Picking at her long nails, painted gold and black, Kayla Duggan speaks calmly as she recalls the darkest time in her life. It’s one familiar to thousands of women across the country.
Duggan tells her parenting counselors about the pain of catching only glimpses of her son growing up.
At age 3, Giovanni is now walking and talking, but a foster mother tucks him in at night.
Parenting for Duggan, as with thousands of other young mothers battling heroin addiction, has been reduced to a few hours in the park, when she grasps at small details and wonders: Why is her son wearing girls’ shorts? How did he get that bruise? What is Giovanni’s life like during those many hours and days when he is not with her?
"I'm missing the good stuff," said Duggan of Worcester, Massachusetts.
Fighting heroin is daunting for the estimated 435,000 Americans hooked by this epic addiction, but for women with children, seeking help forces some of them to make nearly impossible choices.
Like many who find that it takes multiple trips to rehab centers to beat their addictions, Duggan, 26, relapsed in her recovery program, and the state took her son into foster care.
Child welfare agents are considering putting Giovanni up for adoption if Duggan doesn’t agree to enter a residential treatment facility. But that would mean being away from her son for at least seven months, and probably longer. It also could leave her homeless, which would make it even harder to reclaim her son, even if she makes it through the program.
This is among the painful choices that many opiate-addicted women across the country wrestle with. Those who still have custody of their children find that in most cases, they can’t take their children with them to residential addiction treatment centers — even though that’s the kind of treatment that seems to work best for mothers with young children.
But kid-friendly centers are scarce. Across the country, there are 3,473 residential treatment centers, but just under 14 percent can accommodate mothers and their children, according to data from the Substance Abuse and Mental Health Services Administration, an arm of the U.S. Department of Health and Human Services created to reduce the effects of substance abuse and mental illness in America.
Even worse, the number of those centers dwindles each year.
In 1993, SAMHSA called the need for more treatment programs that accept women with their children "crystal clear." Today, as opiate addiction has become a national crisis, that advice still has not been heeded.
Centers that provide beds for moms and children struggle to keep funding, or they have weeks-long waiting lists. Drug-addicted moms fear that their children will be taken by social services.
With so few beds available, some moms just aren’t going for treatment. As a result, some land in prison and their kids end up in state care anyway.
When Brandi Shultz was arrested as a result of her heroin addiction, her son was able to stay with her family. But for other women, Shultz said, the problem is real. She's serving 4 ½ years at the Ohio Reformatory for Women near Columbus for drug trafficking.
"There should be a way for us as mothers to get our kids," said Shultz, 25. "It's either lose our kids or save our lives."
Making the choice
Sitting among Giovanni's toys in his old playroom, a room Kayla Duggan usually keeps sealed off, she talked about the struggle to fight and addiction and hold onto her child.
Compared to a decade ago, heroin use among women has increased by 100 percent, according to the Centers for Disease Control. With numbers on the rise, Dr. Kimberly Johnson, director of SAMHSA’s Center for Substance Abuse Treatment, said that drug treatment programs can’t keep up with need, particularly for women.
"Even though we are increasing the amount of services available, the need is increasing faster," Johnson said. "If a woman is seeking a gender-specific program, there is not that much availability to that."
Duggan had been down this path before. She gave up her first child for adoption. This time, though, Duggan is determined to be a parent to her son.
Duggan searched desperately for a program that would take in both her and Giovanni, similar to the one where she lived in 2012, and where she gave birth to her son.
Her search seemed futile. Either the waiting list was too long or her son was too old to go with her. Duggan's social worker suggested that she go to treatment alone, but that, Duggan said, could mean she'd never be reunited with her son.
Dr. Mark Libon, vice president of Behavioral Health Services at Dimock Community Health in Boston, said that going to treatment often benefits mothers, particularly in the eyes of the state.
"Typically, it's in their favor to be in treatment," Libon said. "The likelihood of reunification is higher if they were in a treatment."
That's why Duggan said the state wants her to complete a residential program without her son before they consider reuniting the pair.
If she went back to a program that allowed her and her son to be together, Duggan said, things would be different when she got out, but her social workers aren't convinced.
Department of Children and Family officials would not comment on Duggan's case.
While Libon said it's important not to separate mothers and children, the state took Giovanni from Duggan shortly after she left the program where she got sober with him. He was then returned to her again, but went back to state care after another relapse.
Medics found her in her apartment virtually dead, but they revived Duggan with the opioid antagonist Naloxone, a drug that reverses heroin overdoses. They took her to the hospital, where she recovered quickly.
Given her record with both drugs and the legal system, Duggan said her case workers aren’t sure she should have her child. But Duggan says that her son is about the only reason to stay sober. Without him, Duggan said, she wouldn’t have motivation.
Keeping families together
Motivation is exactly why Johnson said treatment that keeps mothers and children together works.
"Including children in a woman's treatment increases the probability that she will enter treatment and that she will stay in treatment once she enters it," Johnson said. "Staying in treatment is the single most important variable in reducing substance use."
In fact, the National Institutes of Health says that a handful of studies show that women who have their children in treatment are likely to stick with the program longer than women who don't.
One of these women is Elizabeth Celorier, who just completed a program with her nearly 1-year-old twins. At 15 months sober, Celorier graduated in July from the Serenity House in Hopkinton, Massachusetts. At the time, Celorier said she was well on her way to regaining custody of her kids, who lived with her but technically were under state care. It's all thanks to attending treatment with them, she said.
"Being a mom is hard enough. Being a mom in recovery is that much harder, and I don't think people understand that," said Celorier, 38. "Women need to feel like they're not being punished; that they're not being looked down upon. That we're still a person."
That's what the Serenity House offered her. Johnson said that's because having children in treatment allows women to access a new level of care, focused both on staying sober and being a mom.
"I think having child care available, and when women actually need a residential level of care, having their children be able to live with them allows another level of treatment," Johnson said.
Fabiola Powell, the Serenity House's clinical coordinator for pregnant and postpartum women, said the key to her program is that dual level of care.
"I think for a resident who comes into our program with an infant, they have to learn not only how to be in recovery, but also balance the responsibility of being a parent at the same time," she said.
The Serenity House has 30 beds for women and four slots for children up to 5 months old. Like most other residential programs, Powell said the Serenity House follows a highly structured schedule each day.
At these programs, women go to group meetings, such as Alcoholics and Narcotics Anonymous, parenting classes, doctor appointments for themselves and their children, and therapy — both individually and in groups. Women are responsible for daily chores and other duties.
This structure, said Michelle Farmer, a clinical supervisor at the program, reflects their future.
"We're trying to teach them here, with the support of community members and counselors, what life would look like on the outside, but with more therapeutic supports in place," Farmer said. "It reflects outside life as well."
Women typically stay in residential programs anywhere from six to 12 months, according to SAMHSA.
For Nitika Rose, 44, a program for women and children in Worcester that is now closed taught her the lesson Powell outlined.
"The program was really good. You have to take care of you, and you still have to take care of your four kids," Rose, of Boston, said of the mother-and-child program she attended in 2005. She is currently back in treatment without her children at My Sister’s House, a treatment program run by Dimock Community Health in Boston. "I got my kids. I'm going to be safe."
When women can't access those programs, though, Rose said they just don't get treatment.
"Women don't want to come into programs just for that simple fact. Who's going to watch their children?" Rose said, shaking her head. "Not everyone has family or parents."
Treatment on the inside
With few options for child care in treatment, some women who avoid treatment altogether for fear of losing their children end up losing them anyway when the women land in prison.
According to the Bureau of Justice Statistics, women are the fastest growing population in prisons, increasing at an average rate of 3.4 percent each year since 2010. The Bureau’s most recent statistics show the rate at which women are imprisoned for drug offenses is higher than men, with one-quarter of all incarcerated women in prison for drug offenses, compared to 15 percent of men.
A majority of women in jails — 82 percent — have been or are dependent on drugs or alcohol, according to a new report from the Vera Institute of Justice’s Safety and Justice Challenge, a national organization focused on jail reform. Nearly the same amount — 79 percent — of women in jails are mothers.
Gary Mohr, director of Ohio's Department of Rehabilitation and Correction, said those numbers likely wouldn't be so high if there were more treatment available to women and mothers in the community.
Mohr has seen this trend firsthand. When he started as a prison warden in Ohio in 1974, there were 297 women in the state’s prisons, he said. By August, the female prison population in Ohio approached 4,300.
"By far, the most common offense women come to prison for is fifth-degree drug possession," Mohr said. "It is clear to me that we are over-incarcerating, especially women. The conclusion is that treating non-violent, addicted women in a community setting is twice as effective at one-third the cost (of incarceration)."
Given the increase in drug-addicted women in prison, Mohr said it makes sense to provide treatment inside prison walls.
At the Ohio Reformatory for Women in Marysville, the Tapestry Treatment program provides women with a therapeutic community for recovery, separate from the main dorms in the prison. There, women focus on starting a substance-free life behind prison walls that can transition with them into the community.
On a recent Thursday, the women sat in auditorium-like rows, listening quietly to a woman recounting her story of addiction. She spilled the dark details of her past.
On the walls, images to inspire strength and perseverance were painted in bright, primary colors: "I am a survivor." "My determination outweighs my situation." Painted sunflowers with pictures of children inside them give the women hope as they navigate their Alcoholics and Narcotics Anonymous meetings and skills training groups.
The unit is a way, Warden Roni Burkes said, for inmates to recover from both their addictions and the lifestyles that landed them in prison. The goal, she said, is to return them to society as better people than they came in.
"Our job is not to punish them. Their punishment is their sentence," Burkes said. "They have and deserve an opportunity to change their lives."
Numbers show that the prison might be achieving that goal. Women who complete the Tapestry program are less likely to return to prison within a three-year span, the prison's records show.
For Brandi Shultz, who posited on the choice between losing your kids or your life, the program is giving her time to heal from her heroin addiction before she returns to parenting her son. Treatment in prison is giving her a third choice, she said.
"The main thing I struggle with is guilt from being away from my son. It's easier for me to feel it and heal it in here," Shultz said. "He's my No. 1 main priority.”
Closing the doors
As Kayla Duggan hunted and hoped for a treatment program that she and Giovanni could attend together, dialing the numbers of every counselor and program director she could find, she couldn't call up the numbers familiar to her. The program she attended in 2012 is now shuttered.
"We need more of those programs," Libon said. "It's much more comprehensive than having these women alone."
In Massachusetts, the governor has made opioid treatment and prevention a priority. In the fiscal year 2017 budget, Gov. Charlie Baker dedicated $171 million to opioid prevention, 8 percent more than the prior year. The budget includes funding for 2,150 more residential treatment beds.
Of those beds, 685 are specifically for women. According to the Department of Public Health, some of those 685 beds could be in programs that allow pregnant or postpartum women, but that depends on licensing, having enough staff, and the demand.
With few programs for women with children, Libon said wait lists grow, and that means it's less likely that mothers like Duggan will get help.