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Figure 1
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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:
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medical facilities (not limited to hospitals), or |
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freestanding programs that may or may not be independent of residential treatment programs. |
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.
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.
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 use of methadone is an established pharmacotherapy for the treatment opioid addiction. |
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.
The lack of adequate data and information in the field of women and substance abuse treatment underscores the need for more research on the ef fectiveness of various treatment approaches 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
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testing and treatment for infectious diseases, including hepatitis, TB, HIV, and STDs. |
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screening and treatment of general health problems, including anemia and poor nutrition, hypertension, diabetes, cancer, liver disorders, eating disorders, dental and vision problems, and poor hygiene. |
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obstetrical and gynecological services, including family planning, breast cancer screening, periodic gynecological screening (e.g., pap smears), and general gynecological services. |
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infant and child health services, including primary and acute health care for infants and children, immunizations, nutrition services (including assessment for Women, Infants, and Children (WIC) program eligibility), and developmental assessments performed by qualified personnel. |
Substance Abuse Counseling and Psychological Counseling
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counseling regarding the use and abuse of substances directly, as well as other issues which may include low self-esteem, race and ethnicity issues, gender-specific issues, disability-related issues, family relationships, unhealthy interpersonal relationships, violence, including incest, rape, and other abuse, eating disorders, sexuality, grief related to loss of children, family, or partners, sexual orientation, and responsibility for one's feelings including shame, guilt, and anger. |
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parenting counseling, including information on child development, child safety, injury prevention, and child abuse prevention. |
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relapse prevention, which should be a discrete component or phase of each woman's recovery plan. |
Health Education and Prevention Activities
![]() | health education and prevention activities should cover the following subjects: HIV/AIDS, the physiology and transmission of STDs, reproductive health, preconception care, prenatal care, childbirth, female sexuality, childhood safety and injury prevention, physical and sexual abuse prevention, nutrition, smoking cessation, and general health. |
Life Skills
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education should include practical life skills, vocational evaluation, financial management, negotiating access to services, stress management and coping skills, and personal image building. |
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parenting, including infant/child nutrition, child development, and child/parent relationships. |
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educational training and remedial services should be provided with access to local education/GED programs and other educational services as identified at intake. |
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English language competency and literacy assessment programs should be facilitated. |
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job counseling, training, and referral should be provided, if possible, via case managed/coordinated referrals to community programs. |
Other Social Services
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transportation for clients to gain access to substance abuse treatment services and related community services. |
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child care. |
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legal services. |
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housing. |
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.
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
Effective treatment is contingent upon a cooperative effort of the client and the treatment staff |
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.
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.
Women who abuse alcohol and other drugs tend to have relationships that are, characterized by unhealthy dependencies and poor communication skills. |
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
Following are examples of unresolved relationship issues and strategies to address these issues; most have been derived from Advances in Alcoholism Treatment Services for Women:28![]() | Issues between mother and children |
- Invite mothers and children to participate in educational activities.
- Involve mothers and children in individual, group, and family therapy sessions.
![]() | Issues of intimacy and friendship (often confused with issues of sexuality) |
- 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.
![]() | Issues of mistrust and competitiveness with other women |
- 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.
![]() | Issues of self-development, independence, and interdependence. |
- 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.
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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.
Staff members must be knowledgeable about and comfortable with discussing sexuality and intimacy issues with women. |
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:
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Conduct workshops and use educational materials on the relationship between substance abuse and sexuality, sexual functioning, and incest and other sexual abuse to show women that their experience is not unique and that it is possible to heal and develop a more satisfying life. |
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Offer group counseling for women only, so that sexual problems and sexuality (including sexual communication styles and the dynamics of sex and power) may be comfortably and openly discussed in language familiar to clients. |
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Encourage women to discuss their sexual problems, and let them know that some sexual problems (for example, physical problems related to drug use such as lack of sexual desire among heroin-addicted women) may resolve themselves over time with continued abstinence from drugs. Other problems that result from underlying experiences such as incest or suppressing sexual feelings as a result of prostitution, will require clients to explore and work out their feelings about those experiences. |
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Refer women who are sexually dysfunctional for medical and psychological assessment to determine the organic and or psychological bases for the dysfunction. Treatment should follow this assessment. For example, the client who has been sexually abused should be referred for psychological counseling or sex therapy to a therapist who can address her needs. Ensure that such counseling is culturally sensitive and that it addresses a women's spiritual needs. |
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Provide specific supportive treatment for the client who has been a prostitute and/or who has exchanged sex for drugs. Help her explore her lifestyle and, through internal and external community resources, give her the tools to change her lifestyle. |
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Hold discussions to inform women of their legal rights, and educate female clients about what constitutes violence and abuse against women including physical battering, forms of verbal abuse, violation of physical space boundaries, forced sex, unwanted touching, or a partner's flaunting of affairs. Raise consciousness about what constitutes abuse, so that women become empowered to stand up for their rights and educate their children about their rights. |
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. |
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:
For many women who have been victims of personal violence, use of alcohol and other drugs can become a coping mechanism. |
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
It is important to note that alcohol abuse by lesbians has been identified as both a cause and effect factor related it) violence among partners. |
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.
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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.
Many women report that concern for their children is a major motivation in their decision to enter treatment for substance abuse problems. |
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.
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
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The psychiatric symptoms may result from the addiction and/or withdrawal from the drug (e.g., depression that comes with cocaine crash, hallucinations with cocaine intoxication). |
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Drugs may be used as self-medication (e.g., alcohol overuse in panic disorders or tranquilizers used for pain, which may become entrenched into an addiction). |
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Addiction and psychiatric illness may coexist (e.g., the alcoholic with bipolar disorder). |
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).
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