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The therapeutic relationship 

From: Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers

Factors in recovery

Even without specific training as a counsellor, health care practitioners who provide care to pregnant women with substance use and/or mental health problems can play a key therapeutic role in helping women move toward a better health outcome. Listening to women’s concerns and fears, and offering guidance and reassurance, can help providers be effective health care allies. Stigma and marginalization prevent many women with substance use and mental health problems from presenting to health care providers. Even women who do enter prenatal care are likely to feel guarded and ashamed of their substance use and/or mental illness. Understanding stigma’s effects and responding non-judgmentally to women who are reluctant to participate in care may help women become more engaged in their own treatment process.

Research confirms that a positive therapeutic relationship between a provider and a client has a helpful impact. Michael Lambert has explored factors that lead to successful change in someone’s life (see Figure 3). Lambert1 concluded that:

  • 40 per cent of a client’s ability to manifest positive change is attributable to extra-therapeutic factors (e.g., safe and stable housing, secure employment, adequate financial resources, positive interactions, supports in the community)
  • 30 per cent is attributable to a client’s experience of the therapeutic relationship (e.g., a health care provider’s non-judgmental attitude, warmth, respect and caring)
  • 15 per cent is attributable to a client’s sense of hope and expectation for recovery
  • 15 per cent is attributable to the provider’s techniques and skills (e.g., cognitive-behavioural therapy, mindfulness-based stress reduction).

Figure 3: Factors influencing ability to change

Therefore, health care providers can have a significant impact by helping a woman find adequate housing and work and develop stable, positive interactions in her life outside of therapy; by focusing on the quality of the therapeutic relationship; by using appropriate therapeutic techniques and skills; and by fostering her sense of hope for change. Encouraging a sense of optimism greatly enhances other factors, such as the therapeutic relationship, and is key to influencing a person’s ability to change.

Communication

A health care provider’s communication style can affect how a woman responds to his or her advice. Even subtle perceived negative attitudes can undermine a woman’s trust in her provider. Care in a provider’s choice of words, demeanour and attention can make it easier for a woman to listen and communicate, and to act on new knowledge.

Using good communication skills includes:

  • showing empathy through engaging in reflective listening (See “Motivational Interviewing”)
  • creating a safe space where a woman can ask any question and disclose medication or other substance use
  • clearly explaining a woman’s options
  • focusing on a woman’s strengths
  • asking open-ended questions
  • using clear language
  • providing feedback
  • taking a non-judgmental approach
  • inviting a woman to share her point of view or concerns.

In addition to general communications skills, it is critical for a provider to be prepared to answer difficult questions, for example: “Will child protection services take my baby away?” “What happens if I test positive after giving birth?” “What happens if my baby goes into withdrawal?” “Do you have to tell my partner about the things we talk about?” “Will you report me if I tell you something in confidence?” It is important to respond directly and immediately to women’s questions, to provide specific information and to be clear and upfront. Women who ask tough questions but don’t get “straight answers” from their health care providers often become guarded and uncertain about disclosing information.

Health care providers may see a woman several times over the course of her pregnancy, and any contact is also an opportunity to develop a trusting relationship with her. During clinical appointments, providers can explore:

  • a woman’s behaviours (e.g., has she been using more, the same amount, less, or has she stopped using altogether? how has she been coping with using or not using? what has been challenging or positive about what she has been doing?)
  • the risks and safety of medications and other substances
  • whether a woman has appropriate support, such as a caring and encouraging partner, family member or friend (since stigma can make a woman feel that she isn’t worthy of support, it is important to validate her right to it)
  • whether she faces issues such as poverty, trauma or racism, or inaccessible environments that exacerbate the challenges a disability presents—and, if so, how she feels these issues impact her life and how she deals with them
  • whether she has experienced or is currently experiencing violence and/or abuse
  • how she copes with conflict and difficult emotions (research2 has shown that women are at highest risk for using substances when they feel negative emotions and experience conflict with others)
  • how she feels about taking medication
  • how she feels about using other substances (e.g., does she feel that using substances harms her? does she feel that it helps her with something such as distracting her from painful memories of abuse?)
  • what she knows about the impact of her substance use on her health and the health of her fetus or infant
  • whether she would like more information about the impact of her substance use on her fetus or infant, and/or whether she has been misled by myths and misinformation
  • how she feels about her pregnancy
  • whether she has envisioned and/or has planned for her life after her child is born (e.g., whether she will have parenting and childcare support, whether she will have safe housing, whether she will be financially secure).

Overall, use of good communication skills can help motivate clients toward positive behavioural change, help them stay actively engaged in their own care and instil hope for the future.

Motivational interviewing

The most common definition of motivational interviewing is a “client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”3 (p. 25). The word “interviewing,” rather than “counselling” or “treatment,” stresses the egalitarian nature of the encounter between provider and client and the fact that they are “viewing” things together.3

Motivational interviewing has been shown to be particularly helpful in working with people who use substances.4 This method focuses on clients’ experiences; draws on their concerns, perspectives and values; and encourages clients to evaluate their own life choices and explore the consequences of their choices in a non-judgmental way.

Four principles guide motivational interviewing:

  • expressing empathy
  • developing discrepancy
  • rolling with resistance
  • supporting self-efficacy.

Expressing empathy

Motivational interviewing uses an empathic communication style. This is achieved through the therapeutic skill of reflective listening.

Reflective Listening

When listening reflectively, the counsellor mirrors, in his or her own words, what the client says and checks that he or she correctly understood the client. As the provider asks open-ended questions and reflects back the client’s words, feelings, context and experience in a respectful and non-judgmental manner, the client comes to feel understood and accepted. Paradoxically, when people feel accepted as they are, they become freer to change than when they are told they need to change. The counsellor sees ambivalence about changing as a normal part of the process.3 Reflective listening is also key to building the client-counsellor relationship, in that it conveys empathy, understanding and acceptance.

Reflective listening is difficult to master, and providers may unwittingly set up roadblocks that can prevent clients from exploring or elaborating on a problem or issue. Some of these roadblocks may even trigger or intensify resistance to change.

These roadblocks3 (p. 68) include:

  • acting as the expert
  • giving advice, making suggestions or providing solutions without first listening to the client’s ideas and asking permission
  • questioning or probing in areas that the client does not see as relevant
  • ordering, directing or commanding
  • warning or threatening
  • disagreeing, arguing or lecturing
  • judging, criticizing, moralizing, labelling, shaming, ridiculing or blaming
  • agreeing, approving or praising—not to be confused with statements of affirmation
  • withdrawing, distracting, humouring or changing the subject.

There are several levels of reflective listening. The most simplistic is to parrot or echo, virtually word for word, what a client says. More complex reflective listening conveys deeper reflection of the client’s meaning, including mirroring the emotional aspect of a client’s words and linking those feelings to her expressed thoughts and to life events.

Developing discrepancy

An important way to help a woman resolve ambivalence is to highlight and amplify discrepancies, from her perspective, between the present behaviour and broader goals and values. Change can be triggered by her heightened awareness that a current behaviour is getting in the way of achieving important goals, or that it conflicts with important values. Discrepancies provide reasons to change. Developing discrepancy involves exploring how she would like to see herself, and how the current behaviour conflicts with that vision. By becoming aware of discrepancies, she can find and articulate her own reasons for changing, rather than having the provider give reasons for change.3

Rolling with resistance

In motivational interviewing, the counsellor avoids confrontation and does not directly oppose a client’s resistance to change. Arguing for change—or even taking up the side of the client’s ambivalence that favours change—usually leads to a counterproductive dynamic in which clients feel they have to defend their position and they become entrenched in resistance. Instead, the counsellor views resistance as a natural part of change and uses it as an opportunity to involve the client in weighing the pros and cons of continuing behaviours and exploring options for and barriers to change. Respecting that a woman is the primary resource for finding answers and solutions, the provider invites—but does not impose—new perspectives. How the provider responds to resistance will influence whether it increases or decreases; resistance is a sign for the provider to shift his or her approach and a cue to examine the woman’s underlying assumptions about change.3

Supporting self-efficacy

Self-efficacy refers to a person’s belief that she has the ability to carry out, and succeed at, a specific task. For change to occur, a woman must have a sense that change is possible and that she can make it happen—the sense of expectancy and hope for recovery is noted in Figure 3. To build her self-confidence, the counsellor can explore the woman’s past successes, or provide successful role models that she can identify with.3 The provider’s belief in the woman’s ability to change is key, but the woman, not the provider, is responsible for choosing and carrying out change.

Trauma and safety

A crucial determinant of maternal and fetal health involves assessing a woman for current violence, safety or trauma issues and providing immediate resources if issues arise. Many women who struggle with substance use and mental health issues have experienced sexual or physical abuse in their past. For example, as much as 38 per cent of the general population in Ontario report childhood physical or sexual abuse.5 And in a U.S. national comorbidity study,6 which surveyed a sample of adults in the general population, the estimated lifetime exposure to severe traumatic events was 61 per cent in men and 51 per cent in women. Women were more likely than men to develop stress symptoms following rape, sexual molestation and physical attack, being threatened with a weapon or childhood physical abuse. While men were more likely than women to be exposed to traumatic conditions, women were twice as likely to develop symptoms of post-traumatic stress disorder (10 per cent vs. five per cent). This difference may be related to the fact that women are 13 times more likely than men to be raped or sexually molested.6

A 2000 report states that:

Among those seeking help for substance use problems, women report past abuse much more frequently than men. In fact, most women in substance use treatment programs report physical and sexual abuse over their lifetime, and about one-quarter have received a diagnosis of post-traumatic stress disorder (PTSD).7 (p. 416)

In addition, research suggests that when women involved in violent or abusive relationships become pregnant, the violence and abuse often continue during the pregnancy, although in some situations abuse may begin when a woman becomes pregnant.8 Up to 40 per cent of first incidents of domestic violence occur while the woman is pregnant.9

Supportive discussions at every visit can help reassure a woman that she has choices and options in terms of dealing with violence and trauma. Connecting her with supports (e.g., agencies, services) can help her cope with these issues as well as the physical and emotional challenges of pregnancy.

Legal issues

Health care providers in Canada have a legal responsibility to report any child who needs or may need child protection services; this obligation only applies to the child once born. Providers should contact their local child protection services for reporting responsibilities and procedures, and should discuss the issue and obtain written consent from the pregnant woman if considering a referral to a child protection service during the prenatal period.

Many women who use substances fear their provider will report them to authorities, which presents a challenge in attending to their health care needs. Helping a woman understand her rights and the provider’s responsibilities—before the birth—can help her to make decisions around her substance use while pregnant and to evaluate her behaviour. Women should be encouraged to have open communication with child protection services. Decisions regarding supervision and custody are less likely to be adversarial when women are engaged in services.10 (See “An Example of Key Principles in Action” for an illustration of an outreach program that has successfully worked with child protection services and women who use substances to help women retain custody of their children.)

It may also be helpful for care providers to introduce the woman to the supportive services (e.g., parenting classes) available through child protection services before the child is born. This would provide further opportunities for her to discuss her concerns (e.g., how she would be followed clinically; whether she would be able to take her child home; what the expectations for behaviour change would be in order to regain custody and access, if the child were removed from her care).

If a woman presents to a provider with probable signs of violence, a health care provider will have to decide whether it might be appropriate to contact other agencies or authorities to help protect the woman. It is important to consult with a woman’s advocacy service such as a rape crisis centre or a legal clinic to get clarification about what can and cannot be disclosed about potential abuse a woman may face, and about the roles and limits of police and court powers.

Summary

Developing trust and rapport with a woman becomes more feasible when a provider shows empathy, communicates well, has a thorough grasp of the realities of the woman’s life, draws on effective counselling strategies, uses a non-judgmental approach and understands the legal issues regarding the safety of the woman and her baby. Being able to talk comfortably and sensitively—but also directly—about difficult and “taboo” subjects such as substance use encourages open dialogue and honesty, which can lead the woman to become more fully informed and in a better position to make optimal choices for both her own and her child’s well-being.

References

  1. Lambert, M.J., Implications of outcome research for psychotherapy integration. In Norcross, J.C. & Goldstein, M.R., Handbook of Psychotherapy Intergration (pp. 94–129). New York: Basic Books. Cited in Centre for Addiction and Mental Health. (2005). Beyond the Label: An Educational Kit to Promote Awareness and Understanding of the Impact of Stigma on People Living with Concurrent Mental Health and Substance Use Problems. Toronto: Author. Available: www.camh.net/About_Addiction_Mental_Health/  Concurrent_Disorders/beyond_the_label_toolkit05.pdf. Accessed July 13, 2007.
  2. Harrison, S. & Ingber, E. (2004). Working with women. In S. Harrison & V. Carver (Eds.), Alcohol & Drug Problems: A Practical Guide for Counsellors (3rd ed.; pp. 247–271). Toronto: Centre for Addiction and Mental Health.
  3. Miller, W.R. & Rollnick, S. (2002). Motivational Interviewing: Preparing People for Change (2nd ed.). New York: Guilford Press.
  4. Burke, B.L., Arkowitz, H. & Dunn, C. (2002). The efficacy of motivational interviewing and its adaptations: What we know so far. In W.R. Miller & S. Rollnick (Eds.), Motivational Interviewing: Preparing People for Change (2nd ed.). New York: Guilford Press.
  5. MacMillan, H.L., Fleming, J.E., Trocmé, N., Boyle, M.H., Wong, M., Racine, Y.A. et al. (1997). Prevalence of child physical and sexual abuse in the community: Results from the Ontario Health Supplement. Journal of the American Medical Association, 278 (2), 131–135. Cited in Gitberg, M. & Van Wyk, L. (2004). Trauma and substance use. In S. Harrison & V. Carver (Eds.), Alcohol & Drug Problems: A Practical Guide for Counsellors (3rd ed.; pp. 415–434). Toronto: Centre for Addiction and Mental Health.
  6. Chu, J.A. (1998). Rebuilding Shattered Lives: The Responsible Treatment of Complex Post-traumatic and Dissociative Disorders. New York: John Wiley & Sons. Cited in Gitberg, M. & Van Wyk, L. (2004). Trauma and substance use. In S. Harrison & V. Carver (Eds.), Alcohol & Drug Problems: A Practical Guide for Counsellors (3rd ed.; pp. 415–434). Toronto: Centre for Addiction and Mental Health.
  7. Ouimette, P.C., Kimmerling, R., Shaw, J. & Moos, R.H. (2000). Physical and sexual abuse among men and women with substance use disorders. Alcoholism Treatment Quarterly, 18 (3), 7–17. Cited in Gitberg, M. & Van Wyk, L. (2004). Trauma and substance use. In S. Harrison & V. Carver (Eds.), Alcohol & Drug Problems: A Practical Guide for Counsellors (3rd ed.; pp. 415–434). Toronto: Centre for Addiction and Mental Health.
  8. Public Health Agency of Canada. (2004). Physical Abuse during Pregnancy. Available: www.phac-aspc.gc.ca/rhs-ssg/factshts/  abuseprg_e.html. Accessed July 8, 2007.
  9. Rodgers, K. (1994). Wife assault: The findings of a national survey. Juristat, 14 (9), 1–21. Cited in Greaves, L., Cormier, R., Devries, K., Bottorff, J., Johnson, J., Kirkland, S. et al. (2003), Expecting to Quit: A Best Practices Review of Smoking Cessation Interventions for Pregnant and Postpartum Girls and Women. Vancouver: British Columbia Centre of Excellence for Women’s Health. Available: www.hc-sc.gc.ca/hl-vs/pubs/tobac-tabac/expecting-grossesse/  index_e.html. Accessed July 9, 2007.
  10. Selby, P. & Ordean, A. (2007). Hospitals, doctors and pregnant women with substance use problems: Working together. In N. Poole and L. Greaves (Eds.), Highs & Lows: Canadian Perspectives on Women and Substance Use. Toronto: Centre for Addiction and Mental Health.

Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers

General issues and background

Psychotropic medications and other substances: Properties, effects and recommendations

Resources

Index of drugs

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