Comprehensive Treatment for Women 177

· 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 informa
tion; and

- complete and up-to-date information on the
child(ren) if these records are maintained with the
mother's record; and

· The services provided to the client (either directly by the
program or through referral) are meeting her needs and
helping to ensure her recovery.

The treatment

To help each client identify her strengths and increase her level of process should
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 develop
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 wornen 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.

Relapse prevention should be a discrete component of the treat-

ment 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

· Provide physical and mental health care services.

For substance abuse treatment to be effective, health services

must be available to meet the immediate and long terms

needs of women in treatment. If the treatment program is

part of a health care facility, these services can be arranged

readily through the various specialty centers or through

referral to other health facilities, whether or not the treat

ment program itself is affiliated with any of these facilities.

If the program is freestanding, arrangements may either be

permanent (i.e., the physician, nurse, physician's assistant,

psychologist, or psychiatric social worker is part of the staff,

either full time or part time); or contractual. In the latter

case, the services can be provided at the treatment program

or off-site.

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 special

ist to conduct ongoing health education classes on nutrition

(and its role in recovery); self-examination for breast can

cer; 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

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.

Preconception Counseling

CSAT has identified preconception counseling, including the full
range of reproductive options, as an important aspect of substance abuse
treattment. Specifically, the following issues have been recommended by

CSAT, in its TIP on Pregnant, Substance-Using Women, to be addressed in
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.

Assist with the development of parenting skills. Counseling, with information on child 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 read ing 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 wornen'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 o1~ clients can be referred to self-help groups specializing in children and youth (e.g., Al Atot, Al Ateen, A1 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.

Arrange for legal services when necessary. Few programs

have consulting attorneys on staff, but most have arrange
Stafshould be ments for referral to legal support systems (e.g., legal aid,
trained to offer law schools, or organizations which specialize in child or
support and assis- spouse abuse). Staff should be trained to offer support and
tance to help assistance to help women deal with legal issues, such as real
women deal with or anticipated loss of child custody cases, domestic violence
legal issues. 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
wornen'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 avail
able; having successful working women who represent