Chapter 3

Treatment of Alcohol and Other Drug Abuse: An Introduction

In its 1990 report on the treatment of alcohol problems, the Institute of Medicine provided a definition of treatment that applies to treatment of other substance abuse as well and that takes into account the continuum of care, from outreach (identification) to continuing care:

Treatment refers to a broad range of services, including identification, brief intervention, assessment, diagnosis, counseling, medical services, psychiatric services, psychological services, social services, and follow- up, for persons with alcohol problems.¹

        The need for an array of comprehensive services much more extensive than one that merely focuses on alcohol and other drug use has been also underscored in CSAT's Comprehensive Treatment Model for Alcohol and Other Drug Abusing Women and their Children, which describes the types of medical, psychological, and social services that should constitute the full range of treatment for women and their children (presented in appendix A; the categories of services recommended in the comprehensive model are described in section 3.4.1). As the model states, "Treatment that addresses alcohol and other drug abuse only may well fail and contribute to a higher potential for relapse.²

        Treatment programs must not only offer a continuum of services-both internal and external, from outreach through follow-up and continuing care-they must integrate these services within the larger community. Because many factors affect a woman's substance abuse problem, the purpose of comprehensive treatment, according to the CSAT model, is to "address a woman's substance abuse in the context of her health and her relationship with her children and other family members, the community, and society."³ An understanding of the interrelationships among the woman/client, the treatment program, and the community is critical to the success of the comprehensive treatment approach. The intent is to consider the holistic needs of women-an adaptation of the World Health Organization's definition of health as well-being rather than an absence of disease. As CSAT notes in its statement of mission, goals, and programs:

The general consensus among those foremost in the field of addiction is that, for most individuals, treatment and recovery services work best in the context of a community-centered, coordinated system of comprehensive services designed to assure a continuum of support for recovery.⁴

        Thus, the comprehensive treatment model makes clear that caring for women with substance abuse problems must be part of a broad public health and social services response. The interrelationships between a treatment program offering comprehensive services for women and the community are depicted in Figure 1 (see page 70). This model depicts the various aspects of the community which impact on the client and with which she may interact in the process of initiating alcohol or other drug use, continuing its use, and engaging in and continuing the recovery process. These include, for example, the availability of illicit drugs in her community, local laws and practices that govern distribution of alcohol, the local economy and related unemployment rates (which impact on her ability to obtain gainful employment), and the availability of health and social services prior to, during, and following treatment. Within the context of the treatment program are the various phases of care with which the client interacts and which are related in turn to the myriad of community variables. For example, the degree to which the treatment program can provide comprehensive services is in part dependent on the availability of social and other support services in the community (e.g., primary health care, low-income housing) as well as on the ability of the program to formulate and maintain community linkages. This model thus describes the interdependence of the client, the treatment program, and the broader community in which they exist.

3.1        CSAT's Vision of Treatment

        From CSAT's perspective-and from the perspective of many in the field of addiction treatment-the goals of treatment service and recovery programs should be the following:

        In addition, CSAT believes that the reduction of crime, unemployment, and other socioeconomic costs of addiction are important goals of treatment programs.

3.2        Treatment Methods and Modalities

        This section presents an overview of methods and modalities for substance abuse treatment. Because it is assumed that the reader has received training in substance abuse treatment and/or has experience in the field, this section will not present the different philosophies of treatment or describe treatment methods and modalities in detail. Rather, it will provide a framework for considering the issues and strategies addressed in the next three chapters that relate to the primary stages of care: outreach, comprehensive treatment, and continuing care. Research has demonstrated that no single modality of care is effective for all individuals and that clients may experience varying degrees of success with different modalities (or combinations of modalities) at different times. The combination of comprehensive services required can vary according to the gender, race, ethnicity, socioeconomic status, age, and physiological and neurophysiological condition of the client. This chapter also presents a condensed discussion of key issues related to women in recovery, as well as issues that apply to all stages of care.

                                           Figure 1

3.2.1      Treatment Methods

        Generally, treatment of substance abuse includes the following methods:

-   the use of antabuse in the treatment of alcoholism. Antabuse is an alcohol-sensitizing drug used primarily during the initial course of treatment and rehabilitation; and

-   the use of methadone in the treatment of heroin addiction. Although originally developed for use in detoxification of heroin addicts, methadone is now used primarily as a maintenance drug for indefinite periods;

(Please note: Although it is not commonly used, naltrexone has been an adjunct in the treatment of opioid addiction. Data does not support its effectiveness.)

         These methods of care are not mutually exclusive. In fact, they are often used in combination or sequentially at different stages in the treatment process. For example, many programs combine psychosocial treatment with social learning and/or nontraditional healing methods. Methadone treatment usually includes rehabilitative counseling, psychotherapeutic services, and comprehensive medical services.

        Increasingly, as treatment of substance abuse is linked with programs that provide services to persons with AIDS or who are HIV-positive, persons in the field are struggling to determine the most appropriate combination of care modalities to serve these clients. The CSAT Comprehensive Treatment Model suggests that, at a minimum, the [treatment] program must provide for pre- and post-test counseling for clients seeking to be tested for HIV. Individual counseling and support groups should be provided for clients diagnosed with HIV or AIDS. Staff should be properly trained to intervene on⁵ behalf of those who are HIV- seropositive, whether symptomatic or asymptomatic.

3.2.2      Modalities of Care

         Modalities of substance abuse treatment can be classified in many ways. Among these are: by setting (e.g., inpatient/medical facility-based, residential, or outpatient); by length of care (e.g., short-term or long-term); and by philosophical approach (e.g., medical model or social services model).

        The remainder of this chapter summarizes the services provided in the most frequently used types of modalities based on the setting of care: inpatient detoxification, residential treatment and rehabilitation, outpatient detoxification, and outpatient treatment. Generally, these classifications apply for treatment programs that address problems of substance abuse or a combination of alcohol and other drug use. In reality, treatment is not usually static, but often occurs in different settings and with the use of different treatment modalities. Most commonly, there is a continuum of services from the following:

        Inpatient or residential detoxification. whatever the setting or approach, is designed to facilitate the client's safe physiological withdrawal from drugs. Services usually include intensive client counseling to encourage further treatment and referral of detoxified persons to appropriate treatment programs for continuing care. Detoxification programs can last from one to seven days. However, they may be longer for women withdrawing from addictive prescription drugs, for pregnant women, for women who present with medical risks, or for those who have co-occurring disorders, including for example, mental health disorders, eating disorders, and other health problems.

        Inpatient detoxification services can include the following: nursing care; individual, group, and family counseling; physical examinations (including laboratory tests); psychiatric evaluations; the provision of medications (for social setting programs, these would be limited to medications for other health problems); education concerning alcohol and other drugs; and referral for longer term treatment. Inpatient detoxification, which focuses on medical stabilization, is provided in two types of settings:

Residential treatment and rehabilitation are provided to individuals who need treatment services in a controlled and structured environment over a longer period of time.

        Many clients are referred to residential treatment programs because they are experiencing withdrawal symptoms, psychotic manifestations, or severe illness related to substance abuse. In the latter case, they are usually stabilized in a medical facility before entering the residential program for treatment. Others are referred (or refer themselves) because the counselor or the client believe that the structured setting will benefit the client. Sometimes hospital-based residential programs are the only treatment resource available or the only one that is covered by the client's third-party payer (public or private). As with inpatient detoxification, two types of settings predominate:

        Residential treatment and rehabilitation services can be short-term (seven to 60 days, depending on the type of facility) and longer term (30 days to six months or longer). Freestanding residential programs usually have treatment methods lasting 30 days to six months; quarterway houses (usually seven to 21 days long), and halfway houses (usually 14 to 60 days long, but which can last up to six months). It should be noted that these "typical" duration periods are frequently-if not primarily-driven by coverage decisions by third party payers (including Medicaid, Medicare, and private health insurance companies), rather than by standards of care set by the treatment community.

        In its grant programs, CSAT tries to ensure that programs seek the optimum length of treatment necessary to meet the primary goal of recovery. Programs funded by CSAT-particularly programs serving pregnant and postpartum women and infants, and parenting women and their children-have longer terms of stay (six to 18 months). CSAT funds up to 12 months of residential treatment.

        As with detoxification programs, residential treatment and rehabilitation services can include 'nursing care; individual, group, and family counseling; physical examinations (including laboratory tests); psychiatric evaluations; and provision of medications. For social service programs, medications are limited to clients with other health problems. These programs may include more comprehensive services such as employment counseling, referral for primary health care and social services, and referral of pregnant women for prenatal care. Therapeutic communities that are freestanding residential treatment programs use the social setting, drug-free treatment modality.

        Outpatient detoxification services are less common than inpatient detoxification services. They are usually provided under the observation and supervision of trained treatment personnel to a client whose condition requires monitoring and observation for a period of time but does not require admission to an inpatient treatment facility. The services, which usually last seven to 14 days, can include nursing and related care; individual, group, and family counseling; physical examinations (including laboratory tests); psychiatric evaluations; drug testing; and provision of medications (for detoxification and/or other health problems). During this period, the program may also arrange for outpatient follow-up care, either in the same facility or in another facility that offers outpatient treatment services. Outpatient detoxification services are provided through the following:

        Outpatient treatment services are programs in which clients may participate for widely varying periods (from 30 days to a year or more). More intensive outpatient programs may require visits totalling eight to 10 or more hours per week. Some hospital-based programs require hospitalization five days a week during daytime hours, or even daily, including weekends. Less intensive programs may require visits two or more times per week for individual counseling and participation in program-sponsored group counseling or 12-step meetings. Services usually include individual, group, and family counseling; employment counseling; and referral for health (medical and mental) and social (e.g., housing and Aid to Families with Dependent Children [AFDC]) services if not available in the treatment program itself. These programs are often affiliated with inpatient services and provide continuing care and follow-up services.

        Self-Help/Support Groups. Mutual help or facilitated support groups such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) are increasingly used by women recovering from alcoholism or other drug dependence. For example, women now comprise more than one-third of AA participants. The involvement of women in self-help groups may be related in part to their convenience, which is an important attribute when the woman's motivation and possible roles as primary caregiver need to be considered.

As Covington notes:⁶

mutual help groups ... are free and, in most urban communities, readily available throughout most of every day ... [they] are often found in women's centers or other places in communities that provide other types of help to women ... [who] are permitted to come and go freely without records being kept or contracts drawn. Meetings occur as scheduled through cooperative efforts; they are dependable and consistent in their format.

        Covington also notes that women "can use meetings for a variety of different purposes as well as staying sober. As a woman's needs shift in recovery, the meetings she attends may change to reflect this."⁷ A particularly useful advantage of mutual self-help groups for the woman in continuing care is the fact that the meetings provide an opportunity for social activities that are alcohol-and drug-free.⁸ Covington has also cautioned, however, that the 12-Step Model has limitations of which programs should be aware. These include, for example, the fact that "the ideology does not [necessarily] encourage attention to the relational, cultural, or sociopolitical factors that foster substance abuse in women... [and that] much of the AA literature was written 20- 50 years ago and is overtly sexist in its content and connotations."⁹ It should be pointed out that there is an increasing number of women's 12-step groups that are addressing the specific needs and circumstances of women.

        Several of the CSAT Treatment Improvement Protocol (TIP) documents describe the use of support groups such as AA, NA, Women for Sobriety, and Rational Recovery in the treatment process. For example, the TIP Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse¹⁰ describes the use of support groups in sequential, parallel, and integrated approaches to addressing dual disorders. The TIP Pregnant, Substance Abusing Women,¹¹ describes the use of support groups in the context of comprehensive service delivery.

3.2.3      Treatment of Multiple Drug Use/Abuse

         Since many individuals in substance abuse programs use more than one drug, programs are increasingly combining treatment for alcohol problems with treatment for other drug problems. For example, in 1990, of 7,743 treatment programs that received federal funds administered by the state alcohol and drug agency, 67.1 percent were combined alcohol and other drug treatment programs, 18.1 percent were programs exclusively for the treatment of alcoholism, and 14.9 percent were programs for the treatment of other drugs.¹² No gender disaggregated data were available.

3.3        Knowledge About Effective Treatment for Women

         Gender-disaggregated data for treatment outcome continue to be relatively scarce, in spite of an expanded interest and a federal mandate to make such data available. Some descriptive data are available (e.g., proportion of clients who are women), and relatively more data are available for women in treatment for alcoholism. Outcome data from several federal data bases are forthcoming, and other studies that are specifically designed to determine treatment outcomes for women or that will provide gender-disaggregated data are currently underway.

        The lack of gender-specific treatment outcome data hinders the valid design or adaptation of treatment methods specifically for women. Nonetheless, at least with respect to the treatment of alcoholism, the Institute of Medicine's earlier (1980s) research on treatment outcomes remains valid. Quoting Braiker, the Institute notes that such research either failed "to distinguish between outcome rates for women and men or excluded [women] from the study sample altogether."¹³ Although the data are minimal, those that exist, according to Blume and Roman, suggest the following:

In general, in treatment for alcohol problems, males and females with comparable sociodemographic characteristics (marital status, employment, social stability, etc.) and at the same levels of problem severity appear to do equally well in the same treatment settings. ¹⁴

        Notably, however, Blume states that "what is not known are the components of treatment that would improve treatment outcome for both males and females."¹⁵ In fact, few research studies have demonstrated the effectiveness of specific attributes of substance abuse treatment for any client, irrespective of gender. The experience of those who have provided treatment services for women in a variety of settings suggests that women have more successful outcomes when they receive gender-specific treatment for at least several months.¹⁶ 

        The relative appropriateness of a particular method of treatment for women has not been determined. In fact, there has been little research on which to base any determination. The use of methadone is an established pharmacotherapy for the treatment of opioid addiction. However, its use as a treatment form has led to some degree of controversy. Examples of those who disagree with its use in the treatment of pregnant women are those who see methadone as only a replacement for heroin with another highly addictive substance. The CSAT Treatment Model states that:

pharmacotherapy intervention (e.g., methadone) should be provided on an as-needed basis and should include provision of, or established referral linkages, for concomitant assessment and monitoring by qualified medical or psychiatric staff."¹⁷

        There is, however, no consensus in the field on the use of methadone in the treatment of pregnant women. CSAT's TIP document, Pregnant, Substance- Using Women, recommends methadone maintenance combined with psychosocial counseling and medical services for pregnant opioid-addicted women. The primary reason for this recommendation is that the fetus is also dependent on the opioid and could be spontaneously aborted if the woman is no longer taking the opioid and the fetus has withdrawal symptoms in utero. The physician prescribes as small a methadone dosage as possible to help ensure that the fetus can be born. After the birth, the physician provides medical assistance to help the mother and child withdraw from the drug(s).

        In the treatment of pregnant heroin-addicted women, according to CSAT's 1992 report, State Methadone Maintenance Treatment Guidelines, "methadone maintenance by itself is not necessarily sufficient to reduce perinatal complications."¹⁸ In its 1993 update of that document, CSAT suggested that for pregnant women who are enrolled in programs that use methadone to treat heroin addiction, methadone "must be offered in conjunction with prenatal care reinforced by psychosocial counseling and other medical services."¹⁹ Importantly, CSAT notes that pregnant women who received methadone prior to pregnancy can initially be maintained on their prepregnancy dose, but those who did not receive methadone prior to pregnancy should receive inpatient care for a general and obstetrical assessment, a determination of their physiologic dependence on heroin and other drugs, and to initiate their methadone treatment.²⁰

        Treatment of pregnant women at the point of withdrawal from crack or cocaine is a particular problem, and, as CSAT has noted, "The evidence is extremely limited for all methods of medical withdrawal." Although inpatient or residential treatment is "the ideal whenever possible... these facilities may not always be available."²¹

        The lack of adequate data and information in the field of women and substance abuse treatment underscores the need for more research on the effectiveness of various treatment approaches for women. For example, in a 1993 study of the accessibility, relevancy, and validity of published literature concerning minority women and substance abuse, a thorough search of the literature revealed only 200 relevant articles, of which only 92 were research-based.²² Thus, in spite of longstanding purported interest on the part of the public health community and widespread media attention to such problems as babies born to crack cocaine-using women, only limited funds have been made available for research to design an effective program specifically for substance abusing women.

3.3.1      Critical Components of Treatment for Women

In its Comprehensive Treatment Model, CSAT recommends that the following services, among others, be provided either on-site or through referral as part of the treatment process :²³

Medical Interventions

Substance Abuse Counseling and Psychological Counseling

Health Education and Prevention Activities

Life Skills

Other Social Services

        It is important that all treatment components be accessible to all women. This may entail making accommodations for women with disabilities and for older women. Chapters 4, 5, and 6 detail strategies related to these types of services in the outreach/identification, comprehensive treatment, and continuing care/follow-up phases of treatment, respectively.

3.4        Case Management

        Case management is a critical component of any substance abuse treatment program. For programs that provide comprehensive treatment services which require accessing and coordinating numerous sources of such services and which involve multiple disciplines of different care providers, it is imperative. The International Certification Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc. (ICRC/AODA) has defined case management to include the following:

... activities which bring services, agencies, resources, or people together within a planned framework of action toward the achievement of established goals. It may involve liaison activities and collateral contacts.²⁴

        Case management should be an integral part of the treatment process, from the point of intake through continuing care. In describing practical aspects of case management in the treatment of alcohol and other drug disorders, Kulewicz suggests that:

In the treatment process, either inpatient or outpatient, the basic concepts remain the same. Effective treatment is contingent upon a cooperative effort of the client and the treatment staff. The treatment staff usually consists of the primary counselor, counselor, clinical supervisor, staff psychologist, and consulting psychiatrist. It is not unusual to include the staff physician and/or nursing staff member in those cases where it is appropriate to meet the individual client's needs. The interacting and consulting efforts on the part of the team enable the treatment process to be continually monitored and updated on an ongoing, regular basis.²⁵

        In treatment programs serving women, especially those offering comprehensive services, the client's records-including for example the treatment plan, the counselor's notes and those of other treatment providers, and follow-up forms from programs to which the client has been referred- the basis for case management. These records must be current and complete, reflecting the full range of services provided to the client and the full range of her needs. Additional information regarding the client should be discussed during periodic case management conferences (usually held weekly), and any determinations made on the basis of this conference should be recorded in the client's file.

        Examples of the application of case management techniques provided in Chapters 4, 5, and 6.

3.5        Issues Related to Treatment of Alcohol and Other Drug Use in Women

3.5.1       Relationships and Other Gender Issues

         A number of experts in the field of women and addiction have noted that women who abuse alcohol and other drugs tend to have relationships that are characterized by unhealthy dependencies and poor communication skills .²⁶ Because many recovering women have had few positive relationships, they have few models for developing healthy relationships.

        Covington and Surrey have described a useful model for understanding the importance of relationships in women's lives and in the process of substance abuse and recovery. Termed the "relational model," it emphasizes the centrality of relationships for women, considers their role as caretakers, addresses the issue of co-dependency, and focuses on strengths in women's relationships as a means of recovery. Covington and others have found the model to be helpful in "conceptualizing the contexts and meanings of substance abuse in women's lives and particularly helpful in suggesting new treatment models.²⁷

- Invite mothers and children to participate in educational activities.

- Involve mothers and children in individual, group, and family therapy sessions.

- Hold therapy groups and workshop sessions in which educational material and experiential exercises are used to help clients understand the difference between intimacy and sexuality.

- Encourage nonsexual friendships between women and men.

- Review patterns of relationships through individual and group therapy.

- Explore personal needs and wants in the following areas: economic, sensual/sexual, emotional, social, intellectual, and spiritual.

- In some circumstances, recommend periods of celibacy.

- Involve the clients in women-only therapy groups and include discussions designed to empower women to trust themselves first, as a basis for developing trust in others.

- Educate clients about women's history, including socialization of women's relationships with one another.

- Use group living situations to refocus attention on individual needs.

- Use visual aids to enable the client to see and analyze various aspects of her life's activities (the "circle overlap").

        The concept of "codependency" was developed to describe the complex interrelationships that can occur with the underresponsibility/ overresponsibility dynamics that develop in many relationships marked by alcohol and other drug use.²⁹ Until recently, most substance abuse treatment programs have addressed primarily the needs of men. Therefore, to the extent that codependency issues have been confronted, this has been done primarily with male clients vis-`-vis their female partners.

        There is a significant lack of clarity in the definition of the terms enabling" and "codependency," with viewpoints expressed in the literature deriving from the particular author's vantage point. Sociopolitical issues concerning gender relationships and relative positions in society are often not addressed in the substance abuse treatment literature. Rather, there seems to be a focus on the "pathology" of codependency, which implies (and can encourage) guilt on the part of the woman.³⁰ As Beattie has described in her books on codependency, the client needs to learn that she can continue to care about people, but that she has choices. She is responsible for her behavior and the consequences of that behavior, including unhealthy codependency.³¹ Identifying her codependent behaviors and those with whom she is involved in these behaviors is an important step in recovery from codependent relationships. These behaviors include, for example, controlling relationships, repressing feelings, self-neglect, and not setting boundaries.³²

        Treatment program staff, clients, and their partners need to address the imbalances of responsibility and gender patterns found in families and personal relationships that are so often destructive to both women and men. When a woman has gained a degree of stability in treatment, it is often helpful for her to participate in both women-only and mixed gender codependency groups for support in recovering from unhealthy codependent behavior characterized by past relationships. Treatment programs should ensure that clients who are codependent have access to groups (either on-site or through referral) that address issues of codependency, including, for example, Codependents Anonymous (CoDA) and Families Anonymous.

        An example of a client who has relationship problems along with treatment strategies to address them is shown on the following page.

3.5.2      Issues of Sexuality

         Women in treatment for substance abuse problems often must not only address issues of sexuality faced by other women, but a myriad of other issues as well. As noted in Chapter 2, women who have abused alcohol and other drugs have many physiological repercussions that may affect their sexual functioning (e.g., hormonal changes, liver damage). Covington has found that women recovering from alcohol abuse were much less likely to report satisfaction with their sexual functioning than were nonalcoholic women (55 percent versus 85 percent, respectively).³³ She also has identified related psychological repercussions, including diminished self-worth, an avoidance of relationships, and possible depression related to sexual functioning.³⁴ Comparable data relating sexual functioning to the use of other drugs is not readily available.

        Many women go through treatment without addressing their sexuality and intimacy issues, in part because few counselors are prepared to deal effectively with women's sexual concerns. Because alcohol and other drug use and sexuality can be entwined, staff members must be knowledgeable about and comfortable with discussing sexuality and intimacy issues with women in individual and women- only group sessions. If staff members are unable or unwilling to talk openly about these issues, a woman's fears and concerns will only be exacerbated, and the possibility of a healthy recovery may be limited. Staff members also must be comfortable talking with women about incest, rape, or sexual abuse issues since these are often the core problems underlying sexual dysfunction in women who abuse substances.

        An additional issue to be addressed is the fact that, as a recently published CSAT report, State Methadone Maintenance Guidelines, states: "because addicted women rarely have highly paid roles in the drug-dealing network, prostitution is common and also negatively influences intimate relationships."³⁵ Sexual relationships with injecting drug users also place the woman at-risk for AIDS/HIV, as is discussed in Chapter 2. Both of these are issues that can be addressed through individual and group counseling focusing on intimate relationships; however, the issue of prostitution is one related to economic status and self-sufficiency as well.

        The following types of strategies are useful to address sexuality issues:

3.5.3      Women, Violence, and Substance Abuse

        The first comprehensive national survey of the health of American women, conducted in 1993, found that thirty percent of women (an estimated 30 million women) suffered some type of abuse as a child. Ten percent reported having been sexually abused, 13 percent reported having been physically abused, 27 percent reported having been emotionally or verbally abused .³⁶ This same study found that in the year prior to the survey, seven percent of women reported being physically abused and 37 percent reported being emotionally or verbally abused by their partner. ³⁷ Two percent of respondents -an estimated 1.9 million women - reported having been raped in the previous five years.³⁸

        The prevalence of violence against women in the general population, while of startling proportions, is overshadowed by the reported prevalence among women who enter substance abuse treatment programs. In her review of published research on sexuality and drinking behavior, Wilsnack found that between 41 percent and 74 percent of women in treatment for alcohol and other drugs reported being childhood or adult victims of sexual abuse, including incest .³⁹ A number of researchers (e.g, Bergman, et al ⁴⁰ and Covington ⁴¹ ) have found significantly higher proportions of a history of sexual and/or physical abuse among women in treatment than among comparison groups of women. In some cases, at least half of the women entering treatment have been battered or raped and most have been emotionally abused. There is little data available on women's exposure to violence in their environment (e.g., murder, armed robbery, or assault), which has also been linked with post-traumatic stress disorder (PTSD) and which can contribute to the woman's vulnerability to seeking drug-induced means of removing herself from her unsafe and insecure environment.

        The wide range of findings with respect to history of sexual abuse among women in treatment is in part due to the difference in definitions of abuse used by the researchers. For example, in describing a range of 30-80 percent in reported incest among women in treatment for heroin addiction in studies published over several decades, Worth⁴² noted the inconsistent definitions of incest used by the authors of the published studies.

        Most women who are victims of partner violence do not discuss the incidents with anyone and most who are victims of any type of crime and who required medical treatment are not referred to any type of support service by a treatment provider.⁴³ Both as a result of the violence itself and the inadequacy of support systems, the victim endures physical and psychological impacts that are well documented. It is also important to acknowledge that racial, ethical, and cultural differences do exist in patterns, interrelationships, and outcomes associated with violence. These factors have not been systematically examined.

        The psychological impact of violence includes mood disorders (e.g., depression), anxiety disorders (e.g., PTSD), and low self-esteem. A recently- published CSAT TIP entitled "Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse," specifically addressed the relationship between sexual abuse (including incest) and alcohol and other drug use:

Clinicians note that long-term responses to childhood and adult sexual abuse often include symptoms associated with PTSD and other psychiatric problems, including an increased risk for [alcohol and other drug] AOD disorders.⁴⁴

        Paone and others have noted that, for many women who have been victims of personal violence, use of alcohol and other drugs can become a coping mechanism, whereby they self-medicate to alleviate feelings of  anxiety, guilt, fear, and anger that result from the violence.⁴⁵

        Because the partner of the woman in treatment is often a user of alcohol or other drugs, the link between such use and violence is also an important consideration for treatment programs, particularly those which have as an objective family reunification. It is important to note that alcohol abuse by lesbians has been identified as both a cause and effect factor related to violence among partners .⁴⁶ Alcohol consumption has been linked to fight-related homicide, assault, rape, and spouse and child abuse, all of which the woman may have experienced just prior to entering treatment and to which she may be vulnerable following treatment. For example, in a national study of homicide perpetrators, 36% were under the influence of alcohol alone at the time of the crime and an additional 13% were under the influence of alcohol in combination with another drug.⁴⁷ A subsidiary issue is the fact that, increasingly, use of alcohol by the victim is seen as related to increased vulnerability to victimization. However, this should in no way be interpreted as suggesting that, for example in the case of spouse abuse, this vulnerability is "an excuse for [or] a direct cause of' ⁴⁸ the crime. Use of crack cocaine has also been associated with violent behavior, but minimal data are available specifically with regard to its impact on personal violence directed at women, or conversely, personal violence committed by crack cocaine-addicted women.

        Chapters 4, 5, and 6 address issues related to outreach, treatment, and follow-up of women in treatment who have experienced personal violence. These issues include assessing the woman to identify dual diagnoses (including, for example, PTSD), individualizing treatment to ensure that the woman's abuse history is addressed, and prevention relapse.

        An example of a woman client presenting with sexual abuse is and strategies to address them is presented on the following page.

3.5.4      Children

         Women are the primary caretakers of children in the United States (as in most countries) even when a spouse or partner is present in the home. The proportion of female-headed family households (no spouse present) is significant: in 1992, nearly one-third of families with children under 18 fell into this category.⁴⁹ Low-income women who are single heads of households have particular problems, with diminished economic and/or geographic access to treatment, health, social, and other support services.

        Substance abuse treatment programs need to address the issues of women with children. In terms of outreach and identification, many women report that concern for their children is a major motivation in their decision to enter treatment for substance abuse problems.⁵⁰ For example, in a recent study of cocaine or crack-addicted mothers in New York City, 75 percent of-respondents indicated that "concern for their children would be their major motivation for entering treatment."⁵¹ However, lack of access to treatment programs that can meet their needs impedes the ability of women to obtain care. As Coletti et al noted:

Mothers without access to child care may have to forego treatment, leave treatment early, or face the frustrations of bringing young children with them - if children are allowed on the premises."⁵²

        The lack of adequate treatment programs for women with children was identified by the General Accounting Office in 1992; that agency found that, in 1991, 105,000 cocaine or crack-addicted women were in need of treatment.⁵³ Note that this does not include women addicted to any other type of drug, including alcohol. (The CSAT Women and Children's Branch is currently funding 65 programs designed to serve women and their children. This is part of CSAT's effort to expand services to meet the needs of women with children.) In addition to inadequate availability of treatment programs, the lack of regular affordable child care (and health care services) and the fear of interference by the Department of Social Services in the family may be important barriers to treatment. These factors need to be considered in designing outreach and treatment services for women with children.

        An important consideration for treatment is the fact that the mother's abuse of alcohol and other drugs has been demonstrated to impair mother and infant bonding and development of nurturing relationships.⁵⁴ Thus, even if the mother is motivated to care for her child (see above discussion), it may be psychologically (and practically) difficult for her to do so while she is still abusing alcohol or other drugs. Treatment program staff need to ensure that in all phases of care the woman's positive motivation and nurturing instincts are encouraged and that she is given access to the social support systems that promote and sustain her role as mother.

        For these reasons, and to help ensure retention in treatment and continued recovery in follow-up, child care and attention to parenting issues must be major components of treatment for women. Specific strategies to address these issues are discussed in the remaining chapters of the manual.

3.5.5      Dual Disorders

         The recently-published CSAT TIP report, "Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and other Drug Abuse," points out that:

"The term dual diagnosis is a common, broad term that indicates the simultaneous presence of two independent medical disorders .... The equivalent phrase dual disorders also denotes the coexistence of two independent (but invariably interactive) disorders.⁵⁵

        That same report identifies common examples of dual disorders: major depression with cocaine addiction, alcohol addiction with panic disorder, alcoholism and polydrug addiction with schizophrenia, and borderline personality disorder with episodic polydrug abuse. The report also suggests that the term "mentally ill chemically affected people" is the preferred designation for those who have an alcohol or other drug disorder and "a markedly severe and persistent mental disorder such as schizophrenia or bipolar disorder."⁵⁶ Using the broad definition of dual disorders, they can include eating disorders and others that interfere with full well-being and functioning.

        Accurate diagnosis and appropriate treatment of clients who have dual disorders is difficult, particularly in the early treatment for substance abuse. In fact, according to Dackis and Gold, there are three diagnostic possibilities in dually diagnosed clients:⁵⁷

        It is important that staff members of treatment programs serving women are aware of the general classification of mental health disorders (e.g., mood disorders, anxiety disorders, personality disorders, and psychotic disorders) and that they are aware of gender differences in presentation of these conditions among women. For example, given the high proportion of women clients who are adult or childhood victims of sexual or physical abuse (see 3.4.3 above), and the relationship between posttraumatic stress disorder (PTSD) and history of sexual abuse, staff members should be aware of treatment approaches related to PTSD and be aware of similar symptomatology (e.g., blackout phenomena) associated with alcohol or amnesia related to the PTSD.

        Increasing attention is being paid to the need for treatment program staff to detect and screen for dual disorders (and make referrals for identified problems) or to immediately arrange for screening by medical or mental health professionals early in the outreach or treatment process. Strategies related to addressing dual disorders should be an integral part of the treatment plan, as should continued attention to any identified dual disorders, because progress in treating these disorders affects the outcome of the substance abuse treatment process. Addressing dual disorders may also be a key factor in relapse prevention. Maintaining contact with the agency where the client was sent for medical or mental health treatment, or with the provider on the program staff, is an important part of the treatment process.

        It is also important that health care providers identify substance abuse as a disorder that often co-occurs, with other medical and mental problems. They must try to avoid the tendency to project negative attitudes about people who have substance abuse problems. These problems should be seen as part of a complex set of physical and psychological actions and reactions that will continue if not directly addressed. The lack of early detection by health care providers has been exacerbated by the tendency of many physicians to prescribe sedatives/hypnotics or tranquilizers to those already experiencing substance abuse.⁵⁸

        Concurrent treatment for clients with dual disorders is also crucial. This does not mean that addiction specialists treat the addiction and mental health professionals (psychologists, psychiatrists, etc.) treat the psychiatric disorder. Concurrent treatment involves all treatment professionals in case management to identify the impact the diagnoses have on one another and to determine the most appropriate and effective course of treatment. Given the complex interaction between substance abuse and mental health disorders, and the many issues that need to be considered in outreach, treatment, and continuing care, treatment program staff serving women are encouraged to review the CSAT TIP report on dual disorders (referenced above).

References

1. Institute of Medicine. (1990). Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy of Sciences Press, 84.

2. Center for Substance Abuse Treatment. (1993). CSAT Comprehensive Treatment Model for Alcohol and Other Drug Abusing Women and Their Children. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.

3. ibid.

4. Center for Substance Abuse Treatment. (1993). Providing National Leadership in Treatment Services: Mission, Goals, and Programs. Rockville, MD: U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration, 3.

5. State Methadone Maintenance Treatment Guidelines, 69.

6. Covington, S. (199 1). Sororities of Helping and Healing: Women and Mutual Help Groups. In Roth, P., Ed. Alcohol and Drugs are Women's Issues, Vol. 1. Metuchen, NJ: Scarecrow Press, 91.

7. ibid.

8. ibid.

9. Covington, S. (1994). Spirituality. A Paper Prepared for Policy Research Incorporated. Bethesda, MD: Policy Research Incorporated, 2.

10. Center for Substance Abuse Treatment. (1994). Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; pp. 13-14.

11. Center for Substance Abuse Treatment. (1993). Pregnant, Substance-Using Women. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, 10.

12. U.S. Department of Health and Human Services. (1992). State Resources and Services Related to Alcohol and Other Drug Abuse Problems. Rockville, MD: National Institute on Drug Abuse and National Institute on Alcohol Abuse and Alcoholism, 14.

13. Institute of Medicine. (1990). The Diagnosis and Treatment of Alcoholism in Women. In Broadening the Base of Treatment for Alcohol Problems, 351.

14. Institute of Medicine. (1990). Populations Defined by Structural Characteristics. In Broadening the Base of Treatment for Alcohol Problems, 356.

15. ibid.

16. ibid.

17. CSAT Comprehensive Treatment Model for Alcohol and Other Drug Abusing Women and Their Children, 4.

18. Center for Substance Abuse Treatment. (1992). State Methadone Maintenance Treatment Guidelines. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, 174.

19. Center for Substance Abuse Treatment. (1993). State Methadone Treatment Guidelines. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, 90.

20. State Methadone Maintenance Treatment Guidelines, 177.

21. Center for Substance Abuse Treatment. (1993). Pregnant, Substance-Using Women. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, 22.

22. Policy Research Incorporated. (1993). Substance Abuse Among Women From Ethnic/Racial Population Cohorts: Review of the Relevance, Accessibility and Validity of the Literature. Clarksville, MD.

23. CSAT Comprehensive Treatment Model for Alcohol and Other Drug Abusing Women and Their Children, 4.

24. Kulewicz, S.F. (1992). The Twelve Core Functions of a Counselor. Somerville, MA: David & Goliath Creative, 57.

25. Kulewicz, S.F. (1992). The Twelve Core Functions of a Counselor. Somerville, MA: David & Goliath Creative, 57.

26. Bepko, C. The Responsibility Trap. (1985). New York: The Free Press, 198232.

27. Covington, S.S. and Surrey, J.L. (undated). The Relational Model of Women's Psychological Development: Implications for Substance Abuse, (unpublished document), 2.

28. U.S. Department of Health and Human Services. (1985). Advances in Alcoholism Treatment Services for Women. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 15.

29. See National Coalition on Domestic Violence. (1988). Chemical Dependency, Codependency, and Battered Women. In NCADV Voice (Special Issue) and in Wetzel, J.W. (199 1). Working with Pregnant Women at High Risk for HIV Infection: Outreach and Intervention. Bulletin of the New York Academy of Medicine, 67(3), 291-300.

30. ibid.

31. Beattie, M. (1989). Beyond Codependency and Getting Better All the Time. San Francisco, CA: Harper & Row, Publishers, p. 15.

32. Beattie, M. (1990). Codependents' Guide to the Twelve Steps. New York, N.Y.: Prentice Hall Press, 65.

33. Covington, S.S., Ph.D. (1991). Awakening Your Sexuality: A Guide for Recovering Women. San Francisco: Harper, 232.

34. ibid.

35. State Methadone Treatment Guidelines, 69.

36. The Commonwealth Fund. (1993) Survey of Women's Health. New York, NY: The Commonwealth Fund, 9.

37. Survey of Women's Health, 8.

38. Survey of Women's Health, 9.

39. Alcohol Problems in Women: Antecedents, Consequences, and Intervention, New 204- 205.

40. Bergman, G., Larsson, G., Brismar, B., et al, (1989). Battered Wives and Female Alcoholics: A Comparative Social and Psychiatric Study. J. of Advanced Nursing; 14:727-734.

41. Covington, S.S. and Kohen, J. (1984). Women, Alcohol & Sexuality. Advances in Alcohol & Substance Abuse, 4(l).

42. Worth, D. (1994). Good Girls, Bad Girls. New York, NY: Unpublished Paper, 3.

43. Survey of Women's Health, 9.

44. Center for Substance Abuse Treatment. (1994). Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse. Rockville, MD: Substance Abuse and Mental Health Services Administration, 44.

45. Paone, D., et al, (1992). The Impact of Sexual Abuse: Implications for Drug Treatment. Journal of Women's Health, 1(2): 149-153.

46. Diamond, D., & Wilsnack, S.C. (1978). Alcohol Abuse Among Lesbians: A Descriptive Study. Journal of Homosexuality, 4: 123-142.

47. Wieczorek et al, (1990). Cited in: U.S. Department of Health and Human Services (1993). Eighth Special Report to the U.S. Congress on Alcohol and Health. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, 246.

48. Eighth Special Report to the U.S. Congress on Alcohol and Health, 247.

49. U.S. Department of Commerce, Bureau of the Census. (1993). Statistical Abstract of the United States: 1992. Washington, DC: U.S. Government Printing Office, 55.

50. Wilsnack, R.W., Wi1snack, S.C., and Klassen, A.D. (1984). Women's Drinking and Drinking Problems: Patterns from a 1981 Survey. American Journal of Public Health (74), 1231-1238.

51. Chavkin, W. and Paone, D. (1993). Treatment for Crack-Using Mothers: A Study and Guidelines for Program Design. New York: Beth Israel Medical Center Chemical Dependency Institute, 4.

52. Coletti, S.D., et al, (1992). PAR Village: Specialized Intervention for Cocaine Abusing Women and Their Children. J. Florida Medical Association. 79(10): 701-705.

53. U.S. General Accounting Office. (1991). Drug Abuse - The Crack Cocaine Epidemic: Health Consequences and Treatment.

54. DeLeon, G. and Jainchill, N. (1991). Residential Therapeutic Communities for Female Substance Abusers. Bul. of N.Y. Acad. Med.; 67(3): 277-289.

55. Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug Abuse, 4.

56. ibid.

57. Dackis, C.A., and Gold, M.S. "Psychiatric Hospitals for Treatment of Dual Diagnosis." (1992). In Lowinson, J., Ruiz, P., et al, Eds. Substance Abuse: A Comprehensive Textbook. Baltimore: Williams and Wilkins, 467-485.

58. Mondanara, J., M.D. (1989). Chemically Dependent Women: Assessment and Treatment. D.C. Lexington, MA: Heath and Company, 114.