Chapter 7

Program Management Issues

Treatment programs must address program management issues that cut across phases of care. Some of these issues have been addressed in other chapters of the manual that correspond to the phases of care (e.g., staff composition as it relates to outreach). The issues are either listed (if they have been addressed in detail in a previous chapter) or briefly summarized under the following categories: policies and procedures, staff training, staffing and gender sensitivity, legal and regulatory issues, linkages with other agencies, and financing mechanisms.

The program staff should determine if the program's policies and procedures are respectful of the clients and based on valid treatment assumptions as well as the realities of women's lives.

7.1 Policies and Procedures

The treatment programs' policies and procedures not only reflect their philosophies and standard procedures pursuant to public regulations and guidelines, but also their recognition of the importance of gender and cultural differences. A number of issues concerning program policies and procedures relate specifically to women in treatment and should be addressed by any program in reviewing its policies and procedures and when initiating treatment services for women. In doing so, the program staff should determine if the program's policies and procedures are respectful of the clients and based on valid treatment assumptions as well as the realities of women's lives. While it is important to have clearly defined rules and a structured treatment environment, it is also important that the rules not be so restrictive as to hinder the potential for clients to remain in treatment and realize successful outcomes.

Because the treatment program staff (especially the counselors) knows the particular needs of clients, it is important that program directors hold frequent staff meetings to review policies and ensure that they are appropriate and conducive to effective treatment. Program managers are urged to involve staff in decision-making with respect to organizational arrangements, policies, and procedures whenever possible. Women who have completed treatment can also be a source of practical information and suggestions regarding program policies and procedures.

Many of the policies and procedures relating to women in treatment (e.g., ensuring access to comprehensive services) have been discussed throughout Chapters 4, 5, and 6. Key policies should address the following issues:

	duration of treatment, which may need to be longer for women, in view of their parenting and other caretaking roles, as well as the multiple presenting problems that may need to be addressed in treatment (e.g., history of sexual abuse); in any case, the length of stay should be individualized within the program's range;
	gender discrimination and harassment (Section 7.5);
	the need for flexible outpatient program hours based on clients' daily schedules. Nine-to-five weekday office hours are often unmanageable for working women and may be difficult for women with children if child care is not provided. Programs with evening-only hours but without child care do not meet the needs of women who must make babysitting arrangements and who are concerned about leaving their children in environments where illicit drugs and alcohol are used or where violence occurs;
	the degree to which documents used by the program in outreach, treatment, and continuing care reflect knowledge of and sensitivity to women's issues and are devoid of gender and cultural stereotyping;
	for outpatient programs, the number of appointments that a client can miss during treatment and still remain in the program. For women with children who must arrange for child care (if it is not provided by the program), this restriction may be seen as difficult or impossible for practical reasons;
	requirements in residential programs that there be "no naps during the day," which could be difficult and not medically appropriate for pregnant women;
	for programs that have "strip search" policies, these should be carried out only when necessary and then by same-gender staff specifically trained to perform the searches in the most sensitive and least intrusive manner, and
	decisions regarding establishment of a smoke-free environment in most of the program's facilities, if this is not the policy for the entire facility. For the programs that have children in treatment with their mothers, the entire facility should be smoke free.

7.2 Staff Training

On an ongoing basis, the treatment program should identify the training needs and requirements of program staff as they relate to female clients.

On an ongoing basis, the treatment program should identify the training needs and requirements of program staff as they relate to female clients. Training needs to be more intensive when the program is initiating operations or when female clients are being recruited for the first time. Staff training should focus on ensuring that all staff (women and men) have an understanding of the particular needs of women in treatment and that they have the capacity to meet these needs.

If the state licensing and credentialing agency has materials that are used to assess the competency of counselors, these materials can be adapted by the program for use as a partial basis for the training. The program should also prepare alternative model treatment plans that are appropriate for women under a variety of circumstances (e.g., with or without children, with or without a supportive spouse or significant other). The program should involve in the training as many local resources (individuals, organizations, and materials) as possible to strengthen relationships with potential referral sources in the area.

Program management also should provide periodic training for staff, identifying the topic areas through feedback from staff (with staff members specifying their own training needs) and from ongoing and structured supervision. In this regard, all treatment programs should have clearly identified and written guidelines for staff performance and treatment procedures, with periodic clinical supervision by either program staff or consultants. The program can use a variety of mechanisms to monitor the knowledge, skills, and attitudes of staff with respect to women in treatment. Management can include the use of role playing exercises, the review of treatment plans prepared for and by the women, review of aggregate outcome data, and the subjective feedback obtained through focus groups involving staff and invited experts knowledgeable about women in treatment.

Staff training needs can be met in several ways:

	involve in-house program staff who may have particular expertise in the topic areas for which training is necessary (e.g., treatment planning);
	invite external experts to regularly scheduled staff meetings or those specifically arranged to address a given topic;
	arrange for staff to attend workshops and conferences that address general issues relating to substance abuse treatment, treatment of women or other issues related to comprehensive services for women. Support staff members in participating in workshops and conferences and presenting papers whenever possible; and
	exchange training resources and sessions with other facilities or organizations (e.g., with the local medical or nurses association, particularly those with which the program has ongoing relationships). This can facilitate linkages and be a more cost effective method of training.

Many treatment program staff serving women may benefit from training in many topic areas, including the following:

	understanding of women's issues related to substance abuse, including physiological effects, dual diagnosis, social service needs (e.g., child care);
	gender role stereotyping in general and with respect to substance abuse in particular;
	family, parental, friend, and other relationship issues for women in treatment;
	approaches to addressing a client's history of sexual and physical abuse and other violence in the treatment process;
	intake, assessment, and orientation procedures and instruments appropriate for women (and for their children, if in treatment with the woman);
	cultural competency with respect to ethnic/racial groups, different age groups (e.g., adolescents and older women), lesbians, women in the criminal justice system, and women with disabilities; and
	ethical issues, including those discussed in section 7.5.

All of these issues also should be addressed as part of clinical supervision.

7.3 Staffing and Gender Sensitivity

Making a program gender sensitive is challenging to many administrators.

Although the commitment to engage, treat, and retain women in treatment is the responsibility of all program staff members, it must originate with the program's administration and must be based on client needs and expectations. However, making a program gender sensitive (which changes the status quo in many treatment programs) is challenging to many administrators because addressing the specific needs of women requires a variety of changes in such areas as staffing, training, and treatment arrangements (e.g., treatment hours) as well as ensuring that there is ongoing clinical supervision. These changes also present a challenge to program staff who must participate in and adapt to these new arrangements. If a treatment program for women is to work, its board of directors, advisory board, administrators, and staff members, must all be committed to reevaluating program goals, policies, and services that are offered directly by the program or for which referrals are made.

Program rules must be established and enforced to prevent the intentional and unintentional sexual harassment of female clients.

Making a program gender sensitive is challenging because it requires all staff members to develop a commitment to and an understanding of the issues related to female clients. Some staff members may have difficulty accepting new approaches to treating women in recovery, particularly when such approaches address issues relating to sexual behavior and sexual abuse. Both female and male staff members who have been victims of sexual abuse may be uncomfortable talking with women about sexual behavior. To work effectively with female clients, all staff members need to explore their own feelings and experiences regarding sexuality and sexual abuse, either individually or in a group. In addition, all staff should be trained in program practices that relate to establishing and maintaining appropriate boundaries with clients. Program rules must be established and enforced to prevent the intentional and unintentional sexual harassment of female clients. However, it should be understood that "appropriate boundaries" can vary by culture. Through staff supervision, program management can identify particular knowledge, skills, and attitudes that need to be improved with respect to gender issues, both for individual staff members and for program staff overall.

A number of treatment providers have found that involving male therapists in the recovery process makes the male partners of the women in treatment more likely to interact with the treatment center and their female partners in various activities, including family-related sessions.¹ Male therapists can also be healthy role models for women who will necessarily interact with men in work, social services, and other aspects of their lives after treatment. This may have positive long-term benefits on the recovery process for the women.

Staff members must be knowledgeable about and sensitive to the issues and needs of the women in the treatment program.

Both female and male staff members (as well as clients) must understand what constitutes sexist attitudes and behavior and be able to identify such behavior among the staff and clients. Staff members must also be knowledgeable about and sensitive to the issues and needs of the women in the treatment program, including those of heterosexual and lesbian women and women of different abilities, ages, ethnicities, races, and religions. Staff must receive training to improve their knowledge and sensitivity as necessary.

If at all possible, the program staff and the program's board of directors and advisory board should reflect in their membership the client population with regard to ethnicity, race, gender, disability, sexual orientation, and language.

7.4 Addressing Legal and Ethical Issues In the Program

In addition to the legal service needs of individual clients (e.g., concerning child custody or spouse abuse), treatment programs for women confront two types of legal issues:

gender issues concerning the relationship between the individual client and staff member, such as sexual harassment and job discrimination; and
institutional problems, such as the federal, state, and city regulation of substance treatment services.

Although the sexual harassment of women in substance abuse treatment programs is a known problem, many programs do not have policies to address such harassment.

Although the sexual harassment of women in substance abuse treatment programs is a known problem, many programs do not have policies to address such harassment. Strict and clearly delineated policies with respect to the potential sexual harassment of clients and the liability that the problem represents for the programs are absolutely essential. These can be developed with assistance from local legal aid programs or agencies, based on federal and state guidelines and legal statutes.

Institutional regulations affect the kind of treatment that can be offered to women and how it may be delivered. These include federal regulations that apply across states (e.g., the Americans with Disabilities Act, mentioned in Chapter 5) as well as state and local public health and safety and other regulations that necessarily vary by locality.

Before planning for establishment of a treatment program or adding services to an existing program, providers must be thoroughly familiar with the regulations that apply to them. These regulations may include licensing of the facility by the local and/or state health department(s) and accreditation by the state alcohol and other drug abuse agencies. Although these regulations will be applicable to most, if not all, treatment programs, those serving women and their children may also face requirements related to the care of the children (e.g., for child care and for early childhood education). The program should obtain all required licenses and certifications as quickly as possible. This will help ensure the safety of the facility, build credibility with funding sources, and may be necessary to obtain third party payments.

In addition to legal issues, ethical issues need to be of concern to all treatment staff. The most commonly known are those related to client confidentiality, fraternizing between staff and clients, and sexual harassment. Most programs have policies that include ethical standards related to these issues. However, staff of treatment programs must also be aware of and seek to ensure adherence to basic ethical principles which are considered to apply across cultures and which can be used to guide substance abuse treatment. These principles-in particular justice and nonmalevolence-are of increasing interest to those concerned about civil and human rights and liberties. Jillson has described four ethical principles as they apply to health policy in general; their applicability to substance abuse treatment is as follows:²

Client autonomy is an important goal for the client and the treatment staff to work toward during the recovery process.

	The principle of autonomy is the capacity to reason and to alter one's decisions and plans based on such reasoning and to act on the basis of one's decision. Client autonomy is an important goal for the client and the treatment staff to work toward during the recovery process. As the client becomes physically and emotionally stronger, her ability to reason and make decisions must be respected and strengthened as it aids in her recovery. It should be noted that this ethical principle may be difficult to apply early in the treatment process. However, when the client's judgment is likely to be impaired by recent and/or extensive use of alcohol and/or other drugs, such impairment does not absolve the treatment program from its obligation to ensure that the woman's autonomy is protected in the treatment process.
	The Principle of beneficence is related to goals held by people and social institutions on their behalf. This is seen by some as the most important moral obligation of health and social service programs. When beneficial goals can be agreed upon by program managers, staff members, and clients, they should be pursued. For example, both the program and the woman might agree that an appropriate treatment goal is for the woman to be employed within a certain period of time. However, beneficial goals can be particularly difficult to implement in substance abuse treatment because there is an assumption that there is an agreed-upon definition of what is beneficial, to whom, and under what circumstances. For example, the treatment program may have treatment goals (and related general outcome indicators) that are not appropriate for every woman in treatment; moreover, the policy-related goals of funding agencies may differ from those of individual treatment programs receiving funding. Finally, the beneficial outcome for a woman's child(ren) may conflict with treatment approaches designed to ensure a beneficial outcome for the woman herself. For example, while it may be preferable for the woman to have time to recover without having her children with her in treatment, it may be preferable for the children to be with their mother throughout the duration of treatment.
	The principle of equity holds that each person must be given her/his due and that equals must be treated equally. While the treatment program cannot be responsible for ensuring justice and equity in all aspects of their clients' lives, it can ensure that all clients receive equal access to its services, that all are treated with equal respect by program staff, and that attempts are made to provide equal access to services outside of the program. This is critical to women in treatment, particularly to disadvantaged women because services have been disproportionately lacking for them and available services may not address their particular needs. The paucity of related health and social services for disadvantaged clients (and for some populations of women in particular) is also an issue related to distributive justice.
	The principle of non-malevolence, or "first, do no harm," holds that social institutions - in this case, treatment programs - should not impose harm or evil upon those affected by their actions. This is an apparently obvious virtue which, in practice, raises difficult societal issues. example of how this principle applies in substance abuse treatment is the importance of ensuring that research and evaluation (whose intent is, ostensibly, to obtain data and information for use in improving the delivery of treatment services in general) does not in any way violate the integrity of the woman in treatment. Another is the need to ensure that protecting (as well as improving) the basic physical and mental health of the client is a focal point of service delivery; for pregnant and post-partum women in treatment, difficult trade-offs may be required of treatment staff. For example, the program may need to determine when it is necessary to make arrangements for placement of a newborn or young child in other living arrangements when the mother continues to abuse drugs and is deemed incapable of caring for the child.

7.5 Linkages with Other Agencies

The importance of establishing relationships with other community-based agencies to ensure that clients have access to comprehensive services has been addressed in Chapters 4, 5, and 6. If the treatment program is part of an umbrella agency that provides services not offered at the program site (e.g., health services), these services can be arranged through the umbrella agency. For freestanding substance abuse treatment programs, the arrangements may either be permanent (e.g., the service provider is part of the staff, either full-time or part-time) or arrangements can be made for regular or as needed consultations at the program site or the site of the service provider.

The program should establish and maintain a network of agencies that can meet the broad range of women's needs. To do so, the program staff should compile a list of health and other social service agencies that are resources for client services. This list should include the name of the agency, the service provided, its location, the telephone number, hours of service, the cost of service, information on accessibility to women with disabilities, and the name of the contact person. This list should be updated frequently and should be accessible to all staff members for use in referral to comprehensive services.

There are many opportunities throughout the treatment process for contacts with organizations that do not refer clients. For example, the program staff could collaborate with a local school/community college, university, or other organization that houses a media center to produce a professional quality audiotape or videotape on women and substance abuse treatment and mental health. Such materials would be useful to the program itself, to other providers in the community and to use in prevention and outreach by a broad range of organizations. Some collaborating agencies provide such production services free of charge, if they are assured proper credit for their efforts. Involving the clients in the process of planning for and producing the tape can be a challenging and rewarding experience for both clients and counselors; it is also likely to enhance the tape's usefulness. Other examples of contacts include exchanging training resources (mentioned previously in this chapter), setting up coalitions to exchange information on changes in health systems delivery and financing and its effect on substance abuse treatment programs, and exchanging written and audiovisual materials.

7.6 Financing Mechanisms

Because women need more and different comprehensive ser vices than are, generally provided to men, it is likely that additional costs will be incurred.

Because women need more and different comprehensive services than are generally provided to men (e.g., child care, perinatal care, injuries resulting from sexual abuse and violence), it is likely that additional costs will be incurred to provide and arrange for the services for women that are described and recommended in this manual. Creative strategies must be employed to secure public and private money to fund the essential services that recovering women require. Examples of funding sources for treatment programs include the following:

	direct grants from federal agencies (e.g., CSAT, NIDA, NIAAA, Office of Minority Health);
	funding from the state alcohol and drug abuse authority, including the Substance Abuse and Mental Health Services Administration (SAMHSA) block grant funds, five percent of which are set aside for women's programs;
	grants from local and national private foundations that support substance abuse treatment programs specifically or health services for women and/or children generally; and
	state Medicaid agencies.

Ongoing and one-time donations from women-owned businesses, businesses targeting female consumers, and women's organizations can help to support nonprofit women's alcohol and other drug treatment programs. By involving these organizations either through defined collaborative arrangements or by having representatives serve on the program's board of directors, programs may be establishing relationships for potential financial support. Treatment programs can also sponsor community-wide symposia of issues directly and indirectly related to alcohol and other drug abuse and invite representatives of potential funding sources to speak or participate. In addition, programs can design and implement income generating projects to help ensure that the programs are economically self-sufficient to the degree possible.

To help gain their support for treatment of women, (including their economic support) community leaders need to be educated about treatment of women. Program staff, either independently or in coalition with other organizations, can encourage third party payer organizations to have insurance and managed care coverage reimbursements more in line with realistic costs for substance abuse treatment and intervention. If these efforts do not elicit an appropriate response from insurance companies, managed care providers, HMOs, and public medical assistance programs, it may be necessary and desirable to join with other agencies and community groups providing services for substance-abusing women to advocate for local and state legislative and administrative changes. Pennsylvania, for example, has successfully begun to mandate Medical Assistance reimbursement for long-term, halfway house services and to require insurance companies to provide at least minimal coverage for treatment of alcohol and other drug problems.

Each treatment program should have a development plan that includes identification of resource needs, potential sources of funding, and strategies to ensure financial sustainability. CSAT has issued a guide entitled "Funding Resource Guide for Substance Abuse Programs" that programs can use to assist them in preparing and implementing such a development plan.³

References

Personal Communication: Senella, A.M., Bachrach, K., Star, K., and Zinn, 1. (1994). Review of Practical Approaches in the Treatment of Alcohol and Other Drug Abusing Women. Tarzana, CA.

Jillson, I.A. (1989). Towards a Framework for Consideration of Ethical Issues in International Health. Invited Presentation: National Council of International Health Annual Conference: Toward a Healthier World: Influencing Policies and Strategies. Washington, DC, 8-9.

Center for Substance Abuse Treatment. (1993). Funding Resource Guide for Substance Abuse Programs. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service.