 I'd like to welcome everyone to our seventh seminar of the year. We have one more after today. I see that we have a great audience and with some very young members. Welcome to all of you. I'm very pleased to introduce Fiona Martin. Fiona is Assistant Professor in the Department of Sociology and Social and Geology here at Dalhousie University. She's cross-appointed to gender and women's studies. She has ideas from beings and a master's and a PhD from the University of Melbourne. She's a sociologist whose research focuses on women's substance abuse and on harm reduction services in Atlantic Canada. So those are general areas of hers and those topics come together in her specific focus of research right now, which is the politics of drug treatment for pregnant women and mothers. She's principal investigator on a three-year project which is on pregnant women's access to and experiences of methadone maintenance treatment in Nova Scotia and all of this brings her here before us today. Please join me in welcoming Fiona. Hi everyone and thank you very much for having me here today. So I'm going to start this talk just by giving you a bit of background on some roadblocks that I encountered when I was doing my research. What this talk will focus on is the findings of a study that I undertook several years ago on young pregnant women in the process of disengaging from injecting drug use. What was interesting is that my initial aim wasn't to explore disengagement per se. I actually set out to talk to more what are called socially integrated drug users who are actively using, who are also pregnant women and mothers. And not surprisingly I found it extremely difficult to recruit this population. I learned a couple of important lessons from the outset. One was that I was obviously using a flawed recruitment strategy that didn't adequately anticipate how unwilling active drug users who are also pregnant women and mothers would be to come forward and talk to an outsider, a university researcher, about their experiences. And I also realized how likely it would be for this population to either be engaged in drug treatment or to describe themselves as trying to stop, reduce or modify their injecting drug use. I draw your attention to these lessons learned because they tell us a lot about this topic. And I'd like to take a moment before describing the study and outlining its key findings to give you a bit of background which will help put the kinds of circumstances that the women that I was speaking to were experiencing into perspective. So first of all, it's important to realize that when we talk about drugs we're talking about a moral and legal category of substances. We can define drugs in technical terms as substances with psychoactive properties that have an effect on the operation of the central nervous system but this isn't usually what people mean when they talk about drugs. What people usually mean when they talk about drugs is a category of substances that are remarkable for their legal and moral status. Alcohol, for example, is not commonly considered a drug. Neither is caffeine, even though both are psychoactive substances that have an effect on the central nervous system. Fifty years ago, nicotine wasn't considered a drug. We don't consider someone who's using delotted, on prescription to treat pain, a drug user, but we would consider someone who's homeless using the same substance in the same quantities a drug user. The fact that we might increasingly consider a substance like delotted a drug rather than a medicine is precisely because of the fact that it's used by people who are homeless off prescription. That is that it's been diverted to illegal drug markets. So it's to the legal status of psychoactive substances or the perceived character of the people who use them that we most commonly refer when we talk about drugs. Correspondingly to study people who are using drugs is to explore how they interpret and experience the management of being identified as a group of people using a morally and legally sanctioned group of substances. Likewise, we can view addiction as a medical fact, a disease with a distinct etiology and symptomology. And from this view, addiction is a condition that pre-exists its discovery by medical science. However, this is to ignore how closely linked both popular and clinical understandings of addiction are to cultural notions of desirable and undesirable forms of behavior. Consider the normative or judgmental nature of terms like abuse, misuse or problematic substance use. These terms clearly imply that users are exceeding somehow standards of normal behavior and or their ethical responsibilities to themselves and others. This poses a particular problem for mothers in pregnant women. Becoming a mother in contemporary Euro-American societies and cultures comes with a powerful set of normative expectations that appear to have intensified over the last 50 years. Pregnancy is now regarded an at-risk state that requires constant intervention, surveillance and monitoring on the part of health professionals and the pregnant woman herself. Childhood similarly appears to be rife with risks to a child's safety, his emotional well-being, his long-term health and even his neurobiological development that only the devoted mother can protect against. These insights help to explain why so many women voluntarily seek out information and support to address their drug use during pregnancy. They also explain why so many women cite concern for their children as their primary reason for doing so. They also help to explain why pregnant women and mothers who continue to use drugs are so often labeled selfish, uncaring, irresponsible and neglectful of their children's needs regardless of their actual mothering practices. This is particularly so in the case of women from disadvantaged backgrounds. Whereas drinking alcohol or using other drugs during pregnancy and parenthood cuts across all social divisions, it's the societal disapproval and stigmatization of women for doing these things is disproportionately attached to poor and racialized women. Again, it's only certain drugs associated with certain drug users that is compatible with motherhood. We can think of a recent discussion around psychotropic drug use, the use of antidepressants during pregnancy as an example. Finally, it's important to recognize that the services and supports that are available to this population are extremely limited. Even though women's drug use became the object of public health research starting in the 1980s and has since become a kind of explosive topic or area of study in clinical and epidemiological research, evidence suggests that the supports offered in existing services and programs designed to meet the needs of this group are still extremely limited. For example, over the last 30 years, a number of hospital-based specialized maternity clinics have been established in major cities across Australia, New Zealand, North America, the UK and Europe. These services are designed to provide integrated care to chemically dependent pregnant women and they're often held up as examples of less punitive, more harm reduction focused approaches to this group. This is largely because pregnant women are given priority access to substitution treatments through these services, things like methadone, buprenorphine, and other drug treatment regimes. However, women who are unwilling or unable to become stable through the course of their pregnancies, who are homeless or who continue to use street drugs, for example, experience high degrees of surveillance and monitoring in these services and forms of coercion that can sometimes prevent them from attending or can make disclosing a need for more support something that they're unwilling to do. In short, because women's caregiving responsibilities are often called upon to justify the allocation of resources for this group, the structure and organization of drug treatment supports for pregnant women and mothers are often guided by a commitment to fetal and child health rather than maternal well-being. Certainly it's the case that while abstinence may no longer be a requirement of maintaining custody of children in many countries in the world, adhering to drug treatment regimes now is. Moreover, existing drug treatment services and programs, like many health services, are hampered by limited funding and by an individualistic approach to changing health behavior, which severely limits what they can and do accomplish in terms of improving drug-using women's health and well-being. So the women I interviewed for this study were not impervious to any of these normative and legal constraints. Not only was I unable to recruit many research participants who identified as actively using in virtually all cases the women that I spoke to explained why and how they were trying to stop, reduce or modify their injecting drug use. And I don't think that that fact was unrelated to all of the details that I've just outlined. So the focus of my research therefore became on how women interpreted and experienced this moment in their lives, disengaging from injecting drug use and becoming a mother. So for this I drew on a sociological approach to recovery. And I put recovery in quotation marks because I think it is a bit of a misnomer for the complexity and back and forth nature of this process. That's why I've opted to use the word disengagement instead. So from a sociological perspective, recovery is fundamentally dependent on a drug user or addict's social and personal identity undergoing change. It requires engaging in new relationships, new practices, new configurations of one's life. It's a less of a pharmacological process and more of a social one. From this perspective motherhood can be seen as a major motivating and facilitating role. In achieving a normative social identity. In fact, some scholars go so far as to say that being a mother is the most likely event that will empower a woman who uses drugs to abstain. This approach to recovery on the part of drug using women while recognizing the social dimensions of the experience I think overstates the simplicity of this process and doesn't actually acknowledge the complexity of identity transition. For example, pregnant women and mothers, even those who are in drug treatment are highly likely to experience ongoing stigmatization and social exclusion. Many women who have children who are on methadone maintenance treatment programs, for example, don't enjoy that experience because they perceive themselves, they perceive that others perceive them as kind of highly stigmatized methadone mothers, which acts as a kind of barrier to the identity transition that they're hoping to make. Becoming a mother and engaging in drug treatment on their own, in other words, can hardly be said to repair one's social identity. Further complicating matters is the fact that as Karen Hughes argues, to cease engaging in drug using living and identity practices is in a sense to cease to be oneself. She describes how active drug use brings into being a particular sense of self through one's engagement in routine, living and identity practices, such as using, scoring, coming up with money for drugs, etc. This is why Hughes argues recovery is such a complex process that often involves what she calls the inevitable pull of one's former sense of self. This research and other studies have more recently drawn attention to the fact that recovery invariably involves the loss of a familiar way of life and its pleasures that aren't easily forgotten or replaced. It also suggests that recovery can be a dynamic, circuitous process due to the plural, fragmentary and sometimes contradictory nature of identity. Another important consideration is the fact that drug use is a powerful, embodied experience, which a growing number of sociological studies have explored. Given Western cultural views of the self as a property of the mind, which many drug users draw attention to when they talk about their experiences of getting out of it, for example, means that the experience of using drugs, particularly intense experiences of using drugs like injecting and injecting drugs like heroin, can manifest as a powerful experience of becoming body. Others have considered how the embodied experience of drug use can be examined from a phenomenological perspective in terms of a drug user's sense of being in the world. So from this perspective, women drug users with children can have two competing embodied experiences of being in the world, existing with and for others and existing exclusively for the sake of the embodied self. Taken together sociological approaches to recovery draw our attention to the ways in which people come to know and experience themselves through their engagements and habits, rituals and embodied practices and also through their interactions with others. They raise a number of questions, therefore, about women's experiences of drug treatment, disengagement and motherhood that haven't been very extensively explored in most treatment focused studies. Exploring disengagement in the lives of women with children from a sociological perspective as a complex experience of living with and negotiating conflicting ways of being oneself might help to inform these existing approaches and could possibly also inspire others. So now I'll just move on to give you a few details about the study that the preceding findings are based on. So the study I undertook involved semi-structured, in-depth interviews with 21 young women who were pregnant and or mothers and had a significant history of injecting drug use as well as which was undertaken within the context of a larger ethnographic research project on young injecting drug users. The majority of participants were recruited through a specialist maternity clinic for women with substance use issues at the Royal Women's Hospital in Melbourne, Australia. Interviews were one-off, lasted between one and three hours, and were designed to elicit an induced and accompanied self-analysis on the part of participants. The young women that I spoke to were between 18 and 27 years old, and all but three had injected drugs within the last 12 months. Seven were pregnant with their first baby, six were pregnant with their second, and three were new mothers of young babies aged six months or younger. The remaining five women each had a child aged six months to two years. 18 of the research participants, so the vast majority, described themselves as attempting to disengage from injecting drug use at the time of our interview, although they were at very different stages of this process. It's to the accounts of these women that the remainder of this discussion will focus. And particularly, I will look at the accounts of pregnant women who were either pregnant or mothers of a first baby, aged six months or younger, many of whom had made their first real sustained attempt to engage in drug treatment. And then I'll turn to discussing the accounts of mothers of children who were slightly older, six months or older, who had either successfully disengaged from injecting drug use, or relapsed. Okay. I might just have a drink of water, but you can watch me too. So, through this section of the talk, I'm actually going to be putting up, hopefully, I'll be putting up quotes from interviews that I'm hoping that you'll be able to read while I'm speaking, and it won't be too distracting to be doing both things at the same time. If I am going too quickly or if I need to kind of reconfigure that plan, no, don't be shy. So, from early on in the study, several things became clear. First, all of the women who were in the process of disengaging from injecting drug use said that they were powerfully motivated by care and concern for their children. This was a particular focus in the interviews that I undertook with pregnant women and mothers of young babies. As a number of other studies have found, worry about the effects of drugs as well as losing custody of their children prompted many women in the study to stop or reduce their illicit drug use and approach drug treatment services. One of the most striking themes to emerge in my interviews with pregnant women and new mothers was the detailed way in which they spoke about having a moral and ethical responsibility to care for and protect their children. A duty they said would be impossible to fulfill while they maintained their drug habit. Some women talked about this conflict in practical terms, emphasizing their baby's physical dependence on others for care. For example, Lily, a new mother of a two-month-old baby girl explained her reasons for trying to stop using drugs in the following way. She made reference to the fact that she was a single mother and her daughter would have no one if she went back to using what she called full-on. Several women also talked about this conflict in emotional and relational terms. They imagined that if they continued to inject drugs, they'd be unable to be there for their babies or provide them with the kind of life that they deserved. The focus of these discussions was rarely on basic necessities on clothing, housing or feeding their children but rather making sure that their children as future people would be happy, experienced stability and feel loved. In some cases, women's own difficult histories or childhood seemed to inform this concern. And, for example, described her son as a new person in the world for whom she hoped to provide a good life compared to the crap life that she had had. Is that working? Are you able to read? Many women said that it was assuming this responsibility for the life of another person that was the primary incentive created to affect change in their own lives. Jasmine explained her reasons for deciding to continue with an unplanned pregnancy, for example, with reference to the idea that it would help her turn her life around. Alongside determination to do what was best for their babies, another important theme emerged in all women's accounts of disengagement but particularly those in the latter stages, that is, those who had a baby aged six months or older. Many of these women had not injected drugs for a significant period of time, but they nonetheless felt as though they didn't really belong in the normal world. For some, this was clearly due to ongoing stigmatization. 24 years old and six months pregnant with her second child, Leanne tried to give up heroin in her first pregnancy and it's not clear why she lost custody of her son but she described having her second baby with a new partner, the only person outside of her drug-using networks that she'd become close to as her last chance to get back what she had lost. Leanne saw her current circumstances as extremely precarious. This was despite the fact that she was avoiding her former drug-using associates as she called them and was engaging in new activities and relationships. And this seemed to be due in no small part to the very fact of being stigmatized. Leanne was stabilized on methadone maintenance treatment which she felt reproduced some of the same patterns of dependence that she'd experienced when she was a heroin user. It also increased her frustration at being able to live a normal lifestyle. She felt that because of this she was still fundamentally a junkie in the eyes of others. Nowhere was this more apparent than in her recent dealings with the Department of Human Services which is the state agency in Victoria, Australia responsible for child protection. She, in a very detailed way, described the way in which the image of herself that was mirrored back to her by Department of Human Services staff and professionals was as someone who could not be trusted and was not going to be able to cope. Becoming a mother and disengaging from injecting drug use also seemed to leave many women feeling socially isolated. With the exception of two who mentioned reconnecting with a close friend from their pre-drug using days most women's only significant adult relationships were with a partner or with a family member. Several felt somewhat cut off from the outside world as a result. Sarah, for example, contrasted her current domesticated existence with her old life when she went from one social thing to the next. She went on to describe having been stuck at home for a year since her son was born, not doing anything. This was exacerbated by the fact that she felt little connection to the older middle-class mothers she'd met at a local mothers group. In turn, Sarah also struggled to do without those aspects of her life that she denied herself in order to be a good mother and a good partner. This became clear when she described losing touch with some of her old so-called drug-using friends. At the end of her interview, Sarah summarized that even though giving up drugs had changed her life for the better, she had yet to find herself in the process of making the transition between being a drug addict and being a mom. This account illustrated another important theme that emerged in interviews, which was women's ambivalence. Invariably at some point women in the process of disengagement would mention aspects of their old lives that were difficult to give up, replace or live without. Most hesitated noticeably before going into much detail here, but some did refer to things like the intensely pleasurable effects of injecting drugs, particularly heroin, which they also said were impossible to describe in words and could only be understood by someone who had been there. However, a number of women sort of tried to describe this for me. As one young mother Tamara explained, the feeling heroin gives you always stays in your mind, even if you never touch it again. Another young woman, Esther, a mother of a seven-month-old girl who had relapsed shortly before our interview, explained how good it felt to have a taste again. She admitted that she'd been thinking about it constantly ever since, and she said the very idea made her feel high, extremely. Am I going too fast? Some women said that the pleasures of injecting itself were the most difficult to give up or forget. Kay Lee, a 25-year-old pregnant woman and mother of a six-year-old girl, had recently begun to dabble with heroin again. She explained she could go without drugs themselves, but not the feeling and intensity of using a needle. She described the particular appeal of injecting as the way that she'd always used drugs, and she described it as seeing the needle go into your skin and pulling it, or they say jacking it back, watching the blood, and then knowing that you're pushing it in. She summarized this with the phrase, the feel of the steel. This account was corroborated by other women in the study who described sensations like tingling or aching in the places in their bodies where they used to inject drugs, even at the thought of doing so again. And for some this was accompanied by physical sensations like pleasure or excitement. Some of the new mothers I interviewed had only just recently stopped injecting drugs and were struggling to imagine life without the activities and routines that had previously sustained them. Lily, for example, disclosed that she was worried about having some of the same thoughts as she used to. As our interview progressed it became clear that Lily didn't miss any drug in particular, but addiction as an all-consuming way of life. Before moving on to the discussion I'd like to draw your attention to the fact that certainly not all women in this study talked about having ambivalent feelings about disengaging from injecting drug use. Several, in fact, expressed only disgust and contempt for their former lives. These women fell into two general categories. Those who had only recently stopped using and those who had not been injected drugs for significant length of time, but were still stigmatized and treated like junkies. Women in the former group, like Jackie, were more likely to talk about disengagement in black and white terms and to judge other drug-using mothers. Women in the latter group who felt that they were heavily stigmatized were more likely to renounce all aspects of their former lives, the drugs, their partners, their friends, even themselves. It was also notable that women who had relapsed did not necessarily condemn themselves or their actions and seemed to find ways to normalize their drug use, providing that they felt that their children were adequately cared for. For example, Kaylee described herself as a drug user, not an addict. She explained the key difference was her ability to keep her drug use to herself so that it didn't have an impact on her daughter. When I asked Kaylee what it had a bigger impact on her life using drugs or being a mother, she said that the path that she was taking through life was not straight, but it was of her own choosing. So the findings of this study clearly demonstrate or support the idea that disengaging from injecting drug use is made possible by disengaging from one's former drug-using networks and engaging in new activities and relationships or relational configurations such as the work of caring for children. Many women in this study clearly saw becoming a mother as a turning point that opened up the possibility for them to reinvent themselves and to turn their lives around. That said, it was also clear that being a mother and avoiding one's former drug-using networks were not on their own enough for these women to reinvent themselves. Some felt deeply discredited by their former lives as addicts or junkies. And for these women the ability to adopt a non-addict identity to see themselves as worthy and capable of being mothers required others' recognition, which was not always forthcoming. Leanne, for example, appeared to experience what criminal justice theorist John Braithwaite would call stigmatizing shaming. That is, the communication of disapproval in ways that are disrespectful and block access to acceptable social roles. Even though most women felt that becoming a mother had changed their lives for the better many also felt somewhat let down by this process. All of these women had cut off contact with old drug-using friends but few had any means to form non-drug-using relationships. They appeared, in other words, to have few bridging ties to people outside of their former drug-using networks. Those who did venture into the non-drug-using world felt that they needed to conceal their past in order to avoid being stigmatized. Most women were also single, stay-at-home mothers who did not have the qualifications or the resources that they needed to seek out meaningful work or education. So the day-to-day work of caring for a child paradoxically allowed for some aspects of the normal life that they hoped to find but prevented them from cultivating others namely working, studying, finding a partner and making new friends. This seemingly common experience of loneliness or social isolation has received relatively little attention in the treatment literature. Many women also felt keenly the loss of their former drug-using networks and their sense of which had changed their sense of belonging in the world. Sarah, for example, had successfully disengaged from injecting drug-use in part by virtue of her attachment to her child and her new partner and her sense of responsibility as a mother. But disengaging from injecting drug-use had left a void in her life in terms of the pleasures of going from one social thing to the next. Other women said that they'd never forget the feelings that drugs gave them and missed the thrill and intensity of using. Some felt lost without the everyday rhythms and routines of maintaining a drug habit which, as Lily suggested, can give structure and meaning to one's life. Each of these findings seems to reinforce Hughes' argument that drug-taking practices and relationships are in and of themselves constitutive of particular identities and ways of being oneself that people carry with them even in the process of making a transition to a non-drug-using identity. An interesting theme to emerge in these accounts was the particular significance of injecting as a sensorial embodied experience. Several women claimed to crave the intensity of the feel of the steel. Some would suggest that this is clearly the expression of operant conditioning. That is, when the pleasurable effects of the drug become associated with injecting, and therefore this act becomes the desired psychopharmacological fix. However, if we accept a view that injecting involves crossing bodily boundaries and symbolic boundaries, boundaries between one way of being in the world in relation to the other and another way of being in the world in relation to one's physicality, it's possible that the feel of the steel also engages the injector in embodied living and identity practices in familiar ways of being and experiencing herself. More research is needed to explore whether this is a common experience or not, but it's possible that injecting as a uniquely embodied practice of the self might be particularly difficult to forget. Interestingly, very few women were comfortable discussing or exploring their ambivalence, the pull of their previous drug-using living and identity practices. They were much more likely to engage in what appeared to be negative contexting, that is, frequently reminding themselves of how awful life on drugs had been, what a bad person they were when they were a drug user, etc. Many women also reaffirmed that they could not, would not, ever allow themselves to become the archetypal junkie mum. This in particular appeared to motivate several women at the earlier stages of disengagement, but at the same time renouncing the junkie, limited women's ability to discuss the pleasures or sense of being in the world that their former drug-using living and identity practices had provided. This in turn seemed to make it difficult for them to integrate their past and their previous, their past previous selves with who they were now and who they were going to become. So in this study exploring mothers' accounts of disengaging from injecting drug use revealed that the transformation of personal identity is complex indeed. The women interviewed struggled to disentangle themselves from their previous addict identities and this was a struggle that was complicated by their ongoing stigmatization and because of their limited ability to lead normal lives. For many, disengaging from injecting drug use also meant disengaging from practices and relationships that were once integral to who they were. Some were ambivalent about this process despite their care and their concern for their children. They felt that who they were had somehow been lost in the process of migrating between being an addict and being a mother. These findings could help to explain things like the relatively high rates of postpartum relapse among this group. If women who attempt to stop or reduce their drug use in pregnancy are also engaged in an attempt to restore their discredited social identities their success or failure will depend on more than whether they have access to effective drug treatment however. It will also depend on whether they have the non-judgmental support of others and the recognition that they are effectively making a transition into a new identity. Specialized drug treatment services for pregnant women and mothers could potentially provide some of these supports by helping women to establish bridging ties to non-drug using networks and relationships and by making an active effort to avoid stigmatizing women. And yet, even with these kinds of supports, some mother's sense of self and belonging will remain closely entangled with drug using living and identity practices. Indeed, feeling the embodied pull of these practices is seems to be an unavoidable part of recovery even for women with children. This group however is likely to perceive their ambivalent feelings as particularly threatening. They're much less likely to explore or discuss them with others as a result for they have a great deal at stake in making a quote-unquote successful recovery. It seems all the more important therefore to help them find ways to accept and come to terms with ambivalence and not just overcome it. Doing so might also help to mitigate women's fears of being judged by health and welfare professionals which has been found consistently to be a significant barrier to care. Likewise, perhaps we also need to develop a broader continuum of services and programs that would benefit women who use drugs and their children. As others have argued, not all women view their addictions in ways that correspond with drug treatment modalities or ideologies. They don't always see their addictions as fundamentally morally or physically damaging. Indeed, several women in this study were neither ready nor willing to stop using entirely even though they very much wanted what was best for their children. Rather than direct energy and resources toward achieving abstinence or preventing relapse, services and programs might be more likely to engage and support such women if they focused on helping them address the points of tension between their drug use and their parenting. Research on the various formal and informal strategies that women who are active drug users use to prevent harm coming to their children could provide a very helpful starting point in women's initiatives. Finally, there is widespread recognition that we need to improve women's access to and experiences of drug treatment. But perhaps it's also to take more seriously how broader social contexts, the moral and legal regulations surrounding drug use, for example, or the fact that those who suffer the most damaging effects of drug use come from impoverished and disadvantaged backgrounds needs to be made central to the project of rethinking drug treatment. Thank you. Questions? That's a good question. Yes and no. I think it depends on where in Canada you're talking about, because I think actually one of the... Canada and Australia in terms of best practices in drug treatment settings are very similar. But the largest divides in that... bearing that in mind then, the largest divides would be, for example, between sort of resource poor and resource rich areas. So if I undertook this study in say Toronto or Vancouver I'm not sure that things would have looked that different except the fact that there are sort of different forms of social exclusion and stuff that play out in those cities that are different to Melbourne. But I think the real difference will be what I see carrying out this kind of research in Nova Scotia where there just seems to be a real lack of support for or resources for a kind of systematic establishment of drug treatment for this group. And I imagine that likewise if I'd done the research in a rural area of Australia I would have confronted different circumstances. Just wondering if you've done any research or you know of any research sort of just thinking of sort of what's going on in the states where women are being jailed and prosecuted for behaviorism and pregnancy. So if you see this sort of breakfast on the fetus and the sigmatization and surveillance of pregnant women do you see that leading to criminalization or pre apprehensions or anything? In Canada? Well as you most of you know a fetus has no legal right of personhood in Canada nor in Australia so that's the reason why apprehensions don't happen when women are pregnant. I can only sort of speak to how service providers would sort of get around that sometimes in Australia which was for example if a woman had an older child they could make a child protection notification on behalf of that older child they would actually talk about it in those terms like how to kind of work with the constraints that they were facing in terms of when and how they could make a child protection notification so I don't see in Canada unless that law changes are going to be apprehended for using drugs in pregnancy they can't be legally but they are if they have older children quite often Yeah right away after birth Yeah Yes So there's that interesting comment around the engagement that the person had with the authorities of are you okay or are you going to relapse and so I wondered what other kind of pressure points do you have inside of the system through which women are required to seek care that might lead to what we would call performance you know that you need to act a role you have to have this confessional quality of denouncing your former self and seeking to rebirth which of course has strong religious connotations which are deeply embedded you know in a lot of drug treatment programs kind of spend that line so I wondered if you saw systematic qualities that generate these kind of responses I did for sure that's sort of who talks about the script that women have to use to mobilize resources to also navigate the system and that script is very much one they learn very quickly what they're expected to say and think and feel about their experiences and increasingly you know this includes a kind of rationalization of one's drug use in response to a logic of having been really abused and so this script is something I think women learn but I don't think it's always the case that there's this kind of distance between the self that's presented and a sort of social and personal identity many women come to kind of see and understand their own experiences through those scripts which are both helpful in some senses and I think kind of damaging and limiting in others for example if your drug use was just a kind of flawed strategy to deal with psychic pain then that means that you sort of got to kind of cut out or cut out this entire part of your life because it was a misguided strategy it was a flawed attempt rather than acknowledge the things that that might have brought you at a particular point in time um so there is a very clear and very very dominant and quite homogenous script I think that people women learn that they have to adopt and they have to speak when engaging with services especially if they had a kind of long history of involvement with health and welfare system whether they were themselves wards of the state for example as children and there's an interesting tension for me in doing this research because a lot of sociological studies in this field now adopt this kind of narrative analysis to drug users accounts they look at the scripts that researchers are given as you know they imagine that researchers are sort of perceived as a kind of extension of health and welfare services that drug users are performing a kind of social self for researchers as well as for health and welfare providers and while I do think that that did shape what women had to tell me in for some reason I feel like at certain moments or points they were actually quite honest with me about their experiences these moments when feelings of ambivalence would kind of bubble up and there would be very like spontaneous and unique and creative ways of describing what it was that they missed what it was that they were struggling to do without so I didn't want to kind of shut that down by drawing on a narrative approach entirely but I could talk more to your question after maybe yes many women's experiences can become mothers just anecdotally you know whatever your identity was before often it gets changed and a lot of that can be vital how useful thinking is to sort of control for those common features versus take advantage of it in designing treatment plans so to say okay all of them it goes through this identity transformation so we won't incorporate that into the treatment plan or should that be utilized they do use it there's a sort of there's a kind of language that's actually often used in treatment focused studies which is about sort of it's a kind of really objectionable language I find about how to leverage for example women's concerns for their children to better engage them in services how to take advantage of the window of opportunity that pregnancy presents it's very much described in those terms but after that point there isn't very much attention given to what it actually means to become a mother or what it actually means to be pregnant on an experiential level the kinds of complicated and mixed feelings that you might have in you know suddenly having another person who you're responsible for and doing that with very few supports there isn't actually a lot of space I don't think dedicated to exploring those experiences in treatment settings it's more like pregnancy and motherhood are acknowledged as good moments to engage women in treatment but after that point generally speaking there isn't that much exploration of what those experiences are actually like just like there isn't in mainstream obstetric care you know you kind of go in you get checked you've got like maybe 10 minutes with your physician and then you're out again right yes yes yes thanks so much for that I was sitting here thinking about a story and I'll get around to a question but a little story I spent a period of time at the Dalhousie legal aid service and I had a client there who described she had gone into a shopping mall and left her 8 year old son with her then boyfriend in the car and came back to the car and the guy that was showing her son how to inject and it was just such a shocking dramatic incident to me that it burns in my mind and as you were talking I was thinking both about the role of children and family services in the background through all of this discussion and I think that the systems in Australia and Nova Scotia anyway are not too different in terms of the types of intervention when they happen unlike in New Zealand but anyway and the risk indicators that are used yes but what I was thinking about the reason I told that story was there was a partner in all of this and I noticed you did you mentioned in at least one that the woman had gone on to a new crowd or a new partner or new associations I wondered if you explicitly looked at that aspect of it and in particular about whether one's partner is a user or not and how strong that influence would be in these circumstances I didn't include it here but I did so one of the things that women did in addition to engaging in drug treatment is almost all of the women that I spoke to whose partners or the father of their babies were still using if they were still around but they were still using they left those partners and some women had partners who embarked on the journey with them they engaged in drug treatment also but this was more unusual either women were single mothers or they became single mothers because they left a drug using partner and what was interesting about this was that I mean not only were women sometimes conflicted about cutting someone out of their life who they loved and it was an important part of their life but it also meant that it was another barrier to the kind of normal family that they wanted to build that in order to to do what was best for their children to become normal mothers it also meant becoming single mothers so there weren't too many cases perhaps because of the particular moment in which I was talking to women which was you know at the sort of a period of time in which they were under intense scrutiny but also going through a kind of very substantial change there weren't too many women who there weren't any women who had partners in their lives who were still injecting drug users my question is how do you see the law or do you see the law as a helpful or therapy agent for overcoming any of the challenges you mentioned today that is a great question I wish I knew that I'd actually be very happy to hear from members of the audience what they think I'm sure you would do a much better job of answering that question than I would you know other than child protection mandatory reporting requirements you know those those are the sort of most those are the kind of I guess legal regulations that have the most direct impact on this population but you know ending prohibition might be a good thing you know there's a kind of misconception that I was trying to kind of draw attention to in the introduction and I'm not sure if I did it all that well that the harms caused by drugs are you know they're it's a result of their pharmacological properties and that's often a justification usually a huge justification for making substances illegal right I noticed you know that for example methamphetamine has been moved from a schedule three drug to a schedule one drug I was moved I think in 2010 in the control drugs and substances act and there's no question that the broader context of a kind of moral panic around crystal meth informed that they would move but the result and the outcome is almost always making the lives of people who use that substance a lot more chaotic a lot more difficult a lot more dangerous making it likely that they will be arrest arrested charged and imprisoned for using the drugs so the laws around substances and you know there's been quite a lot of research done on this but you know I think you could quite easily argue are doing a lot more harm than they're doing good so that would be another very general armchair pie in the sky answered your question yes I don't know the full range of programs and services that are being offered to this group I do know that you know some of the most progressive community based programs and services in Canada are still very much hampered by limited resources by the kinds of constraints that they have to meet to get ongoing funding how they have to kind of describe the work that they're doing and the potential outcomes that they're going to be able to achieve through that work which which does mean that the supports offered in even the best most community based programs are going to be very individualizing and individualistic sort of focusing on improving health behaviors you know encouraging women to make better choices certainly we don't require women to be completely abstinent when they're pregnant or mothers to maintain custody of their children but we do require them in a pretty coercive and invasive way to adhere to treatment regimes which don't always work for everyone and so to answer your question I think a more genuinely harm reduction approach to this population would be helpful focusing for example on not just minimizing the harms associated with using substances but minimizing the harms associated with using substances while you're responsible for caring for children so being able to have open conversations with women about if they're going to use is there someone around who can look after their kid you know what's the situation like in their house how are they doing for money you know I mean harm reduction has been implemented also in very individualizing and individualistic ways but we haven't even gotten to the point that mainstream populations have gotten to for pregnant women and mothers because there's this absolute kind of barrier stop stopping point which is their responsibilities for their children yeah we'll just go around the social worker but I just wanted to add on to that speaking of therapy not keeping women in poverty yeah anger assistance so you know you get $535 a month rent where are you supposed to keep your children living in a positive environment that's what you have for rent 200 and something for personal how are you supposed to buy your children so we're keeping women in poverty and then we're apprehending them if there needs to be a law change or a policy change that would be a therapy and that's again so again it's like the potential chaoticness of women's lives or the harms that they're doing to their children is attributed to the drugs right that they're taking these drugs which mean they have no control over their behavior whereas if their circumstances were different and they were taking the drugs then their lives would look a whole lot less chaotic and would be a whole lot less chaotic so I agree with you oh sorry I'm going to finish briefly passing sort of that what are drugs in the sort of holistic what are the drugs we want to condemn which are the ones that are being used like SSRI's by women who are pregnant there's been shifts in a very different sort of population I'm wondering if there's a way to sort of capitalize on some of that in the population that you're working with and I was wondering if any of them noticed some of those shifts and noticed sort of the discrepancy or the topsy double standard discrepancy is pretty obvious but I think you're right to use the language I think you could leverage some of those arguments that are made in favor of keeping women on psychotropic medications during pregnancy the arguments made are almost always about the risks of her ceasing to use those drugs are far greater than the risk posed to the health of her fetus if she continues to use them right especially with SSRI's then it's the mental health of the woman that's referred to in that argument and you could I think if you were a savvy legal person make a case that the mental health of women who are using illicit drugs is just as likely to be compromised if they're forced into certain situations that aren't going to work for them vis-a-vis drug treatment or abstinence that this actually represents a huge risk to their health and well-being so I think there is actually some potential there that's been opened up by the sort of acknowledgement that substances can and do play a vital role in people's lives and sustaining health and normality that you could capitalize on to make an argument that the same goes for other populations yes I was wondering about following a little bit of a line of thought here how significant it has been to medicalize as a way of seeking positive intervention the worry that in doing that you move away from the socialized aspect of understanding understanding vulnerability and marginalization so far so I wonder in this context to speak of disengagement as in the interests of the child and I wondered about breaking that a little bit in the sense of disengagement from drug use not always being in the best interests of the child and how much of an appetite is there for that kind of thinking in drug treatment programs and as well as the idea of disengagement you cannot disengage from poverty which is likely the largest cause of child endangerment and so I wondered about using that language of engagement disengagement suggests again like the traditional individual action in this space which seems to color the whole way the interventions that follow that proceed I mean I think that medicalizing so say for example following up on the previous question if people were able to make an argument that for example a mother, a pregnant woman who's using say she's a street user of Dilaudid for example that getting her off that substance would compromise her mental health wouldn't be good for her and the risks of that would be greater than the risks that using the substance pose for her baby if we were able to make that kind of argument then you would have to make an argument about the way in which that substance actually addresses the mental health of the woman which would of course involve kind of sucking the complexity of the experience that's social, that's embodied that's you know for some people spiritual into this sort of medical argument I'm using this drug because I'm suffering emotionally and there will be consequences I mean this is sort of the political terrain that this field actually is that there are always consequences that are sometimes unforeseen of making those kinds of arguments and medicalization on one hand opens up avenues for treatment de-stigmatization it also sort of circumscribes the ways in which we can kind of understand people's experiences and I don't think I'm addressing the second part of your question but I might have to do that later I'm running out of steam and I think you are too I teach and I can always tell when people are like it's time to go now it's time I like you but I want to go well I think we better let Fiona sit down for a moment oh I meant you not me but well before I thank Fiona I want to make a couple of announcements one is that there's one more seminar this year which is on Friday March 27 it's Peter Tuwig of St. Mary's University speaking on the most suitable worker regulating nursing assistance in Canada 1945-1970 the Hope Law Institute is co-sponsoring the Canadian Centre for Ethics and Public Affairs and event later this month it's called Vaccination and there's a series of topics but it's summed up into what extension vaccines be mandatory looking both at childhood immunization and also at adult healthcare workers vaccination and this features Scott Halperin who's with the Canadian Centre for Vaccinology Bob Strang who's the Chief Public Health Officer for Nova Scotia Janet Hazelton President of the Nova Scotia Nurses Union and they give us an idea of a public law institute and so that's down at the Public Library March 23 from 7 to 8.30pm and I've printed off some posters I'll just leave a couple of piles of them in case you want to take the information because it's not on our regular poster schedule it's a separate event now I can't imagine how hard it would be to get research ethics approval for a project of this sort in Nova Scotia I don't know about it so it seems to me both the problems with how you go about this and what Fiona was mentioning at the start about how hard it was to actually get access to this population means that Fiona has done a lot of hard work and provided us with a very important window into a world that we don't often have access to so the work is extremely valuable and I hope that we'll have a lot more but in the Nova Scotia and Atlantic and Canadian context and it's a particular interest to me in that it's so we have a fair amount of work on injection drug use generally but once you layer on the pregnancy and the motherhood then you're also involving another life or potential life or life in this population and the analysis gets all the more complex as a result and I think you've gained an appreciation of that today and I really would ask you to join me in thanking Fiona for this wonderful presentation