Working with clients who are also pregnant is challenging for several reasons. First, we must consider damage to our clients and to their unborn children. Second, we may need to cope with unpleasant countertransference if we believe our clients are doing damage to their unborn children. Third, pregnant clients need to be admitted for services within 24-hours, if an agency in Maryland is to receive public grant-funding. Ethically, pregnant clients cannot be discharged for non-compliance, without consultation of the state, potentially making it more complicated for us as clinicians to enforce treatment structure and agency policies.
I share supervision sessions with a friend and co-worker. I don’t think she would mind if I shared. She recently conceived after trying for many months, and was having difficult countertransference in relation to a young pregnant client. It had been difficult for her to reframe this client’s use, as she saw it as insensitive, neglectful and uncaring toward the unborn child. She found herself judging, and having expectations that, like her, every woman should take great care of her health during pregnancy. It was also difficult for her to reconcile why it was difficult for her to conceive, while it was not for her client. We spent time a lot of time in supervision trying to make sense of these issues, assessing her obligations at a clinician, and also trying to find ways she could let go of dynamics not within her control. I shared all of her feelings, though perhaps not with the same intensity. In the end, my friend called on her empathy. She said, “How would I feel if my character was being judged during my most difficult days?” My co-worker demonstrated strength and ethics by identifying her bias, by sharing it in supervision, and by actively working to correct for it.
As substance abuse clinicians we have the obligation to inform clients on the ways substance abuse can affect their pregnancies and children. The Substance Abuse and Mental Health Administration (SAMHSA) explains that continued substance abuse during pregnancy is a major risk factor for fetal distress, developmental abnormalities and negative birth effects. We may also need to take extra care in connecting our pregnant clients to prenatal care services, as SAMHSA notes that clients may delay prenatal care, fearing legal consequences. Clients should know how risks to their unborn children can be reduced by seeking prenatal care early. In conjunction with a physician, it may also be important to discuss how opioid-maintenance therapies may do less harm than sporadic misuse, and that continued use of some psychiatric medication may be preferable to the damage done to unborn children through maternal stress hormone. It may also be helpful to explain that there are many clients who receive substance abuse treatment while pregnant and that there are many programs specifically for clients who are pregnant (e.g., The Center for Addiction and Pregnancy at Hopkins Bayview). It may be helpful to explain that parents are rarely charged due to substance use and pregnancy, though there is a real risk of Child Protective Services (CPS) involvement, especially if a child is born drug-dependent. Clients may also need to know that an open CPS case does not mean losing parental rights. We may also need to provide clear explanations of our obligation to report to CPS in cases of child abuse or neglect. (Indeed, my co-worker did call CPS, due to her client’s ongoing recklessness and high-risk use while pregnant.)
We may also need to be prepared to educate clients on their options including temporary custody, open- and closed-adoption and abortion, without conveying bias. We may have greater rapport and influence if we utilize a gentle empathic style that takes into consideration the additional stress, demands and guilt that may arise for women who are using and pregnant. Using motivational interviewing, the motivation that may arise from maintaining custody of a healthy child can be a foundation on which treatment is built.