Pregnant substance abusers in voluntary and coercive treatment in Norway: Therapists' reflections on change processes and attachment experiences.

AIMS AND OBJECTIVES: To explore therapists' discourses on treatment processes, when working with pregnant substance abusers in voluntary and coercive treatment, and looking for the clinical implications of these discourses.

BACKGROUND: Treatment of substance use disorder faces many challenges. One is pregnancy and motherhood, which are vulnerable and complex processes. The literature emphasises lack of optimal and knowledge-based treatment for this group.

DESIGN: The study follows a Foucauldian inspired discourse analysis.

METHOD: Forty therapists from four different residential units in Norway, offering both voluntary and coercive treatment of pregnant women with substance use disorders, were interviewed in focus groups. The semi-structured interview schedule focused on exploring how therapists' discourses on change processes and relationship experiences informed their clinical practice.

RESULTS: How to start "healthy" attachment processes between the pregnant woman and the unborn child was the dominant discourse among the therapists. Another important theme was coercion, and whether that as a contextual frame was negative or positive in creating attachment between mother and child. Other discourses were varieties of understanding attachment when the mothers had difficulties with substance abuse, the mothers' own attachment histories, and social and cultural challenges.

CONCLUSION: Systematic work with attachment issues between the pregnant woman and her unborn child was the dominant perspective of nearly all the therapists. The contextual factors in the lives of the women were less prioritised, even though they are of decisive importance for the relationship between mother and child.

RELEVANCE TO CLINICAL PRACTICE: Treatment professionals need to focus more on the discursive dilemmas encountered in the relation between substance use disorders and the unborn child.