Treatment of Alcohol and Other Drug Abuse: An Introduction g

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

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

Example of Presenting Problem

Alternative Strategies -Sexual Abuse In addition to addressing substance abuse:

A 23-year-old woman with a should consider the following to address the
history of multiple drug abuse issue of sexual abuse:
(heavy alcohol use since age 13,
occasional crack use since age 15, Have a trained female staff person, or a
and nonmedical use of tranquilizers consulting female psychologist meet with the
client to determine if there is a history of
since age 18) is having difficulty sexual abuse and to carry out a complete
adjusting to the outpatient psychological assessment of the client.
program's schedule and is reluctant Because disclosure at intake may be difficult,
periodic assessment is necessary.
to discuss the underlying causes of
her substance abuse. She is the If it is found that the client has a history of
mother of two children and has sexual abuse, arrange for individual and
group counseling to address this issue
recently left an abusive relationship specifically. Therapy could be provided by
with her husband. trained staff in the program or by referral to a
rape crisis center or to a mental health
professional specializing in sexual abuse
problems.

· Arrange for counseling to address the spouse abuse problem, including individual counseling for the woman, therapy for the spouse, and family therapy.

· Arrange for legal and other assistance, as necessary, to address the spouse abuse issue. Arrange for temporary care of children, if appropriate, and, at a minimum, for child care while the client is in treatment.

· The treatment team should ensure that comprehensive services are being provided.

· In discharge planning, either conduct directly or arrange for post-treatment psychological

assessment and evaluation of client outcome in terms of psychosocial measures and for

counseling. Also arrange for housing and other social service needs as necessary.

(This will depend on the client's relationship with her spouse at discharge.)

3.5.4 Children
Women are the primary caretakers of children in the United States (as
in most countries) even when a spouse or partner is present in the home.
The proportion of female-headed family households (no spouse present) is
significant: in 1992, nearly one-third of families with children under 18
fell into this category 49 Low-income women who are single heads of
households have particular problems, with diminished economic and/or
geographic access to treatment, health, social, and other support services.
Substance abuse treatment programs need to address the issues of
women with children. In terms of outreach and identification, many
women report that concern for.their children is a major motivation in their
decision to enter treatment for substance abuse problems.5° For example,
in a recent study of cocaine or crack-addicted mothers in New York City,
75 percent of respondents indicated that "concern for their children would
be their maJor motivation for entering treatment."5' However, lack of
access to treatment programs that can meet their needs impedes the ability
of women to obtain care. As Coletti et al noted:
Mothers without access to child care may have to forego treatment,
leave treatment early, or face the frustrations of bringing young
children with them - if children are allowed on the premises."s2
The lack of adequate treatment programs for women with children was
identified by the General Accounting Office in 1992; that agency found
that, in 1991, 105,000 cocaine or crack-addicted women were in need of
treatment." Note that this does not include women addicted to any other
type of drug, including alcohol. (The CSAT Women and Children's Branch
is currently funding 65 programs designed to serve women and their
children. This is part of CSAT's effort to expand services to meet the
needs of women with children.) In addition to inadequate availability of
treatment programs, the lack of regular affordable child care (and health care services) and the fear of interference by the Department of Social Services in the family may be important barriers to treatment. These factors need to be considered in designing outreach and treatment services for women with children.

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

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

3.5.5 Dual Disorders

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

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

Treatment of Alcohol and Other Drug Abuse: An Introduction 99

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

Accurate diagnosis and appropriate treatment of clients who have dual disorders is difficult, particularly in the early treatment for substance abuse. In fact, according to Dackis and Gold, there are three diagnostic possibilities in dually diagnosed clients:5'

· The psychiatric symptoms may result from the addiction and/or withdrawal from the drug (e.g., depression that comes with cocaine crash, hallucinations with cocaine intoxication).

· Drugs may be used as self-medication (e.g., alcohol overuse in panic disorders or tranquilizers used for pain, which may become entrenched into an addiction).

· Addiction and psychiatric illness may coexist (e.g., the alcoholic with bipolar disorder).

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

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

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

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