All persons who work in the treatment program must be knowledgeable about, supportive of, and sensitive to what it takes to meet the treatment needs of women.

Chapter 5 - Comprehensive Treatment for Women

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 treat
ment process are offered and presented separately for the treatment envi
ronment; intake, orientation, and assessment; the treatment process; and
cultural sensitivity/competence. For several of the populations, the infor
mation 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.

5.1 The Treatment Environment

Clients arrive at the treatment program through a variety of mecha-
nisms: 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 confi
dence are imperative.

All persons who work in the treatment program - clinical, admin
istrative, 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).' Decorations should reflect the cultural diversity of the community.

5.2 The Intake, Orientation, and Assessment Processes

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 partici

pants in the program;

· to gather information about the client's physical and mental

health and social history. Ties 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 adminis

trative 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.

5.2.1 The Intake Interview

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.

At the time of the intake interview, if appropriate, the woman
should be accompanied by one or more family members or a significant
other. This may increase the likelihood that reliable information will be
obtained and it helps to gain the support and understanding of the family
member(s) or significant other. However, in the case of abusive relation-
ships, it probably is not appropriate to involve the family or significant
other(s) in the intake interview. The family and/or significant other(s)
should be involved only when the counselor or case manager believes that
such involvement will help the client's healing process. If the family or
significant other is present during intake, the counselor or intake worker
should interview the client both alone and with a family member present.
The counselor or intake worker should also ensure that, if the woman has
children, arrangements are made for their care, whether the woman is to be
in an inpatient or outpatient treatment program.

A preliminary discussion of the nature of the disease of addiction is 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)?

164 Comprehensive Treatment for Women

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 cooccurring 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.'

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;

. malnutrition; injuries;

· sexual dysfunction;

· sexually transmitted diseases (STDs);

· tuberculosis (TB); and

upper respiratory illnesses.

Age category and race/ethnicity should also trigger certain ques-
tions. 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 1» 1993,
be asked probing questions regarding diabetes.

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 con-
ducted 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 particu-
lady important that clients be screened for this infectious disease and that
treatment be initiated immediately if the client meets the criteria for treat
ment 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.'

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?