Chapter 8
Reflections
This manual was developed in response to an awareness at CSAT that women's
needs have not been adequately addressed by most substance abuse treatment
providers. The underlying assumption of this manual is that women have, to some
degree, different physical, psychological, social, economic, legal, and behavioral
treatment issues than those experienced by men. As a result, substance abuse
treatment modalities and strategies have to be adapted and/or developed to
meet the needs of women. It is also important to recognize that differences among
women in ethnicity, culture, race, age, ability/disability, economic status,
educational attainment, and sexual orientation necessitate different treatment
strategies.
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The underlying
assumption of this
manual is that women
have, to some degree,
different physical,
psychological, social,
economic, legal, and
behavioral treatment
issues titan those
experienced by men.
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The manual described strategies for three stages of the treatment process:
outreach when the program attracts the woman to treatment, comprehensive care
when the program must address the woman's needs and retain her through the full
course of treatment, and continuing care when the program helps to ensure that
the recovering client's needs are met, as much as possible. Many of the strategies
presented in the individual chapters (e.g., discussion of comprehensive services)
apply across the continuum of care, as do discussions of particular issues related
to special populations (e.g., older women). Moreover, because addiction is a
chronic condition that is characterized by relapse on the part of many clients,
many of the basic premises apply across the stages of care. Some of these have
been highlighted in one section of the manual (e.g., the need to use screening and
assessment tools that are gender-specific and culturally sensitive) rather than
being repeated throughout the stages of care.
8.1 Two Key Themes: Comprehensive Services and Linkages
The issues addressed in this manual have been varied, reflecting the
complex nature of substance abuse and many of the problems faced by women in
treatment. Increasingly, substance abuse treatment programs
must address the physical and mental health problems of women in treatment for which they may have received little attention, if any, prior to
treatment. The consistent theme of the manual has been recognition of the
need to provide comprehensive services for women in treatment. However, few programs have sufficient resources to provide a complete range of
services in-house, nor should they be expected to do so. Most communities
have public and/or private sector organizations which provide services
directly or which facilitate access to them. Treatment programs, therefore,
need to establish strong contacts with other organizations to refer clients for
services and to receive referred clients.
Contacts and linkages are another theme of the manual. The ability
of treatment program staff to establish successful relationships with the
staff of health and social service agencies is critical to meeting the comprehensive needs of women in treatment. It is also essential to establish
linkages with community-based organizations which represent women of
color, adolescent and older women, lesbians, women in the criminal justice
system, and women who have differing physical and mental abilities.
These linkages help to ensure that treatment program staff have an
increasing understanding of and sensitivity to the wide range of differences
in women needing treatment; they also serve as an important source of
referrals and resources for speakers and facilitators.
A number of sensitive issues that need to be addressed directly in
the treatment process have been raised in the manual. These include for
example, the increasing incidence and prevalence of HIV, AIDS, and
sexually transmitted diseases among substance-abusing women, and the
connection between sexual and physical violence and addiction. However,
as has been noted in the manual, there are a variety of approaches to providing services to women who present with these problems. For example,
opinion varies regarding the point at which counseling regarding prior
history of sexual abuse should be initiated during the treatment process and
how it should be addressed. Moreover, cultural and other values play an important
role in terms of what is acceptable to the female client and what is permissible by
local norms as expressed in public policy or the law. An example of the impact of
cultural values is the divergent opinion concerning HIV and AIDS (e.g.,
counseling concerning safe sex practices and ensuring that condoms are available
for clients). Although these are difficult and contentious issues, programs need to
face them directly if their services are to meet the needs of their female clients.
Program management and clinical staff should be sufficiently knowledgeable
about the advantages and disadvantages of alternative strategies in terms of their
client population. It is important for the staff to discuss these strategies with their
clients and delineate a clear rationale for selecting the approach which is
recommended for each client. If changes are made, all staff need to be made
aware of the changes and the treatment protocol should be adjusted accordingly.
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To facilitate recovery, researc h and evaluation are needed to determine which treatment
modalities are most effective for women
in general and for
specific groups of
women. |
8.2 Do We Know What Works for
Women?
The manual was prepared using both published and unpublished research
and the experiential knowledge of women who are noted experts on the treatment
of women for alcohol and other drug problems. However, it must be emphasized
that there are many theories and approaches to the treatment of alcohol and other
drug use in women and that the wide range of treatment programs reflects that
diversity. Do we know with any certainty what works for women in treatment? If
we think certain specific strategies work, are they more effective for certain
populations under different circumstances? These questions apply in general to the
treatment for alcohol and other drug abuse as well as the treatment of women
specifically. It is important to coordinate efforts between funding sources,
programs, and researchers to evaluate empirically approaches to engage and retain
women in treatment. To facilitate recovery, research and evaluation
are needed to determine which treatment modalities are most effective for
women in general and for specific groups of women.
The diversity of theoretical views and biases hampers the development and
implementation of research and evaluation studies that could identify differences in
treatment outcome. For example, the underlying concept of addiction serves as an
explicit or implicit foundation for the design of research and evaluation. Many in the
general public (and some in positions of leadership) still support the view that in
general, alcohol and other drug abuse is a moral condition, particularly where
women are concerned. Many others support the medical model perspective,
defining substance abuse as a disease in the physical sense. But if the field is to
address successfully the complex problems of alcohol and other drug abuse among
women and to evaluate the success of treatment programs, it must develop
successful, replicable treatment models. The focus should be on what treatment
models and specific services are effective for which group of women in a variety of
physical, psychological, social, and cultural circumstances.
In identifying what treatment approaches successfully engage and retain
women in treatment and result in their recovery, it is important to look at specific
aspects of the treatment process, examining the combination of treatment
modalities and services that is most effective under different circumstances for
diverse populations. For example, to consider the appropriateness of
requirements (or standards) for the duration of residential treatment and
frequency of outpatient visits for women in varying circumstances, the following
types of questions should be addressed:
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Treatment programs are operating in a health care system that is
in the midst of major changes and reform. How will alcohol and
other drug programs fit into the overall plan? What is the current
financial impact on the programs of the changing health care
industry?
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Process and outcome evaluation are increasingly important to the
viability of alcohol and other drug abuse programs for women.
Programs that are funded in the future may be those which can
document successful outcomes that are replicable in different
environments. How can treatment programs serving women with
complex health and socio-economic problems document activities and outcome and for what
outcomes will they be held accountable, whether or not they have
"control" over the outcome (e.g., employment)?
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Programs must have community partnerships and must receive
funding from sources other than the government in order to
survive. However, there is increasing competition for scarce
resources in both the public and private sectors. This can result
in a competitive environment rather than a cooperative one.
What are the possibilities for generating income on joint fund-
raising efforts and for sharing of services to make the best use
of scarce resources?
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Cultural competence does not just mean having racial and ethnic
diversity among the staff and board members. It means ensuring
attitudinal and behavioral change, incorporating understanding, and
respecting a diverse client population and target group. It must be
acknowledged that there is no consensus regarding cultural
"norms" and accepted practices and language, even among a
particular group of women. Program staff must be aware of the
diversity within and among their particular client and target
populations. In this regard, staff training is critical.
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Participatory decision-making is key to ensuring that a program
meets client needs and is well managed. These programs will
more than likely identify, target, and treat clients using strategies
that have been successful with that client population. Feedback
from staff and clients is part of an on-going program assessment
and is an important part of program operations.
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Safety of the treatment environment is important for all clients, but
particularly for women and their children, if the children are living
with their mothers. However, for a number of reasons, substance
abuse treatment programs are often located in areas that are not
safe: they are accessible to potential clients, the facility is
affordable, or other communities are not amenable to having
substance abuse treatment facilities in their neighborhood. To protect client safety, some
treatment programs take precautions that make them appear to be
impenetrable and therefore uninviting. Programs need to strike a
balance between client safety and accessibility.
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From the
perspective of the
staff member of
the treatment
program, the
Millions of
American women
who have
substance abuse
problems become
the one woman in
treatment.
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8.4
We Do This Because...
In reflecting on the strategies for providing treatment services, it is often
easy to get lost in the detail, to lose sight of the fact that those who provide
substance abuse treatment services for women do so because there is the
possibility of recovery. However, on a daily basis, from the perspective of the staff
member of the treatment program, the millions of American women who have
substance abuse problems become the one woman in treatment for whom services
are provided, care is demonstrated, and in whom hope is invested.
The following case study is the true story of a woman who completed
treatment in a program funded by the CSAT Division of Clinical Programs' Women
and Children's Branch. "Anita's" story is a reminder of why we devote our energies
to each woman who is in our care.
One Woman's
Story
Today Anita is healthy and happy. She is taking care of her three children. She is
employed. She is a college student. But she didn't always
live her life this way....
Anita was admitted to treatment for crack cocaine use in November 1989, when she was three
to four months pregnant. During
the
course of treatment she delivered a substance free baby girt,
Stephanie. After successfully completing treatment in April of 1990, she returned to her mother's home.
Approximately two months later, Anita relapsed and was once again hooked on crack
cocaine.
Her mother would not tolerate her lifestyle nor allow Anita to live in her home. She
notified the local
child protective services office, which removed Anita's infant daughter from the
home. Anita's life continued to deteriorate. On one occasion she was choked to the point
of unconsciousness and was left in
a vacant lot. Another time she accepted a ride with two men who promised her drugs. When she realized
that they both had guns, she escaped from their car. They became angry and fired at her. Fortunately,
Anita was not hurt physically. At this point, she "had hit bottom " and decided to seek help again.
Anita admitted herself to a treatment program in January 1991. She was two
months
pregnant. The program has a detoxification center, a residential care facility, and an outpatient
continuing care
program. Anita was first admitted to the detoxification center. She remained
there for one month until bed
space was available in the residential facility. Anita completed the six-month course of treatment in May.
Treatment included direct attention to her substance abuse, prenatal care and other health services,
counseling to address her problems with relationships, and referrals for social services, including job
training. After completing this treatment phase, Anita entered an outpatient continuing care
program and attended
support groups. She remained in the outpatient program until September 1991. When she left the
residential treatment program she had a full-time job and a stable living environment in her mother's
home. During this time, Anita delivered her baby, Shauna, who was substance-free. After three months,
she moved into her own apartment with her infant. Once she completed
all the
required treatment phases,
the program's advocacy department assisted Anita in regaining custody of Stephanie.
In April 1993, Anita was hired as a program assistant for the treatment program. She wanted
to
be a role model and provide hope to those, like herself, who are still in treatment. Since then, "she
has been promoted and is working on her bachelor's degree in social work. In the year since
she has been employed by the treatment program, Anita has married,
and all three of her Stephanie and Shauna-live with her and her husband,
who is adopting the children
Today, Anita continues to participate in self help meetings, is drug-free, and committed
to recovery.