Minding the Baby – Minding the Parent: A qualitative interview study of the experience of parenthood in the context of substance use disorder
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- Institutt for psykologi 
The mind altering and regulative effects of substances affect the caregiver incompatible with sensitive caregiving. Thoughts and emotions often circle around substances and substance-related physical symptoms instead of attending to the emotions and practicalities of childcare. The parent becomes unpredictable and “out of sync” with the infant in ways that potentially threaten child development and secure attachment. This dissertation was motivated by a search for better preventive strategies for children-at-risk because of parental problems of substance addiction. The overarching aim was to investigate how the parents themselves, based on the assumption that understanding the parental perspective is necessary in any intervention, experienced parenthood and addiction. The work is grounded in the philosophy of science of critical realism. The parents’ experiences are discussed from a psychodynamic, an ethical, and a gender perspective. Sixteen women and eight men participated in focus group discussions and interviews. The qualitative data have been analysed according to Interpretative Phenomenological Analysis (IPA) (Eatough & Smith, 2008), resulting in four papers based on the following four questions: 1. What kind of theoretical framework can support a study of parenthood and addiction, bearing the child in mind? 2. How does substance abuse influence the mental preparation for motherhood during pregnancy? 3. How do women with addiction experience mandatory placement during pregnancy, and what ethical dilemmas do their experiences expose? 4. How do men with drug addiction experience fatherhood? Paper I, “Minding the baby”, outlines the theoretical and conceptual framework of the dissertation. The mentalizing theoretical model, rooted in several scientific disciplines and traditions, is seen as an integrative theory with explanatory power of problems of addiction, the psychology of parenthood, and child development. The clinical adaptations of the mentalizing theory added to the perceived usefulness of this framework. However, to grasp the complexity of the issue under study, sociocultural theory supplemented the conceptual framework to account for the role of participation in developing caregiving competence, and to give due attention to structural and cultural influences. Paper II, “Mental preparation for motherhood”, describes the subjective experience of the “journey” through pregnancy towards the role of a mother. A prominent finding was that awareness of the symptoms of pregnancy was often delayed and distorted. Also, being high and occupied with drugs and drug-related problems, and fear of not living up to the expectations of the professionals, influenced the psychological preparation. In some of these women, severe feelings of guilt, which otherwise serve to adjust negative behaviour (Elvin- Novak, 1999), contributed to continued use of substances. The experience of ambivalence runs like a red thread through the findings. Ambivalence as a clinical issue is discussed. Paper III, “Pregnancy and substance use – the Norwegian § 10-3 solution”, uses two cases to discuss ethical dilemmas in interventions that involve elements of coercion. The § 10-3 of the Municipal Health and Care Services Act give access to incarceration of pregnant women when intake of substances are seen as a serious threat to the foetus. The findings confirm those of Paper II in terms of a surface adaptation and fear of the evaluations of the professionals, which might compromise the preparation for the caregiving role. The bioethical principles of autonomy, beneficence, non-maleficence, and social justice (Beauchamp & Childress, 2009), come up short as a tool to solve the many dilemmas of the situation. A more relationally oriented framework based on mutual respect and trust, and interpersonal and communicative competences, is suggested as an alternative. Paper IV, “The good, the bad, and the invisible father”, describes how men with problems of addiction think about themselves, and how they find themselves mirrored as fathers. A common experience was being the weaker parent and left out of the child and domestic sphere. Gendered roles in the family, a feminized social service, and more sceptisism toward men’s motives and their ability to change are described as obstacles to a present and participating fathering role. The findings are discussed in relation to two opposing discourses of modern fatherhood, the present and the absent father. Fathers’ experiences of being weak and/or invisible call for more attention to the fathering role of men with problems of addiction. The four papers illustrate how parenthood and problems of substance addiction collide and result in a dominant experience of ambivalence. Parents feel pulled between hope and despair, between the forces of addiction and the wish to be a good parent. Ambivalence is further strenghtened by professional and sociological ambivalence. This, together with a sense of insecurity from being under critical examination can result in surface adaptation and endanger the mental preparatory work to support parenthood and caregiving. The unique opportunity for change during early parenthood is threatened by the dynamics of addiction, impingemements on supportive relationships, stigma and social exclusion. A familyoriented approach where the professional helping relationship is used to enhance sensitive caregiving and parental mentalizing is suggested to facilitate healthy child development as well as parental sobriety. The findings indicate a need to further thematize and support men´s development of caregiving competence. Finally, parenthood and addiction requires a complex explanatory model with generative mechanisms at several domains and levels: biological, psychological, relational as well as the larger social, political and structural conditions.