Who Parents the Parents? Examining Approaches of Frontline Staff in an Integrated Substance Use Disorder and Parent-Infant Mental Health Treatment Program

Background and Purpose: Caregivers with a substance use disorder (SUD) represent a significant cause of entry in to the child welfare system (CWS) and involve approximately 50-80% cases. As a group, caregivers with a SUD are more likely to utilize a range of maladaptive parenting strategies. The cumulative negative impact of problematic parenting practices (PPP) has been strongly connected to children’s socio-emotional development. Therefore, it is critical to intervene with maladaptive parenting that occurs both as a result of and alongside a SUD. Integrated residential SUD and parent-infant mental health (PIMH) programs for caregivers and their young children offer an innovative and promising approach to intervention in the CWS. However, little is known about how frontline staff who are not specifically trained in PIMH approach PPP in a milieu setting. This study seeks to fill this gap in order to identify areas for improvement in program development and implementation for integrated intervention.  

Methods: A revised institutional ethnography of one agency implementing integrated residential SUD and PIMH treatment for caregivers and their children ages 0-5 was conducted over a two-year period. Data was collected through regular observation and semi-structured interviews with frontline staff (N=30, 27% white, 63% black, 10% hispanic). Utilizing grounded theory informed by content knowledge of SUD, parenting, child welfare, and PIMH, all data was analyzed using an open coding strategy. Next, concepts and categories reflecting recurring themes in the data were identified and a codebook was developed. The author and two Research Assistants then analyzed the data deductively using the codebook and resolved disagreement through consensus. Nvivo 12 aided analysis.

Results:  Patterned differences among frontline staff approaches to problematic parenting behavior emerged by role and parenting status. Residential Associates (RAs), responsible for providing care outside of formal counseling reported they did not have official guidance for negotiating maladaptive or harsh parenting behaviors that regularly arose. Instead, each RA devised her own response. RAs who were also parents guided clients based off their own experiences. RAs who were not parents reported they did not feel comfortable or have the authority to intervene with problematic parenting behaviors. All but one clinician who were not explicitly trained in PIMH also reported they did not integrate a focus on parenting in to their work with clients. Instead, parenting intervention was managed through the PIMH clinician in once a week sessions.

Conclusion and Implications: Findings reveal a potential practice gap in integrated SUD and PIMH residential treatment. Without official guidance for intervening with problematic parenting behaviors opportunities for regular intervention across the treatment setting are likely to be missed. A core principal of PIMH is reflective and “in the moment” intervention. These principles as well as parenting work is likely to be negatively impacted by inconsistent messages across treatment team members and without opportunities for continual reinforcement. RAs and clinicians who do not have experience with PIMH should be trained in basic principles of PIMH. Further, more coordination between the PIMH clinician, SUD clinician, and RAs would likely enhance treatment and positive outcomes.