Part 3: Beyond the Clinical—Mental Health, Trauma, and the Social Roots of Substance Use
Series: More Than One Life: Navigating Substance Use Disorder in Pregnancy
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🔄 A Brief Return: Where We’ve Been
It’s been a while since we’ve gathered in this space, and the world has shifted beneath our feet. For those just joining us—and for those who need a reminder of why this conversation matters—let’s revisit the ground we’ve covered.
In Part 1, we met Maria, whose story of navigating prescription opioid use during pregnancy revealed a hidden epidemic. We learned that 1 in 12 pregnant individuals use substances, yet fear and stigma keep most silent. We shattered myths—like the dangerous belief that medication-assisted treatment harms babies—and established a fundamental truth: substance use disorder isn’t a moral failing. It’s a medical condition that deserves compassionate, evidence-based care.
In Part 2, Amanda’s journey showed us what’s possible when clinical excellence meets radical compassion. We explored how diagnosis and treatment must center around dignity, not discipline. We learned that MAT—with buprenorphine or methadone—saves lives when embedded in comprehensive care. Most critically, we framed this work through the lens of reproductive justice: the right to have children, not have children, and parent in safe, supportive environments.
Today, as we return to this series, the stakes have only grown higher. We’re living through a moment where empathy is now seen as a radical left concept—where cruelty is increasingly embraced as strength, and compassion dismissed as weakness. We’ve watched our society vote for leaders who wear cruelty as a badge of honor, who model contempt for the vulnerable as a form of leadership. When those in power actively promote punishment over support, when basic human compassion becomes politically partisan, the message trickles down into every institution—including healthcare.
In this cultural climate, pregnant individuals with substance use disorders face not just medical challenges, but a society that seems increasingly willing to abandon them. What does it mean for a pregnant person’s mental health when the world around them grows deliberately crueler? What happens to their anxiety when empathy is now seen as a radical left concept rather than a basic human value? How do we expect people to seek help when “help” increasingly looks like punishment?
This is the water we’re swimming in. And it’s precisely why Part 3 of this series matters now more than ever.
👤 Meeting Keisha: When Everything Intersects
Keisha sat in the clinic parking lot for twenty minutes before she could bring herself to walk inside. Seven months pregnant, she’d been managing her anxiety with a dangerous combination of prescribed benzodiazepines and unprescribed alcohol. She knew it couldn’t continue. But walking through those doors meant risking everything.
In our current political moment—where cruelty has been elevated to virtue—Keisha’s fear wasn’t paranoia. It was a survival instinct. She’d watched the news. She’d seen the rhetoric. She knew that in a culture that increasingly views suffering as deserved and compassion as enabling, her struggles would be weaponized against her.
What Keisha’s providers would eventually learn was that her substance use emerged from a web of interlocking challenges: untreated anxiety that began in childhood, domestic violence she’d witnessed and experienced, housing instability that left her constantly on edge, and a healthcare system that had repeatedly dismissed her mental health concerns as “drug-seeking behavior.”
But there was something else—something harder to name but impossible to ignore. Keisha was drowning in a culture that had turned its back on people like her. A culture that celebrates punishment over support, that frames poverty as personal failure, that views mental illness as weakness. Every day, she absorbed messages that she was less than human, undeserving of care, a burden on society.
“Is it any wonder she self-medicated? Is it any wonder she sat in that parking lot, terrified?”
📊 The Hidden Epidemic: When Mental Health and Substance Use Collide
Let’s be clear about what we’re facing. Among pregnant individuals with substance use disorders, approximately 70% have co-occurring mental health conditions. Yet fewer than 25% receive integrated treatment for both. In a society that increasingly embraces cruelty as policy, this isn’t just a treatment gap—it’s an abandonment.
The Numbers Tell a Story:
🔹 Depression affects up to 40% of pregnant individuals with SUD, compared to 10-15% in the general pregnant population. But depression isn’t just brain chemistry gone awry. It’s also a rational response to impossible circumstances—to a world that tells you you’re worthless, to systems that punish rather than support, to a culture that has replaced empathy with judgment.
🔹 Anxiety disorders affect nearly half of pregnant individuals with SUD. Many describe their initial substance use as self-medication—a desperate attempt to quiet racing thoughts in a world that feels increasingly hostile. When you’re living in a society that views your struggles as moral failures, when seeking help might mean losing your children, and when poverty is treated as a character flaw rather than a policy choice, anxiety isn’t a disorder. It’s a logical response.
🔹 PTSD appears in 30-60% of pregnant individuals with SUD—rates that mirror combat veterans. But unlike veterans, these individuals don’t receive thanks for their service in surviving poverty, racism, and violence. Instead, they receive contempt. Their trauma is dismissed, their coping mechanisms criminalized, and their attempts at survival pathologized.
⚠️ The Culture of Cruelty: How We Got Here
We need to name what’s happening. We’re living through a cultural moment where cruelty has been normalized, even celebrated. Where “personal responsibility” has become a cudgel to beat the vulnerable. Where empathy—once considered a basic human value—is now derided as weakness or “radical left” ideology.
This cultural shift doesn’t exist in a vacuum. It shapes policy. It influences medical practice. It determines who gets care and who gets punished.
Consider how this plays out for someone like Keisha:
In healthcare settings: Providers influenced by this cultural moment might see her substance use as a choice deserving punishment rather than a symptom deserving treatment.
In policy: Legislators embrace increasingly punitive measures—mandatory reporting, automatic child removal, criminal prosecution—framing them as “protecting children” while ignoring the trauma they inflict on families.
In communities: Neighbors and even family members absorb these messages, leading to isolation and shame precisely when support is most needed.
In media: Stories focus on “crack babies” and “addict mothers,” perpetuating stereotypes that make seeking help feel impossible.
“When a society chooses cruelty over compassion, it creates the very conditions that drive substance use. Then it punishes people for the predictable results of its own choices.”
🌊 Trauma’s Long Shadow: Understanding the Real Roots
The ACEs (Adverse Childhood Experiences) framework shows us that among pregnant individuals with SUD, most have experienced four or more adverse events before age 18. But in our current cultural moment, we need to expand this understanding.
We’re not just talking about individual trauma. We’re talking about:
Layers of Trauma:
💔 Systemic trauma: Living in a society that actively works against your survival. That strips away social safety nets. That treats healthcare as a privilege rather than a right. That criminalizes poverty and mental illness.
💔 Political trauma: Existing in a political climate that dehumanizes you. That debates your worth. That uses your struggles as talking points while refusing to provide actual support.
💔 Cultural trauma: Absorbing daily messages that you’re a burden, a failure, a problem to be solved rather than a person to be supported.
For Black and Indigenous communities, add the weight of historical and ongoing racial trauma. The legacy of slavery, genocide, and systemic violence doesn’t just echo through generations—it’s reinforced daily by a culture that refuses to reckon with its past or present.
When we pathologize substance use without acknowledging these layers of trauma, we become part of the problem. We perpetuate the very systems that create the conditions for suffering.
🏠 The Social Determinants That Shape Everything
Let’s talk about what “personal responsibility” rhetoric deliberately ignores:
The Reality Check:
🏚️ Housing instability affects 40% of pregnant individuals with SUD. In a housing market that prioritizes profit over people, in cities that criminalize homelessness rather than addressing it, “just get stable housing” isn’t advice—it’s mockery.
💰 Economic precarity forces impossible choices. When minimum wage hasn’t kept pace with living costs, when a single medical emergency can trigger bankruptcy, when childcare costs more than rent, substance use might be the only way to cope with unbearable stress.
👊 Intimate partner violence affects up to 50% of pregnant individuals with SUD. In a culture that consistently fails survivors, that questions their credibility, that offers thoughts and prayers instead of safe housing and economic support—staying and self-medicating might feel safer than leaving.
🚪 Social isolation deepens every challenge. But this isolation isn’t accidental. It’s the predictable result of a culture that encourages us to see each other as competitors rather than community, that frames needing help as failure, that has systematically dismantled the social structures that once provided support.
🧠 The Neurobiology of Surviving a Cruel World
When we understand the neuroscience, everything shifts. Chronic stress and trauma fundamentally alter brain structure and function. The amygdala becomes hyperactive. The prefrontal cortex goes offline. The stress response system dysregulates.
Now add the stress of living in an increasingly cruel society. Every news cycle that celebrates punishment over rehabilitation. Every policy that strips away support. Every cultural message that you’re unworthy of care. These aren’t just abstract political issues—they’re biological stressors that shape neural pathways.
In this context, substance use isn’t just psychologically understandable—it’s neurobiologically predictable:
Opioids calm an overactive amygdala overwhelmed by constant threat
Stimulants activate a prefrontal cortex shut down by chronic stress
Alcohol dampens a stress response system in constant overdrive
“What we call ‘addiction’ might be better understood as a traumatized brain’s desperate attempt to survive in a society that has abandoned it.”
💚 Reimagining Support in a Culture That Resists It
True healing requires more than individual treatment—it requires cultural transformation. But while we work toward that larger change, we must create pockets of resistance, spaces of radical compassion in a cruel world.
Acts of Rebellion:
🌟 Trauma-informed care becomes an act of rebellion. In a culture that asks “What’s wrong with you?”, we ask “What happened to you?” In a system that demands compliance, we honor survival strategies. In a world that punishes vulnerability, we create genuine safety.
🌟 Peer support offers what professional care alone cannot: the revolutionary act of saying “I’ve been there, and you’re not alone.” In a culture that isolates and shames, peer support creates community. It embodies the truth that healing happens in relationship, not isolation.
🌟 Integrated care addresses the whole person. Not just substance use. Not just mental health. But housing, food security, safety, dignity. It recognizes that in a society that fragments and compartmentalizes suffering, true healing requires addressing all the pieces.
🩺 The Physician’s Role: More Than Biology and Clinical Science
Medicine is a reflection of culture—and that’s why being a physician, health advocate, or healthcare worker in this moment requires thinking beyond biology and clinical science. The culture outside our clinic walls shapes everything that happens within them.
Is it the responsibility of physicians to solve all of society’s problems? No, obviously not. We cannot single-handedly dismantle systemic oppression or reverse political cruelty. But what is our responsibility is to make these stories human and real. To help people understand that behind every “addict mother” headline is someone like Keisha—someone’s daughter, someone’s friend, someone doing their best in impossible circumstances.
The reason it’s so hard for people to get help for mental health and substance use disorders is because we as a society have stigmatized them. And when physicians participate in that stigma—when we see only one framing that views people as criminals rather than patients—we become part of the problem.
It shouldn’t be surprising that pregnant individuals feel profound shame in seeking help for substance use. They’ve absorbed a lifetime of messages that their struggles make them unfit mothers, bad people, criminals. When healthcare providers reinforce these messages—even unconsciously—we confirm their worst fears.
“Part of what makes it hard for people to feel empathy is that they only see one side, one framing. As physicians, we have the power—and the responsibility—to change that framing.”
Our role is to:
Humanize what has been demonized
Contextualize individual struggles within systemic failures
Advocate not just for individual patients but against the systems that harm them
Educate colleagues and communities about the real roots of substance use
Resist the culture of cruelty, even when it’s professionally risky
🎤 Voices from the Frontlines of Resistance
In this cultural moment, the voices of those with lived experience aren’t just valuable—they’re revolutionary. They challenge the dominant narrative. They humanize what’s been demonized. They offer proof that recovery is possible even in impossible circumstances.
“When the whole world tells you you’re worthless, finding one person who sees your worth can save your life. My peer counselor was that person.”
- A mother in recovery“They want us to take personal responsibility while taking away every resource that would make responsibility possible. It’s gaslighting on a societal scale.”
- Current patient“My substance use wasn’t the problem—it was my solution to problems no one else was addressing. When my care team understood that, everything changed.”
- Recent graduate“In a world that profits from our suffering, choosing to heal is an act of resistance.”
- Peer support specialist
⚖️ From Individual Pathology to Collective Healing
Individual treatment will always fall short if we don’t address systemic factors. In this political moment, that means:
The Fight Ahead:
✊ Fighting for economic justice even as inequality is celebrated. Living wages, affordable housing, universal healthcare—these aren’t radical ideas. They’re basic requirements for human dignity.
✊ Defending reproductive justice as rights are stripped away. The right to parent in safety. The right to seek treatment without fear. The right to be seen as fully human.
✊ Resisting criminalization even as punishment is politically popular. Treatment, not incarceration. Support, not surveillance. Healing, not harm.
✊ Building community in a culture that promotes isolation. Mutual aid networks. Support circles. Chosen families. Revolutionary love in action.
🌅 Keisha’s Journey: Finding Light in Dark Times
When Keisha finally walked into that clinic, she found something unexpected: a pocket of resistance. A care team that refused to participate in the culture of cruelty.
Her provider didn’t just screen for substances—she acknowledged the courage it took to seek help in this political climate. She validated Keisha’s fear of the system while working to create safety within it. She recognized that Keisha’s anxiety wasn’t just a personal struggle but a rational response to an irrational world.
Keisha’s treatment plan addressed multiple layers:
✅ Trauma-focused therapy that connected personal experiences to systemic oppression
✅ Psychiatry that acknowledged how political stress compounds mental health challenges
✅ Peer support from others surviving and resisting
✅ Case management that fought systems rather than enforcing them
✅ Group therapy that built solidarity and collective healing
The journey wasn’t smooth. Systems designed to punish don’t easily bend toward healing. But in that clinic, in that moment, a different way was possible.
🏝️ Creating Islands of Compassion in an Ocean of Cruelty
As providers, as family members, as community members, we face a choice. We can participate in the culture of cruelty, enforcing its judgments and perpetuating its harms. Or we can resist.
Resistance looks like:
Refusing to use stigmatizing language even when it’s normalized
Challenging punitive policies even when they’re politically popular
Creating spaces of unconditional positive regard in a conditional world
Amplifying the voices of those most impacted
Building systems of care that operate on love, not fear
This isn’t easy work. In a culture that increasingly views compassion as weakness, choosing empathy is a radical act. But it’s precisely because empathy has become revolutionary that it’s more necessary than ever.
📢 Conclusion: Why This Matters Now More Than Ever
Keisha’s story—like Maria’s and Amanda’s before her—reminds us that behind every statistic is a human being deserving of dignity. In a cultural moment that seems determined to strip that dignity away, our work becomes not just medical but moral.
We cannot single-handedly change the culture of cruelty that surrounds us. But we can create spaces where that culture doesn’t reign. Where compassion is practiced even when it’s politically unfashionable. Where healing is possible even in hostile times.
Because here’s what the architects of cruelty don’t understand:
“Humans are wired for connection. We survive through community. We heal in relationship. And no amount of political rhetoric can change that fundamental truth.”
When we understand that substance use during pregnancy emerges from complex interactions of trauma, mental health, social inequity, and yes, cultural cruelty, we can stop participating in the harm. We can start building something better, even if it’s one patient, one family, one community at a time.
🔜 What’s Next: Innovation as Resistance
In our next issue, we’ll meet Jasmine, whose journey through an innovative integrated care program offers hope in dark times. Her story demonstrates that even in a culture hostile to compassion, there are people and programs doing revolutionary work.
Coming in Issue 4:
🚀 Programs that achieve 75% retention rates by treating people as humans, not cases
🚀 Peer doula initiatives that build power in marginalized communities
🚀 Technology that brings care to those the system has abandoned
🚀 Models of resistance disguised as medical programs
Don’t miss Issue 4: Innovation in Action—New Models for Better Outcomes. Because in times like these, innovation isn’t just about better medical care. It’s about imagining and building a world where everyone—regardless of their struggles—is worthy of love, support, and the chance to heal.
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