# The Experience of Alcohol and Drug Recovery Service Staff Working with Mothers Who Have Had Their Children Removed

Authors: Sarah McFarline; Naomi White; Lynda Russell
Journal: Health & Social Care in the Community
 (2023)

---

## Abstract

Parenting can be impacted by substance misuse, and children can be at risk of maltreatment, leading to their removal from their mothers. Successful treatment of substance abuse relies on these women gaining effective support from services. Previous research has demonstrated the impact working in this field can have on staff, including high staff turnover, vicarious trauma, and burnout. The present study further explores the experience of staff members working in a Drug and Alcohol Recovery Service in Scotland who work with mothers who have had their children removed. Six interviews with nurses and social care workers were analysed using interpretive phenomenological analysis (IPA). Two superordinate themes were developed from the data: (1) complexity and tension within working relationships and (2) emotional experiences and attempts to resolve them. Participants described the complexity of their roles, including the dual role of supporting mothers while also being involved in the child removal process by providing reports and evidence and how they respond and work with mothers after removal and conflicts with the wider system. They also highlighted their attempts to cope with the emotional impact of being part of this process and the empathy they have with mothers, especially when they are parents themselves, and described the complexities of trying to cope and manage when working in this challenging area. Clinical implications, including training needs and requirements, are discussed.


---

## Body

## 1. Introduction

Similar to other parts of the world, substance misuse among mothers is a serious issue for parenting and is associated with the risk of child maltreatment [1–6]. In Scotland, parental substance use is commonly identified as a concern in child protection conferences and reported at similar levels to domestic abuse and neglect [7].Previous research has highlighted that mothers who misuse substances have complex and multiple issues, including complex trauma, mental health difficulties, poverty, and experiences of domestic abuse [8–10]. It can be argued that women in addiction services who have had their children removed may be additionally traumatized, and the loss can be associated with shame and stigma and a perception of being a “flawed mother” [11]. In order to meet the complex needs of mothers in this population, research has highlighted the importance of care which is multisectoral, integrated [12], and trauma-informed [13, 14]. Also, the relationships between mother and service provider, among staff, between staff and management, and between community partners are seen as crucial for effective service delivery [12].Being part of a process that involves child removal and providing support to vulnerable mothers is likely to be highly emotional for staff [15]. Workers may feel uncomfortable with trauma-informed practice, with trepidation centred around a lack of training, fear around exacerbating difficulties, and not having resources or time [16]. Professionals working with parents who misuse substances report a burden of care and anxiety over their sense of responsibility [17]. Within the Scottish context, addiction staff are expected to attend and provide reports and information to multi-agency meetings, such as child protection case conferences and reviews. They can face a dilemma as they need to share information to prevent harm in line with Child Protection Guidance [18] but also respect a family’s right to a private life [19].In addition, the role was viewed as emotionally exhausting [20]. Previous studies have highlighted the risk of staff developing vicarious trauma [21–24]. Vicarious trauma is a psychological response that can develop as a result of engaging empathically with clients who have been exposed to trauma. There is also the potential for positive outcomes, such as posttraumatic growth (PTG) [15]. Definitions of PTG, which is also known as adversarial growth, include a greater appreciation of life, improved relationships, and increased spirituality [25].Barriers to best practice include declining resources [17], restrictions on service delivery, and the complexity involved in providing a service to a population with high relapse rates and comorbid mental health difficulties [26, 27]. These pressures can filter down to staff, which can lead to burnout and high turnover [28].It is clear that this is a complex area, with demands on services and staff to provide effective support to mothers who have had their children removed. Similarly, while there is an evidence base highlighting the impact trauma-focused work can have on staff generally, there is a lack of research solely focused on staff working in addiction services [29]. Research has demonstrated the importance of staff-client relationships but highlighted that further research should be carried out to examine staff members’ experiences of this relationship. In particular, there is limited research looking at the lived experience of staff working with mothers with an addiction who have had their children removed and the impact removal has on them, their relationship with the mother, and the service as a whole.


### 1.1. Aims

The aim of this study was to investigate the experiences of staff members working in addiction services with mothers who have social work involvement and have had their children removed. The study focuses on the following:(1)
How do staff members experience working with mothers with an addiction who have had their children removed?(2)
How do staff make sense of the wider system around them, such as working alongside the social work team and their relationships with them?(3)
How do staff understand and report the challenges associated with this role and their resulting training needs?


## 1.1. Aims

The aim of this study was to investigate the experiences of staff members working in addiction services with mothers who have social work involvement and have had their children removed. The study focuses on the following:(1)
How do staff members experience working with mothers with an addiction who have had their children removed?(2)
How do staff make sense of the wider system around them, such as working alongside the social work team and their relationships with them?(3)
How do staff understand and report the challenges associated with this role and their resulting training needs?


## 2. Method

### 2.1. Design

This study involved analysis of qualitative data using interpretive phenomenological analysis (IPA) to explore how staff report their experience of working with mothers who have had their children removed. IPA is theoretically underpinned by phenomenology, hermeneutics, and ideography [30]. IPA helps the researcher examine and seek insight into the participants’ experiences and how they make sense of them while acknowledging the impact of the researcher’s own interpretation of them [31].


### 2.2. Procedure

Interviews were collected from multiple members of staff from different teams in an Alcohol and Drug Recovery Service in Scotland. This study focuses on the interviews with staff members from the team that work solely with parents with social work involvement.Author LR carried out the recruitment and interviews, and SMF carried out the data analysis. One-to-one semistructured interviews were carried out in private clinic space, and they lasted approximately one hour (range 32–68 minutes, average 43 minutes).Ethical approval was granted by the UK NHS Research Ethics Committee (Ref: 17/WS/0255).


### 2.3. Participants

Participants recruited for this study were staff working in an Alcohol and Drug Recovery Service in Scotland. Six members of staff from the specialist team for parents with social work involvement participated, and all had experience working with mothers who have had children removed.Due to the specialist nature of this small team, limited information about participants is provided to protect confidentiality and reduce the likelihood of individual staff members being identified. For example, all pseudonyms and pronouns are gender-neutral. Staff were either nurses or social care workers. Almost all participants (5/6) had been working in addiction or alcohol and drug recovery services for over 10 years at the time of their interview, although this may include working in generic services and not just the specialist team.


### 2.4. Analysis

Data analysis followed the 6-step process for IPA outlined in Smith et al. [30]. These steps included (1) reading and rereading transcripts, (2) initial noting, (3) developing emergent themes, (4) searching for connections across emergent themes, (5) moving to the next case, and (6) looking for patterns across cases. A summary was written for each transcript to ensure the principle of ideography was withheld. Patterns identified across cases were clustered into superordinate themes, creating higher order organisation.A number of steps were taken to ensure rigour during data analysis. Firstly, in addition to the primary researcher (SMF), another member of the research team read two transcripts (NW) and the associated emergent themes, allowing interpretations to be discussed. Alongside this, a research diary was used for the duration of the study. This allowed for an acknowledgment, or “bracketing off” [30], of the researcher’s assumptions and preconceptions. The research diary also served to encapsulate the decision-making process during the development of themes, aiding reflexivity, and transparency. The researcher discussed any known assumptions or biases prior to data analysis and sought to maintain a reflective stance throughout. The study used the consolidated criteria for reporting qualitative research (COREQ) checklist [32]. The researcher developed a summary for each interview to help the analysis remain grounded in the participant’s narrative.


## 2.1. Design

This study involved analysis of qualitative data using interpretive phenomenological analysis (IPA) to explore how staff report their experience of working with mothers who have had their children removed. IPA is theoretically underpinned by phenomenology, hermeneutics, and ideography [30]. IPA helps the researcher examine and seek insight into the participants’ experiences and how they make sense of them while acknowledging the impact of the researcher’s own interpretation of them [31].


## 2.2. Procedure

Interviews were collected from multiple members of staff from different teams in an Alcohol and Drug Recovery Service in Scotland. This study focuses on the interviews with staff members from the team that work solely with parents with social work involvement.Author LR carried out the recruitment and interviews, and SMF carried out the data analysis. One-to-one semistructured interviews were carried out in private clinic space, and they lasted approximately one hour (range 32–68 minutes, average 43 minutes).Ethical approval was granted by the UK NHS Research Ethics Committee (Ref: 17/WS/0255).


## 2.3. Participants

Participants recruited for this study were staff working in an Alcohol and Drug Recovery Service in Scotland. Six members of staff from the specialist team for parents with social work involvement participated, and all had experience working with mothers who have had children removed.Due to the specialist nature of this small team, limited information about participants is provided to protect confidentiality and reduce the likelihood of individual staff members being identified. For example, all pseudonyms and pronouns are gender-neutral. Staff were either nurses or social care workers. Almost all participants (5/6) had been working in addiction or alcohol and drug recovery services for over 10 years at the time of their interview, although this may include working in generic services and not just the specialist team.


## 2.4. Analysis

Data analysis followed the 6-step process for IPA outlined in Smith et al. [30]. These steps included (1) reading and rereading transcripts, (2) initial noting, (3) developing emergent themes, (4) searching for connections across emergent themes, (5) moving to the next case, and (6) looking for patterns across cases. A summary was written for each transcript to ensure the principle of ideography was withheld. Patterns identified across cases were clustered into superordinate themes, creating higher order organisation.A number of steps were taken to ensure rigour during data analysis. Firstly, in addition to the primary researcher (SMF), another member of the research team read two transcripts (NW) and the associated emergent themes, allowing interpretations to be discussed. Alongside this, a research diary was used for the duration of the study. This allowed for an acknowledgment, or “bracketing off” [30], of the researcher’s assumptions and preconceptions. The research diary also served to encapsulate the decision-making process during the development of themes, aiding reflexivity, and transparency. The researcher discussed any known assumptions or biases prior to data analysis and sought to maintain a reflective stance throughout. The study used the consolidated criteria for reporting qualitative research (COREQ) checklist [32]. The researcher developed a summary for each interview to help the analysis remain grounded in the participant’s narrative.


## 3. Results

Analysis resulted into two interrelated superordinate themes and 5 subordinate themes (Table1). Themes are illustrated with substantiating excerpts or quotations.Table 1
Superordinate and subordinate themes.
Superordinate themesSubordinate themesComplexity and tension within working relationshipsDuality of role: “I felt like I was really part of that child being removed”Response to removal: “become an absolute pest, you know …a good pest”Conflict with the wider system: “we are not compatible with them”Emotional experiences and attempts to resolve themEmotional impact and empathy: “my world would be destroyed if anybody took my children”Complexity within attempts to cope: “I don’t mean you become desensitised...”


### 3.1. Complexity and Tension within Working Relationships

Across narratives, the participants convey the complexity of the role and describe how they navigate relationships, both with their clients and with the wider system. Their accounts illustrate tension between their professional role and their contribution towards potential child removal, wanting to show empathy and alliance with the mothers. Their accounts suggest an ambiguity at times over where they position themselves and their professional identity.


#### 3.1.1. Duality of Role: “I Felt Like I Was Really Part of That Child Being Removed”

Participants explained how the nature of their role means that they provide support but will also give evidence at child protection and social work meetings regarding their clients’ substance use and ability to care for their children. Alex described that their work with the mothers can be “kind of seen as punitive…you try and balance that.” Alex describes an attempt to balance it by being “transparent,” which suggests an awareness and a proactive attempt to mitigate the perceived harshness.A perceived scrutiny is also described by Sam, who feels that during child protection meetings: “all eyes are on you.” Alex highlights that not only can staff fall into opposing roles of supportive and punitive, but that they perceive that staff and clients can find themselves in conflicting roles:“I am like a detective, because it is trying to catch them out, which doesn’t feel nice either… sometimes it feels like a bit of a cat-and-mouse game with them”Alex uses vivid language to describe their position, with the imagery of a hunt. The description conveys the opposing roles of cat/mouse or detective/criminal and suggests an uneasiness with this role; it “doesn’t feel nice” to play the role of pursuer.The challenge of being part of a system in which women lose “complete care of their children” whilst trying to engage them in clinical work is illustrated by Morgan. They describe a tension between providing information that could be viewed as detrimental to the mothers, whilst also engaging them in therapeutic work. They articulate the difficulty of maintaining trust and effective working relationships when they perceive that the mothers may feel they have done the “biggest…the worst” thing.The participants highlight a potential breakdown in the working relationship following removal and the challenge of trying to support mothers when they are “very angry” (Sam) and “the relationships could be volatile” (Ainsley). Sam’s account furthers this by alluding to how it feels to be part of the removal process, which can feel like a “betrayal.”Alex articulated the sense of responsibility and guilt they felt:“I will never forget the first case…I felt really guilty because I’d this good relationship with this client erm and then I felt like I was really part of that child being removed…”Alex’s repetition of “really” emphasises the strength of the guilt they felt. Their account conveys the powerful and lasting impact the experience had on them. They also highlight the shift in the relationship by providing the contrast, “I’d this good relationship….”


#### 3.1.2. Response to Removal: “Become an Absolute Pest, You Know … a Good Pest”

The participants describe their behaviour following a removal. Taylor highlights how they have perceived a sense of blame for the removal and how they attempt to manage this:“…you need to keep a relationship going with that person, who is totally traumatised. Sometimes you get blamed, however, if you persevere with that person… I always say “so what are we going to do about this?”… to include myself in that overall picture.”It appears from their account that their response to getting blamed is to go into a collaborative, problem-solving mode. Their narrative highlights further complexity in their role, being both part of the problem and then part of the solution.Across accounts, their descriptions convey an impression of pushing towards the mothers and a tension between respecting the mothers’ autonomy whilst striving proactively to help them. This is illustrated by Taylor:“…[I’ll] be up rattling their doors, you know become an absolute pest, you know …a good pest, you know you go up chapping their doors, shouting through their letterbox, “… we can fix this””The description is vivid, and the imagery it evokes of rattling and chapping doors, gives the impression of insistence and perhaps desperation to reach the client. There is a sense of determination to “fix” the situation.This is mirrored in Morgan’s account, as they state “you need to keep goading” mothers to attend meetings. The languages used portrays an image that the mothers are reluctant and are being driven to engage by the participants. This is further highlighted by Alex:“myself and a few of my colleagues will physically go and pick people up and take them places just the first time.”In this account Alex uses a figure of speech, of picking someone up, and it conveys an impression of unwillingness and a certain lack of autonomy.


#### 3.1.3. Conflict with the Wider System: “We Are Not Compatible with Them”

When describing their relationships with the wider system, the participants give the impression of tension, and describe an incongruence between how they work with the mothers, and how other teams and services, such as social work, do:“I think after the child’s removal that they (the mothers) expect us to drop them the way social work drop them”Alex’s view that mothers are “dropped” is emotive and powerful, and highlights a contrast. This image also juxtaposes with the earlier description of when they will “physically…pick (mothers) up.” Morgan offered an insight into the incompatibility with other teams and services:“…although we are completely integrated with our social work colleagues, we are not compatible with them”Morgan’s account of being integrated but not compatible suggests friction, and they describe a “conflict of thought processes.” The word “conflict” is repeated a number of times when describing working with the wider system. Their account also highlights tension within the relationship with their own management:“you are directed…to do something completely alien…our clients will say sometimes that we don’t listen to them, that’s the times when we feel like managers don’t listen to us….”In this account, Morgan is describing frustration with how they are being “directed.” The description suggests a parallel process, as they relate this back to times when clients are frustrated with them. The description also conveys powerlessness and reluctance. Their account illustrates that they have built a relationship and know what will not work for their clients; “you know it’s never going to work, but you are directed.” This is echoed by Ainsley:“are we setting, are they setting them up to fail…quite possibly they are, aye”Importantly, Ainsley shifts from using “we” to “they,” which suggests a separation between her team and the wider system. The use of “setting them up” suggests a perception of an inevitability of failure, and, like Morgan’s account, this implies a sense of powerlessness and a flawed system.However, the relationship with the wider system is not solely described negatively. There is an impression of participants trying to be balanced and not too critical, as they highlight that their social work colleagues have “really big caseloads” (Taylor) and “a very challenging job” (Alex).However, there is tension even when they are trying to be balanced, as they go on to describe their view of their role following removal:“when the child is removed it is literally like “right that’s it,” erm the parent is kind of dropped”Alex’s account highlights the tension between trying to be balanced in their view of colleagues and the frustrations they feel on behalf of their clients.


### 3.2. Emotional Experiences and Attempts to Resolve This

Across interviews, participants illustrated the lasting emotional impact of working with mothers who have had their children removed. There is a sense from their accounts of trying to strike a balance between gaining experience and managing the distress, but not becoming desensitised. Their accounts suggest an emotional complexity to the role and the ongoing blurred boundaries.


#### 3.2.1. Emotional Impact and Empathy: “My World Would Be Destroyed If Anybody Took My Children”

Participants reflected on their experience of the removal process and how they coped with this “harrowing” (Robin) experience. Across interviews, participants illustrated the challenging and emotional impact of the role:“The distress it causes the parents and the distress it causes the child, it was quite hard to live wi’ for me”Robin’s account of the experience as hard to live with might imply a sense of guilt. There is an impression of a lasting impact: “afew that stand out in my mind because of the distress,” and the account describes how the impact “stays with us all.” It is likened to “baggage,” which conveys being saddled with something heavy. Their account suggests that certain memories are “stuck,” which is further emphasised:“it was really upsetting… it was absolutely heart-breaking, it was heart-breaking… sorry, I am getting emotional because I still remember it”Importantly, they apologised to the interviewer, which suggests discomfort over becoming emotional. The idea of staff being emotionally impacted is also highlighted by Ainsley when asked about training needs:“educate them around what’s gonnae happen, what the experiences, what they are maybe going to go through, the trauma”The use of “trauma” to describe what staff go through is powerful, and Ainsley perceives that it “doesn’t get any easier.” The account suggests the inevitability of the emotional impact for staff and supports the idea of a long-lasting effect.In endeavouring to empathise with the clients, Sam describes imagining if they were in “their shoes.” This is further highlighted by Taylor:“it is just so traumatic for them… I try to put myself in that position and my world would be destroyed if anybody took my children”The imagery and emphasis of their world being “destroyed” is poignant, acknowledging their perception of the huge impact and totality of removal.Despite describing this level of empathy, participants all reported a need for training around how the mothers feel following removal:“we don’t think enough about it in a lot of ways, we don’t have enough training for us...about how these women feel”Sam offers an explanation for this perceived lack of understanding, “maybe we don’t even ask them enough.” This is reiterated by Robin: “we need to ask the parents.” From their accounts of the removal, it would seem that they do have an understanding of the emotional impact for their clients, yet the participants perceive that they need more training on this. This reinforces the idea of complexity in the role. There is a sense that they perceive a lack of mastery over the emotional aspect of their role and wish for something concrete, like training, to help them.


#### 3.2.2. Complexity within Attempts to Cope: “I Don’t Mean You Become Desensitised”

Across narratives, participants described their attempts to cope up with the emotional impact of their role. They convey tension between empathising with the mothers while also trying to maintain a professional role:“You toughen up, I am not saying I don’t think about my job when I go home, I do”Taylor appears quick to clarify that, despite becoming more inured to the job, empathy hasn’t been lost and they still care and think about their work. Robin similarly articulates tension in the role, describing a removal which was highly distressing and how they tried to manage this by saying to the mother, “let’s start thinking about the future.” They reflected on this pragmatic reaction to distress and described it as “avoidance,” rather than giving due space to the grief and distress. They further described their perception of the professional role:“I just wanted to absolutely break my heart. As a worker you cannae do that, you’ve to be the strong person for this person who is crumbling beside you.”The imagery of a client “crumbling beside you” conveys fragility, further emphasising the perceived pressure to be strong “as a worker.” These contrasting images emphasise the conflict between the instinctive reaction to the distress with a perceived obligation to uphold a professional front.This is reflected in Sam’s account, that over time they are “becoming hardened to it,” and in Alex’s reflections:“I really struggled with it, but I think as time has went on I can hold it as a more holistic picture and really will persevere with things now”The use of the word “persevere” suggests an endurance despite their discomfort. Their perception seems to be that by developing an ability to focus on the bigger picture rather than solely empathising with the mother, they are able to continue their work. This is supported by Robin’s account:“So I think probably you become more confident…, I don’t mean you become desensitised, that’s a risk… you can become desensitised because you see it constantly, but I think you learn from each experience”Robin’s account suggests that they recognise the risk of becoming desensitised by the frequency of child removal, while also recognising the positive aspects of exposure to it in terms of gaining knowledge and confidence. Again, there is a sense of tension or ambiguity in the role, the balancing act between becoming more experienced in dealing with removals and maintaining a sense of empathy for clients.


## 3.1. Complexity and Tension within Working Relationships

Across narratives, the participants convey the complexity of the role and describe how they navigate relationships, both with their clients and with the wider system. Their accounts illustrate tension between their professional role and their contribution towards potential child removal, wanting to show empathy and alliance with the mothers. Their accounts suggest an ambiguity at times over where they position themselves and their professional identity.


### 3.1.1. Duality of Role: “I Felt Like I Was Really Part of That Child Being Removed”

Participants explained how the nature of their role means that they provide support but will also give evidence at child protection and social work meetings regarding their clients’ substance use and ability to care for their children. Alex described that their work with the mothers can be “kind of seen as punitive…you try and balance that.” Alex describes an attempt to balance it by being “transparent,” which suggests an awareness and a proactive attempt to mitigate the perceived harshness.A perceived scrutiny is also described by Sam, who feels that during child protection meetings: “all eyes are on you.” Alex highlights that not only can staff fall into opposing roles of supportive and punitive, but that they perceive that staff and clients can find themselves in conflicting roles:“I am like a detective, because it is trying to catch them out, which doesn’t feel nice either… sometimes it feels like a bit of a cat-and-mouse game with them”Alex uses vivid language to describe their position, with the imagery of a hunt. The description conveys the opposing roles of cat/mouse or detective/criminal and suggests an uneasiness with this role; it “doesn’t feel nice” to play the role of pursuer.The challenge of being part of a system in which women lose “complete care of their children” whilst trying to engage them in clinical work is illustrated by Morgan. They describe a tension between providing information that could be viewed as detrimental to the mothers, whilst also engaging them in therapeutic work. They articulate the difficulty of maintaining trust and effective working relationships when they perceive that the mothers may feel they have done the “biggest…the worst” thing.The participants highlight a potential breakdown in the working relationship following removal and the challenge of trying to support mothers when they are “very angry” (Sam) and “the relationships could be volatile” (Ainsley). Sam’s account furthers this by alluding to how it feels to be part of the removal process, which can feel like a “betrayal.”Alex articulated the sense of responsibility and guilt they felt:“I will never forget the first case…I felt really guilty because I’d this good relationship with this client erm and then I felt like I was really part of that child being removed…”Alex’s repetition of “really” emphasises the strength of the guilt they felt. Their account conveys the powerful and lasting impact the experience had on them. They also highlight the shift in the relationship by providing the contrast, “I’d this good relationship….”


### 3.1.2. Response to Removal: “Become an Absolute Pest, You Know … a Good Pest”

The participants describe their behaviour following a removal. Taylor highlights how they have perceived a sense of blame for the removal and how they attempt to manage this:“…you need to keep a relationship going with that person, who is totally traumatised. Sometimes you get blamed, however, if you persevere with that person… I always say “so what are we going to do about this?”… to include myself in that overall picture.”It appears from their account that their response to getting blamed is to go into a collaborative, problem-solving mode. Their narrative highlights further complexity in their role, being both part of the problem and then part of the solution.Across accounts, their descriptions convey an impression of pushing towards the mothers and a tension between respecting the mothers’ autonomy whilst striving proactively to help them. This is illustrated by Taylor:“…[I’ll] be up rattling their doors, you know become an absolute pest, you know …a good pest, you know you go up chapping their doors, shouting through their letterbox, “… we can fix this””The description is vivid, and the imagery it evokes of rattling and chapping doors, gives the impression of insistence and perhaps desperation to reach the client. There is a sense of determination to “fix” the situation.This is mirrored in Morgan’s account, as they state “you need to keep goading” mothers to attend meetings. The languages used portrays an image that the mothers are reluctant and are being driven to engage by the participants. This is further highlighted by Alex:“myself and a few of my colleagues will physically go and pick people up and take them places just the first time.”In this account Alex uses a figure of speech, of picking someone up, and it conveys an impression of unwillingness and a certain lack of autonomy.


### 3.1.3. Conflict with the Wider System: “We Are Not Compatible with Them”

When describing their relationships with the wider system, the participants give the impression of tension, and describe an incongruence between how they work with the mothers, and how other teams and services, such as social work, do:“I think after the child’s removal that they (the mothers) expect us to drop them the way social work drop them”Alex’s view that mothers are “dropped” is emotive and powerful, and highlights a contrast. This image also juxtaposes with the earlier description of when they will “physically…pick (mothers) up.” Morgan offered an insight into the incompatibility with other teams and services:“…although we are completely integrated with our social work colleagues, we are not compatible with them”Morgan’s account of being integrated but not compatible suggests friction, and they describe a “conflict of thought processes.” The word “conflict” is repeated a number of times when describing working with the wider system. Their account also highlights tension within the relationship with their own management:“you are directed…to do something completely alien…our clients will say sometimes that we don’t listen to them, that’s the times when we feel like managers don’t listen to us….”In this account, Morgan is describing frustration with how they are being “directed.” The description suggests a parallel process, as they relate this back to times when clients are frustrated with them. The description also conveys powerlessness and reluctance. Their account illustrates that they have built a relationship and know what will not work for their clients; “you know it’s never going to work, but you are directed.” This is echoed by Ainsley:“are we setting, are they setting them up to fail…quite possibly they are, aye”Importantly, Ainsley shifts from using “we” to “they,” which suggests a separation between her team and the wider system. The use of “setting them up” suggests a perception of an inevitability of failure, and, like Morgan’s account, this implies a sense of powerlessness and a flawed system.However, the relationship with the wider system is not solely described negatively. There is an impression of participants trying to be balanced and not too critical, as they highlight that their social work colleagues have “really big caseloads” (Taylor) and “a very challenging job” (Alex).However, there is tension even when they are trying to be balanced, as they go on to describe their view of their role following removal:“when the child is removed it is literally like “right that’s it,” erm the parent is kind of dropped”Alex’s account highlights the tension between trying to be balanced in their view of colleagues and the frustrations they feel on behalf of their clients.


## 3.1.1. Duality of Role: “I Felt Like I Was Really Part of That Child Being Removed”

Participants explained how the nature of their role means that they provide support but will also give evidence at child protection and social work meetings regarding their clients’ substance use and ability to care for their children. Alex described that their work with the mothers can be “kind of seen as punitive…you try and balance that.” Alex describes an attempt to balance it by being “transparent,” which suggests an awareness and a proactive attempt to mitigate the perceived harshness.A perceived scrutiny is also described by Sam, who feels that during child protection meetings: “all eyes are on you.” Alex highlights that not only can staff fall into opposing roles of supportive and punitive, but that they perceive that staff and clients can find themselves in conflicting roles:“I am like a detective, because it is trying to catch them out, which doesn’t feel nice either… sometimes it feels like a bit of a cat-and-mouse game with them”Alex uses vivid language to describe their position, with the imagery of a hunt. The description conveys the opposing roles of cat/mouse or detective/criminal and suggests an uneasiness with this role; it “doesn’t feel nice” to play the role of pursuer.The challenge of being part of a system in which women lose “complete care of their children” whilst trying to engage them in clinical work is illustrated by Morgan. They describe a tension between providing information that could be viewed as detrimental to the mothers, whilst also engaging them in therapeutic work. They articulate the difficulty of maintaining trust and effective working relationships when they perceive that the mothers may feel they have done the “biggest…the worst” thing.The participants highlight a potential breakdown in the working relationship following removal and the challenge of trying to support mothers when they are “very angry” (Sam) and “the relationships could be volatile” (Ainsley). Sam’s account furthers this by alluding to how it feels to be part of the removal process, which can feel like a “betrayal.”Alex articulated the sense of responsibility and guilt they felt:“I will never forget the first case…I felt really guilty because I’d this good relationship with this client erm and then I felt like I was really part of that child being removed…”Alex’s repetition of “really” emphasises the strength of the guilt they felt. Their account conveys the powerful and lasting impact the experience had on them. They also highlight the shift in the relationship by providing the contrast, “I’d this good relationship….”


## 3.1.2. Response to Removal: “Become an Absolute Pest, You Know … a Good Pest”

The participants describe their behaviour following a removal. Taylor highlights how they have perceived a sense of blame for the removal and how they attempt to manage this:“…you need to keep a relationship going with that person, who is totally traumatised. Sometimes you get blamed, however, if you persevere with that person… I always say “so what are we going to do about this?”… to include myself in that overall picture.”It appears from their account that their response to getting blamed is to go into a collaborative, problem-solving mode. Their narrative highlights further complexity in their role, being both part of the problem and then part of the solution.Across accounts, their descriptions convey an impression of pushing towards the mothers and a tension between respecting the mothers’ autonomy whilst striving proactively to help them. This is illustrated by Taylor:“…[I’ll] be up rattling their doors, you know become an absolute pest, you know …a good pest, you know you go up chapping their doors, shouting through their letterbox, “… we can fix this””The description is vivid, and the imagery it evokes of rattling and chapping doors, gives the impression of insistence and perhaps desperation to reach the client. There is a sense of determination to “fix” the situation.This is mirrored in Morgan’s account, as they state “you need to keep goading” mothers to attend meetings. The languages used portrays an image that the mothers are reluctant and are being driven to engage by the participants. This is further highlighted by Alex:“myself and a few of my colleagues will physically go and pick people up and take them places just the first time.”In this account Alex uses a figure of speech, of picking someone up, and it conveys an impression of unwillingness and a certain lack of autonomy.


## 3.1.3. Conflict with the Wider System: “We Are Not Compatible with Them”

When describing their relationships with the wider system, the participants give the impression of tension, and describe an incongruence between how they work with the mothers, and how other teams and services, such as social work, do:“I think after the child’s removal that they (the mothers) expect us to drop them the way social work drop them”Alex’s view that mothers are “dropped” is emotive and powerful, and highlights a contrast. This image also juxtaposes with the earlier description of when they will “physically…pick (mothers) up.” Morgan offered an insight into the incompatibility with other teams and services:“…although we are completely integrated with our social work colleagues, we are not compatible with them”Morgan’s account of being integrated but not compatible suggests friction, and they describe a “conflict of thought processes.” The word “conflict” is repeated a number of times when describing working with the wider system. Their account also highlights tension within the relationship with their own management:“you are directed…to do something completely alien…our clients will say sometimes that we don’t listen to them, that’s the times when we feel like managers don’t listen to us….”In this account, Morgan is describing frustration with how they are being “directed.” The description suggests a parallel process, as they relate this back to times when clients are frustrated with them. The description also conveys powerlessness and reluctance. Their account illustrates that they have built a relationship and know what will not work for their clients; “you know it’s never going to work, but you are directed.” This is echoed by Ainsley:“are we setting, are they setting them up to fail…quite possibly they are, aye”Importantly, Ainsley shifts from using “we” to “they,” which suggests a separation between her team and the wider system. The use of “setting them up” suggests a perception of an inevitability of failure, and, like Morgan’s account, this implies a sense of powerlessness and a flawed system.However, the relationship with the wider system is not solely described negatively. There is an impression of participants trying to be balanced and not too critical, as they highlight that their social work colleagues have “really big caseloads” (Taylor) and “a very challenging job” (Alex).However, there is tension even when they are trying to be balanced, as they go on to describe their view of their role following removal:“when the child is removed it is literally like “right that’s it,” erm the parent is kind of dropped”Alex’s account highlights the tension between trying to be balanced in their view of colleagues and the frustrations they feel on behalf of their clients.


## 3.2. Emotional Experiences and Attempts to Resolve This

Across interviews, participants illustrated the lasting emotional impact of working with mothers who have had their children removed. There is a sense from their accounts of trying to strike a balance between gaining experience and managing the distress, but not becoming desensitised. Their accounts suggest an emotional complexity to the role and the ongoing blurred boundaries.


### 3.2.1. Emotional Impact and Empathy: “My World Would Be Destroyed If Anybody Took My Children”

Participants reflected on their experience of the removal process and how they coped with this “harrowing” (Robin) experience. Across interviews, participants illustrated the challenging and emotional impact of the role:“The distress it causes the parents and the distress it causes the child, it was quite hard to live wi’ for me”Robin’s account of the experience as hard to live with might imply a sense of guilt. There is an impression of a lasting impact: “afew that stand out in my mind because of the distress,” and the account describes how the impact “stays with us all.” It is likened to “baggage,” which conveys being saddled with something heavy. Their account suggests that certain memories are “stuck,” which is further emphasised:“it was really upsetting… it was absolutely heart-breaking, it was heart-breaking… sorry, I am getting emotional because I still remember it”Importantly, they apologised to the interviewer, which suggests discomfort over becoming emotional. The idea of staff being emotionally impacted is also highlighted by Ainsley when asked about training needs:“educate them around what’s gonnae happen, what the experiences, what they are maybe going to go through, the trauma”The use of “trauma” to describe what staff go through is powerful, and Ainsley perceives that it “doesn’t get any easier.” The account suggests the inevitability of the emotional impact for staff and supports the idea of a long-lasting effect.In endeavouring to empathise with the clients, Sam describes imagining if they were in “their shoes.” This is further highlighted by Taylor:“it is just so traumatic for them… I try to put myself in that position and my world would be destroyed if anybody took my children”The imagery and emphasis of their world being “destroyed” is poignant, acknowledging their perception of the huge impact and totality of removal.Despite describing this level of empathy, participants all reported a need for training around how the mothers feel following removal:“we don’t think enough about it in a lot of ways, we don’t have enough training for us...about how these women feel”Sam offers an explanation for this perceived lack of understanding, “maybe we don’t even ask them enough.” This is reiterated by Robin: “we need to ask the parents.” From their accounts of the removal, it would seem that they do have an understanding of the emotional impact for their clients, yet the participants perceive that they need more training on this. This reinforces the idea of complexity in the role. There is a sense that they perceive a lack of mastery over the emotional aspect of their role and wish for something concrete, like training, to help them.


### 3.2.2. Complexity within Attempts to Cope: “I Don’t Mean You Become Desensitised”

Across narratives, participants described their attempts to cope up with the emotional impact of their role. They convey tension between empathising with the mothers while also trying to maintain a professional role:“You toughen up, I am not saying I don’t think about my job when I go home, I do”Taylor appears quick to clarify that, despite becoming more inured to the job, empathy hasn’t been lost and they still care and think about their work. Robin similarly articulates tension in the role, describing a removal which was highly distressing and how they tried to manage this by saying to the mother, “let’s start thinking about the future.” They reflected on this pragmatic reaction to distress and described it as “avoidance,” rather than giving due space to the grief and distress. They further described their perception of the professional role:“I just wanted to absolutely break my heart. As a worker you cannae do that, you’ve to be the strong person for this person who is crumbling beside you.”The imagery of a client “crumbling beside you” conveys fragility, further emphasising the perceived pressure to be strong “as a worker.” These contrasting images emphasise the conflict between the instinctive reaction to the distress with a perceived obligation to uphold a professional front.This is reflected in Sam’s account, that over time they are “becoming hardened to it,” and in Alex’s reflections:“I really struggled with it, but I think as time has went on I can hold it as a more holistic picture and really will persevere with things now”The use of the word “persevere” suggests an endurance despite their discomfort. Their perception seems to be that by developing an ability to focus on the bigger picture rather than solely empathising with the mother, they are able to continue their work. This is supported by Robin’s account:“So I think probably you become more confident…, I don’t mean you become desensitised, that’s a risk… you can become desensitised because you see it constantly, but I think you learn from each experience”Robin’s account suggests that they recognise the risk of becoming desensitised by the frequency of child removal, while also recognising the positive aspects of exposure to it in terms of gaining knowledge and confidence. Again, there is a sense of tension or ambiguity in the role, the balancing act between becoming more experienced in dealing with removals and maintaining a sense of empathy for clients.


## 3.2.1. Emotional Impact and Empathy: “My World Would Be Destroyed If Anybody Took My Children”

Participants reflected on their experience of the removal process and how they coped with this “harrowing” (Robin) experience. Across interviews, participants illustrated the challenging and emotional impact of the role:“The distress it causes the parents and the distress it causes the child, it was quite hard to live wi’ for me”Robin’s account of the experience as hard to live with might imply a sense of guilt. There is an impression of a lasting impact: “afew that stand out in my mind because of the distress,” and the account describes how the impact “stays with us all.” It is likened to “baggage,” which conveys being saddled with something heavy. Their account suggests that certain memories are “stuck,” which is further emphasised:“it was really upsetting… it was absolutely heart-breaking, it was heart-breaking… sorry, I am getting emotional because I still remember it”Importantly, they apologised to the interviewer, which suggests discomfort over becoming emotional. The idea of staff being emotionally impacted is also highlighted by Ainsley when asked about training needs:“educate them around what’s gonnae happen, what the experiences, what they are maybe going to go through, the trauma”The use of “trauma” to describe what staff go through is powerful, and Ainsley perceives that it “doesn’t get any easier.” The account suggests the inevitability of the emotional impact for staff and supports the idea of a long-lasting effect.In endeavouring to empathise with the clients, Sam describes imagining if they were in “their shoes.” This is further highlighted by Taylor:“it is just so traumatic for them… I try to put myself in that position and my world would be destroyed if anybody took my children”The imagery and emphasis of their world being “destroyed” is poignant, acknowledging their perception of the huge impact and totality of removal.Despite describing this level of empathy, participants all reported a need for training around how the mothers feel following removal:“we don’t think enough about it in a lot of ways, we don’t have enough training for us...about how these women feel”Sam offers an explanation for this perceived lack of understanding, “maybe we don’t even ask them enough.” This is reiterated by Robin: “we need to ask the parents.” From their accounts of the removal, it would seem that they do have an understanding of the emotional impact for their clients, yet the participants perceive that they need more training on this. This reinforces the idea of complexity in the role. There is a sense that they perceive a lack of mastery over the emotional aspect of their role and wish for something concrete, like training, to help them.


## 3.2.2. Complexity within Attempts to Cope: “I Don’t Mean You Become Desensitised”

Across narratives, participants described their attempts to cope up with the emotional impact of their role. They convey tension between empathising with the mothers while also trying to maintain a professional role:“You toughen up, I am not saying I don’t think about my job when I go home, I do”Taylor appears quick to clarify that, despite becoming more inured to the job, empathy hasn’t been lost and they still care and think about their work. Robin similarly articulates tension in the role, describing a removal which was highly distressing and how they tried to manage this by saying to the mother, “let’s start thinking about the future.” They reflected on this pragmatic reaction to distress and described it as “avoidance,” rather than giving due space to the grief and distress. They further described their perception of the professional role:“I just wanted to absolutely break my heart. As a worker you cannae do that, you’ve to be the strong person for this person who is crumbling beside you.”The imagery of a client “crumbling beside you” conveys fragility, further emphasising the perceived pressure to be strong “as a worker.” These contrasting images emphasise the conflict between the instinctive reaction to the distress with a perceived obligation to uphold a professional front.This is reflected in Sam’s account, that over time they are “becoming hardened to it,” and in Alex’s reflections:“I really struggled with it, but I think as time has went on I can hold it as a more holistic picture and really will persevere with things now”The use of the word “persevere” suggests an endurance despite their discomfort. Their perception seems to be that by developing an ability to focus on the bigger picture rather than solely empathising with the mother, they are able to continue their work. This is supported by Robin’s account:“So I think probably you become more confident…, I don’t mean you become desensitised, that’s a risk… you can become desensitised because you see it constantly, but I think you learn from each experience”Robin’s account suggests that they recognise the risk of becoming desensitised by the frequency of child removal, while also recognising the positive aspects of exposure to it in terms of gaining knowledge and confidence. Again, there is a sense of tension or ambiguity in the role, the balancing act between becoming more experienced in dealing with removals and maintaining a sense of empathy for clients.


## 4. Discussion

The study aimed to explore the experiences of Alcohol and Drug Recovery Service staff working with mothers who have had their children removed, how they make sense of the systems around them, and perceive their training needs. Two superordinate themes were developed: the complexity and tension within working relationships, and the emotional experiences of staff and their attempts to resolve them, while the themes are presented separately, they are interrelated, further highlighting the intricacy of the role.Through their accounts, participants expressed friction between being part of a system that is involved in child removal while also providing support for mothers. When describing working with the wider system, there was a sense of tension and frustration. Through their descriptions, it appears that participants responded to the discomfort of being part of removal process by becoming fervent in their role of supporter; actively pursuing the mothers to provide assistance. It would seem from the participants’ accounts that the process of removal is highly emotive for staff, with distressing cases leaving a long-term impression for them. This appeared to be particularly apparent for staff members who had children themselves. Participants offered explanations of how they attempt to cope with this and strike a balance between “toughening up” while still maintaining empathy for their clients.The findings build on previous research of mothers being traumatised by the removal of their child [11]. Not only do the staff reflect on the trauma of removal experienced by the mothers, but they describe finding it traumatic themselves. They conveyed a lasting emotional impact and guilt, which is consistent with research carried out by Whittaker et al. [17], and represent a burden of care for professionals working in this field. They described participants’ accounts of struggling with support and surveillance of these mothers, similar to the findings of this study about the duality of being part of the removal process while also providing support. Similarly, Wiig and colleagues [20] found that staff often felt conflicted between rescuing the child and supporting the adults. They also demonstrated the emotionally challenging and exhausting aspects of working with parents in these services.Whittaker et al. [17] highlighted ways in which participants described parents who misuse substances, including subthemes of: “dishonest, damaged, and inadequate.” Interestingly, in the present study, parents were not described in such ways. This may be due to how datasets were collected; the Whittaker et al. [17] study utilised a focus group, whereas the present study involved a one-to-one interview with the team psychologist.


### 4.1. Limitations

The interviews were carried out in one service in one health board in Scotland, resulting in a potential underrepresentation of other contexts. This means that the findings may not represent the experiences of practitioners in other areas. However, the analysis aimed to be transparent and contextualised so that readers could evaluate the level of transferability.Further participant information on age, ethnicity, socio-economic status, and parenthood was not recorded for this study. These elements are important to include as they would allow for a greater depth of interpretation and understanding in terms of potential power dynamics. Research has highlighted the barriers to participation of minority ethnic groups in qualitative research, such as stigma and a lack of cultural and religious sensitivity [33].The sample was made up of social care workers and addictions nurses, which impacts the homogeneity of the sample. However, there is commonality across all participants in terms of a shared experience of working in addiction services with mothers who have had their children removed. Interviews were carried out by a clinical psychologist embedded in the team (LR), which may have resulted in bias within the findings. Efforts were made to mitigate this, by the interviewer addressing concerns around confidentiality and explaining that no identifiable information will be made available to service managers. Analysis was carried out by a different member of the research team (SMF), with a credibility of analysis examined by a further team member (NW).Recruitment bias may have also occurred, and it is possible that those who took part may have had different experiences from those who chose not to. Staff members who were struggling in their role or were experiencing burnout may be less likely to take part, particularly as it involved speaking to someone in the team.


### 4.2. Clinical Implications

The analysis highlighted the ambiguity experienced and how participants attempted to make sense of their role and professional identity. These insights may allow services and wider members of the team, such as clinical psychologists and management, to better understand and provide support to staff members facing these challenges. The analysis suggests that participants feel a tension and incompatibility with members of the wider system, such as social work colleagues and management. This is an important finding as research has emphasised the magnitude of positive working relationships in order to provide effective care [12]. This highlights the need for services to examine the integration of health and social care further.A key area that was illustrated throughout the accounts was the perceived need for training. Interestingly, participants described a desire for training into the emotional impact for mothers who have had children removed, whilst also articulating their own empathy and understanding of this. They also highlighted a need for new staff embarking on this role to be better informed of the powerful and lasting emotional impact the role is likely to have on them. Managers should ensure that adequate supervision and support is provided, so that staff feel that they are valued and that their well-being is important.The findings of this study highlight the importance of using a trauma-informed approach. This can be done via guidance from agencies such as Substance Abuse and Mental Health Services Administration [34]. In Scotland, NHS Education for Scotland (NES) has developed a National Trauma Framework [35], which acknowledges the importance of increasing knowledge of trauma and psychological theory, developing formulations to enhance understanding, providing supervision, and providing guidance at the leadership level.The findings suggest that staff can struggle with the role, particularly in two areas: their relationships with mothers generally, and staff who are also parents experiencing possible issues around enmeshment and overidentification with the mothers they work with. It would be beneficial for them to have space to talk through this in regular reflective practice groups with a clinician who was independent from their line management and in protected time within their posts and job descriptions. This would allow for a safe space for them to reflect on their practice, the emotional impact of this work, and talk through any issues such as enmeshment.This research also illustrated the resilience and determination of the participants in this study. It is important that staff feel supported by management and are protected from burnout. Managers could monitor this is by using a validated measure such as the secondary traumatic stress scale (STSS) [36].


## 4.1. Limitations

The interviews were carried out in one service in one health board in Scotland, resulting in a potential underrepresentation of other contexts. This means that the findings may not represent the experiences of practitioners in other areas. However, the analysis aimed to be transparent and contextualised so that readers could evaluate the level of transferability.Further participant information on age, ethnicity, socio-economic status, and parenthood was not recorded for this study. These elements are important to include as they would allow for a greater depth of interpretation and understanding in terms of potential power dynamics. Research has highlighted the barriers to participation of minority ethnic groups in qualitative research, such as stigma and a lack of cultural and religious sensitivity [33].The sample was made up of social care workers and addictions nurses, which impacts the homogeneity of the sample. However, there is commonality across all participants in terms of a shared experience of working in addiction services with mothers who have had their children removed. Interviews were carried out by a clinical psychologist embedded in the team (LR), which may have resulted in bias within the findings. Efforts were made to mitigate this, by the interviewer addressing concerns around confidentiality and explaining that no identifiable information will be made available to service managers. Analysis was carried out by a different member of the research team (SMF), with a credibility of analysis examined by a further team member (NW).Recruitment bias may have also occurred, and it is possible that those who took part may have had different experiences from those who chose not to. Staff members who were struggling in their role or were experiencing burnout may be less likely to take part, particularly as it involved speaking to someone in the team.


## 4.2. Clinical Implications

The analysis highlighted the ambiguity experienced and how participants attempted to make sense of their role and professional identity. These insights may allow services and wider members of the team, such as clinical psychologists and management, to better understand and provide support to staff members facing these challenges. The analysis suggests that participants feel a tension and incompatibility with members of the wider system, such as social work colleagues and management. This is an important finding as research has emphasised the magnitude of positive working relationships in order to provide effective care [12]. This highlights the need for services to examine the integration of health and social care further.A key area that was illustrated throughout the accounts was the perceived need for training. Interestingly, participants described a desire for training into the emotional impact for mothers who have had children removed, whilst also articulating their own empathy and understanding of this. They also highlighted a need for new staff embarking on this role to be better informed of the powerful and lasting emotional impact the role is likely to have on them. Managers should ensure that adequate supervision and support is provided, so that staff feel that they are valued and that their well-being is important.The findings of this study highlight the importance of using a trauma-informed approach. This can be done via guidance from agencies such as Substance Abuse and Mental Health Services Administration [34]. In Scotland, NHS Education for Scotland (NES) has developed a National Trauma Framework [35], which acknowledges the importance of increasing knowledge of trauma and psychological theory, developing formulations to enhance understanding, providing supervision, and providing guidance at the leadership level.The findings suggest that staff can struggle with the role, particularly in two areas: their relationships with mothers generally, and staff who are also parents experiencing possible issues around enmeshment and overidentification with the mothers they work with. It would be beneficial for them to have space to talk through this in regular reflective practice groups with a clinician who was independent from their line management and in protected time within their posts and job descriptions. This would allow for a safe space for them to reflect on their practice, the emotional impact of this work, and talk through any issues such as enmeshment.This research also illustrated the resilience and determination of the participants in this study. It is important that staff feel supported by management and are protected from burnout. Managers could monitor this is by using a validated measure such as the secondary traumatic stress scale (STSS) [36].


## 5. Conclusion

This study investigated the experiences of staff members working in Alcohol and Drug Recovery Services with mothers who have had their children removed. Across their accounts, participants described the complexity and tension inherent in a role where they are both part of the removal process and the supportive system. Their narratives suggested a sense of determination to fix the situation following a removal and the challenges of working with other professionals with different priorities. Participants described the often-long-lasting emotional impact of the role and further complexity within their attempts to cope.



---

*Source: 2983040-2023-02-16.xml*