrice SATC — Unit A Female African American Masters/CADC 22 years 1Ms. Francis SATC — Unit A Female African American Associates/CADC 27 years 4Ms. Gabriella SATC — Unit D Female African American Masters/CADC Over 30 years 1Ms. Gertrude SATC — Unit D Female African American Bachelors/CADC 3 years 2Ms. Karen SATC — Unit D Female African American Bachelors/CADC 15 years 4Ms. Linda SATC — Unit A Female African American Bachelors/CADC 2 years 5Ms. Lucy SATC — Unit A Female Bi-racial Doctorate Less than 1 year 3Ms. Nancy SATC — Unit A Female White Doctorate/CADC 18 years 2Ms. Sarah SATC — RH Female African American Masters 11 years 1Ms. Tonya SATC — Unit A Female African American Masters/CADC 10 years 1

2 I use Ms. and Mr. when referring to the professionals because the women were re-quired to refer to them in this manner. The professionals believed that this formalitywas a necessary part of the women reestablishing boundaries. This boundary wasstrictly enforced.

95J.M. Blakey / Children and Youth Services Review 34 (2012) 91–102

ways of coping with their lives. They planned to remain in a struc-tured setting as long as they could. Tahlia stated:

When I !nish inpatient treatment, I'm going upstairs to SafeHaven [a recovery home] and then to Freedom Place [a transition-al living program at THW]. I'm going to stay as long as I can so I canget what I need to get.

Going through the motions was a characteristic of surviving; thesewomen participated in substance-abuse treatment just to meet theirchild protection requirements. They did the minimum required ofthem (e.g., come to treatment for 90 days) instead of beginning thehard work of understanding how and why they had started usingdrugs and begin to make lasting changes. Lisa, a woman who wasconsidered thriving said:

My thing is to focus on me so that I'm better for him… I just wantto change those things that kept me bound… I'm looking forchange. I'm looking to be different. I'm looking to be better. ‘Causeif I'm better, he's gonna be better… This time, like I said, it's allabout the bonding and having a relationship and being able to par-ent my child without the separation, without coming in doing mytime and that's it. It's about growing up.

4.1.2. Acting-out behaviorThe second characteristic of surviving consisted of women engag-

ing in acting-out behaviors, which tended to interfere with theirlonger-term goal of regaining custody of their children. These behav-iors often involved doing things that interfered with the treatmentprocess and could potentially lead to discharge from treatment.Acting-out behaviors consisted primarily of bringing drugs onto theunit and deviating while out on appointments.

Kai went on a shopping trip with the women and staff to Wal-Mart, where she saw a drug dealer for whom she sold drugs. Shesaid that he asked her where she had been and then gave her somedrugs. Kai reported:

I guess my mind was already made up once I closed my hand.When I didn't say, “no, I'm cool,” or whatever. But I couldn't saynothing. I was stuck, and it was like I thought I was ready whenI came in here. I knew I would do anything I had to do to get mybaby whereas DCFS goes [says] I didn't think about my daughterbeing here, somebody watching her while we were shopping. Ididn't think about her. I didn't think about that DCFS worker. Ididn't care about the people knowing that I used the shit. I didn'tcare about if they would of kicked me out. I ain't cared about thatworker knowing—getting my baby, going to back court. I didn'tthink about none of that until after I did the stuff.

Kai used drugs while inWal-Mart. She was so high that she set theopen pack on the table. Ms. Nia, the staff person who brought her toWal-Mart, saw the drugs and made her throw them away. Kai admit-ted that she intended to bring the drugs back to the unit. Kai was notkicked out that night, but she continued to get high when she deviat-ed while on medical appointments. She !nally was discharged fromthe program and her daughter was taken into custody. Kai neverreengaged in services, which led to loss of custody.

Deviating, another form of acting-out behavior, is a term used atthe treatment center to describe women who go on approved passesto the doctor or apply for economic assistance but while they are out,they go to unapproved places (e.g., going to be with their boyfriend orgoing to their mother's house) or do unapproved things (e.g., going toget their nails and hair done).

The substance-abuse treatment counselors believe that the devia-tions are problematic for several reasons. For one thing, they think

that deviating makes the women more prone to relapse. The treat-ment center restricts the places that the women can go for the !rst60 days because they want to give the women some time to learnways of coping with dif!cult, stressful situations besides drug use.According to Candace's progress notes, she deviated repeatedly.Almost 3 months after entering treatment, Candace relapsed whenshe and a peer left treatment to apply for economic assistance.Candace's progress notes state:

Patient disclosed her side of the story of how she and a peer re-lapsed… Patient stated that her peer was acting funny and startedtalking about the dope and places she knew in Highland. Patientstated that when they got on the train, they started talking aboutgetting high. Patient stated that as they kept talking, they decidedthat they would get high… Patient stated she had to go to hermother's home to get money to get back to the center… Patientstated she was not going to get high any more. Patient seemed re-morseful about her actions. Patient is at risk of relapse… Patient'streatment plan will be amended to re"ect her recent drug use.

Deviations also were seen as problematic because the womenwere using dishonesty and manipulation (things they used in theiraddiction) to get their needs met. Being honest demonstrated to thetreatment staff that the women were getting better because theyfound healthier ways than lying and manipulation to meet theirneeds. Ms. Francis, a substance-abuse treatment counselor, stated:

It is important for the women to be honest and take ownership.Most of the addicts are like people pleasers. They're looking for ap-proval. So they basically don't tell the truth. They got this streetcode/ethics that if you're honest, you're a squealer. They reallydon't like squealing on each other unless it's really, really detri-mental. They keep each others' secrets until they get mad. Thenonce they get mad, you !nd out who deviated and who's notworking an honest program. We got about two or three womenthat are really striving to work an honest program.

Finally, the counselors suggested that deviations were quick !xesto larger issues that were surfacing while the women were in treat-ment. Ms. Karen, one of the treatment counselors, offered the follow-ing explanation:

The deviations are thewayswomen use to get their needsmet in thebestway they knowhow… They're really just trying to soothe them-selves, to put it in laymen terms… They're trying to !x the situation.

For example, Harriet, 39-year-oldmother of eight, deviated immedi-ately after having a major !ght with her eldest daughter, who was car-ing for her youngest son. Harrietwas gonemore thanhalf of the day andbecame defensive when the staff confronted her about her where-abouts. Harriet said she would not con!rm or deny being at homewith her signi!cant other. Later, she admitted that she was at homewith her signi!cant other and stated that shewouldn't deviate anymorebecause she didn't want to further jeopardize her recovery. WhenHarriet was asked why she deviated in the !rst place, she repliedthat she didn't know why. Then she added, “Because I needed toget some [sex].”

Acting-out behaviors were connected to surviving because thesebehaviors met an immediate need or desire. The women rarelythought about the long-term consequences of their actions untilafter they had acted. Surviving women engaged in these acting-outbehaviors even though these behaviors often led to relapse or gotthem kicked out of the program, both of which jeopardized theirchild protection case. Part of moving toward thriving involved !ndingmore adaptive ways to meet their needs or cope with feelings thatarose in treatment.

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Lisa, a woman who was thriving, shared what she does when shewants to act out:

When I want to act out, when I want to "are up, I can't help butseeing my son's face. And no one and nothing is more importantthan my being here. I'm getting what I need from here. I utilizeit… to help me stay sober and to help me bond, nurture, and carefor my son. It's all about the child. It's not about me anymore. I'vedone what I've done. I can't change anything that I've done. It'swhat I do today. And that's forward.

4.1.3. Failure to follow recommendationsThe majority of women are given the same substance-abuse treat-

ment recommendations: Remain in treatment at least 90 days, go to arecovery home, enroll in an outpatient treatment program, get anAlcoholics Anonymous or a Narcotics Anonymous sponsor, and goto 90 meetings in 90 days. The substance-abuse treatment counselorsbelieve that if the women follow their recommendations, they willnot relapse. Ms. Linda, a substance-abuse treatment counselor stated:

I tell themwe're giving you your discharge papers the same as youwould get discharge papers from a hospital saying this is what youmust do in order to maintain your health. If you don't followthrough, you're gonna have a relapse, plain and simple. And sothey leave and they don't follow through, so then they relapse.So you can be discharged from the hospital, and that doesn't meanyou're completely well, but you're not sick enough to stay.

In this study, child protection deferred to and supported thesubstance-abuse treatment center's recommendations as far as thewomen's addiction was concerned. If the treatment center recom-mended certain things, child protection included those recommenda-tions as part of the women's case plan requirements. If a womanchose not to follow child protection or substance-abuse treatment'srecommendations, child protection still held her accountable. Insome cases, child protection held women to a higher standardbecause the women knew what was recommended and insisted ongoing their own way. Mr. David, a child protection caseworker,offered:

One of my clients needed housing that is supportive of recovery.The client rejected the treatment center and my recommendationto go to a place that offers long-term housing with a recoverycomponent… Well, she didn't want to do that. Three or fourmonths later, she failed. The baby came into custody. She didn'tget that second chance. We made our recommendation. Onceyou're in recovery, you're supposed to be sailing along. The clockhas started. All they have to do is to work the plan.

Failing to follow treatment recommendations was characteristic ofsurviving because the professionals interpreted it as the womenbeing unwilling or not open to listening to feedback from the profes-sionals. Many of these women insisted that they knew how to stayclean and that their involvement with child protection was the resultof a one-time slip-up. For instance, Bailey said:

I'm giving them 30 days. I need a refresher course so I don't messup again. I came back into treatment to keep custody of my son.These other people may need 90 days, but all I need is 30 daysand I'll be straight.

Bailey left treatment and relapsed. She returned to treatment asecond time and stayed only 13 days before relapsing again. Custodyof Bailey's son was transferred to her mother, and her child protectioncase was closed.

For women to move from surviving to thriving, they needed tostop going through the motions and do the hard work of looking atthe ways their histories of substance abuse have interfered withtheir ability to parent and lead the life they indicate that they want.They also needed to !nd healthier ways of coping that did not inter-fere with their long-term goal of regaining custody of their children.Lastly, they needed to follow the recommendations given by bothchild protection and substance-abuse treatment.

4.2. Characteristics of thriving

Three characteristics of thriving in"uenced whether the womencompleted treatment, remained abstinent, and retained custody oftheir children: (1) internal motivation, (2) taking responsibility, and(3) engaging the material. Of the 13 women who regained custodyof their children, 11 had internal motivation, 10 took responsibilityfor their situation, and 11 were characterized as engaging the materi-al. Of the 13 womenwho lost custody of their children, two had inter-nal motivation, one took responsibility for her involvement in childprotection, and two engaged the material.

4.2.1. Internal motivationInternal motivation is an intrinsic desire to work for the sake of

accomplishing the goal rather than engaging in the activity to obtainsome sort of external reward (Ryan & Deci, 2000). Womenwith inter-nal motivation have an internal desire or a drive for their lives to bedifferent. Tahlia, an example of a woman with internal motivation,said:

So I pretty much had a made-up mind to come in here and dowhat I needed to do… you know, when you put your mind to do-ing something… I take advantage of the opportunities to grow inany area that I can as possible, and I'm very motivated in spite ofmy drug use…and just go on through all I've been through in thislast six months. I've never been motivated like I'm motivated now.You know, I'm not even thinking about the days because it seemslike the weeks are just passing by and I'm coming up on twoweeks now and it's so quick. So I'm very motivated in completingthis phase of the program and going to the next phase…so I'mlooking at all these stages that I can go through… I mean, I'm atthat point where this is something that I need to do not just be-cause I'm a new mom but because I need help.

Some of the other womenwho were internally motivated gave thefollowing reasons for getting clean and putting their lives backtogether:

• “Because it is the right thing to do for myself and my children”• “I want to be a better mother to my children”• “I'm tired of living this drug lifestyle, I'm ready for a change”• “I'm getting older. It's time for me to get my life together”• “I don't want to die”• “I don't want to be like my mother”• “I want to learn how to be a great parent”.

Most of the thriving women were internally motivated, but not allof the women started out that way. Initially, some of the womenweremotivated by proving DCFS wrong. As time went on, their motivationbecame more internally focused.

Belinda, 26-year-old mother of two, talked about her reasons for!nally getting herself together:

They [DCFS] told me I'm never gonna see my son again. We're ter-minating your rights…You're done. Sorry it didn't work out… Buta part of me was just like—you know what—they're full of shit.

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They don't know what they're talking about. They're not takingaway my son forever from me, you know…. They think they'regonna do this, and I'm just gonna be like, “Oh my God, my life isover.” I can't live anymore and go get high… I'm one to proveyou wrong. That's me. I'll dig my teeth into whatever I can justto prove you wrong. And I've always been like that with every-thing I do… It's drive… Like I said before, just like “I'm not givingup, you're not gonna get the best of me” sort of thing. That's theway I see it. There's this drive that's inside of me that “I'll showyou.” But the longer I've been clean, the more clear things are.The more time I spent in treatment, the more I realized that Ihad an addiction. The more I realized that I wanted differentthings out of life, [the more] I realized that I wouldn't have thosethings as long as I kept getting high. I knew there's no way if Iwas using. There's no way.

In contrast, women who were externally motivated engaged in anactivity or a course of action because they believed it would lead to adesired outcome or a reward outside of themselves or to satisfy someexternal requirement (Ryan & Deci, 2000). Some of the women's ex-ternal motivations were:

• “DCFS is making me do it”• “I want my family to be proud of me”• “My [signi!cant other] threatened to leave me if I lose the baby”• “DCFS could help me with housing and other things I need”.

The problem with external motivation was that it did not seem tosustain the women, especially when they were faced with dif!cultiesor obstacles.Ms. Gabriella, a substance-abuse counselor, explainedwhy:

There's nothing wrong with having external motivation. I thinkthat's good, and I think that keeps people going in the beginning…But I think in order to sustain them, they will desire to recover be-cause of internal reasons—because they feel they're worth it andthey can see the value in it.

The reality was that even the threat of losing custody of their chil-dren was not enough for most of the women who remained in survivalmode. Thrivingmeant that thesewomen had an internal desire for theirlives to be different. They saw value in accomplishing their goals not be-cause someone else said they had to but, instead, because they them-selves wanted a richer, fuller life for themselves and their children.

4.2.2. Taking responsibilityThe second characteristic of thriving involves taking responsibili-

ty. Women in thriving mode take responsibility for their decisionsand mistakes and begin to understand how their choices have createdtheir present circumstances. They do not make excuses or blameother people for their current involvement with child protection.Dallas said:

I was trying to !ght them. I was focused on what DCFS wasn'tdoing right… When I started burning my energy on me and startgetting clean, that's when me and DCFS had a new relationship.

Other women con!rmed the importance of taking responsibility.Lashaun, 41-year-old mother of six, reported:

My active drug use cloudedmymind to the point that I failed to rec-ognize I was neglecting and verbally abusing my daughter, whichlikely led to the sexual incident in the hallway. And through proces-sing the situationwithmy counselor, I'm accepting responsibility formy actions and no longer blamingmydaughter for calling DCFS…At!rst I would be angry just to hear my daughter's name mentioned,but now I realize I can't blame my daughter for calling DCFS. Itwasn't her fault, but mine.

The professionals in this study believe that taking responsibility isan important aspect of recovery and central to women's healing. Forthe substance-abuse counselors, this belief seems to come directlyfrom the 12-step model, which focuses heavily on taking responsibil-ity. According to the Alcoholic Anonymous World Services (2004),Step !ve states “Admit to God, ourselves, and to another humanbeing the exact nature of our wrongs.” Step eight states “Make a listof all persons we harmed, and become willing to make amends tothem all.” Step ten states “Continue to take personal inventory, andwhen wrong, promptly admit it.”

Ms. Francis, a substance-abuse treatment counselor, said:

They need to take responsibility for their disease. Just saying, “I gota disease” and then not taking responsibility and owning up tohow the disease or addiction has created all these problems intheir life… I know they're getting thirsty when they start doingthat. Taking responsibility means acknowledging that they willalways have to go to meetings and have perseverance because thisis a disease. Just because they stop using drugs doesn't mean theycan stop.

The substance-abuse treatment counselors believe that takingresponsibility largely determines women's success. Ms. Gertrude, asubstance-abuse treatment counselor, concluded:

Some of them have got to the point that they can't accept respon-sibility. Everything that has happened to them is someone else'sfault. Lashaun—she took responsibility for her children and whereshe went wrong with them. Look at where she is at now. I believethat Lashaun is going to make it.

Most of the counselor' work with the women actually seems tocenter on getting the women to take responsibility for their actions.Ms. Sarah, a substance-abuse treatment counselor, reported:

Early on, Belinda had an inability to take responsibility for her de-cisions. She would talk about DCFS being out to get her. I wouldstop her real quick. We talked a lot about her role, and I madeher look at her lack of responsibility that she had going on in herown life, not only her addiction, but the domestic violence thatshe was involved in.

The DCFS caseworkers, too, believed in the importance of takingresponsibility. Mr. Edwards, a DCFS caseworker, said:

Barbara has lost eight kids, but she hasn't been destroyed by it.She's never given me the song and dance or put that blame any-where else. I haven't seen any of that with her—not life circum-stances, none of that.

In contrast, Bailey, a 32-year-old mother of three, was unable totake responsibility, saying:

They didn't makeme come to treatment. I came onmy own becauseI needed a refresher course. I missed something the last time I was intreatment…I wasn't out of control. I was using every now and then. Idon't know howmy son tested positive because I only used the !rsttwo months before I found out I was pregnant. After I found out, Istopped… I don't know how I got involved with child protection.

Ms. Lucy, Bailey's substance-abuse treatment counselor, thoughtthat Bailey's inability to take responsibility attributed to her relapseand subsequent return to treatment. Ms. Lucy stated:

Bailey was hard because she never believes it's her fault. She wasalways pointing the blame at other people rather than looking at

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the part she played. Bailey doesn't like her life but doesn't have thedetermination to !gure out her responsibility in it… She was frus-trating to have as a client… Now she's back and will have the sameoutcome if she doesn't start looking at herself.

Taking responsibility is important to thriving because it is largelyindicative of the women's readiness to look at how their behaviorand the choices they make contribute to the outcome. Taking respon-sibility also is important because it is the point at which the womenrecognize that if they created these circumstances, they can createothers and take steps toward making that a reality.

4.2.3. Engaging the materialEngaging the material is about doing the work necessary to get

well. Women who engage the material come into treatment and ex-plore their reasons for using drugs and alcohol, look at the factorstriggering their drug use, and make connections between their druguse and their current life circumstances.

Dawn described the process that ultimately ended in her engagingthe material:

I was so angry about that at !rst I wanted to kill her [child protec-tion caseworker]. But I'm glad because it got me to where I'm atnow. I'm a different person. I'm a better person… I used to talkabout going home a lot, leaving—and that use to worry her [Ms.Nancy, Dawn's treatment counselor] a lot. I don't talk about leav-ing no more. I talk about more positive things… I think that it'sall about change. You just have to change your whole way of be-ing, everything in you. They help you do that if you just do thework.

Throughout the women's progress notes, the substance-abusetreatment professionals indicated the importance of engaging thematerial and tracked the women who were and those who were notengaging the material. According to Mackenzie's case notes:

The patient was very emotional, crying as she described a rush ofpainful feelings she is experiencing without the use of illicit drugs.Patient verbalized, “I didn't know how heroin could take away allof your feelings.” Patient stated, “Now they are coming back on meat once.” Patient expressed relief of being able to talk about child-hood experience of growing up in a dysfunctional family and wit-nessing her father beat her mother and how she stabbed himduring one incident when she was 13. Patient also expressed con-fusion of feeling anger and guilt toward her deceased mother whobeat her after the incident. Patient expressed willingness to ad-dress and work-through issues and feelings that have been sup-pressed during addiction.

The substance-abuse treatment professionals believe that engag-ing the material is essential to recovery and regaining custody ofthe children. Ms. Linda, a treatment counselor, said: “The womenwho came here and engaged in the material—they're the ones whousually are reunited with their children.”

Many of the professionals indicated that they were more likely tohelp women who were engaged than women who were not trying towork toward understanding their addiction or regaining custody oftheir children. Ms. Connie, a child welfare caseworker, said:

It's just sometimes it may be easier to engage with some clients.We have to show efforts. Just like parents have to make effortsin court, we're held to the same standard. So we make our effortsregardless of their effort. We have parents that disappear for threemonths. Each month we call a relative: “Have you heard anythingyet?” Each month we'll do a search to see if we come up with any-thing. So we do our part in reaching out and engaging clients…

But the level might not be the same… If it seems like you aren'ttrying, then we !gure why bother. We do the bare minimum. It'shard to still make an effort when clients aren't accepting of yourhelp. It's easier if they're engaging with us and wanting our help.

Ms. Linda, a substance-abuse treatment counselor, con!rmed thedif!culty of working with clients who are unwilling to engagethe material:

Our job is to engage clients and help motivate them, but we haveto have something to work with. If you present me with a stone-wall, there's not a whole lot I can do. I can use everything that I'vegot, and if all you're going to give us is that stonewall, then I'll dowhat I have to but will focus on helping clients that want myhelp… But when you !nally do engage with them, it's rewarding.This can be [clients] whomay have all of their defenses up, not ful-ly buying it all, but if they really are willing to listen, at least will-ing to hear what you have to say, I can get through to that person.

Engaging the material was found to be an essential part of movingtoward thriving because the women were willing to face and dealwith troubling aspects of their histories that often contributed totheir drug use and subsequent involvement with child protection.They were open to receiving feedback and suggestions. They under-stood that the bene!ts of substance-abuse treatment were beyondjust helping them to satisfy their child protective service plans. Treat-ment for them was an important step toward long-term healing andrecovery.

5. Discussion

The purpose of the current study was to illuminate the experi-ences and feelings of mothers struggling to overcome addiction andto highlight the main differences between the women who regainedcustody and those who lost custody of their children. Most of thewomen who lost custody exhibited behaviors characteristic of surviv-ing or being primarily in survival mode. The majority of women whoregained custody of their children exhibited behaviors characteristicof thriving.

The characteristics of surviving and thriving tended have a snow-ball effect. For example, the womenwho lost custody of their childrenhad entered treatment to satisfy their child protection service plan re-quirement. As a result, they often went through the motions, super!-cially complying with substance-abuse treatment. They focused onthe number of days they had to complete rather than what theywere supposed to be learning. As time went on, they began to engagein acting-out behaviors that involved breaking rules, which often ledto their being discharged or leaving treatment against medical advice.Finally, they failed to follow treatment recommendations by leavingtreatment against medical advice or failing to participate in aftercaretreatment services. Failing to follow treatment recommendationsresulted in relapse, which ultimately led to their losing custody oftheir children.

Most of the women who regained custody of their children cameto the system with internal motivation, which often led them to ar-range to enter treatment before child protection of!cially became in-volved with the case, and/or once child protection became involved,they entered treatment committed to understanding the things thathad contributed to their drug use. Entering treatment voluntarilydemonstrated that they took responsibility for their involvementwith child protection by focusing on the actions that led to their chil-dren being substance exposed or neglected. Because these womenwanted to get the most out of treatment, they engaged the materialdesigned to help them understand their actions and found healthierways to work-through the complicated histories that often had con-tributed to their drug use.

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Overall, surviving and thriving were useful constructs that cap-tured the women's approach to their involvement with substance-abuse treatment and child protection and also illuminated the rea-sons that some women regained custody while others lost custodyof their children. Against the prevailing conclusion, some womenwho had surviving characteristics retained or regained custody oftheir children and some women who had thriving characteristicslost custody of their children.

Darla and Victoria are examples of women with thriving charac-teristics who lost custody of their children. Darla had internal motiva-tion and engaged the material. After months of hard work, shesuccessfully regained custody of her daughter. However, Darla lefttreatment on a day pass and never came back. Darla's daughter wastaken into custody. Darla disappeared and never reengaged in ser-vices. Custody of Darla's daughter was given to the father. Darla's!le suggests that she was struggling with her parenting responsibili-ties, which may have been too much for her to handle. Rather thanrisk child protection removing her daughter again, Darla gave upand walked away from her responsibilities as a parent.

Victoria is an example of another woman who had all of the thriv-ing characteristics but lost custody of her children. This may havebeen primarily because Victoria started thriving too late in the pro-cess. By the time she started to turn things around, her children hadbeen in care for more than two years. In the past, Victoria wouldstart making progress and then relapse or get arrested again. The chil-dren needed permanency and there were relatives and foster parentswho were willing to adopt the children. As a result, Victoria lost cus-tody of her children.

Tabitha and Tonia are examples of women who retained orregained custody of their children but had surviving characteristics.The reason they retained custody of their children was that their IFRcaseworkers refused to take them to court. The IFR program is aunique program that employs a child welfare caseworker and a sub-stance-abuse treatment specialist who work together to meet theneeds of the family. The child welfare caseworker works with thewoman around her parenting issues, while the substance-abuse treat-ment specialist focuses on the addiction. Tonia did enough to satisfyher child welfare caseworker, which is why her case was neverbrought to court. Tabitha continued to use drugs after repeatedlycompleting outpatient and residential treatment. I am not sure whyTabitha's child welfare caseworker did not take her to court. Failingto hold Tabitha accountable led to her continued abuse of the system.

The IFR program is an alternative response to the traditional childprotection system. The IFR program integrates child welfare andsubstance-abuse treatment services in hopes of increasing access tosubstance-abuse services, improving treatment outcomes, shorteningthe time children spend in out-of-home placement, and increasingreuni!cation (Ryan, Marsh, Testa, & Louderman, 2006). To date, therehave been limited reviews of the program and its impact on whetheraccess to these services affects reuni!cation. Ryan, Marsh, Testa, andLouderman (2006) randomly assigned clients to control and demon-stration groups. The control group received the traditional services,and the demonstration group received traditional services plus inten-sive case management from a recovery coach. They found that clientswho participated in the IFR programwere more likely to achieve familyreuni!cation. However, this study made no mention of unintendedeffects such as in Tabitha's case. More research is needed to evaluatethe intended and unintended effects of these types of alternative re-sponse programs.

The availability of effective services that meet the needs of clients-particularly substance-abuse treatment facilities for women—is amajor concern that impacts reuni!cation. Marsh et al. (2006) foundthat child welfare clients face a range of problems in addition to sub-stance abuse, and that receiving tailored services enables them to besuccessful. Perhaps this is why reuni!cation rates among substance-abusing women in this study were higher than other studies have

found (Marsh et al., 2006). The substance-abuse treatment centerwhere I collected data is a women-only center that provides compre-hensive services, including allowing women to have their childrenwith them while they are receiving treatment. The literature suggeststhat this type of substance-abuse treatment program is the most ben-e!cial. Nonetheless, these types of treatment facilities are rare, whichlikely affects reuni!cation rates.

This idea of surviving and thriving characterizes the women'soverall approach to substance-abuse treatment and their involve-ment with child protection. With a few exceptions, the women whowere in survival mode lost custody of their children and the womenwho were thriving retained or regained custody of their children.The exceptions indicate that the concept of surviving and thriving isnot static but, rather, is "uid and can change. Surviving and thrivingare helpful because they illustrate clear differences in women's atti-tudes, beliefs, and behaviors that ultimately affect their involvementwith substance-abuse treatment and the outcome of their child pro-tection case. Beginning to understand why some women successfullyretain or regain custody while other women lose custody of their chil-dren perhaps can help substance-abuse treatment and child welfareprofessionals more quickly identify women who are in survivalmode or move from thriving to surviving and, as a result, can inter-vene in a way that can help them get back on track.

6. Limitations of the study

Although these !ndings are compelling, they cannot be general-ized to all women who become involved with child protection, or toall women who enter child protection because of substance abuse.Women who do not have histories of substance abuse often have dif-ferent experiences with child protection. Further, White women orother women of color may experience child protection differentlythan African American women. Another limitation of this study isthat the !ndings cannot be compared to other types of substance-abuse treatment programs. Gender-speci!c, comprehensive pro-grams that allow children are extremely rare, which may havecontributed to higher reuni!cation rates than other studies havefound. Moreover, this study took place in a large, urban, Midwesterncity. These kinds of programs may not exist in rural areas. Only twosuch programs were available in the entire state of Illinois, both ofwhich were located in the city. Finally, I was not able to obtain datafor all the women in this study. I was not able to !nd out the outcomeof one woman's child protection case. Moreover, I was only able to in-terview a small number of child welfare caseworkers. While the inter-views I was able to obtain were helpful, it is possible that other childwelfare caseworkers would have identi!ed additional factors not ex-plored in this study. The factors identi!ed in this study were the mostsalient based on the available data. Subsequent studies may !nd otherfactors that are more representative of their study populations.

7. Implications for practice

As voiced by the professionals in this study, the women who suc-cessfully demonstrated that they wanted help (i.e., following treatmentrecommendations and engaging in the material) were more likely toreceive help from the professionals. Although this may be a naturalresponse, social workers in general have been trained to work withdif!cult, challenging populations. It is imperative that each womanentering the substance-abuse treatment and child protection systemsreceive the same base level of services regardless of her behavior.

Moreover, reuni!cation rates were higher (50%) for the women inthis study. Previous studies report that only 12%–20% of substance-abusing parents regained custody of their children (Marsh et al.,2006). One possible explanation for the higher rates in our study isthe type of treatment setting. Women-only, comprehensive programsthat allow women to bring children into treatment with them have

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been shown to be most effective (Covington, 2002). This study con-!rms these !ndings. Few of these types of programs exist, though(Grella et al., 2009). There is a need for more programs that caterto pregnant and parenting women struggling with histories ofaddiction.

Another possible explanation for the higher reuni!cation rates inthis study is that the women who regained custody of their childrenwere more likely to receive IFR versus traditional child protection ser-vices. IFR services involve: (1) child welfare caseworkers and sub-stance-abuse treatment counselors working together to providecomprehensive services during the recovery process; and (2) coordi-nation of assessments, treatment, and support services.

The main difference between IFR and traditional child protectionservices is court involvement. IFR has no court involvement; there-fore, cases are closed when the worker and the supervisor believethat the family is stable, that the parents have demonstrated sus-tained abstinence, and that the child will be safe. Receiving traditionalservices meant that cases were more likely to remain open longer,which in turn meant that the women had to continue to demonstrateprogress. This was much more dif!cult for the women who were notinterested in making long-term changes. Moreover, receipt of tradi-tional services meant that the women were court-involved. There-fore, the women had to convince multiple people (e.g., judge,county/state attorney, guardian ad litem, and caseworker) of their so-briety and ability to parent their children safely.

Further, traditional cases meant that parents were subject to per-manency timelines, which pointed to a de!nite end, whereas IFR re-cipients were not subject to permanency timelines becausetechnically they were not court-involved. Nonetheless, IFR casescould be brought into court for noncompliance. This study's !ndingssuggest that alternative child protection programs, especially thosedealing with substance abuse, may contribute to higher rates ofreuni!cation and, therefore, should be explored further.

8. Areas for future research

There is a need for more research that explores factors contribut-ing to mothers' regaining or losing custody of their children. In orderto increase reuni!cation among women struggling with addiction, itis necessary to understand the reasons why women lose custody oftheir children. Moreover, this study included only African Americanwomen involved with child protection. Future research shouldexpand the interview samples to include all women involvedwith the child protection system because of their histories of addic-tion. It will be important to understand whether all women with ad-diction histories experience many of the same things or whetherdifferences exist by race. Finally, it will also be important to includesubstance-abusing women who are involved with child protectionin more rural counties or states. Services tend to be scarcer inrural or resource poor areas which could impact the !ndings in thisstudy.

9. Conclusion

Across the country, child protection agencies are struggling withburgeoning caseloads that often involve substance abuse, with littlehelp from the professional literature concerning why these cases re-sult in loss of custody. Although the factors presented in this studyare by nomeans exhaustive, they help us understand factors that im-pede or facilitate reuni!cation among women with histories of ad-diction who become involved with the child welfare system.Understanding the factors from multiple perspectives can lead tothe development of practices that increase the likelihood ofreuni!cation for families struggling to overcome addiction.

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