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 Centre for Addictionand Mental Health |
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Key principlesFrom: Exposure to Psychotropic Medications and Other Substances during Pregnancy and Lactation: A Handbook for Health Care Providers On this page:
Several principles can be integrated into clinical approaches to working with pregnant or breastfeeding women who use psychotropic medications or other substances. These principles will not necessarily apply equally to all women. Some women taking psychotropic medication may live in a stable environment that includes a support network, safe housing and secure employment. Some women may have substance use problems and endure violence and poverty. Some women may live with both substance use and mental health problems. Awareness of the key principles will allow providers to apply the most relevant principles to individual women in their care. Consider the determinants of healthWhen assessing a woman’s health before, during and after pregnancy, practitioners need a holistic approach that—in addition to substance use and mental health problems—takes into consideration the determinants of health. These determinants include:1,2
Women whose care takes into account their overall home environment, social support systems and other factors that affect their day-to-day living benefit more than those whose drug use alone is taken into account. For example, many women at risk of using substances during pregnancy face numerous social and economic stresses. Unemployment, violence, poverty and other issues may not only blur the importance of stopping substance use and seeking health care services, but may even create an environment where substance use serves as a benefit by numbing them to some of the realities of their lives. It is unreasonable to request that a woman stop using substances without addressing the multiple stressors that challenge a woman’s successful cessation.3 Provide women-centred careInterventions with pregnant and breastfeeding women who use substances have traditionally focused on fetal health; women-centred care is an approach to clinical encounters that places value on a woman’s needs in the context of her life circumstances, such as whether she is experiencing violence or whether the pregnancy was wanted.3,4 This requires a holistic approach to health, including mental and physical health, as well as an awareness of the socio-economic context of a woman’s life. A women-centred approach focuses on a woman’s long-term health and intrinsic reasons for change—in this way it addresses longer-term motivation (i.e., beyond pregnancy and breastfeeding) for becoming and remaining abstinent from substances. Understanding how a woman’s unique situation impacts her substance use and mental health will allow practitioners to offer interventions tailored to individual women’s realities, priorities and needs. The British Columbia Centre of Excellence for Women’s Health proposes a women-centred model that encompasses a wide range of considerations (see Figure 1). Figure 1: Providing women-centred care
Fight stigmaThe prejudice and discrimination at the heart of stigma affect the extent to which pregnant women with substance use and/or mental health problems receive both prenatal and postnatal care. A woman who is thought to be endangering the health of her fetus or baby (e.g., by not abstaining from substances or not following a doctor’s or midwife’s advice) has typically been considered a “bad” mother. This stigma can contribute to women with substance use and mental health problems keeping their symptoms and problems secret. As a result, they may avoid getting the help they need. Statistics Canada reports that only 32 per cent of people with a mental health problem seek professional help;5 this means the majority receive no care at all. A pregnant woman who uses substances has the additional fear that disclosing information may lead to losing her child to child protection services (e.g., Children’s Aid Society or Children’s Services). As a result, she may minimize important issues that are fundamental to developing an effective treatment plan with her doctor. In addition to compromized medical care, stigma can affect other areas of a woman’s life, including limiting her ability to secure employment; find safe and stable housing; be accepted by her family, friends and community; make friends or have other long-term relationships; and take part in social activities. People with substance use and mental health problems often internalize prejudice and discrimination. This self-stigma leads them to believe the external messages from others and the media. The guilt and shame that often result from stigma can lead to low self-esteem, social isolation, weaker support networks, increased poverty, depression, loss of hope for recovery, and even suicide. These outcomes can clearly affect a woman’s ability to cope with her own and her child’s care, both during pregnancy and afterward. To help mitigate stigma’s effects as much as possible, providers can:
Examine partner/social supportFew interventions focus on a woman’s partner or social environment, yet both cessation and relapse are affected by the presence of people who use substances in close proximity to the woman,3 as well as the amount of support a woman has. It is important to acknowledge the presence of others who use substances in a woman’s life and to determine the dynamics of those relationships. When exploring a partner’s behaviour, it is crucial to acknowledge potential power, control and abuse issues in a way that ensures the woman’s safety. Validate a woman’s entitlement to social support—because of stigma and the resulting shame, a woman may not feel that she deserves help. Encourage women to find appropriate support (e.g., confiding in a trusted friend, seeking a referral for additional services). Integrate a harm reduction philosophyHarm reduction—any program or policy that aims to reduce the harmful consequences of substance use without requiring the cessation, or even necessarily the reduction, of drug use—offers a practical approach to managing addiction.6 These strategies prioritize the goals of a person who uses substances, with an emphasis on immediate and realizable goals. Harm reduction initiatives are flexible, recognizing individual differences and the potential for a woman to re-evaluate her goals. They provide a maximum range of treatment options such as drug substitution, drug maintenance and interventions that adopt safer methods of use. A woman’s decision to use drugs is acknowledged as a personal choice, for which she takes responsibility. In this way, harm reduction strategies can help circumvent the stigma associated with substance use because they take a non-judgmental approach to people who use drugs. Harm reduction can also mean helping women reduce or prevent the harm associated with other high-risk behaviours (e.g., unsafe sex) or environments (e.g., physical abuse, unsafe housing).3 By examining behaviours and environments, and offering information, providers encourage women to make healthier and safer choices for themselves, even if complete abstinence is not feasible, and support them in finding safer environments. Effective therapeutic intervention includes recognizing that some women may currently be ambivalent about their substance use or resistant to abstinence. Examples of harm reduction choices include:
Identify concurrent disordersRecent research7–11 has indicated a high prevalence of concurrent disorders—co-occurring substance-related and mental disorders. It is estimated that in Canada, between 40 and 60 per cent of people with severe mental illness will develop a substance use disorder in their lifetime.11 And opioid dependence is associated with almost every major mental illness (most commonly with mood and anxiety disorders, eating disorders and personality disorders). If concurrent disorders are not recognized and treated, negative effects can include:
Prevent relapseThe risk of relapse is high for women who, while pregnant and breastfeeding, stop using substances.3 During pregnancy, the fetus provides daily motivation to abstain from or decrease substance use. Women who have quit or reduced use need to be re-motivated to deal with the postpartum pressures to return to substance use. Since relapse is often delayed while women are breastfeeding, support for breastfeeding not only provides obvious benefits to the infant, but also presents an opportunity to extend the woman’s experience of not using substances post-pregnancy. In this time, providers can help women explore their own intrinsic reasons for cessation. An example of key principles in actionSheway is an innovative outreach and drop-in program located in the Downtown Eastside of Vancouver. With a service philosophy that respects and supports women’s self-determination in the level and pace of change in their lives, Sheway provides holistic services to pregnant women with substance use problems, and support to mothers and families until their children are 18 months old. [Read more about Sheway...]
References
General issues and background
Psychotropic medications and other substances: Properties, effects and recommendations |
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Last updated: Apr 17, 2008 4:20 PM Published: Sep 05, 2008 6:19 PM ID#P35813 |