Women who have alcohol and other drug problems have treatment and recovery needs that must be addressed directly in both the design and management of the treatment process, as discussed in Chapter 3. In this chapter strategies related to the treatment process are offered and presented separately for the treatment environment; intake, orientation, and assessment; the treatment process; and cultural sensitivity/competence. For several of the populations, the information provided in Chapter 4, Outreach, is applicable to treatment as well, and is therefore not repeated. Information related to treatment issues that cross stages of treatment (e.g., relationships, sexuality, and dual diagnosis) are addressed in Chapter 3 and mentioned in this chapter only in terms of specific strategies.
Clients arrive at the treatment program through a variety of mechanisms: self-referral; referral by a family member, significant other or outreach worker; referral by a health or social welfare agency; or referral by the criminal justice system. In the latter case, treatment may be in lieu of incarceration. Regardless of how they arrive, ensuring that they remain in the program for the duration of the treatment experience, whether a three-day detoxification program or a six-month therapeutic community program, is critical. All necessary measures should be taken to ensure that the treatment environment-physical, social, and healing-is safe and conducive to successful outcomes. Program consistency and staff confidence are imperative.
All persons who work in the treatment program - clinical, administrative, and support staff - must be knowledgeable about, supportive of, and sensitive to what it takes to meet the treatment needs of women. Each staff member must treat clients with understanding and respect, convey optimism about positive client outcomes, and impart a nurturing attitude.
The treatment facility itself must meet all local and state codes for health and safety and federal requirements for accessibility (pursuant to the Americans with Disabilities Act). The facility should be secure and safe; indoor and outdoor areas should be well lit. If necessary and possible, arrangements should be made for part-time security guards to ensure the safety of clients, particularly during evening hours. It is also important that the facility be as clean, well-ventilated, and as pleasantly furnished as possible. Fresh paint, cheerful wallpaper, and plants can inexpensively transform a cold and drab facility into an inviting, friendly place. Often, local donors will supply materials and labor for this effort. Colorful posters can be obtained free of charge from the National Clearinghouse for Alcohol and Drug Information (NCADI). 1 Decorations should reflect the cultural diversity of the community.
The overall goal of the intake, orientation, and assessment process is to establish a foundation for a positive, trusting relationship between the client and the counselor. Specifically, the objectives of this process include the following:
to determine the factors that resulted in the client's seeking treatment and her expectations of the treatment process;
to identify any existing health or social needs that require immediate attention and to make the necessary arrangements to have these needs addressed;
to begin to develop a counseling relationship between the client and the counselor, as well as other staff of and participants in the program;
to gather information about the client's physical and mental health and social history. This information serves as a foundation for the treatment plan and will also support the ongoing counseling relationship;
to gather information required by the program for administrative purposes (including client contact information and demographic data); and
to orient the client to the goals, philosophy, and structure of the treatment program.
Throughout this initial treatment engagement process, the program staff must recognize that this is a critical time to build trust in order to ensure successful treatment. However, clients may not disclose sensitive information (e.g., regarding sexual abuse or history of mental disorders) for some time. Because the symptomatology of certain conditions may not present early in the process or be obvious to the treatment staff, assessment data and information have to be collected, recorded, and used to adjust the treatment plan throughout the process.
The intake interview usually consists of an initial assessment from which a comprehensive treatment plan, including clearly specified treatment goals within a defined time frame, will be developed. The counselor should ensure that the client understands why this information is needed, and should assure her that confidentiality will be observed. The importance of client confidentiality cannot be overemphasized. In fact, confidentiality regulations must be strictly observed throughout the treatment process. (See appendix B for a sample confidentiality statement and a consent form for release of confidential information.)
Because a client may be fearful, confused (especially if she is in the process of detoxification or suffers from a co-occurring mental disorder), in a state of denial, and may have short-term memory loss and/or difficulty concentrating, it is seldom possible to do a complete assessment at intake. Intake personnel must be patient and supportive, and repeat questions and information until they believe the client understands the information that is needed and that which must be conveyed. In particular, in view of the possibility that the client may have experienced sexual abuse, it is preferable for the first point of contact at intake to be with a female counselor. If this is not possible, male counselors who carry out the intake interviews with female clients should be trained in gender-related issues.
The program staff should ensure that intake procedures are simple and relevant to a woman's living situation. For example, homeless women cannot easily make calls to a treatment program, and intake workers (both on the telephone and in person) must be sensitive to the particular needs of this population. If the woman has been contacted by an outreach worker, that worker should help the woman to move into and through the intake process.
A preliminary discussion of the nature of the disease of addiction critical during the intake interview to educate clients and their families or significant others. Education on this subject should continue throughout treatment. This may help the client forgive herself and, if the family or significant others participate, may help to change those judgmental attitudes that can hinder recovery.
It is essential to obtain as accurate and complete a substance abuse and treatment history as possible during the intake interview. However, depending on a client's physical and emotional condition at the time of the interview, it may be possible only to identify the current symptoms that are related to her alcohol or other drug use. Questions that can help identify a client's current alcohol or other drug-related problems include the following:
What types of drugs has she used in the last 24 hours, in what amounts and by what method? In the previous month? Three months?
What is her current symptomatology? Is she currently having alcoholic delirium tremens (DTs), seizures, or symptoms of withdrawal from other drugs (e.g., heroin, methadone, or a prescription medication)?
Based on her previous withdrawal experiences, is she at risk of developing DTs or seizures?
Is she in need of detoxification and does her physical status warrant inpatient or outpatient detoxification?
What specific treatment modalities seem to be indicated for her (e.g., use of medications, traditional healing methods such as acupuncture and/or intensive individual counseling)?
There are a number of standardized instruments that are useful for assessing the nature and extent of alcohol or other drug abuse as well as co-occurring disorders. These include the Diagnostic Interview Schedule, the Addiction Severity Index (ASI), the Michigan Alcoholism Screening Test, and the Beck Depression Inventory. Because these instruments have been viewed as not relevant to or sufficiently useful for women, several organizations have begun to adapt them for use in the assessment of women. For example, the ASI has been adapted by a number of treatment programs, and the College of Nursing at the University of North Carolina has developed and initially validated an instrument used to identify alcohol dependence specifically in women.2
In addition to the data concerning her alcohol and other drug use, as complete a medical and psychological history as possible should be obtained from each client, including the following information:
general medical status;
medical problems that have been correlated with abuse of alcohol and other drugs; and
women's health issues (e.g., gynecological and obstetrical information, breast cancer).
The following are examples of medical problems correlated with alcohol and other drug use that may be observed through the physical assessment:
anemia;
cancers of the liver, esophagus, mouth, and stomach;
cardiovascular disease;
cellulitis from intravenous or intramuscular needle use;
cirrhosis;
eating disorders;
gastrointestinal disorders (including ulcers);
hepatitis;
HIV or AIDS;
hypoglycemia;
injuries;
malnutrition;
sexual dysfunction;
sexually transmitted diseases (STDs);
tuberculosis (TB); and
upper respiratory infections.
| Infectious diseases are, critical issues for treatment programs, particularly for residential programs. |
Age category and race/ethnicity should also trigger certain questions. For example, a woman who is African American, age 45 with a history of heart disease in her family, is likely to be at risk for hypertension or cardiovascular disease. An Hispanic women who is overweight should be asked probing questions regarding diabetes.
| In 1993, CSAT issued a comprehensive and detailed Treatment Improvement Protocol (TIP) entitled: "Screening for Infectious Diseases Among Substance Abusers. " |
If a physician, nurse or physician's assistant is available, the medical history can be taken by that health professional. If, during the intake process, the counselor determines that further medical assessment is necessary, a referral should be made so that this assessment can be conducted as soon as possible. Because of the significant increase in the rates of TB in the United States over the past five years, and the threat that TB poses to the health of other clients and program staff members, it is particularly important that clients be screened for this infectious disease and that treatment be initiated immediately if the client meets the criteria for treatment or prophylaxis. It is important that intake workers be observant of the characteristics of infectious TB.
Infectious diseases are critical issues for treatment programs, particularly for residential programs. It is imperative that program staff detect infectious diseases and treat them (or refer women for treatment) as soon as possible. In 1993, CSAT issued a comprehensive and detailed Treatment Improvement Protocol (TIP) entitled: "Screening for Infectious Diseases Among Substance Abusers." This is a useful document for all substance abuse treatment programs and should be a reference document in programs serving women .3
If the standard form in use at the program does not include questions specifically related to women's health, those questions should be asked and recorded on the counselor's summary of the intake, and the counselor should work with the program director to revise the "standard" form or to design a separate form for recording such information. This will help to ensure that the information is consistently obtained and recorded for all female clients and that this task is not left to the discretion of the individual counselor.
If the woman is of childbearing age, it is important to identify (preferably during the intake interview) whether she could be pregnant and if she is pregnant, her gestation period. Pregnancy will affect the treatment modality used, and the types of health services to which a client should be referred immediately and throughout the treatment process.
The mental health assessment, which should be carried out in collaboration with trained mental health providers if possible, should provide an evaluation of the client that includes co-occurring mental illness, developmental disabilities, cognitive impairment, and biopsychosocial stressors/vulnerabilities. Obviously, a comprehensive assessment for multiple disorders cannot be accomplished at an intake interview, but it is critical to initially make the following determinations:
What symptoms may indicate a co-occurring mental disorder?
What symptoms may be an effect of alcohol or other drug abuse?
What may be a side effect of withdrawal?
Is there cognitive impairment related or unrelated to substance abuse? For example, is the woman limited in her ability to understand treatment components?
Has the woman been so physically and/or sexually abused that she will be unable to focus on her substance abuse problem?
It needs to be emphasized again that differential diagnosis of a co-occurring mental or emotional disorder is likely to be difficult at intake. Relevant information needs to be collected, recorded, and used throughout the treatment process.
The manner and timing of symptomatology varies with the condition and the individual woman and her substance abuse history. For example, a panic or anxiety disorder can become more pronounced as the substance abuse stops. Cocaine-addicted clients may require more frequent psychiatric assessments because of the paranoia that can accompany heavy crack/cocaine use and the depression that often follows the cocaine euphoria. Symptoms of AIDS dementia in women infected with HIV will occur later in the progression of AIDS, which can be at any point in the substance abuse treatment process. According to many experts, in order to make an appropriate diagnosis, the client should be drug-free for a period of time so that the symptoms of alcohol and other drug use can abate. However, clinicians do not agree on the appropriate length of time between onset of abstinence and diagnosis.4 The range is two weeks to two months or more. Dual diagnosis is also discussed in Chapters 2 and 3.
In addition to performing the medical and mental health assessment, the counselor should obtain as much information as possible concerning the woman's family and social history and her current life status to ensure that her immediate and long-term needs will be met as completely and as quickly as possible. If possible, the information obtained during the intake process (and used in the initial and on- going assessment of the client's needs) should include the following:
substance abuse history, including previous treatment experiences;
family history and current status (in general, and history of substance abuse);
employment history and status;
living arrangements;
legal or criminal justice status;
financial information;
educational history;
longest friendships and relationships;
current relationship status;
sexual orientation;
country of origin, circumstances concerning arrival in this country and citizenship status;
primary language spoken;
death or current terminal illness of loved ones (to identify grief issues);
pregnancies, children, etc.; and
birth control knowledge.
At intake, the client may not divulge information about medical problems, psychological problems, or behavioral or familial circumstances of which she is ashamed, about which she feels guilty or is unwilling to accept help, or which she believes would result in further stigma or legal penalties if known to the treatment program. This reluctance to divulge information (or to disclose) is particularly evident early in the intake and assessment process, because some clients may think staff members will reject them if they reveal certain details about their lives. This can be a particular problem in rural areas where almost everyone may "know everyone else."
Women may also fear that what they say will be repeated by another client or staff member (who may know their family or friends in the community). This "talking outside," whether real or perceived, may be a major problem in community-based outpatient substance abuse treatment programs and can be a particular problem for women who fear losing custody of their children. Women need to be assured that the information they disclose to treatment program staff will remain confidential for use only in the treatment process or when otherwise approved by the client for release. The client should be helped to feel empowered to disclose sensitive information.
The orientation process is another crucial step in building trust between the client and the program staff. To the extent that the client can become comfortable in the treatment setting, acquire confidence that staff members will respond to her questions and needs clearly and sensitively, and understand the scope of the treatment program and her role in the treatment process, she is more likely to fully engage in and complete treatment. During orientation, the client should be fully informed about such matters as:
the nature and goals of the program, the program's philosophy and specific modalities of care and services;
the physical facility (this should include a tour of the facility);
client rights and privileges (See appendix B for sample principles of conduct and client rights statements.);
the rules governing client conduct and infractions that can lead to disciplinary action or discharge from the program;
the hours during which services are available; and
treatment costs and payment procedures, if any.
The program should make the intake interview and orientation setting as comfortable and private as possible for the client and her family. They should be informed by the treatment staff about the disease of addiction and its physical and mental health effects. Written and audiovisual information (e.g., booklets, flyers, and videotapes) should be available and include materials that the woman and her family can keep. Many of these resources can be obtained from the National Clearinghouse on Alcohol and Drug Information (NCADI), state and local clearinghouses, libraries, and elsewhere. The counselor should also give to each woman a resource directory of public health and social services available in the community, particularly those with which the program has agreements for provision of services. Information and resources should be available in alternative formats to accommodate women with disabilities and those who are not functionally literate.
| Having a female staff member as the first contact during orientation to the program can help the client understand how women feel during treatment. |
Female staff members should be available to meet with the woman during orientation. Otherwise, the counselor should try to refer the client to a local woman's self-help group, taking the client to the meetings, if possible and if appropriate. Having a female staff member as the first contact during orientation to the program can help the client understand how women feel during treatment, how they cope with the realities of daily life during treatment (e.g., child care, relationships, housing), and how barriers to recovery (e.g., emotional obstacles) can be overcome.
To develop a treatment plan that addresses a woman's specific needs and keeps her engaged in the treatment process, it is essential to prepare a comprehensive assessment. The International Certification Reciprocity Consortium/Alcohol and Other Drug Abuse (ICRC/AODA) has defined the assessment process as including the following:
... those procedures by which a counselor/program identifies and evaluates an individual's strengths, weaknesses, problems, and needs for the development of the treatment plan.
This assessment is based on information obtained during intake (and recorded on intake and standardized assessment forms) and on the counselor's, case manager's, or team's clinical observations. Staff preparing assessments of client's needs should acknowledge that clients may not have disclosed fully information related to their substance abuse, physical and mental health, and social needs. The assessments will, in many cases, be provisional, contingent on the program staff building trust throughout the treatment process. This requires flexibility in both assessment and treatment planning. It necessitates ensuring that relevant information (e.g., regarding history of exposure to violence) is recorded in the client's file, reported to the clinical team, and used in revising her treatment plan and in providing services.
The client assessment is, essentially, a synthesis of information gathered during intake. It should include a summary of the client's strengths and factors that may impede recovery. It should include space to record the basis for the determinations (e.g., program intake forms, standardized assessment instruments, clinical observation). The assessment should include issues related to basic living skills, such as the following:
developing and maintaining personal health and hygiene;
finding and retaining a job;
obtaining housing;
managing money;
maintaining a household; and
parenting.
The assessment is critical to the program's determination of what specific treatment methods will help empower the client to set and achieve her own treatment goals and make necessary changes to achieve those goals. In that regard, clinical staff must recognize that some women may find it difficult to address immediately the broad range of problems associated with substance abuse, co- occurring mental disorders, physical health problems, or life skills areas. For example, some women who have been unemployed for some time may find it difficult to re-enter the work force, become independent from social support systems (e.g., AFDC) and become drug-free at the same time. (Strategies related to providing services in life skills areas are presented in Section 5.3.1: Providing Comprehensive Treatment Services.)
The treatment plan serves as the fundamental basis for providing care to the client throughout her treatment process. While most programs have standardized forms for the treatment plan, each plan needs to address the specific needs of each client, based on the assessment described above. The assessment form should clearly delineate the relationship between the findings of the assessment and recommendations to be included in the treatment plan. The counselor or case manager works with the client to determine the following:
the priority of the full range of problems that need to be addressed (including those directly and indirectly related to substance abuse and other physical and mental health and social service issues related to the woman and her family);
immediate and long-term treatment goals; and
the most appropriate treatment methods and resources to be used.
At intake, the treatment plan can address only the immediate problems presented by the client and observed by the clinical staff. In fact, some clinicians think it is inappropriate to set long range goals at this point because the client may be concerned only about the immediate needs of herself and her family. The treatment plan should specify the services to which the woman will be referred, including the agency or agencies to which referrals are made. Throughout the course of treatment, results of all referrals must be recorded, including outcomes, if known.
As discussed in Chapter 3, the length of the treatment process and the types of modalities used in treatment vary significantly from one program to another. The information provided in this section is intended to be general enough to apply across treatment modalities. Where appropriate, information specific to modalities of care (e.g., inpatient detoxification, outpatient drug free treatment) is provided. Because it is assumed that the reader is a trained substance abuse counselor or administrator and/or has experience in substance abuse counseling, general information concerning approaches to individual, group, and family counseling, and use of medications in treatment (e.g., antabuse and methadone) and other general treatment methods are not addressed. Rather, aspects of the treatment process or of specific modalities of care that relate predominantly to women are described. However, while some treatment strategies may appear to be simple, they have been shown to have demonstrable impact on the success of substance abuse treatment programs-for both women and men.
In planning and implementing treatment services, the program staff should try to ensure that there is a coherent link between the treatment philosophy of the program, the treatment modalities that are used, and the specific services offered for women. This apparently obvious consideration can sometimes be overlooked by programs, particularly when there is a change in staff leadership and a consequent change in program philosophy, or when funding considerations dictate changes in services. The staff needs to ensure that the weekly schedule of program services - including individual and group counseling, participation in self-help groups on- and off-site, specialized group meetings (e.g., for adolescents, women with a history of sexual or physical abuse, or pregnant women, sessions on spirituality and personal growth), and time for personal activities (e.g., vocational training, GED classes) - not only reflects the program's treatment philosophy but also takes into account the varying needs of the clients and the reality of scheduling comprehensive services outside of the program.
For programs in which children are present with their mothers, the need for personal time between the mother and her child(ren) is critical. Staff should be aware that balancing the substance abuse treatment needs of the woman (with other needs such as addressing mental health disorders) with the needs of her children requires that considerable attention be given to scheduling activities: those that meet collective needs of the clients; the individual needs of the woman; and those of her child(ren). Throughout treatment, the program should ensure that the clients benefit from effective case management.
The client is participating in the individual and group counseling sessions as agreed in her treatment plan, including attendance at 12-Step or other self-help group meetings and fulfilling other requirements set by the program;
The client's alcohol and other drug use is monitored (e.g., through urine testing, observation, and/or self-report);
The client's record is complete and up-to-date, with the following information:
- progress notes of all individual and group counseling sessions, including notes from staff or consultant health and mental health providers and notes from meetings of the treatment team;
- reports of physical and mental health and social assessments (with a summary of the findings of these assessments and their implications for the treatment process);
- records of referral for services outside the program, including outcome of the referral;
- changes in the treatment plan based on new information; and
- complete and up-to-date information on the child(ren) if these records are maintained with the mother's record; and
| The treatment process should gradually lead clients to develop higher self-esteem and then to develop healthier and more loving relationships with others. |
To help each client identify her strengths and increase her level of confidence, the treatment services provided should be designed to help clients appropriately and effectively relate to themselves, and their family, friends, and institutions. The treatment process should gradually lead clients to develop higher self-esteem and then to develop healthier and more loving relationships with others. If treatment services are truly comprehensive, they will likely include strategies that will involve not only services within the treatment program itself, but a community-wide support system to ensure continued care and support for a woman's physical, emotional, financial, psychological, spiritual, legal, and family needs over the treatment continuum. Because few treatment programs can respond to all the identified needs of substance-abusing women, they must develop referral mechanisms, collaborative agreements and tracking systems that allow women, especially those with children, to receive services before, during, and after treatment.
Within the treatment program, counselors should address the following issues:
the etiology of addiction, especially gender-specific issues related to addiction (including social, physiological, and psychological consequences of addiction and factors related to onset of addiction);
low self-esteem;
race, ethnicity, and cultural issues;
gender discrimination and harassment;
disability-related issues, where relevant;
relationships with family and significant others;
attachments to unhealthy interpersonal relationships;
interpersonal violence, including incest, rape, battering, and other abuse;
eating disorders;
sexuality, including sexual functioning and sexual orientation;
parenting;
grief related to the loss of alcohol or other drugs, children, family members, or partners;
work;
appearance and overall health and hygiene;
isolation related to a lack of support systems (which may or may not include family members and/or partners) and other resources;
life plan development; and
child care and child custody.
The ability of women to identify their own needs and to address those needs directly is a factor in their seeking treatment for substance abuse, staying in treatment, and continuing recovery. However, the treatment program staff, and in particular the clients' counselors or case managers, must help women identify those needs and disclose information throughout the treatment process. The staff must continuously work with women to revise their treatment plans based on reconsideration of their needs. Women's "issues" are not stagnant; they may and often do change during the treatment process.
| The staff must continuously work with women to revise their treatment plans. Women's "issues" are not stagnant; they may and often do change during the treatment process. |
Relapse prevention should be a discrete component of the treatment process and should integrate the client's specific issues into the general modality of care. Relapse strategies are described more fully in Chapter 6.
Treatment providers should be careful to acknowledge clients with children in their various roles: as individuals by addressing their personal needs and enhancing their self esteem, as mothers by addressing their parenting role, and as members of a community by helping them to participate in various organizations and activities. Treatment plans for women with children should include a children's component; one that offers prevention strategies to reduce the children's risks of developing poor physical and mental health problems, including substance abuse. Such a component could include training for parents, health care for the children, family outings, and therapeutic activities designed specifically for the children of clients.
Arrangements for services outside the program should be clearly defined, preferably with ongoing contracts or cooperative agreements with the service provider. A standard referral form should be used to describe the service proposed and record the service provided and the outcome, if any. This form should be returned to the treatment program and be included in the client's treatment record. If arrangements are made for other health or social services, a staff member, or trained volunteer, or, in the case of residential treatment, a "senior resident" or staff member should accompany the woman to the service provider, if possible. Having someone accompany the client to services, at least for the first time, may help her begin to trust and understand how to accept support, even if she is in a confused state.
Substance abuse often leaves women debilitated, confused, fearful, or disorganized; they also may experience short-term memory loss or craving for alcohol and other drugs. Therefore, it may be difficult for them to either contact or interact with representatives of the referral agency independently.
5.3.2 Strategies for Providing Comprehensive Treatment Services
Strategies that can help ensure that the woman's health and social needs are met include the following:
Health Services
The program should ensure that a network of physical and mental healthcare providers is established to help address their clients' general problems and those requiring specialty care. The provider(s), whether on staff or consultants, should be knowledgeable about addiction in general, the particular physical and mental addiction problems of women, the socioeconomic and gender factors that relate to women's addiction and general physical and mental health. They should also be sensitive to diversity based on race, ethnicity, age, disability, and sexual orientation.
Arrange for health education. Arrangements should be made for a health care provider or health education specialist to conduct ongoing health education classes on nutrition (and its role in recovery); self-examination for breast cancer; basic gynecological care; HIV risk reduction; the effects of alcohol and other drug use during pregnancy; basic children's health care issues; the physiology and transmission of STDs; reproductive health; female sexuality; preconception care; prenatal education; childbirth education; family planning; childhood safety and injury prevention; physical and sexual abuse education and prevention; and smoking cessation, especially for pregnant women.
Provide testing for HIV, STDs, and TB. Arrangements should be made to have pretest counseling, HIV, STD, and TB testing and post-test counseling available on-site, if possible, or at a location convenient for the clients.
Adjust treatment requirements for pregnant women. Programs should develop a plan of action and a network of resources to provide a comprehensive program for women who are pregnant and their babies after delivery.
Arrange for developmental evaluations of children born while their mothers are in the program. Identify and address problems while the mother is in treatment. Contact state agencies responsible for developmental services, including assessment of developmental status/problems, and identify Title XX day care slots available in the community. Outreach or other staff can seek help from churches and charitable organizations to obtain equipment to establish a nursery for the newborns. A local child care agency might provide staff to supervise a nursery.
| CSA T has identified preconception counseling, including the full range of reproductive options, as an important aspect of substance abuse treatment. |
Preconception Counseling
CSAT has identified preconception counseling, including the full range of reproductive options, as an important aspect of substance abuse treatment. Specifically, the following issues have been recommended by CSAT, in its TIP on Pregnant, Substance-Using Women, to be addressed in such counseling:6
the various methods of contraception and the attitudes of the woman, her significant other, and her community regarding their use;
the impact on the woman and the fetus of alcohol and other drug use during pregnancy;
the teratogenic impact of prescribed medications, such as Antabuse and various anticonvulsants; and
alternative medications with reduced or no teratogenic potential for such common problems as seizure disorder.
Social and Health Services (basic life skills)
Arrange for safe, reliable and low-cost transportation to and from the facility. Many programs provide bus or subway tokens for female adolescents and adults, especially low-income clients and, if necessary, request an extra bus stop near the facility or an extension of hours for bus service. If possible, have a donated vehicle available on-site, or make arrangements to use vehicles maintained by a local community organization or place of worship. Accessible transportation should be available to women with disabilities.
Ensure economic access. A sliding fee scale based on a client's ability to pay is a significant incentive for women to seek treatment. An assessment of a client's ability to pay should not include her partner's income because she may not have safe access to those finances. The program can help to arrange for "indigent care" at local health facilities at little or no cost. One way to accomplish this is by establishing a relationship with a nearby health service provider who receives McKinney Act funding.
| Parenting education should be integrated with substance abuse counseling to be recovery-oriented. |
Assist with the development of parenting skills. Counseling, with information on child development, child safety, injury prevention, and child abuse prevention should be provided. Parenting education should be integrated with substance abuse counseling to be recovery-oriented. Issues that relate to a woman's upbringing and that affect her parenting ability should be addressed in a way that supports rather than compromises her recovery. Specific strategies include asking a local college or university that offers a major in child development to have interested students assist in providing child care and child enrichment classes. It is also important to help a client weigh her options, such as having family, friends, social agencies, or places of worship provide short- or long- term care for children if they are to avoid placement in foster care. Arrange for a network of healthy families to serve as role models for mothers who have never experienced a normal home life, or develop "adopt-a-mother, adopt-a- family" program such as those operated by "100 Black Women" and other groups.
Assist with educational services. Provide a library or reading room, facilitate access to local public libraries and encourage clients to read. Help to arrange for literacy training or GED/high school diploma or other educational or training opportunities.
Assist with housing. Often, a woman entering treatment may need assistance to access housing, either during treatment (if she is in an outpatient program) or after treatment, if she is in a residential program. In these cases, it is critical that the program have on- going arrangements with public or private social service agencies for access to transitional and permanent housing. Affiliations should also be made with organizations such as housing advocacy groups and domestic violence centers (e.g., a local House of Ruth), which may have temporary housing available. If the woman is an AFDC recipient, the program should contact her case worker to determine if there is public or other housing available for the client.
Provide recreational and cultural activities. Arrange for ongoing recreational and cultural activities with an emphasis on activities which will enhance women's self-esteem and improve their general physical and mental well-being. These activities should be culturally specific, and provided through arrangements with such groups as African American, Hispanic/Latina, or lesbian cultural and service organizations. Activities must be made accessible to women with disabilities, pursuant to the Americans with Disabilities Act (ADA).
Offer a range of child care options. These could include child care services located within residential programs or in shared apartments; day care in the community in which the program is located; or program-based day care. Establishing a network of voluntary child care arrangements is highly recommended. Volunteers may include family members, retired senior citizens, interns from local schools (including colleges offering degrees in early childhood education), places of worship, and self-help group members. Local day care nurseries and schools may be willing to provide scholarships for children of mothers in treatment.
Arrange for family therapy. If it is not possible to have fulltime or part-time licensed family therapists or psychologists on staff to provide counseling to all clients (including heterosexual and lesbian couples and single women), arrangements should be made for these services on a regular consulting basis. In addition, all counselors should receive training to provide at least minimal family counseling. Counselors should be able to address the specific needs of adolescents, older women, women of color, women in the criminal justice system, low-income women, lesbians, and women with disabilities. The children of clients can be referred to self-help groups specializing in children and youth (e.g., Al Atot, Al Ateen, Al Anon) groups.
Provide materials and resources on personal growth and relationships. Low-cost or free books and pamphlets are widely available on codependency, healthy relationships, families, personality development, and self-help ("personal growth"). They should be obtained for clients to use at the program site, or if possible, for clients to keep. Videotapes should be shown regularly to provide information and encourage discussion of the issues between the client and counselor and among the clients during group sessions and informally.
| Staff should be trained to offer support and assistance to help women deal with legal issues. |
Arrange for legal services when necessary. Few programs have consulting attorneys on staff, but most have arrangements for referral to legal support systems (e.g., legal aid, law schools, or organizations which specialize in child or spouse abuse). Staff should be trained to offer support and assistance to help women deal with legal issues, such as real or anticipated loss of child custody cases, domestic violence cases, and incest or victimization in their or their child's experience, and to make referrals to the legal system as appropriate. Treatment programs often work with the public defender's office, free or low-cost legal assistance networks, law school facilities, and city or state offices of human rights to conduct workshops on a variety of topics. Many also arrange for the services of female attorneys specializing in women's legal issues (e.g., abuse, separation and divorce, child custody, pregnancy) as consultants to the program.
Arrange for financial assistance and counseling to ensure economic stability. The program should have ongoing relationships with public and private agencies through which financial assistance for the clients can be arranged, including SSI, Medicare, Medicaid, AFDC, unemployment, and housing assistance. Other successful strategies that have encouraged financial independence include establishing a business (e.g., word processing) on-site so that women can learn marketable skills, increase self-esteem, earn income and, if possible, begin holding a job; arranging for career-oriented field trips to community and women's organizations and to local industries to explore the variety of jobs available; having successful working women who represent diversity in terms of race, ethnicity, age, disability, and sexual orientation serve as role models and mentors; and establishing self- help, job-seeking groups as a support network to help clients deal with the ups and downs of job searches. The power of these groups cannot be overestimated in helping women take the risks involved in finding employment. Working with the local state unemployment office to use its employment network and computers is also useful, as is setting aside time each week for a "resume roundup." During this time women can learn to develop job histories and to translate their life skills into data for their resumes.
It may be possible to have a representative of the local office of the department of labor or a vocational rehabilitation center assigned to the program to assist in vocational assessment and placements at the appropriate time in treatment. A representative of a local department of education and training may be available to evaluate needs, develop appropriate educational plans, and make arrangements for meeting the educational and training needs of clients. In addition, representatives from local financial institutions are often willing to conduct workshops about basic money management-budgeting, paying bills, saving money, and obtaining loans. Another effective approach is to hold training sessions on how to balance checkbooks, secure insurance coverage, find quality medical and child care, and shop wisely.
An example of a woman with economic difficulties presenting for treatment and strategies designed to address those difficulties is shown on the following page.
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| The client's relationships with family, significant others, and friends can be critical to her recovery. Her sexuality is also important although often neglected by treatment programs. |
The client's relationships with family, significant others, and friends can be critical to her recovery. Her sexuality (including sexual functioning and sexual orientation) is also important although often neglected by treatment programs. These issues have been addressed in Chapter 3. Strategies to address relationship and sexuality issues include the following:
Provide time each day for women to talk among themselves about their grief; to share issues of grief related to giving up both alcohol and/or other drugs and the lifestyle associated with these; and grief related to their children, homes, and partners. Encourage women to talk about grief related to losing loved ones when they were drinking or using other drugs and to air feelings of loss that may have been buried during years of substance abuse. Develop a list of the stages of the grieving process for clients;
Encourage clients to keep a journal to reflect on relationship and sexuality issues as well as on their substance abuse; this can help the client to disclose these issues during individual and group counseling. However, it is critical that these journals be protected to prevent disclosure;
Arrange for the services of a member of the clergy or spiritual leader, preferably a woman, to act as a resource to the staff and clients to help diminish denial, fear, and poor self-esteem. This may be particularly important for women who have a history of sexual or physical abuse or poor family relationships (including with their own children or their parents);
Help clients to view assertiveness as a social skill relevant to recovery. Emphasize that life can be easier if one knows how to get what one needs from others without hurting them or becoming anxious. Conduct classes on assertiveness so that women learn to share, to make their needs known, and to protect themselves. Encourage women to identify and discuss well-known assertive women whom they admire;
Advise women to take on more responsibilities as they move through the program to build self-esteem and to promote their ability to function independently of the program;
Arrange for groups in the treatment program to meet regularly to address relationship and sexuality issues. During these sessions, encourage clients to accept that the treatment program is a safe place to explore relationship and sexuality issues, even if there is a threat of domestic violence at home;
Arrange for clients to receive counseling from mental health professionals specifically trained and experienced in working with women's relationship and/or sexuality issues, including posttraumatic stress disorder (PTSD) resulting from child and/or adult sexual or physical abuse; arrange for clients to participate in self-help groups that address these issues; and
Help women learn how to express and begin to trust their anger, and how to deal with it in stressful situations.
Increasingly, the need to address the spiritual needs of the client is seen as an important aspect of substance abuse treatment. The concept of spirituality should not be confused with that of religion, which is the way we attempt to systematize belief in a higher power through specific definition and through rituals, rules of conduct and philosophical frameworks. In contrast, spirituality is not defined nor constrained by specific parameters. In the context of this manual, spirituality may be considered in terms of one's journey toward increasing awareness of oneself and one's relationship to the rest of the world. It is an empowering and healing process. Bjorklund has noted the variations in spiritual journeys, suggesting that "spiritual relationships evolve from how a person has experienced life and how he or she has come to deal with life situations."7 Experience with alcohol and other drugs as a destructive force alters the degree to which one can address our basic human needs, including relationships with other people. The following is a definition of spirituality that has been used in substance abuse treatment:
Spirituality has to do with the quality of our relationship to whatever or whomever is most important in our life.8
Given a broad-based concept of spirituality as focusing on personal empowerment and crossing cultural and religious boundaries, treatment programs can provide an environment that facilitates the clients' spiritual journeys. In fact, the psychotherapist Moore suggested that "psychology is incomplete if it doesn't include spirituality ... in a fully integrated way." 9 The important relationship between spirituality and substance abuse treatment was described by Bjorklund:
Spirituality, because it has to do with what (whom) is important to us, is closely related to values, priorities, goals, and preoccupations. It has to do with whatever is at the center of our life. 10
| Spirituality, because it has to do with what (whom) is important to us, is closely related to values, priorities, goals. and pre-occupations. It has to do with whatever is at the center of our lift. |
In fact, he suggests, "Just to stop [alcohol and other drug use] without other growth and change would simply frustrate a person who has not learned any other way to meet basic human needs... spirituality takes its place with the physical and emotional aspects of a recovery program as a necessary foundation for building a new way of life."11
Programs that implement the Comprehensive Model described in Chapter 3 (including attending to the woman's physical, psychological, social and spiritual needs) help the woman to move from a sense of fear, despair, hopelessness and isolation to one of trust and belief; improve her self- knowledge and self-esteem; and empower her to be self-sufficient and interdependent upon completion of treatment. These goals can be an important part of the recovery process.
To retain women in treatment, the most important task is to ensure that the program is gender sensitive and that the broad spectrum of women's bio- psycho-social needs are met. This includes, for example, addressing their physical and mental health, housing, child care, and legal needs. These topics are addressed throughout this manual. Other specific approaches for retaining women in treatment include the following:
Ensure that, if possible, women have their own "private space" in the treatment setting. This could be, for example, a separate recreation room or meeting area;
Involve partners and family members as appropriate to enhance women's recovery and reduce sabotage;
Recognize the reality of women's lives and responsibilities;
Find ways to help women take control of their own treatment so that they become invested in it;
Help women feel successful as they move from one phase of treatment to another;
Provide positive female and male role models; and
Eliminate barriers to retaining women in treatment that are identified within the program itself. Feedback from clients- particularly from those who leave treatment early-can provide useful information to identify such barriers.
| The discharge plan should be prepared befo re the women completes or leaves treatment. |
In the treatment process, the discharge plan is as important as the initial assessment and treatment plan because this phase serves as a bridge between the treatment process (whatever the modality of care or duration) and continuing care. The discharge plan should be prepared before the woman completes or leaves treatment. The determination about whether a client is ready for discharge should be made jointly by the client and her counselor, or with the treatment team, if the program uses such an arrangement.
The discharge plan should include the following:
- her treatment goals and the extent to which they were met;
- reason(s) for discharge;
- summary of successes and problems encountered during treatment; and
- factors that facilitated and/or hindered her progress.
- alcohol and other drug use;
- physiological health in general;
- mental health;
- employment;
- living arrangements;
- vocational and educational needs;
- parenting ability and status of her children;
- other emotional support needs; and
- financial support needs.
- substance abuse counseling;
- medical and mental health services;
- family therapy, child care, housing, financial and other services; and
- sobriety support groups.
The program should make specific arrangements for continued contact with the client, including periodic visits to the program. This will reassure her that there is a "safe place" to visit in times of emotional, psychological, or physical distress and will also facilitate the follow-up process.
All treatment program components and procedures should be reviewed regularly to ensure that they are culturally sensitive and culturally relevant. This includes outreach, initial contact, intake, the treatment process, discharge, and follow-up. Cultural competence and sensitivity as related to different ethnic and racial groups, age groups, disability groups, and sexual orientations should be reviewed so that appropriate responses can be ensured. For example, during client case presentations made to staff, issues raised by different population groups in treatment should be discussed. Staff should be trained to avoid discriminatory language and behaviors. Moreover, specific rules should be established and enforced with respect to such language and behavior on the part of clients and staff members.
| To help ensure that the clients' culturally specific needs are met, the program should offer clients the opportunity to attend 12-Step or other self-help meetings that are population-specific. |
To help ensure that the clients' culturally specific needs are met, the program should offer clients the opportunity to attend 12-step or other self-help meetings that are population-specific (e.g., for women of color or lesbian women). This could be accomplished through referral, by scheduling regular meetings at the treatment program's location, or by listing these meetings as part of the program's regular activities.
Examples of strategies that relate to specific populations of women follow. They are grouped within the following categories:
Age groups (adolescent and older women);
Ethnic and racial minority group populations; and
Other specific groups of women.
Adolescents
Arrange for role models and provide materials specifically geared to adolescent girls. Identification with appropriate role models is critical for adolescents to gain hope and to progress through treatment. It is also helpful to compile a book that will foster a sense of hope using letters written by young women in recovery.
Conduct home assessments and encourage family involvement in the treatment process where appropriate. Meet various persons who are involved in the adolescent's life, including parents, grandparents, children, partners, other family members, probation or parole officers, social workers, guidance counselors, and teachers. During these meetings, program staff should try to ascertain if there appears to be sexual or physical abuse as well as substance abuse in the family. If possible, visit the young woman's last place of residence and meet the people; this should be done only with the knowledge and consent of the person in treatment.
| Pregnant teenage girls require special support while they are in treatment to help ensure that they remain in school. |
Pregnant teenage girls require special support while they are in treatment to help ensure that they remain in school. Strategies include day care services and special attention to nutrition.12 In addition, girls who became pregnant as a result of rape also need to receive psychological counseling while they are in treatment.13 Provision of services to address sexual abuse concurrent with treatment for the client's substance abuse "ensures that the young women are better able to remain drug and alcohol free." 14
Keep on hand personal care items (e.g., nail and hair care supplies, stationery, and pens) as incentives or rewards for the adolescent girls.
Older Women
Work with appropriate senior service agencies to provide safe, inexpensive, and accessible transportation options that bring older clients to the treatment facility for scheduled treatment activities. This is a critical first step in providing care to this population. Schedule groups during the hours that these agencies offer transportation.
Work with a local senior center or an adult day care center to arrange for space to hold groups at that facility. Establish a relationship with the administrative personnel of the local hospital to arrange for space to hold groups within the hospital setting. The senior transportation program may provide regularly scheduled transportation to these locations, and the scheduling of groups can be coordinated around the available public and senior transportation schedule.
Help train representatives of health agencies so they can identify older women with substance abuse problems and refer clients to the treatment program for services.
Ensure that the facility (both its entrances and furnishings) is accessible to older clients, including those with physical disabilities and/or sensory losses. For example, deep seats that are low to the ground are difficult for some older people to use.
The physical condition of some older people must be kept in mind. Frail older people bruise easily, their bones may be fragile, and their sense of touch may be diminished. Many older women have osteoporosis and generalized bone loss. For example, what might be a therapeutic hug to a young person could bruise or break the bones of some older women. Hearing and vision problems should also be diagnosed and recognized during individual and group therapy. Because thermoregulation does not occur quickly for some women who are much older, it may be appropriate to encourage some older women to wear sweaters during therapy and education sessions.
For homebound older women, regular telephone therapy groups facilitated by a substance abuse counselor may be an appropriate approach. On a specific day of the week, at a specific time of day, the counselor makes a conference call that may include, for example, three clients and the counselor/facilitator. The phone group should be closed, have specific discussion topics, and be of a set duration. Assignments to be completed between sessions need to be developed for each of the members. The group members can decide at the end of the formal, facilitated sessions (eight to 10) whether they wish to exchange telephone numbers and maintain informal telephone contacts. This approach can be extremely valuable: sensitive subjects can be discussed openly, given the degree of anonymity that the telephone offers. The telephone therapy group should be followed up with regular telephone contact between the counselor and the individual group members. These individual calls are also scheduled for a set length of time.
Designing and implementing successful treatment strategies requires racial, ethnic, and cultural knowledge; competency; and sensitivity concerning diverse issues. However, in attempting to describe cultural factors, it is important not to fall into the trap of unintentionally perpetuating stereotypes of ethnic and racial populations. It is also critical to understand that diversity exists within a racial or ethnic group as well as among groups: women of all races and ethnic groups vary by personality, geographic origin, socioeconomic class, religious upbringing, and other factors, all of which play a role in their individual "cultures."
Moreover, many of the cultural differences attributed to one population may apply generally-if somewhat differently-to many racial and ethnic groups. For example, communication styles vary considerably in terms of preferred space (physical distance) between the conversants; the degree to which contact (touching) is appropriate; eye contact (which is value-laden in most societies); and language styles (formal or "street" or other). Differences in communication style also can vary by personality type, socioeconomic class, and religious upbringing. An example of the latter is the "call and response" communication attributes applied by some to African Americans who are religious. They are equally applicable to Roman Catholics irrespective of their race or ethnicity. Therefore it is important for the counselor to assess each individual's cultural orientation carefully. The counselor should not presume the degree to which the various "cultural" factors-not only ethnic or racial background-are predeterminant.
| Counselors and staff should be trained to recognize and con front their own biases toward clients of' other ethnic, racial, and cultural groups. |
Counselors and staff should be trained to recognize and confront their own biases toward clients of other ethnic, racial, and cultural groups; this helps them to be aware of their own nonverbal communication. They particularly need to be cognizant of nonverbal communication that is rejecting, insincere, or judgmental. If these messages, however unintended, are communicated to the client, her response whether verbal or nonverbal, may be inappropriately labeled as defensive or hostile. As with other judgments regarding the client's behavior, counselors and other staff need to be aware that such labeling can unfortunately become a diagnosis that may follow the woman throughout her treatment and severely impede her recovery.
For recent immigrants of any origin, at some point early in the treatment process, the counselor should question clients about citizenship status, degree of acculturation, country of origin, circumstances of move to the United States, country with which they identify, language abilities, literacy level in native and other languages, spiritual/religious base, educational level, housing, and legal issues. However, given laws of deportation, the staff must be very sensitive when asking these questions.
African American Women
As with other ethnic groups, there are regional cultural differences in the behaviors of African American women that have often been shaped by or formed in response to the dominant culture. For example, some African American women may be more inclined to avoid maintaining eye contact because it has been perceived as showing disrespect or as defying authority-a carryover from segregation. In contrast, other African American women may have rejected behaviors that indicate deference to authority and may be perceived by some program staff as defensive or hostile. Staff need to be cleat about the particular viewpoint of the individual client and be cautious about judging behavioral clues.
"Touching" during conversation to convey empathy is typically welcomed and accepted by most African Americans only between those who are close and by intimate friends. However, if touching is secondary to an insult or an act of disrespect that the care provider is attempting to redress, it may be considered intrusive and insincere. It may not be appropriate for a therapist to touch the client unless there is an established level of trust and rapport that merits such intimacy. Touching should not be viewed as a therapeutic approach to gaining trust.
African American women are often reluctant to engage in conversations with and seek assistance from health care professionals, particularly those who are not African Americans, because of negative and demeaning experiences that they have heard about or experienced. African Americans may perceive questions related to finances or sexual behavior as intrusive and as indicative of stereotypical thinking. Because some African American women are reluctant to "put their business on the street," staff should be aware that it may take some time before clients disclose information that the program requires or believes necessary for treatment.
American Indian Women
The American Indian woman often experiences feelings of isolation from the rest of the American Indian community while in treatment. These feelings can be minimized by integrating traditional healers or other community leaders into treatment programs, if so desired by the client. This should be done early in the treatment process when making decisions about treatment placement (i.e., outpatient versus inpatient) and the length of stay. Include the family and/or tribal decision makers in planning the treatment and continuing care program if applicable.
Culturally appropriate and community-specific conceptual processes, including an awareness of historical and contemporary factors influencing substance use and abuse, are critical. Also important is an awareness of the cultural concepts and definitions of health, illness, and substance abuse held by American Indians and how these beliefs can be used as the foundation for treatment. If possible, services in American Indian languages should be provided for those women not conversant in English. If the treatment agency is not nearby, the agency should make arrangements for providing transportation for clients and their families, if appropriate. Program staff members must acknowledge and promote clients' religious beliefs, values, and practices as a significant part of their empowerment and validation. Collaborating with American Indian health care programs and allowing for culturally relevant adaptation of treatment modalities (e.g., sweats, dances, and Talking Circles) are important ways to show respect for American Indian cultures. The Swinomish Mental Health Program manual suggests ways to develop appropriate services for American Indian women.
American Indian female clients should, if possible, be referred to American Indian agencies, educational programs, and vocational training programs when outside resources are used.
Asian/Pacific Islanders
|
The value of spirituality as a source of strength and healing should not be overlooked. |
Recognizing the historical significance of spirituality and religion will help counselors understand the API client. Many API cultures have integrated Western religion with their indigenous beliefs and rituals. The value of spirituality as a source of strength and healing should not be overlooked. For example, some Native Hawaiians use healers and respected elders called "Kahunas" to provide and promote emotional and spiritual guidance and healing.
The case manager should be responsible for locating culturally specific services that have bilingual/bicultural staff, or identify appropriate staff in mainstream service agencies.
Hispanic/Latina Women
If the target population is predominantly Spanish-speaking, all materials should be printed in Spanish, including intake and assessments forms, treatment plan forms, discharge forms, and other documents. The program should also have available educational materials in Spanish. At least some clinical staff (part time or full time) members should be Spanish-speaking.
Programs should establish a library of books and tapes in Spanish that present the stories of Hispanic/Latina women who have addressed (and overcome) similar problems and who can act as role models for women entering substance abuse treatment.
It is recommended that the program host or arrange for referral to AA, Al-Anon, or other 12-Step meetings in Spanish for women only.
Networking with programs and agencies serving Hispanic/ Latina women and their families to arrange for cross-training is extremely helpful. Through this method, the program staff can explore how they handle substance abuse issues, share program information, and formalize communication.
By providing access for Hispanic/Latina women to groups that address women's concerns or general concerns of their cultural community, clients can build confidence as women in roles other than those of addicted persons or mothers. Such groups can include, for example, those relating to expanding women's roles in the economic development of the community, generating housing opportunities, and helping to increase access to health care services.
One avenue which may serve as an incentive for Hispanic women to enter treatment is to invite Hispanic/Latina women from the community to visit the program and explore services for themselves, their children, or other relatives.
Women in the Criminal Justice System
Treatment staff should acknowledge and address the additional stigma that incarcerated women or women with criminal records face; this will be particularly useful during follow-up and continuing care.
Criminal justice and treatment personnel should work together to ensure that each conveys similar messages to female clients, regarding the importance of ensuring that they access substance abuse treatment and determining the appropriate modality for each woman.
It is important to involve women from different ethnic and socioeconomic backgrounds who have "graduated" from the criminal justice system as role models for those in treatment. Such involvement may include their participation in discussion groups at the program, having available written personal histories, or arranging for videotapes in which their personal histories are presented.
The program should develop a referral system to provide legal assistance for such issues as custody and parole.
Women with HIV/AIDS
Substance abuse treatment programs should provide an ongoing HIV/AIDS education, prevention, and treatment component that is fully integrated into the overall treatment system. Programs that are part of a medical center will likely have the appropriate resources to provide medical care to their clients who are HIV- positive or who have AIDS. Most programs will provide services through referrals to outside sources. The treatment program should have formal referral agreements with such sources, which should include case management to ensure that the treatment program is aware of services provided, their outcome, and the on-going health status of the client. In addition to the comprehensive services described previously in this chapter, the special parenting issues, self-care techniques, symptom management, medical needs, and the needs of family members and significant others should be addressed.
Legal assistance should be provided to women with AIDS who may need help drawing up a living will or addressing other legal (or legal/financial) issues such as access to Social Security benefits and life insurance.
The program should also offer appropriate psychiatric and psychological assessments and psychological support for women infected with HIV/AIDS to address the issues of death and dying and custody and care of children when it becomes necessary.
The program should establish liaison with the many support groups that address parenting, general or sexual health, and other issues for HIV-positive and AIDS clients.
Personnel must be prepared to help the women with AIDS and their families deal with the issue of medication for easing pain in the terminal phases of AIDS.
Women with Disabilities
To serve women with disabilities, it is critical that information, policies, programs, and facilities are accessible to them. Providing accessible transportation, particularly in communities where transportation options are limited, is also essential. Women with disabilities who are staff members of the treatment program can facilitate the process of engaging women with disabilities in treatment for substance abuse problems.
Staff members need to be careful not to view a client's disability as the cause of substance abuse, or even as a cause. Sometimes the disability may be the result of substance abuse. For example, a woman's disability could have been the result of an accident that occurred when she was driving while intoxicated. Sometimes the disability may be a minor or irrelevant factor. Counselors may find it helpful to obtain information on the extent, nature, cause, and age of onset of the disability, as well as the woman's assessment of the role of her disability status in her substance abuse problem. This information can be obtained as part of the intake process, but it should not be the first item on the intake agenda.
| It is also important to consider women with disabilities as the experts on their own disabilities. |
Counselors should assess women with disabilities in the same manner that they assess women who are not disabled. They need to cover the same topics and issues during intake and avoid making limiting assumptions about the woman's sexuality or lifestyle. For example, sexuality should not be overlooked in the treatment of women with disabilities. It is also important to consider women with disabilities as the experts on their own disabilities.15 They should be key participants in determining what types of accommodations and help they need to participate in the treatment program.
The language of disability is rapidly changing. In general, the term "disability" is preferred to "handicapped," and 64 woman with a disability" is preferred to "disabled woman," since the woman comes first, before her disability. Language that suggests victimization and suffering should be avoided; for example, avoid the terms "suffers from cerebral palsy," "victim of polio," or "confined to a wheelchair." New terms such as "differently able" or "physically challenged" or "mentally challenged" have been rejected by disability rights activists as euphemisms. However, some people with disabilities may disagree. Thus, when in doubt, ask the woman what terminology she prefers.
National Clearinghouse for Alcohol and Drug Information (NCADI). 600 Executive Boulevard, Suite 402, Wilco Bldg., Rockville, MD 20852.
O'Neil, C., RN, PhD. (1993). Addictions. Nursing Network. 5 (1), 33.
Center for Substance Abuse Treatment. (1993). Screening for Infectious Diseases Among Substance Abusers. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.
Zweben, J.E. (1992). Issues in the Treatment of the Dual-Diagnosis Patient. In Wallace, B.C., Ed., The Chemically Dependent, Phases of Treatment and Recovery. New York: Brunner/Maze, 298.
Kulewicz, S. (1990). The Twelve Core Functions of a Counselor. Somerville, MA: David and Goliath Creative, 39.
Center for Substance Abuse Treatment. (1993). Pregnant, Substance-Using Women. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, 7.
Bjorklund, P.E. (1983). What is Spirituality? Center City, MN: Hazeldon Foundation, 7.
Bjorklund, P.E. (1983). What is Spirituality? Center City, MN: Hazeldon Foundation, 3.
Moore, T. Care of the Soul. (1992). New York, NY: Harper Perennial, xix.
Bjorklund, P.E. (1983). What is Spirituality? Center City, MN: Hazeldon Foundation, 4.
Bjorklund, P.E. (1983). What is Spirituality? Center City, MN: Hazeldon Foundation, 10.
Center for Substance Abuse Treatment. (1993). Guidelines for the Treatment of Alcohol and Other Drug-Abusing Adolescents. Rockville, MD: U.S. Department of Health and Human Services. Public Health Service, 15.
Center for Substance Abuse Treatment. (1993). Approaches in the Treatment of Adolescents with Emotional and Substance Abuse Problems. Rockville, MD:. U.S. Department of Health and Human Services. Public Health Service. x.
ibid.
See for example Linton, S., and Rousso, H. (1990). Sexuality Counseling for People with Disabilities. In Weinstein, E. and Rosen E., Eds. Sexuality Counseling: Issues and Implications. Pacific Grove, CA: Brooks/Cole, 114-34.