Today, it is well understood that no single system can provide comprehensive and effective solutions to the host of problems confronting women in recovery for substance abase.

Chapter 6 -Continuing Care and Follow-up

CSAT defines alcoholism and other drug dependencies as chronic,
progressive disorders comparable to other chronic disorders such
as diabetes and hypertension but often characterized by relapse.
Thus, continuing care for women, which involves activities that support
long-term rehabilitation and prevent relapse of female clients who have
completed specific substance abuse treatment programs, is an essential
component of effective treatment programs.
Given the effects of substance abuse on all areas of a woman's
ability to function-physical, mental, emotional, social, economic,
and spiritual-continuing care services must be both comprehensive and
focused on individual needs. In fact, many believe that continuing care,
which provides the support structures and services that empower women to
live drug-free lives, should span a woman's lifetime, although diminishing
over time. Support structures for women in continuing care may include
frequent contact with other recovering women, individual and family
therapy sessions, regular group support meetings, access to literature, life
skills training, ongoing formal education, vocational training, job place-
ment, and, when needed, respite or hospice care. These services must be
culturally sensitive and competent, convenient, accessible, and affordable.

Today, it is well understood that no single system can provide
comprehensive and effective solutions to the host of problems confronting
women in recovery for substance abuse. In view of this fact, CSAT has
taken the lead in establishing alliances with other programs in the U.S.
Department of Health and Human Services as part of the Substance Abuse
Linkage Initiative. These alliances facilitate new understandings in the
field of substance abuse treatment and establish new directions in acquir
ing additional treatment services that offer more effective avenues for
rehabilitation.

212 Continuing Care and Follow-up

6.1 Issues Related to Continuing Care

Continuing care interventions, designed to address the complex issues in women's lives discovered throughout the treatment process, are often introduced during or near the end of the treatment process.

Services that programs should provide include the following:

case management; the development of relapse prevention skills;

assistance in accessing, and developing skills to access comprehensive services, including, for example, safe and affordable housing and child care; and

- the facilitation of women's entry into relevant education and job training programs.

The use of these services in the treatment process is discussed in Chapter 5. Their role in continuing care and in relapse prevention is described below.

6.1.1 Case Management During Continuing Care

Case management

Case management is essential to the successful continuing care of
women recovering from abuse of alcohol and other drugs. The case man
ager facilitates continuing comprehensive care and follow-up services. The
case manager also helps the recovering woman develop a healthier and
more productive life for herself and her family. For example, the case
manager can help clients obtain benefits and entitlements; assist with and
arrange access to health care, housing, child care, and transportation; and
coordinate appointments with mental health service providers. The case
manager also provides ongoing assessments of clients' recovery and
responds appropriately to requests from clients for additional services. The
case manager is specifically responsible for identifying women who have
relapsed or who are in danger of relapsing and for helping them to return to
treatment, if necessary. Ideally, the case manager should hold weekly case
conferences to ensure that clients' ongoing needs are addressed.

6.1.2 Relapse Prevention and Recovery Skills

In examining issues of continuing care and follow-up for women, it
is important to consider relapse and recovery. The path of recovery is as
unpredictable as the process of addiction. Clinicians and program directors
should be aware of CSAT's definition of alcoholism and other drug depen-
dency as a chronic, progressive disorder often characterized by relapse.

Given this definition, and the fact that women who relapse may be in
particular need of the treatment program's continued support, reentry
opportunities to formal treatment must remain open. Continued relapses
may also indicate the possibility of serious psychiatric problems, such
as depression or bi-polar disorders. Issues related to dual disorders are
discussed in greater detail in Chapters 3 and 5.

Staff of treatment programs must acknowledge that recovery is a
lifelong process and, therefore, should realize that chronic relapse-which
is often viewed as the client's fault-should instead be viewed as a preventable
part of the recovery process. The program staff should be prepared to
accept women who relapse and respond to their needs. Judgmental
reactions on the part of treatment personnel towards women who relapse
must be reduced by providing staff training on appropriate methods and
manners of dealing with women who relapse. They should also periodi
cally examine the program's treatment modalities to improve their
effectiveness. For example, the treatment and continuing care program may
need to determine if its services are helping clients to secure the basic financial, emotional, and physical support needed to maintain recovery.

Largely because of financial constraints, formal treatment is often
not extensive enough for a woman recovering from alcohol and other drug
abuse. Issues related to substance abuse, such as past sexual abuse or
incest, often require separate attention and may go beyond the scope of
substance abuse treatment. Therefore, to prevent relapse, the client may
have to continue addressing these issues long after leaving treatment. The
program needs to help the client obtain services to deal with her specific issues at different times in her recovery.

For recovery to be successful, counselors must help the client identify stressful areas of her life and learn how to locate and use resources to deal with the stress. During discharge planning, the program builds on its efforts throughout treatment to empower the woman to handle stress.

Many programs include a formal relapse prevention component that offers mechanisms for early detection of relapse and mechanisms for intervention. Relapse prevention should in part focus on structured, supervised leisure time that will create a foundation for a client to handle leisure time more effectively after treatment.

Every member of a family can be affected by substance abuse, and this problem often extends across many generations. Therefore, continued family involvement and intervention are necessary to help the woman recover and become a more functional part of her family system. The history and current status of her family members-including significant other(s), children, and parents-are extremely important. For example, if a woman's significant other has been in recovery but relapses, the program should make an effort to help refer him/her to treatment and work closely with the client to help her avoid relapse.

Because many addicted women will need a constellation of
services ancillary to direct treatment, the continuing care network must
include all of the services that she used while in treatment. If any of these
services were not available, it could create stressors that may lead a client
to relapse. These services include housing, health care, employment, and
child care.

6.1.3 Access to Services

Ensuring access to adequate comprehensive services following
treatment is critical to successful recovery. This section briefly describes
issues related to this phase of care.

Traditionally, housing has not been considered a treat
ment program concern. But today, the lack of affordable and safe housing
has become a major obstacle for women leaving treatment and reentering
the community. In addition, it is an added stress factor that can be related
to relapse. Often, clients cannot go back to their previous housing because
they are no longer welcome; they have lost their place in public housing
communities by being in treatment; or they cannot return to their partners.
The housing issue is important to all women who leave treatment, but it is a
particularly critical issue for women who have been physically and/or
sexually abused, women just released from prison, homeless women, and
displaced or runaway teenagers. In most geographic areas, few halfway
houses exist for women with children and for women who are vision- or
hearing-impaired or who have other disabilities. Continuing care must include approaches to help women and their children
locate housing that is inexpensive, safe, and drug free.

Women in early recovery often need frequent, high-intensity
reenforcement of their recovery efforts. During this time (e.g., the first e/orls.
year or two), it may be advisable for clients to live in halfway houses or
group homes with other recovering women, rather than on their own. In this way, clients can develop support structures and positive peer relationships. For those who are too young to manage independent living situations and who do not have an intact home, long-term living arrangements, such as therapeutic foster care, should be developed. Program staff should try to identify a wide range of housing options in the community.

Some ways to help women who are discharged from intensive treatment to find suitable housing include the following:

· form an alliance with the Public Housing Authority and

other housing programs to identify subsidized housing in

safe, reasonably drug-free neighborhoods or recovery

oriented enclaves in high-risk neighborhoods;

maintain a data bank on housing that is accessible to women with disabilities;

network with Habitat for Humanity and similar nonprofit

and church-related groups to locate houses where women in

recovery and their families could live;

hire a housing coordinator to connect recovering women

with housing programs and group living facilities that are

self-governing, self-supporting, based on recovery prin

ciples, and drug free;

work with sister corporations that buy and rehabilitate

apartment buildings and houses, and then sell or rent space

to women in recovery and their families;

target particular blocks of neighborhoods or streets which

are safe for women and children and "zoned drug free"; and

provide long-term halfway house services for women only,

for women with children, and for women who are severely

debilitated from alcohol and other drug abuse. (Providing

graduated phases of decreasing intensity of treatment in

these houses will help clients resume recovery more quickly).

Health Care. The program should make provisions for continued access to adequate health care services, as appropriate, before a woman leaves treatment. Some approaches include the following:

· network with existing women's health services, women's

hospitals, medical colleges, university interns and residents,

and public health nurses to identify primary health care

services for women and their children;

· develop a directory of local physicians, dentists, and health

care and medical facilities, including teaching hospitals, that

can offer flexible payment plans, accept Medicaid, provide

services for the indigent, or provide a limited number of free

hours of service. This directory should include information

on the accessibility of offices and the types of services

offered to women with disabilities;

· meet with physicians, hospital administrators, and health

clinic managers to develop agreements so that all women

can receive gynecological care; pregnant and postpartum

women can receive prenatal, delivery, and postnatal care;

and parenting women can receive pediatric care for their

children; and

· assist women who are eligible for Medicaid in preparing

their applications.

Financial Independence.

Economic self-sufficiency is an important
goal in the recovery process for women. While job readiness should be
part of ongoing treatment, it is essential prior to discharge and during
aftercare. However, problems of illiteracy, inadequate job skills, and child
care can exacerbate a client's difficulties in finding work and thus must be
addressed in the discharge plan and by the continuing care program. The
program can help women overcome these and related problems in the following ways:

teach women how to write resumes and develop job histories using all relevant skills and experiences, including household, church, school, and volunteer work;

conduct assessments of interests, capabilities, literacy, and bilingual skills for placement of the client in appropriate vocational and educational programs;

teach basic skills and techniques needed to obtain a job; for example, rehearsing for a job interview;

provide information on the Americans with Disabilities Act which offers protection against employment discrimination and other forms of discrimination;

provide apprenticeships, job referrals, and job placements that are in environments supportive of recovery and where attention is paid to the physical and psychological exigencies of abuse/addiction and potential impairment; and

establish small, for-profit, majority women-owned businesses in which recovering women can work as paid apprentices or employees, buy shares of stock in the business, and learn business management skills. Examples of potential program and/or client-run businesses include food cooperatives, bakeries, restaurants, clothing shops, building rehabilitation companies, information management services, and child care services. Some portion of the profits could return to the women's treatment program and continuing care program that helped to initiate the business. Start-up money for this type of business is available from sources such as the Department of Housing and Urban Development's Community Development grants and loans, Small Business Administration (SBA) loans, women's business associations, and minority business associations.