The program staff should determine if the program's policies and procedures are respectful of the clients and based on valid treatment assumptions as well as the realities of women's lives.

Chapter 1 - Program Management Issues

Treatment programs must address program management issues that cut across phases of care. Some of these issues have been addressed in other chapters of the manual that correspond to the phases of care (e.g., staff composition as it relates to outreach). The issues are either listed (if they have been addressed in detail in a previous chapter) or briefly summarized under the following categories: policies and procedures, staff training, staffing and gender sensitivity, legal and regulatory issues, linkages with other agencies, and financing mechanisms.

7.1 Policies and Procedures

The treatment programs' policies and procedures not only reflect
their philosophies and standard procedures pursuant to public regulations
and guidelines, but also their recognition of the importance of gender and of
cultural differences. A number of issues concerning program policies and
procedures relate specifically to women in treatment. and should be
addressed by any program in reviewing its policies and procedures and
when initiating treatment services for women. In doing so, the program
staff should determine if the program's policies and procedures are
respectful of the clients and based on valid treatment assumptions as well
as the realities of women's lives. While it is important to have clearly
defined rules and a structured treatment environment, it is also important
that the rules not be so restrictive as to hinder the potential for clients to
remain in treatment and realize successful outcomes.
Because the treatment program staff (especially the counselors)
knows the particular needs of clients, it is important that program directors
hold frequent staff meetings to review policies and ensure that they are
appropriate and conducive to effective treatment. Program managers are
urged to involve staff in decision-making with respect to organizational
arrangements, policies, and procedures whenever possible. Women who
have completed treatment can also be a source of practical information and suggestions regarding program policies and procedures.

Many of the policies and procedures relating to women in treatment (e.g., ensuring access to comprehensive services) have been discussed throughout Chapters 4, 5, and 6. Key policies should address the following
issues:

· duration of treatment, which may need to be longer for

women, in view of their parenting and other caretaking roles,

as well as the multiple presenting problems that may need to

be addressed in treatment (e.g., history of sexual abuse); in

any case, the length of stay should be individualized within

the program's range;

· gender discrimination and harassment (Section 7.5);

· the need for flexible outpatient program hours based on

clients' daily schedules. Nine-to-five weekday office hours

are often unmanageable for working women and may be

difficult for women with children if child care is not pro

vided. Programs with evening-only hours but without child

care do not meet the needs of women who must make

babysitting arrangements and who are concerned about

leaving their children in environments where illicit drugs

and alcohol are used or where violence occurs;

· the degree to which documents used by the program in

outreach, treatment, and continuing care reflect knowledge

of and sensitivity to women's issues and are devoid of

gender and cultural stereotyping;

· for outpatient programs, the number of appointments that a

client can miss during treatment and still remain in the

-program. For women with children who must arrange for

child care (if it is not provided by the program), this restric tion may be seen as difficult or impossible for practical

reasons;

Program Management Issues

· requirements in residential programs that there be "no naps

during the day," which could be difficult and not medically

appropriate for pregnant women;

· for programs that have "strip search" policies, these should

be carried out only when necessary and then by same

gender staff specifically trained to perform the searches in

the most sensitive and least intrusive manner; and

· decisions regarding establishment of a smoke-free environ

ment in most of the program's facilities, if this is not the

policy for the entire facility. For the programs that have

children in treatment with their mothers, the entire facility

should be smoke free.

7.2 Staff Training

On an ongoing basis, the treatment program should identify the
training needs and requirements of program staff as they relate to female
clients. Training needs to be more intensive when the program is initiating basis,
operations or when female clients are being recruited for the first time.
Staff training should focus on ensuring that all staff (women and men) have
an understanding of the particular needs of women in treatment and that requirements of
they have the capacity to meet these needs.

If the state licensing and credentialing agency has materials that are
used to assess the competency of counselors, these materials can be
adapted by the program for use as a partial basis for the training. The
program should also prepare alternative model treatment plans that are
appropriate for women under a variety of circumstances (e.g., with or
without children, with or without a supportive spouse or significant other).
The program should involve in the training as many local resources
(individuals, organizations, and materials) as possible to strengthen
relationships with potential referral sources in the area.

236 Program Management Issues

Program management also should provide periodic training for staff, identifying the topic areas through feedback from staff (with staff members specifying their own training needs) and from ongoing and structured supervision. In this regard, all treatment programs should have clearly identified and written guidelines for staff performance and treatment procedures, with periodic clinical supervision by either program staff or consultants. The program can use a variety of mechanisms to monitor the knowledge, skills, and attitudes of staff with respect to women in treatment. Management can include the use of role playing exercises, the review of treatment plans prepared for and by the women, review of aggregate outcome data, and the subjective feedback obtained through focus groups involving staff and invited experts knowledgeable about women in treatment.

Staff training needs can be met in several ways:

· involve in-house program staff who may have particular

expertise in the topic areas for which training is necessary

(e.g., treatment planning);

· invite external experts to regularly scheduled staff meetings

or those specifically arranged to address a given topic;

· arrange for staff to attend workshops and conferences that

address general issues relating to substance abuse treatment,

treatment of women or other issues related to comprehensive

services for women. Support staff members in participating

in workshops and conferences and presenting papers

whenever possible; and

· exchange training resources and sessions with other facilities

or organizations (e.g., with the local medical or nurses

association, particularly those with which the program has

ongoing relationships). This can facilitate linkages and be a

more cost effective method of training.

Program Management Issues 237

Many treatment program staff serving women may benefit from training in many topic areas, including the following:

· understanding of women's issues related to substance abuse,

including physiological effects, dual diagnosis, social

service needs (e.g., child care);

· gender role stereotyping in general and with respect to

substance abuse in particular;

· family, parental, friend, and other relationship issues for

women in treatment;

· approaches to addressing a client's history of sexual and

physical abuse and other violence in the treatment process;

· intake, assessment, and orientation procedures and instru

ments appropriate for women (and for their children, if in

treatment with the woman);

· cultural competency with respect to ethnic/racial groups,

different age groups (e.g., adolescents and older women),

lesbians, women in the criminal justice system, and women

with disabilities; and

· ethical issues, including those discussed in section 7.5.

All of these issues also should be addressed as part of clinical supervision.

7.3 Staffing and Gender Sensitivity

Although the commitment to engage, treat, and retain women in
treatment is the responsibility of all program staff members, it must origi-
nate with the program's administration and must be based on client needs
and expectations. However, making a program gender sensitive (which changes the status quo in many treatment programs) is challenging to many
administrators because addressing the specific needs of women requires a
variety of changes in such areas as staffing, training, and treatment arrange
ments (e.g., treatment hours) as well as ensuring that there is ongoing
clinical supervision. These changes also present a challenge to program
staff who must participate in and adapt to these new arrangements. If a
treatment program for women is to work, its board of directors, advisory
board, administrators, and staff members, must all be committed to reevalu
ating program goals, policies, and services that are offered directly by the
program or for which referrals are made.

Making a program gender sensitive is challenging because it re
quires all staff members to develop a commitment to and an understanding
of the issues related to female clients. Some staff members may have
difficulty accepting new approaches to treating women in recovery, particu-
larly when such approaches address issues relating to sexual behavior and
sexual abuse. Both female and male staff members who have been victims
of sexual abuse may be uncomfortable talking with women about sexual
behavior. To work effectively with female clients, all staff members need
to explore their own feelings and experiences regarding sexuality and
sexual abuse, either individually or in a group. In addition, all staff should
be trained in program practices that relate to establishing and maintaining
appropriate boundaries with clients. Program rules must be established and
enforced to prevent the intentional and unintentional sexual harassment of
femalc clients. However, it should be understood that "appropriate bound
aries" can vary by culture. Through staff supervision, program manage
ment can identify particular knowledge, skills, and attitudes that need to be
improved with respect to gender issues, both for individual staff members
and for program staff overall.

A number of treatment providers have found that involving male
therapists in the recovery process makes the male partners of the women in
treatment more likely to interact with the treatment center and their female
partners in various activities, including family-related sessions.' Male
therapists can also be healthy role models for women who will necessarily
interact with men in work, social services, and other aspects of their lives
after treatment. This may have positive long-term benefits on the recovery
process for the women.

Both female and male staff members (as well as clients) must
understand what constitutes sexist attitudes and behavior and be able to
identify such behavior among the staff and clients. Staff members must
also be knowledgeable about and sensitive to the issues and needs of the women in the treatment program, including those of heterosexual and
lesbian women and women of different abilities, ages, ethnicities, races, in
and religions. Staff must receive training to improve their knowledge and program.
sensitivity as necessary.

If at all possible, the program staff and the program's board of
directors and advisory board should reflect in their membership the client
population with regard to ethnicity, race, gender, disability, sexual orienta
tion, and language.

7.4 Addressing Legal and Ethical Issues in the Program

In addition to the legal service needs of individual clients (e.g.,
concerning child custody or spouse abuse), treatment programs for women
confront two types of legal issues:

1. gender issues concerning the relationship between the

individual client and staff member, such as sexual harass

ment and job discrimination; and

2. institutional problems, such as the federal, state, and city

regulation of substance treatment services.

240 Program Management Issues

Although the sexual harassment of women in substance abuse
treatment programs is a known problem, many programs do not have
policies to address such harassment. Strict and clearly delineated policies
with respect to the potential sexual harassment of clients and the liability
that the problem represents for the programs are absolutely essential. These
can be developed with assistance from local legal aid programs or agencies,
based on federal and state guidelines and legal statutes.

Institutional regulations affect the kind of treatment that can be offered to women and how it may be delivered. These include federal regulations that apply across states (e.g., the Americans with Disabilities Act, mentioned in Chapter 5) as well as state and local public health and safety and other regulations that necessarily vary by locality.

Before planning for establishment of a treatment program or adding services to an existing program, providers must be thoroughly familiar with the regulations that apply to them. These regulations may include licensing of the facility by the local and/or state health department(s) and accreditation by the state alcohol and other drug abuse agencies. Although these regulations will be applicable to most, if not all, treatment programs, those serving women and their children may also face requirements related to the care of the children (e.g., for child care and for early childhood education). The program should obtain all required licenses and certifications as quickly as possible. This will help ensure the safety of the facility, build credibility with funding sources, and may be necessary to obtain third party payments.

In addition to legal issues, ethical issues need to be of concern to all treatment staff. The most commonly known are those related to client confidentiality, fraternizing between staff and clients, and sexual harassment. Most programs have policies that include ethical standards related to these issues. However, staff of treatment programs must also be aware of