This manual was developed in response to an awareness at CSAT
that women's needs have not been adequately addressed by most
substance abuse treatment providers. The underlying assumption
of this manual is that women have, to some degree, different physical,
psychological, social, economic, legal, and behavioral treatment issues
than those experienced by men. As a result, substance abuse treatment
modalities and strategies have to be adapted and/or developed to meet the
needs of women. It is also important to recognize that differences among
women in ethnicity, culture, race, age, ability/disability, economic status,
educational
attainment, and sexual orientation necessitate different treat-
ment strategies.
The manual described strategies for three stages of the treatment
process: outreach
when the program attracts the woman to treatment, social,
comprehensive care
when the program must address the woman's needs
and retain her
through the full course of treatment, and continuing care
when the program
helps to ensure that the recovering client's needs are yet, as much as possible. Many of the strategies
presented in the indi-
vidual chapters
(e.g., discussion of comprehensive services) apply across
the continuum of care, as do discussions of particular issues related to
special populations (e.g., older women). Moreover, because addiction is a
chronic condition that is characterized by relapse on the part of many
clients, many of the basic premises apply across the stages of care. Some
of these have been highlighted in one section of the manual (e.g., the need
to use screening and assessment tools that are gender-specific and cultur
ally sensitive) rather than being repeated throughout the stages of care.
8.1 Two Key Themes: Comprehensive Services and
Linkages
The issues addressed in this manual have been varied, reflecting
the complex nature of substance abuse and many of the problems faced by
women in treatment. Increasingly, substance abuse treatment programs
must address the physical and mental health problems of women in treatment for
which they may have received little attention, if any, prior to treatment. The
consistent theme of the manual has been recognition of the need to provide
comprehensive services for women in treatment. However, few programs have
sufficient resources to provide a complete range of services in-house, nor
should they be expected to do so. Most communities have public and/or private sector organizations which provide
services directly or which facilitate access to them. Treatment programs,
therefore, need to establish strong contacts with other organizations to refer
clients for services and to receive referred clients.
Contacts and linkages are
another theme of the manual. The ability of treatment program staff to
establish successful relationships with the staff of health and social service
agencies is critical to meeting the comprehensive needs of women in treatment.
It is also essential to establish linkages with community-based organizations
which represent women of color, adolescent and older women, lesbians, women in
the criminal justice system, and women who have differing physical and mental
abilities. These linkages help to ensure that treatment program staff have an
increasing understanding of and sensitivity to the wide range of differences in
women needing treatment; they also serve as an important source of referrals
and resources for speakers and facilitators.
A number of sensitive issues that need to be addressed directly in the
treatment process have been raised in the manual. These include for example,
the increasing incidence and prevalence of HIV, AIDS, and sexually transmitted
diseases among substance-abusing women, and the connection between sexual and
physical violence and addiction. However, as has been noted in the manual,
there are a variety of approaches to providing services to women who present
with these problems. For example, opinion varies regarding the point at which
counseling regarding prior history of sexual abuse should be initiated during
the treatment process and
how it should be addressed. Moreover, cultural and other values
play an
important role in terms of what is acceptable to the female client and what
is permissible by local norms as expressed in public policy or the law. An
example of the impact of cultural values is the divergent opinion concern
ing HIV and AIDS (e.g., counseling concerning safe sex practices and
ensuring that condoms are available for clients). Although these are diffi
cult and contentious issues, programs need to face them directly if their
services are to meet the needs of their female clients. Program manage
ment and clinical staff should be sufficiently knowledgeable about the
advantages and disadvantages of alternative strategies in terms of their
client population. It is important for the staff to discuss these strategies
with their clients
and delineate a clear rationale for selecting the approach
which is recommended
for each client. If changes are made, all staff need
to be made aware of
the changes and the treatment protocol should be
adjusted accordingly.
8.2 Do We Know What Works for Women?
The manual was prepared using both published and unpublished
research and the experiential knowledge of women who are noted experts
on the treatment of women for alcohol and other drug problems. However,
it must be emphasized that there are many theories and approaches to the
treatment of alcohol and other drug use in women and that the wide range
of treatment programs reflects that diversity. Do we know with any cer
tainty what works for women in treatment? If we think certain specific
strategies work, are they more effective for certain populations under
different circumstances? These questions apply in general to the treatment
for alcohol and other drug abuse as well as the treatment of women specifi
cally. It is important to coordinate efforts between funding sources, pro
grams, and researchers to evaluate empirically approaches to engage and
retain women in treatment. To facilitate recovery, research and evaluation
are needed to determine which treatment modalities are most effective for women in general and for specific
groups of women.
The diversity of theoretical views and biases hampers the development and
implementation of research and evaluation studies that could identify
differences in treatment outcome. For example, the underlying concept of
addiction serves as an explicit or implicit foundation for the design of research and evaluation.
Many in the general public (and some in positions of leadership) still support the
view that in general, alcohol and other drug abuse is a moral condition,
particularly where women are concerned. Many others support the medical model
perspective, defining substance abuse as a disease in the physical sense. But
if the field is to address successfully the complex problems of alcohol and
other drug abuse among women and to evaluate the success of treatment programs,
it must develop successful, replicable treatment models. The focus should be on
what treatment models and specific services are effective for which group of
women in a variety of physical, psychological, social, and cultural
circumstances.
In identifying what
treatment approaches successfully engage and retain women in treatment and
result in their recovery, it is important to look at specific aspects of the
treatment process, examining the combination of treatment modalities and
services that is most effective under different circumstances for diverse
populations. For example, to consider the appropriateness of requirements (or
standards) for the duration of residential treatment and frequency of
outpatient visits for women in varying circumstances, the following types of
questions should be addressed:
· Are twice
weekly outpatient counseling sessions sufficient for a poor mother of four
children without a job or job skills who is living in a temporary shelter?
· Will
long-term residential treatment work best for a preg
nant mother
currently living with a violent spouse, whose
children are
in foster care under order of child protective
services?
· Will a five
to seven day inpatient detoxification treatment
work best for
a married woman with two children who is
experiencing
co-occurring symptoms of post traumatic
stress
syndrome, depression, and alcohol abuse?
The treatment program should consider these issues in defining its
treatment philosophy and determining the scope and level of services,
including treatment modalities. It should also consider these types of
questions when preparing or reviewing the program's policies and proce-
dures manuals and
when reviewing the program's achievements.
8.3 Other Treatment Design Considerations
In addition to the issues raised in this manual, there are other
important concerns in the
design and adaptation of services for women.
While some of these
are applicable to both female and male clients, there
are particular aspects that impact specifically on women. These issues are
not addressed in detail, but are listed for consideration by the programs:
· Treatment programs are operating in a health care system
that is in the midst of major changes and reform. How will
alcohol and other drug programs fit into the overall plan?
What is the current financial impact on the programs of the
changing health care industry?
· Process and outcome evaluation are increasingly important
to the viability of alcohol and other drug abuse programs for
women. Programs that are funded in the future may be
those which can document successful outcomes that are
replicable in different environments. How can treatment
programs serving women with complex health and socio-
economic problems
document activities and outcome and for what outcomes will they be held
accountable, whether or not they have "control" over the outcome
(e.g., employment)?
Programs must have community partnerships and must receive funding from sources
other than the government in order to survive. However, there is increasing
competition for scarce resources in both the public and private sectors. This
can result in a competitive environment rather than a cooperative one. What are
the possibilities for generating income on joint fund-raising efforts and for
sharing of services to make the best use of scarce resources?
Cultural competence does not just mean having racial and ethnic diversity among
the staff and board members. It means ensuring attitudinal and behavioral
change, incorporating understanding, and respecting a diverse client population
and target group. It must be acknowledged that there is no consensus regarding
cultural "norms" and accepted practices and language, even among a
particular group of women. Program staff must be aware of the diversity within
and among their particular client and target populations. In this regard, staff
training is critical.
Participatory decision-making is key to ensuring that a program meets client
needs and is well managed. These programs will more than likely identify,
target, and treat clients using strategies that have been successful with that
client population. Feedback from staff and clients is part of an on-going
program assessment and is an important part of program operations.
Safety of the treatment environment is important for all clients, but
particularly for women and their children, if the children are living with
their mothers. However, for a number of reasons, substance abuse treatment
programs are often located in areas that are not safe: they are accessible to
potential clients, the facility is affordable, or other communities are not
amenable to having substance abuse treatment
facilities in their
neighborhood. To protect client safety,
some treatment programs take precautions that make them
appear to be impenetrable and therefore uninviting.
Programs need to strike a balance between client safety and
accessibility.
8.4 We Do
This Because
In reflecting on the strategies for providing treatment
services, it is
often easy to get lost in the detail, to lose sight of the fact that those who
provide substance abuse treatment services for women do so because there
is the possibility of recovery. However, on a daily basis, from the
perspective of the staff member of the treatment program, the millions of American
women who have substance abuse problems become the one
woman in treatment for whom services are provided, care is demonstrated,
and in whom hope is invested.
