Mothers at the Intersection of Trauma,Addiction,and Involvement with the Criminal Legal System: An Analysis of Multiple Case Studies

Abstract

The study focuses on the complex interconnection of race, sexuality, and socioeconomic background in shaping the stories of mothers struggling with addiction disorders as they attempt to recover from traumatic experiences. A sample of 45 mothers was employed in the study. Using case study analysis methodologies, the stories of 6 mothers were used as representative cases based on their individual characteristics, community settings, and institutional experiences. Further, the 6 cases were used to describe the difficulties experienced by participants across 3 major life transitions: (1) childhood (2) initiation to drug use and addiction disorders (3) motherhood. Across these life transitions, participants emphasized the relevance of traumatic experiences and mental health disorders as main reasons for their drug addiction. For each theme highlighted in the narrative of each case, a connection to all other participants was made to summarize the findings in the whole sample. The analysis indicates that while most mothers experienced trauma during their lifetime, mothers who identified as members of racial/ethnic minorities and those who identified as lesbians were more likely to report trauma from prejudice and discrimination. Furthermore, the analysis highlights that mothers who identified as members of racial minorities were more likely to have their children placed in foster care. In the study, mothers’ involvement with the criminal legal system contributed to the challenges they experienced while renegotiating their relationships with their children. These mothers’ lived experiences and the complexity of the dynamics they described—especially their interactions with the legal system—could potentially help other researchers frame new hypotheses that could be tested by larger empirical studies.

Keywords

mothers’ addiction child protective services criminal legal system’s response to addiction mental health problems and addiction disorders motherhood traumatic experiences trauma drug and alcohol addiction qualitative research case study analysis multiple case study analysis

What do we already know about this topic?

Mothers who live in minority communities are more likely than White mothers to be monitored by the criminal legal system.

How does your research contribute to the field?

We expand on issues of diversity, such as mothers’ sexual orientation. We also use an analysis of multiple case studies to offer insights about the lives of mothers living in different communities (e.g., rural v. urban).

What are your research’s implications toward theory, practice, or policy?

Findings from the study can help other researchers develop new hypotheses that focus on the intersectional experiences of mothers suffering from addiction disorders. In addition, the findings can offer insights for new training protocols, treatment programs, and policies that aim to help mothers grappling with addiction disorders as they negotiate the relationships with their children.

Introduction

State intervention and coercive control over mothers and expectant mothers are not new phenomena. An area of particular concern is mothers’ addiction to illicit substances before, during, and after pregnancy. Existing policies continue to penalize women through a paternalistic approach that condemns them for defying expected gender norms.^1,2 Feminist scholars have asserted that the history of the United States is filled with attempts to strip women of any authority over their bodies, pains, and the wellbeing of their children.^3,4 Sadly, when it comes to mothers’ addiction, everyone’s voice but that of the mothers themselves appears to be taken into consideration, and this manuscript aims to fill this gap in the literature.

As Garcia-Hallett and Begum² put it, “[s]ubstance use is viewed as a contradiction of mothers’ responsibility to be constant nurturers and, as such, is treated as an indicator of a bad mother” (p. 23). In the U.S. criminal legal system, ‘using while mothering’ is seen as one of the most irresponsible acts that leads to judge certain crimes (re drug crimes) committed by mothers under a much harsher and punitive lens.^2,5
-7 Such approach to policing motherhood tends to overwhelmingly impact women of color who live in low-income communities that are often heavily controlled by the police.^8,9 For pregnant mothers, punishment can be even harder and always paired with social condemnation for putting their fetuses’ health at risk by injecting drugs.⁸ Prosecuting mothers for the use of drugs while pregnant is part of an ongoing strategy that claims the state’s right to protect the unborn child. This state overreach goes hand in hand with abortion restrictions and increased supervision of women during pregnancy.¹⁰ Currently, half of the U.S. states enforce policies that label the use of illicit substances during pregnancy as “child abuse.”¹¹ While such policies were shaped by the interest of various stakeholders to “protect” the unborn child, they offer no guidance on the future wellbeing of mothers and their children.

This manuscript aims to address the lack of support for mothers and expectant mothers experiencing substance use and addiction disorders. This lack of support is most often the result of lack of understanding and failure to empathize with the experiences of mothers. While the number of programs that focus on mothers’ addiction before, during, and after pregnancy continues to grow nationwide,^12,13 service providers, agents of the criminal legal system, and the community more generally lack the necessary skills and knowledge to evaluate mothers’ wants and needs, and to successfully guide them through the challenges associated with addiction recovery.^12,13 Moreover, for mothers and expectant mothers, addiction is often associated with experience of violence and the consequences of trauma.¹⁴ The stigma associated with addiction during pregnancy often prevents expectant mothers from seeking support and treatment; this is especially problematic for mothers who are members of racial and gender minorities whose experiences were often shaped by prejudice and discrimination.^15,16 Failure to understand the intersectionalities of addiction, motherhood, and violence with race, gender/sexuality, and class can sabotage the recovery process for many individuals, with long-term consequences for themselves and their families—especially their children.

For many mothers struggling with addiction, the criminal legal system becomes the primary “resource.” The irony of it is that any amount of time spent under the supervision of the criminal legal system in jail or prison might have long-lasting effects on mother’s ability to care for their children, as it tends to weaken mother-child ties.¹⁷

It is often said that addiction runs in families and that when mothers engage in the use of illegal substances, addiction tends to become an inter-generational problem.^18,19 But the inter-generational transmission of addiction and violence can be addressed through educational programs that aim to create new knowledge within the community where addiction, trauma, and violence are occurring. It is our hope that the study will help generate knowledge about the complex interconnection among trauma, addiction, and involvement in the criminal legal system among mothers. Such knowledge could influence policies, practices, and training programs for service providers. We believe knowledge is key to building community capacity to help mothers experiencing addiction and violence, and to eliminating the existing gender and race inequities—a core principle of social justice.²⁰

Methods

Study Design and Data Collection

The study is a qualitative study that uses in-depth interviews with individuals suffering from addiction disorders. Human subjects’ approval for the study was provided by the Institutional Review Board at a public research institution and university. The study design, analysis, and reporting were developed by following the 32-criteria specified in the Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist, which is appropriate for qualitative studies that use in-depth interviews.²¹ The study has followed the relevant EQUATOR guidelines. We provide the completed checklist in Appendix 1.

Two main research questions guided the study:

What factors shape mothers’ experiences with substance use and other addictive disorders?

What are the processes through which such experiences take place?

Study Sample

Participants were recruited using multiple methods.

Two large counties in a Midwestern state were identified using data from the Census²² that allowed to select a predominantly White community and a more racially and ethnically diverse community.

Agencies involved in the lives of mothers suffering from addiction disorders from the 2 counties were mapped. The list of agencies included both agencies of the criminal legal system and organizations offering programs/services to mothers grappling with addiction disorders.

Agencies that listed the directors’ contact information were contacted via email or phone. During the first interaction with agencies’ representatives, a synopsis of the study was provided. The agencies who agreed to participate in the study were asked to distribute the recruitment flyer among their clients. The flyer included a short description of the study’s aims, contact information of the principal investigator, and the participant’s incentive for the interview (a $30 gift card).

Interviews were scheduled over an eight-month period—every month from April 2023 through December 2023. Interviews conducted in residential recovery centers were scheduled by selecting a few convenient days during each month. This strategy was used to identify new participants, as a typical residential addiction recovery program will offer continuous services for 26 days to each client.

The distribution of flyers among agencies and service providers also extended outside the walls of the organizations initially contacted, following the snowballing sampling approach. Therefore, several participants directly contacted the principal investigator to schedule an interview without any mediation by service providers.

In total, 110 interviews were completed for the study, including interviews with service providers. However, this manuscript only focuses on the experiences of those study participants who, at the time of the interview, identified as “mothers suffering from addiction disorders”—either “in-recovery” or “in active addiction”—resulting in a sample of 45 women.

Among the mothers, 21% identified as either Black or African American, 70% identified as White Caucasian, and 9% identified as bi-racial. In addition, 19% identified as members of the LGBT+ community, while the remainder identified as female heterosexual women. The average age among mothers was 44, ranging between 27 and 72.

Using a careful multi-stage data analysis process, 6 cases were identified as representative of the experiences of the 45 mothers in the study who were struggling with addiction disorders at the time of their interview and continued to renegotiate their relationship with their children. This case analysis approach was employed to provide contest for the various themes emphasized by participants in their interview narratives. Summary data from all the other interviews were also reported as pertinent to the themes identified. While qualitative methods of research, especially methods that use in-depth narratives, do not necessitate summaries of data from all participants, this method is used to highlight the mothers’ shared experiences. It is important to emphasize that even when similar experiences were grouped, each participant provided unique stories that must be respected as unique experiences. Detailed information about the analysis of interviews is provided in the coding section of this manuscript.

Interview Procedures

The individuals who agreed to be part of the study signed an informed consent prior to the interview. A copy of the informed consent for the study is provided in Appendix 2. All participants who volunteered to schedule an interview completed the interview. None of the participants refused to answer any of the questions in the interview protocol.

Interviews were conducted in different places. Some participants were interviewed in half-way houses, residential recovery programs, jail, work-release programs, drug courts, at the university, or in the interviewer’s car near the participants’ residence. During the interviews, the interviewer was alone with the participant behind closed doors. This allowed for privacy during the interviews. All the interviews were audio recorded using encrypted technology.

Interviewers met regularly with the principal investigator for the study to discuss their observations from the interviews and for developing relevant reflections on the procedures used to interview participants. In addition, such reflections were implemented to discuss the possibility of bias in the analysis of interviews.

The interviews were transcribed verbatim using a professional transcription service approved by the university. Further, the transcripts were stripped of all the identifiers, including the names of the agencies where participants resided at the time of the interview, cities, towns, streets, and even counties. Importantly, while the principal investigator conducted most of the interviews, a team of research assistants were trained and hired to work on the study, and three of the research assistants also completed interviews. Research assistants were selected based on their lived experiences either as individuals in recovery, mothers experiencing addiction, family members of individuals experiencing addiction, or those training to become service providers. All the interviewers identify as female; however, the research team included individuals from a diversity of gender, racial, and ethnic backgrounds.

Prior to each interview, the interviewer introduced herself to the participant by disclosing her name, qualifications (including training), and provided a short synopsis of the study. This short introduction helped create a connection with each participant; overall, we believe this approach helped participants feel at ease during the interview.

The study used a semi-structured interview framework following a deductive-inductive approach.²³ Deductive because the questions for the qualitative interviews were designed using an intersectional lens that allowed to take into consideration the complex interconnection of race, sexuality, and gender identity that shaped participants’ individual experiences in the criminal legal system.^24
-28 Inductive, because the design of the study allowed for an investigation of participants’ experiences as they existed in the field, generating new evidence and building new theoretical conceptualizations from the ground up.

The participants’ narratives used for this manuscript came from a sub-set of the interview questions employed in the study. The interview questions used for this manuscript are listed in Appendix 3. Questions were all in plain English; no use of slang was made to avoid individuals of diverse backgrounds feeling “boxed” into social categories.³⁰

The length of the interviews varied, ranging between 35 min and 150 min.

Coding

A two-stage coding process was used (1) to identify thematic patterns, and (2) to select representative cases that constitute quintessential examples of mothers grappling with addiction disorders as they renegotiate their relationships with their children.

Stage One

Interviews were coded using a 2-part process. The first coding iteration was done by focusing on the concepts guided by the interview questions. Then, for each conceptual coding, multiple themes were identified for each participant.³¹ Moreover, thematic content analysis was developed to identify, organize, and interpret each theme.^32,33 Both direct and latent codes were included in the coding procedures.

Stage Two

The stories of 6 participants were identified as the quintessential examples of the experiences lived by the mothers in the study.^34,35 To be selected, a case had to meet the following criteria: (1) represent a group of participants based on one of the main individual identities of interest for the study (i.e., based on race, ethnicity, sexual identity/sexual orientation, socio-economic background); (2) represent one of the several communities involved in the study; (3) represent one of the main institutional experiences discussed by all the mothers interviewed. Cases were added until conceptual saturation was achieved.³⁶ Importantly, this method of analysis is meant to provide conceptual generalizations^37
-39 that may prove useful for the development of new hypotheses and research questions to be addressed by future studies.³⁸ While the six cases were used to frame the analysis, information from all the 45 interviews were included in the analysis. This method allowed us to examine the different themes in the data through a direct representation of the participants’ narratives, while also facilitating a summary of the main findings for the whole sample. Rather than using the themes to summarize the salient points in the interviews, we believe that directly using the participants’ stories provided us with a deeper understanding of the realities their experienced throughout their lives. Table 1 summarizes the criteria used for the selection of the cases and their representation of the mothers in the sample by individual characteristics, community type, and institutional experiences.

Table 1.

Summary of Cases by Category of Interest.

Case	Individual Identities	Community Settings	Institutional experiences
Paula	African American; LGBT, age 28	Rural community, poor Abandoned as a child	Childhood institutionalization In and out of correctional institutions.
			Gave birth to one of her children while in detention.
Toni	African American; age 70	Urban minority community, poor	Jail, community supervision, half-way house
		Experienced racial prejudice
		Normalization of drug use
Lillian	White Caucasian, LGBT, age 52	Wealthy community	Arrested, DUI, recovery program
		Suburban community
		Travelled around the world.
Tallulah	Puerto Rican and Native American, age 57	Urban, minority community	Arrested, children placed in foster care.
	Puerto Rican and Native American, age 57	Poor community
		Children sent to White community.
Nina	White and Native American, age 37	Urban, minority community	Experienced incarceration
	White and Native American, age 37	Experienced homelessness	Lost custody of her children multiple times
		Lived in different states.
Bianca	White Caucasian, age 45	Rural, White community	Lost custody of her child
		Involved in wealthy criminal enterprise	Able to avoid incarceration due to connections.
		Privileged community

Note. The names listed on the Table are pseudonyms. If not specified, participants identified as heterosexual.

Three members of the research team coded the data analyzed for this manuscript.

Results

Themes

Three main themes were examined across the interviews: (1) childhood experiences and trauma, (2) initiation with drug use and early symptoms of addiction disorders, and (3) motherhood. The 3 main themes reflect the main sections of the interviews used for the manuscript. Additional themes were identified in the narratives provided by the participants.

Six representative cases are used to describe the experiences of mothers included in the study, while also summarizing the experiences of all other mothers interviewed as they related to each theme. Because of our focus on intersectionality, we emphasize the individual identities of each mother by race and ethnicity, sexual orientation, and socio-economic background. Furthermore, the narrative summarized for each case provides information about the social and institutional context in which these mothers grew up, and where they currently negotiate their recovery from addiction disorders and their relationship with their children.

The Intersectional Experiences of Mothers in the Study

We provide the narratives of six of the mothers interviewed. Their real names have been omitted to protect their privacy. Paula, Toni, Lillian, Tallulah, Nina, and Bianca are pseudonyms we use across the analysis to refer to the narratives of the six mothers selected for the study.

Paula

The first story we selected is the story of Paula, a young African American mother who identified as bisexual. Paula’s childhood experiences and trauma contributed to a life-trajectory marked by victimization, risk-taking behaviors, drug use and dependence, and involvement with the legal system.

Paula grew up in a minority community as the only child of a mother who suffered from an addictive disorder. When Paula was 8 years old, her mom decided that she no longer wanted to be a mom – mostly because her new boyfriend did not want to have kids around – so she dropped Paula off at the nearest child protective service center. Several of the mothers interviewed for the study had experienced child protective services as a child. Mothers who identified as Black or African American were more likely to have experienced the foster care system than White mothers. Even after child protective services intervened during their childhood, the White mothers were more likely to report having been raised by another family member (most often grandmother) when compared to participants who were members of racial or ethnic minorities.

Paula lived in foster care from the age of 8 until she turned 16—when she went back to her mother’s house. By the time she returned home, Paula had become pregnant with her first child and was now a habitual drug user. She recalled starting to use heroin as young as 13; “heroin hooked me up,” she asserted. Heroin was the drug of choice of over half of the mothers in the study, which they described as “extremely addictive.”

Paula, who was in her late 20s at the time of the interview, mentioned not having had more than 2 days of sobriety in a row since she started using, except for the time she was in the “hole” of the county jail—where she could not access drugs because “nothing would go through.”

During adolescence, Paula spent a significant amount of time in the juvenile legal system. As an adult, she had been in jail many times, and she had also been incarcerated in prison twice. At the time of the interview, Paula was wearing an ankle bracelet and was living in a half-way house for women involved with the criminal legal system and struggling with addiction. One of the several times she was in jail, Paula remembers going into labor while being booked at the intake office of the county jail. Despite her cry for help, Paula was left alone in a cell without any care until she was finally transported to the emergency room where she gave birth to her daughter. When her water broke, while standing in front of the intake officer, she was told that she had just “peed on myself.” She had to sit on her soiled clothes for several hours before they called the paramedics for help. In Paula’s own words, “by the time I got from booking to the hospital, I was 9 cm dilated (. . .) they didn’t send a nurse to come check me, nothing.” Such indifference was not uncommon among the service providers mentioned by the mothers in the study. Like Paula, several other mothers discussed the lack of empathy they experienced at the hand of nurses, doctors, or intake personnel in residential rehabilitation programs.

After the baby was born, Paula was allowed to keep the baby in her hospital room for only 6 h of the 3-day hospital stay. After that, she was told they had to come and take the baby because she had to “return to custody.” Many of the mothers interviewed described their interactions with agents of the legal system as very rigid, lacking any kindness—contributing to the numerous traumatic experiences that shaped their life trajectories. Throughout the interview, Paula discussed the link between childhood trauma and drug addiction—an issue emphasized by most mothers in the study. Among all mothers interviewed, 88% experienced abuse during their lifetime, including 17% who reported being sexually abused as children. In addition, 12% of the mothers reported witnessing the abuse of either their siblings or their mother and discussed how deeply those experiences affected them through adulthood.

Toni

While trauma from violence was a common thread across the interviews, when asked to describe their childhood, some mothers focused primarily on traumatic experiences that were the direct result of prejudice. This was certainly the case for Toni, who identifies as a female, African American, heterosexual mother.

Toni grew up with a single mom and a brother in the poor part of town– a Black community. Her father remarried and lived about 5 blocks away from them. She would see him and his family all the time. His motto was “where we go, you go!” Toni’s dad preferred light skinned women, Toni remarked; “(. . .) he was married to this lady, and her children were very fair skinned with hazel eyes.” Toni loved her little sisters, but she often felt different because of the remarks people would make about her skin color. When Toni was out with the family, sometimes people would ask her father “where the little Black one came from?” This was upsetting for Toni, as she revisited those memories, she pointed out “and it hit me – that I was different.” As she put it, “Black was different.” Every time people made such remarks, “it did lower my self-esteem.” At school people often called Toni “Blackie,” just to reminder her that her skin was darker than the rest of them. “And that happens within your own race, you know, because uh, a lot of times this – the more fair skinned, uh, children were treated, you know – uh differently. They were treated better!”

Like what most of the mothers in the study reported, Toni’s drug use began during the high school years. Toni, who was in her early 70s at the time of the interview, mentioned that using heroin was common in her community throughout the 1960s and 1970s. Toni never used drugs during pregnancy, at least not since the time she found out she was pregnant with her two babies. However, she always resumed using drugs soon after giving birth. In the study, ¾ of the mothers reported quitting drugs or alcohol the moment they found out they were pregnant but returning to use drugs or alcohol soon after giving birth or within the first 2 years of the child’s life. Only a few moms reported quitting drugs completely after they found out they were pregnant and never using drugs or alcohol again.

Toni had 2 biological children 15 years apart; but she later adopted her sister’s children. Toni’s sister lost her parental rights due to alcohol addiction. For many of the mothers in the study, addiction was a family problem that often affected the participants’ siblings as well as the participants’ children. This was discussed across the interviews with the mothers regardless of their race, ethnicity, sexual orientation, or socioeconomic background. Later in life, Toni found herself in a half-way house as a grandmother. She is now sober, and her vocation is to help others recover.

Lillian

Internalizing prejudice and the fear of facing prejudice can become debilitating. This was certainly the case for Lillian who identifies as a White lesbian mother who grew up “closeted” for fear of judgment.

Unlike many of the mothers in the study, Lillian grew up privileged. Due to her father’s employment, she had had the opportunity to visit and live in other countries, where she learned about a myriad of different cultures. Only mothers who identified as White Caucasian reported being privileged while growing up, attending school in suburban wealthy neighborhoods. The word “privilege” was most often used to refer to participants’ access to economic means. In some cases, however, participants also used the word privilege to refer to their status of being White while growing up in predominantly minority communities. About one-third of the White mothers interviewed grew up in wealthy households, while none of the mothers who identified as members of racial/ethnic minorities reported privilege.

Despite feeling privileged while growing up, Lillian struggled to accept herself and her sexual orientation. During the interview, Lillian admitted that she had lost herself hiding her sexuality behind a heterosexual marriage she did not want. She described her anxiety associated with her sexual orientation, motherhood, and living behind a lie. As reported previously, 19% of the mothers in the study identified as members of the LGBT community. Anxiety was an issue most commonly discussed about the mothers who identified as lesbians. Conversely, mothers who identified as bisexual or pansexual were less concerned about the societal response to their sexuality.

Lillian, who was in her early 50s at the time the interview took place, discussed that only in the last ten years she had learned to accept her sexual orientation. As Lillian recalled, when she turned 40, she was finally able to openly shout “I am a lesbian” to the rest of the world. Lillian described her addiction to drugs as a way to numb the pain that came from living a closeted life. While she used “any type of drug that was available,” Lillian preferred anti-anxiety medications, perhaps due to the stress induced by hiding her sexual orientation. Lillian had 2 pregnancies, from which she had 2 daughters. She stopped using drugs after finding out she was pregnant, but she always went back to drugs afterwards. Lillian reflected on her role as a mom while using drugs.

“I knew when I was taking my kids to meet with drug dealers, they would be in the car that I-I was like, I didn’t even recognize myself. I was like, ‘what the hell are you doing?’ It was terrible. And that’s-that’s the issue that, you know, people have a lot of shame and guilt because of their history of substance abuse from all the things that they did while they were in active addiction.” (Lillian)

While Lillian always loved being a mother to her daughters, she felt guilty about exposing the girls to the dangers of drug dealing. This was a common concern shared by the mothers in the study. While they all loved their kids, most of them continued to use and expose their children to the dangers of drug dealing and drug using, suggesting that addiction can exercise an overwhelming and often uncontrollable force.

“I did some shady, terrible things when I was in active addiction and – that I would never have done today. Like, I would never even think about those things today. (. . .) I had lost who I was. I lost my dignity. I definitely – parenting was like not on the – even on the chart, on the calendar to manage. My kids were – I mean, I would show up at volleyball games and things like that, I would show up, but I was not present.” (Lillian)

Sobriety for Lillian has provided an opportunity not only to reflect on her relationship with her children but also to invest in reconciliation. While this is tortuous path, Lillian continues to work on rebuilding the relationship with her now adult daughters. Like many of the mothers in the study, Lillian had a difficult relationship with her children. Less than 20% of the mothers reported having a close relationship with their children at the time of the interview.

Tallulah

Tallulah, who identifies as Puerto Rican and Native American, was born and raised in a predominantly Black urban community. Tallulah grew up with both parents at home, but her mother died when she was 15. Her dad struggled with alcohol addiction, even though he never truly admitted it. His life got better when he remarried, and his new wife helped him quit drinking and stay sober. Parental addiction was frequently discussed by participants in the study. Roughly, one-third of the mothers in the study had suffered the consequences of parental addiction.

Tallulah used drugs when she was a teenager (pills, marijuana. . . anything she could find), as “everyone was [using] back then.” The addiction became real after the first time she injected heroin. From that moment on, she had to use every day, multiple times a day. When she did not use, she would get very sick. “So, I continued to use not to be sick, you know” she said. “And my justification was ‘I gotta take care of my kids’.” Tallulah used for 17 straight years. She used during pregnancy but only until she found out she was pregnant – namely the first trimester. Mostly, it was her abusive husband who decided when she could use or not use. “Whatever he said!” she emphasized. When the interviewer asked Tallulah if it was difficult to quit using during pregnancy, she said “[a]ctually no, because the motivating factor was higher; those were my babies.” However, after giving birth, she always went back to heroin. “I didn’t have self-esteem. I didn’t feel good about myself.”

Tallulah struggled to find the means to support her addiction and her family. She would do “whatever it took.” In Tallulah’s words, “I begged (. . .), sexual relations, you know.” It was like “you give me this, I give you this, you know.” Tallulah described a vicious cycle, where the need for heroin led her to do things she hated, which also triggered the need to stay high. In Tallulah’s words, “in the end, you used because it wasn’t pleasurable.” Several of the mothers in the study mentioned findings themselves involved in similar situations as Tallulah, where they had to either exchange sex for drugs, or work as exotic dancers (“stripping”) to get money for drugs.

Tallulah’s husband was abusive, but he was—for the most part—physically abusive only while drinking. Then, 1 day, an anonymous tip from a neighbor triggered a child protective service’ visit. Domestic disturbance calls to the police were often the way child protective services got involved in the lives of participants, as police officers would directly refer the case to child protective services when children were present.

Because Tallulah was under the influence of narcotics at the time the police arrived, child protective services were immediately notified. At that time, all her kids were placed in foster care. While Tallulah had asked that the children be placed under the care of her sister Elsa, the arrangement only lasted a few days. Unfortunately, Elsa did not want to deal with Tallulah’s children, so the children were sent back to child protective services—an incident that Tallulah described as extremely traumatizing. It was then that she decided to seek an in-patient detox program. Not knowing where the kids would go next was the biggest fear she had experienced in her life. Her main concern was that her children would not be treated fairly in the foster care system, as they were transferred to another community, which Tallulah describes as a White community nearby. Tallulah knew that because her children are dark skinned that it would be a problem. “They’re my color”—Tallulah argued. “They went somewhere, and the lady was abusive to them.” As the children had been transferred to another community, they had to attend school in a school district that almost exclusively served White families. “They were teased and bullied by other kids because of their color,” Tallulah mentioned.

In the study, mothers who identified as members of racial or ethnic minorities were more likely than those who identified as White to have their children placed in foster care by child protective services and to also have their kids assigned to someone outside the child’s extended family.

Visiting her children during the time they were in foster care was very difficult. As Tallulah put it, “(. . .) and then every time I had a visit set up, it never happened.” But after 6 months, Tallulah got them back, and there was no other court referral pending against her. While in foster care, Tallulah’s kids were not fed properly, and they were not shown any care or support. Tallulah was concerned that the foster family would do the same to other children, so she filed a report against the foster family with child protective services. She later found out that the family had been revoked any permission to foster children, due to the abuses that a small child had endured under their care. Tallulah talked about this as a sort of social justice accomplishment, as she had raised the issue with the agency herself. Now in her late 50s, Tallulah continues to help families grappling with addiction. The desire to help others was a common denominator in the mothers’ narratives.

Nina

The story of Nina also presented a certain level of complexity that exemplified the experiences of mothers in the study. Nina identifies as both White and Native American. Her mother raised her as Native American, following her ancestry. At the time of the interview, Nina was in her late 30s and had 4 children – of whom 3 were under the age of eighteen. Nina also identified as bisexual, and as “an addict in recovery.”

Starting at a young age, Nina suffered from chronic pain. Her mom took her to the doctor who prescribed pain killers. In addition, her mom would share with Nina the pain killers that were prescribed to her. But at some point, the doctor(s) “cut her off the pills” and she turned to the streets. She began to use heroin—snorting first, then injecting. She spent time in jail after getting caught selling pills.

Since the birth of her first child, child protective services got involved several times, but there was a particularly traumatic incident that Nina wanted to share during the interview—the first time that child protective services took her kids away. Nina and her husband got into a fight while drinking. The neighbors called the police and child protective services arrived almost immediately to take the children. The 2 youngest children were still nursing at that time, but they were still removed from the home. Nina remembers “I lost my mind. I had never been away from my children.” While the kids were in foster care, Nina remembers “living in the car, selling drugs, and doing drugs.” Separation from their children was often the source of desperation for the mothers interviewed. Some (like Tallulah) found strength in the desire to defeat the state to bring their children home. However, for a larger group of mothers (including Nina), the separation from their children drove them into a deep state of depression that further worsened their addiction and involvement with the criminal legal system. As some of the mothers in the study explained, they felt as if they had “nothing left.”

Later, while pregnant with the youngest child, she got addicted to fentanyl. “You could snort just a tiny little speck of it, and you were like high - very powerful!” Nina recalls. “Crazy stuff, but I paid extra for it.” Nina tried to stop using during pregnancy, but the stress of labor led her to use again just before the baby arrived. Just like she had been doing for the birth of her other babies, she relied on a midwife to deliver the baby. But this time, due to drugs being involved, the midwife refused service at the last minute. At the hospital, child protective services arrived to assess the situation immediately after Nina gave birth. Nina was not allowed to feed the baby or bond with the baby. The baby ended up spending a few days in the NICU for respiratory distress, but after his health stabilized, the baby went home with Nina. When the child protective services’ officer arrived at Nina’s home a week later for a routine check, Nina was under the influence of a “piece of Suboxone pill I found at the bottom of my purse.” The officer removed the child from the home when he was only 12 days old. Nina sobbed while describing the incident. “It was the worst pain I’ve ever felt in my life” she recalled.

Tragedy struck when her partner overdosed one night and died in their bed. When the paramedics arrived, the police arrived with them and took Nina to jail. Child protective services arrived at the same time and took the kids away. Following the next of kin rule, child protective services assigned Nina’s children to her sister. Unfortunately, long-term tensions and resentments exacerbated the pains of the separation, and Nina found herself fighting with her family over the custody of her children.

This problem is not uncommon among mothers who find themselves negotiating their relationship with their children with the foster care system because of addiction, or because of their involvement with the criminal legal system. While difficult family relations were often described by participants as part of the reasons they began to use drugs, child protective services often complicated matters by empowering abusive family members who limited mothers’ ability to communicate with their children. Several participants described this issue as a true obstacle to their addiction recovery, as it made it very difficult to develop healthy relationships with their children and stay sober or out of jail. This was certainly true for Nina, but also for other participants.

Bianca

Diversity shaped the experiences of the participants in the study, even though both White and minority participants found themselves immersed in similar circumstances. The story of Bianca provides some insights into the different ways White and minority mothers struggled with addiction disorders and attempted to disentangle themselves from the reach of the U.S. legal system.

Bianca identifies as a White, female, heterosexual mother in her mid-40s from a White rural community. When Bianca was growing up, her mom suffered from drug addiction, while her dad was an alcoholic. Her mom died young, at age 42.

Bianca was introduced to pain pills by her mother. At some point, she was taking 50 pills per day. At 16, Bianca started also using cocaine. Later, as a teenager she experimented with crystal meth. Overall, she spent 30 years of her life in active addiction. Bianca recalls “[a]nd then, I went through a divorce, I started drinking and I got to a place where I woke up every single day of my life and I didn’t know where I was or who I was with or if I had been raped or if I had voluntarily had sex. I mean, I didn’t know.”

Prior to embracing treatment, Bianca had had a long-term involvement with the drug dealing business. “I’ve always sold drugs, always sold drugs because I was always, um, I’m the type of drug addict, um, I didn’t do things when, I didn’t get high when things were bad, I got high when things were good.”

At the age of 35, Bianca became pregnant with her daughter while on the pill.

“It was the first time I ever felt happiness, you know? And I thought I-I definitely believe that um, I already had the spiritual belief about me where nothing is a coincidence, everything happens for a reason. So, there was no thought of um, abortion, or you know, adoption or anything like that. I thought, at 35 years old and all the health complications that I have had, it-it was a blessing.” (Bianca)

Life with a newborn was good for Bianca. She had embraced sobriety. Two years after the baby was born, her partner and father of her only child, raped her best friend and was sent to prison. She then started using again. She lost custody of her daughter, who has been assigned to family members—whom Bianca considered “judgmental and unable to help.” While Bianca’s involvement in the drug enterprise had been a long-term affair, she had been able to avoid incarceration. In Bianca’s words, “I knew a lot of people and I knew a lot of people in high places, so I was always like I always given the insight that I needed before I got caught doing something.” Knowing people in ‘high places’ was not commonly discussed among the mothers in the study. However, a few of the mothers (all White Caucasian mothers) mentioned that they felt their position in society/privilege helped them stay out of jail.

At the time of the interview, Bianca was living in a half-way house for women under the supervision of the criminal legal system. Prior to admission to the half-way house, Bianca had spent 26 days in a residential detox and rehabilitation program, which had been strongly recommended by the court. However, Bianca recalled, it was not the first time she had attempted detox. The first time she tried to detox, the center did not do a psychiatric evaluation, and she knew then that the institution was not the right place for her recovery.

Misdiagnoses—or complete neglect of women’s mental health problems—were a common thread across all the interviews with mothers. Misdiagnoses of mental health problems began early during adolescence for many of the participants. About three-fourth of participants discussed suffering from depression and anxiety since early age. A few of the mothers also discussed difficulties with learning disabilities that were not appropriately addressed and often dealt with corporal punishment. Eating disorders and feelings of social anxiety were also discussed by some of the mothers interviewed. Only in a few cases, mental health disorders were diagnosed by a doctor, with bipolar disorder and ADHD being the most common among the diagnoses. Unfortunately, many mental health problems remained unaddressed among the women interviewed, with complications for relapse and inability to develop healthy relationship with their children.

Table 2 provides a summary of the themes explored by the mothers in the study.

Table 2.

Themes Explored by Participants by Life Transition.

Themes	Case Study/Studies	Sample
Childhood experiences
Childhood institutionalization	Paula	1/3 of the minority mothers in the sample
Childhood abuse	Paula	17% of the mothers in the sample experienced childhood sexual abuse
Racism	Toni	1/3 of the minority mothers discussed prejudice.
Privilege	Lillian	1/3 of White mothers grew up wealthy; none of the minority mothers.
Parental addiction	Tallulah	1/3 of the mothers in the sample
Anxiety related to sexual orientation	Lillian	All lesbian mothers suffered from anxiety due to living ‘closeted.’
Initiation to Drug Use
Started in childhood/early adolescence	Paula, Nina	10% of the mothers used early before adolescence.
High school	Toni	85% of the mothers began to use during high school.
Heroin use	Toni, Tallulah, Lillian, Bianca	54% of mothers in the study used heroin as drug of choice.
Drug use during pregnancy	Nina, Paula	25% of the mother used drugs or alcohol during pregnancy.
Drug use before and after pregnancy	Lillian, Toni, Tallulah, Bianca	73% of mothers resumed drug use after the birth of their child.
Early mental health problems	Nina, Paula	Half of mothers suffered from early mental health problems.
Adulthood experiences
Mistreatment by jail authorities while pregnant	Paula	10% of the mothers mentioned mistreatment by authorities.
Neglect of children’s needs to access drugs	Lillian, Nina	80% of the mothers discussed neglecting their kids for drugs.
Difficult relationship with children	Lillian, Nina	80% of mothers experienced strained relationships with their kids.
Domestic violence	Paula, Bianca, Tallulah	88% of the mothers experienced some form of abuse.
Institutionalization in jail or other setting	Paula, Toni, Nina, Bianca	90% of the mothers experienced some form of institutionalization.
Mental health problems	Lillian, Nina, Paula, Bianca	Almost all the mothers discussed some form of mental health problem.
Child protective services’ involvement	Paula, Tallulah, Bianca, Nina	75% of the mothers mentioned child protective service involvement.
Strained relationships with extended family	Nina	About 1/3 of the mothers mentioned not communicating with family.

Note. While the summary of themes examined in the study is useful to have an idea of the various experiences discussed by participants, we must remember that each one of the mothers interviewed had unique experiences. The comparison among mothers is meant to provide an idea of the dominant themes among the interviews to support theoretical generalizations. The names listed on the Table are pseudonyms.

Discussion

The 6 stories were selected specifically because they are unique in their representation of themes that are common across all the 45 interviews conducted with mothers struggling with addiction and fighting against the criminal legal system. Further, the 6 cases reported provided different scenarios that helped us summarize the experiences of all the mothers in the study, while also providing the opportunity to compare mothers’ experiences based on the uniqueness of the environments in which they grew up, experienced addiction, and continued to fight for their freedom, survival, and happiness. The 6 cases were carefully selected to represent different scenarios, communities, and life circumstances that would allow for a more complete analysis of the mothers’ narratives through an intersectional lens. This method of analysis^25,34 allowed us to identify cases that constitute the quintessential examples of the lived experiences of mothers grappling with addiction disorders as they renegotiate their relationship with their children. As we linked the experiences of the 6 mothers’ narratives to the experiences of other mothers in the study, the 6 stories selected provided us with an opportunity for conceptual generalizations that are meant to help to identify new hypotheses for future research studies.³⁸ In other words, the 6 cases exist within the constellation of all 45 cases included in the analysis and represent complete narratives that allow us to better comprehend the reality of mothers grappling with addiction disorders.

The 3 main themes described in each interview focused on childhood trauma, initiation to drug use/addiction, and motherhood. Childhood trauma was the common thread across all the interviews. Most of the mothers in the study had been raised by individuals who struggled with addiction and mental health problems that were poorly addressed by health care providers. Several of the mothers had suffered from mental health problems growing up, but their pains were often dismissed. Drug addiction would often occur due to the use of pain killers, or following symptoms of psychological distress that were misdiagnosed.

In some cases, participants lived in communities where using street drugs was normalized, especially among young people. Incidentally, such communities were the poorest among all those included in the study. For several of the mothers interviewed, using drugs also meant selling drugs, or engaging in other illegal activities that helped them support their addiction, or feed their children.⁴⁰ The heavy police presence in the poorest communities clearly contributed to these participants’ involvement in the criminal legal system, their frequent arrests, and the removal of their children from the home by child protective services.^41
-43 Poor minority women, especially Black women, have historically suffered the consequences of the heavy police presence in their communities.^1,10

For other participants, however, the encounter with the criminal legal system was primarily the result of “using while mothering.” Incidentally, the mothers who lived in low-income communities of color were also more likely to have their children taken and placed in foster care. Some of the mothers would be identified as endangering their children by health care providers when they delivered their babies, but in several cases, child protective services showed up at their door following some random tip from neighbors.

While the exact locations where participants grew up or lived at the time of the interviews could not be specified due to the risk of identifying participants, 2 large counties were targeted for the study, due to their differences in demographics: 1 predominantly White, and the other characterized by a history of racial marginalization, poverty, and high crime rates. This approach allowed us to see the differences among the participants’ stories that are often the result of structural differences based on race, class, politics, and availability of resources.

Theoretical Implications

Intersectionality provided a useful paradigm for the design of the study, for developing the research team that made this study possible, and for the interpretation and analysis of participants’ narratives.^25,26

The intersectional framework also provided us with the incentives of examining the characteristics of the communities in which the stories of the mothers interviewed developed. As Nash²⁸ asserted, the characteristics of the social environment and the timeframe in which narratives are developed must be considered zwhen examining social phenomena. Having a good understanding of the communities that were targeted for the study afforded us the opportunity to better understand the stories of the mothers who grew up and raised their children in those communities.

By offering a theoretical lens, intersectionality allowed us to understand the diversity of experiences of the mothers interviewed that were shaped by time, space, and history of discrimination. By permitting a link between macro (structure) and micro (individual stories), intersectionality allowed us to interpret the many ways in which participants developed their identities and experienced motherhood.⁴⁴

Implications for Policy and Practice

Beyond the individual and social identities participants discussed—based on race, gender, sexual orientation/orientation, ethnicity, and socio-economic status—the mothers included in this study had unique experiences that followed no pre-scripted theory or behavioral pattern. However, in many ways, what brought these mothers together under one common set of limitations is the law and the legal practices as implemented by the agencies involved in the study. Such legal practices most often fail to consider the various ways in which individual and social identities shape one’s experiences and pathways to recovery. Further, those who implement policies pertaining to illegal behavior and substance use problems, may also fail to recognize their biases and how those biases might influence discretionary legal actions such as whether to arrest or remove children from home. As Bilge³⁰ asserted, “[. . .] despite claims of inclusiveness, progressive movements can fail in intersectional political awareness. This failure comes at a significant cost for various subordinated groups, which are silenced, excluded, misrepresented, or coopted” (p. 406-7).

Limitations

The study presents several limitations. First, the interview questions/instruments used were not pilot tested. Only the domestic violence questions were part of a standardized instrument.²⁹ All the other questions used for the interviews included in this manuscript were not pilot tested. Second, we are aware that the study does not create a new theory. Third, the study’s findings are not suitable for empirical generalizations.

Future Research

Despite these limitations, the study offers a glimpse of the lives of mothers struggling with addiction disorders while renegotiating their relationship with their own children as monitored by the state. Their lived experiences and the complexity of the dynamics they describe—especially the interactions with the legal system—could potentially help other researchers frame new hypotheses that could be tested by larger empirical studies. Potential hypotheses could focus, for instance, on the association between race and authorities’ decision to place the children of mothers suffering from addiction in foster care, or on the association between sexual orientation and drug addiction among mothers of young children. More hypotheses are also needed to examine the impact of trauma on substance use and other addiction disorders among mothers.

Conclusion

Using an intersectional lens, the study brings to the fore the social inequities that many mothers and their children experience in the current social arrangement. However, while the mothers in the study struggled, their stories are ones of resilience, courage, and perseverance; their love for their children kept these mothers moving forward and fighting for survival. While the stories featured in this manuscript are stories marked by tragedies, pain, and despair, they are also stories of coping that can help us identify what works with mothers and their children. If we could focus on the connection among the various forms of strength the mothers in the study showed, we could provide better services than those currently existing.

We believe the criminal legal response is unlikely to address the issues that led to addiction and remain convinced that referrals to the criminal legal system are inadequate when addiction is the primary cause of law violations. However, as social changes tend to be very slow, we believe that this study’s findings could help advocate for (1) the design of new training protocols for service providers—including judges and public defenders—possibly targeted at recognizing their own biases and how these biases influence discretionary decision-making (2) the design and implementation of new policies that aim to support mothers in their recovery process as they reconnect with their children, and (3) the funding of new programs that aim to reduce of the pains associated with mothers’ traumatic experiences and childhood wellbeing, which could make a difference in the lives of many families.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251317657 – Supplemental material for Mothers at the Intersection of Trauma, Addiction, and Involvement with the Criminal Legal System: An Analysis of Multiple Case Studies

Supplemental material, sj-docx-1-inq-10.1177_00469580251317657 for Mothers at the Intersection of Trauma, Addiction, and Involvement with the Criminal Legal System: An Analysis of Multiple Case Studies by Monica Solinas-Saunders, Maureen L. Petrunich-Rutherford, Mark D. Thomas, Natasha R. Brown, Kevin L. McElmurry, Melissa A. Jones, Abigail M. Cognetti, Lytina Andrews and Amira Zahabi in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-docx-2-inq-10.1177_00469580251317657 – Supplemental material for Mothers at the Intersection of Trauma, Addiction, and Involvement with the Criminal Legal System: An Analysis of Multiple Case Studies

Supplemental material, sj-docx-2-inq-10.1177_00469580251317657 for Mothers at the Intersection of Trauma, Addiction, and Involvement with the Criminal Legal System: An Analysis of Multiple Case Studies by Monica Solinas-Saunders, Maureen L. Petrunich-Rutherford, Mark D. Thomas, Natasha R. Brown, Kevin L. McElmurry, Melissa A. Jones, Abigail M. Cognetti, Lytina Andrews and Amira Zahabi in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Supplemental Material

sj-docx-3-inq-10.1177_00469580251317657 – Supplemental material for Mothers at the Intersection of Trauma, Addiction, and Involvement with the Criminal Legal System: An Analysis of Multiple Case Studies

Supplemental material, sj-docx-3-inq-10.1177_00469580251317657 for Mothers at the Intersection of Trauma, Addiction, and Involvement with the Criminal Legal System: An Analysis of Multiple Case Studies by Monica Solinas-Saunders, Maureen L. Petrunich-Rutherford, Mark D. Thomas, Natasha R. Brown, Kevin L. McElmurry, Melissa A. Jones, Abigail M. Cognetti, Lytina Andrews and Amira Zahabi in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

The authors are grateful for the support of the Office for Research Development at Indiana University, especially Sarah Mosier and Sandra McMullen. The authors are also indebted to Eric Lambert, Patricia Woosley, Wynette Justin, Noelle Bates, and Krista Grant for their careful administrative support. Finally, the authors are grateful for the work and support of the Editors, the Editorial Board, the anonymous reviewers, and the Journal’s administrative staff.

Authors Contributions

Monica Solinas-Saunders serves as the Principal Investigator for the “Mothers and Addiction Disorders’ Study.” She oversees every phase of the study’s design and implementation, including the recruitment, hiring, and training of research assistants. Additionally, Monica is responsible for coding interview data, and for writing and revising the manuscript. Maureen L. Petrunich-Rutherford, Mark Thomas, Natasha Brown, and Kevin McElmurry are co-Principal Investigators for the study. Their contributions to the grant application and the invaluable conceptual recommendations for the study design and implementation made the study possible. In addition, their editing abilities significantly improved the manuscript. Melissa Jones, Abigail Cognetti, Lytina Andrews, and Amira Zahabi were employed by the Motherhood Addictions Study as research assistants. They all contributed to the study in various ways: conducting interviews, transcribing narratives, compiling notes and field observations, and coding data from the interviews.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was entirely funded by the Indiana University Addictions Grand Challenge.

Ethical/Consent Statement

The study was approved by the Institutional Review Board of Indiana University, Protocol # 18039 “Substance Abuse, Incarceration, and Treatment,” P.I. Monica Solinas-Saunders. Review Type Expedited (Categories 6 & 7). Approved on March 16, 2023; continuing review March 15, 2024. Participants in the study signed the informed consent prior to the beginning of their interview. The 45 interviews with mothers used for this manuscript were part of a larger study of 110 interviews. The IRB protocol here described refers to the larger study of which the mothers were a sub-set of the larger sample of participants. While the complete study with the 110 interviews also includes individuals who are not mothers (e.g., men suffering with addiction disorders, service providers, family members of individuals suffering from addiction disorder), their interviews also focused on motherhood and addiction disorders. This manuscript is the first to be published from the study.

ORCID iD

Monica Solinas-Saunders

Supplemental Material

Supplemental material for this article is available online.

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