Blending Perspectives and Building Common Ground

A Report to Congress on Substance Abuse and Child Protection

April 1999

Appendix B

Center for Substance Abuse Treatment
Comprehensive Treatment Model for Alcohol and Other Drug Abusing Women and Their Children

The purpose of this model is to foster the development of state-of-the-art recovery for women with alcohol and other drug dependence and to foster the healthy development of the children of substance-abusing women. The model is a guide that can be adapted by communities and used to build comprehensive programs over time. The goal of alcohol and other drug treatment is to support a woman's journey to a healthy lifestyle for herself, and for her family whenever possible. Because alcohol and drug dependent women tend to have few economic and social resources, comprehensive treatment is extremely important. The purpose of comprehensive treatment is to address a woman's substance abuse in the context of her health and her relationship to family, community, and society. This relationship is influenced by gender, culture, race and ethnicity, social class, sexual orientation, and age.

Treatment that addresses the full range of a woman's needs is associated with increasing abstinence and improvement in other measures of recovery, including parenting skills and overall emotional health. Treatment that addresses alcohol and other drug abuse only may well fail and contribute to a higher potential for relapse.

Confidentiality and informed consent, as well as the establishment of universal precautions against spread of communicable diseases, are essential throughout all aspects of treatment.

Although this treatment model has been designed specifically for women and their families, many components apply to men as well.

I. Program Structure and Administration

Development of joint cooperation among substance abuse agencies, schools, courts, probation, health and mental health providers, job training programs, and human service agencies. Creation of an inventory of local, State, and Federal resources available to the treatment program.
Establishment of an advisory body to assist the treatment program in collaborating with other resources and organizations, and to advocate on behalf of the program. This body should reflect the cultural and socioeconomic diversity of the women and include recovering persons as well as community leaders. Training and support are necessary.
Cross training of staff in collaborating organizations should foster the development of an integrated continuum of care for each woman in treatment and must address differences in philosophy, experience, and style of various disciplines.
Staffing should include individuals who are culturally competent and sensitive to and knowledgeable about treating substance abusing women.
Substance abuse treatment in correctional facilities should be delivered by trained and certified personnel.
Staff training should encompass the guidelines generated in CSAT's TIPs that relate specifically to Perinatal Substance Abuse.
Clinicians and program managers should participate in staff training. Such training should lead to understanding the impact of psychological and psychiatric disorders, incest, physical and sexual abuse and their impact on recovery, and readiness for treatment, family dysfunction, multi-addiction, and the importance of flexible treatment approaches.

II. Clinical Interventions and Other Services

Intake Screening and Comprehensive Health Assessment

Admission priority must be given to women who are known to be pregnant, HIV-positive or who have AIDS, and/or TB. Pregnant/postpartum women should be immediately referred for obstetrical care. (See TIPs.) Immediate referrals must be made if the program cannot provide appropriate care for these women. Documentation of referrals and admissions is essential.
Assessments for possible pregnancy, HIV status and exposure to and/or existence of TB should begin immediately.
Same-day intake services should be offered whenever possible.
Assessment may occur over a period of time. A complete health assessment must be conducted, and must include a physical examination, psychosocial (including psychiatric assessment where indicated), as well as an assessment of a woman's reproductive, oral, and nutritional health status.
Other assessments must include a substance abuse history; physical, emotional, and sexual abuse history (past and present); educational level and intellectual functioning; work history; family assessment; current living situation and childcare responsibilities; and racial/cultural/ethnic factors that are relevant to treatment. There should be an assessment of patient eligibility (and subsequent registration) for Medicaid, Medicare, SSI, public assistance, and other health and human service benefits.
An individualized treatment plan, including a plan for relapse prevention and continuing care, must be developed in collaboration with each woman entering treatment.

Medical Interventions

Medical assessments and subsequent care should be provided through arrangements with healthcare facilities accessible to individuals in the community or on-site, and should include the provision of preventive and primary medical care (including prenatal care, if appropriate); medical or medically supervised detoxification services, where clinically indicated; linkage to psychiatric care; provision of or established referral linkages as needed for acute medical care; testing and treatment for hepatitis, tuberculosis, HIV and HIV disease, sexually transmitted diseases, anemia and malnutrition, hypertension, diabetes, cancer, liver disorders, eating disorders, gynecological problems, dental and vision problems, and poor hygiene. It is preferable to have a healthcare professional available to consult directly with the program.
Women's Health Services. Preconceptional care should be provided either on-site or through referral, for nutrition, family planning, and general gynecological services to those women deemed appropriate.
Pharmacotherapy intervention should be provided on an as-needed basis and should include provision of, or established referral linkages, for concomitant assessment and monitoring by qualified medical or psychiatric staff. Interventions should promote equal access to treatment for all women based on assessment of their ability to participate in treatment.
Urine testing should be used where clinically appropriate, and should be conducted on an initial and random basis. (See TIPs.) The program should follow informed consent guidelines responsive to State reporting requirements, if applicable.
Infant and Child Health Services. Infant and child health services should be provided either on-site or through referral and should include the following: primary and acute healthcare for infants and children, including immunizations, nutrition services (including assessment for WIC eligibility), and a developmental assessment by qualified personnel. For treatment programs without medical personnel on-site, a back-up medical plan that identifies a protocol for pediatric emergencies must be in place.
Early Intervention Services. Access to an age-appropriate, comprehensive developmental assessment by qualified personnel, including an assessment of learning and developmental disabilities, should be provided to all children, beginning at birth. On-site provision of, or referral to, early intervention and remedial programs, and linkages with State Individuals with Disabilities Education Act (IDEA) should be encouraged.
Home-Based Support. Public health nursing and/or social work visits should be provided to high-risk postpartum women and their infants, especially to new mothers and those who are discharged within 24 hours after delivery. Linkages and referrals should be established with home care agencies.
Counseling for HIV-positive/AIDS Patients. The program must provide for pre- and post-test counseling for HIV-positive/AIDS patients as well as individual counseling and support groups. Staff should be properly trained to intervene on behalf of those who are HIV-seropositive, whether symptomatic or asymptomatic. Appropriate care for HIV-positive children must also be assured.

Linkages and Collaboration

Appropriate linkages to local, State, and Federal programs must be maintained for those services not provided on-site.
Linkages with outreach, outpatient, and residential programs should be maintained as a means to assure appropriate matching of women to substance abuse treatment. Similarly, linkages with parental/child programs (e.g., Head Start) should be encouraged.
Support should be offered with the criminal justice system where appropriate, and should include intervention with juvenile or adult justice authorities, TASC (or related case management/tracking systems), Legal Aid, and/or Bureau of Indian Affairs. Access to needed legal services should be provided if not available through Legal Aid, probation, immigration, child welfare, foster care, and legal service.

Substance Abuse Counseling and Psychological Counseling

Substance abuse education and counseling, psychological counseling (where appropriate), and other therapeutic activities should be provided by practitioners who are licensed or certified to provide these services and matched in competency to the populations served.

Services should be offered in the context of families and relationships, including individual/group/family therapy. Counseling for partners and fathers of babies should be promoted/provided at critical times throughout treatment.

Counseling should address low self-esteem; race and ethnicity issues; gender-specific issues; family of origin relationships; attachment to unhealthy interpersonal relationships; interpersonal violence, including incest, rape, and other abuse; eating disorders; sexuality; parenting issues; grief related to loss of alcohol and other drugs, children, family, partner, work, and appearance; creating a support system that may or may not include family and/or partner; developing a vision for the future and creating a life plan; and therapeutic recreational activities for women alone and with their children.

Parenting Education. Counseling, including information on child development, child safety, injury prevention, and child abuse prevention should be provided. Parenting education should be integrated with substance abuse counseling in order to be recovery-oriented. A woman's family of origin issues that affect parenting should be addressed in a way that supports rather than compromises her stage of recovery.

Relapse prevention should be a discrete component or phase of each woman's recovery plan.

Flexibility and creativity should be stressed in the use and timing of therapeutic approaches. Accusatory, judgmental, and humiliation techniques are inappropriate and have not been proven to be effective.

Health Education and Prevention Activities

Health education and prevention activities should include HIV/AIDS education; the physiology and transmission of sexually transmitted diseases; reproductive health; understanding female sexuality; preconception care; prenatal education; child birth education; childhood safety and injury prevention; physical and sexual abuse education and prevention; and nutrition, and smoking cessation classes, especially for pregnant women; and general health education.

Life Skills Education. Life skills education should be offered and should cover practical life skills such as parenting (where appropriate); vocational evaluation, financial management, negotiating access to services, stress management and coping skills; and personal image building.

Educational Training and Remediation Services

Educational training and remediation services should be provided, with on-site provision of or case-managed linkages to local education/GED programs and other remediation issues identified at intake.
English language competency and literacy assessment programs should be facilitated.
Job counseling and training should be provided, if possible, via case managed/coordinated linkages to community programs.

Transportation. Transportation to programs is needed to access treatment and related community services.

Housing. Access to safe, drug-free housing throughout treatment is all-important.

Childcare Services. Age-appropriate care of infants and children should be provided at treatment facilities using a developmental model. Respite care should also be available. If space or licensing requirements prohibit on-site care, contractual arrangements with local licensed childcare providers should be provided.

Continuing Care. Continuing Care should be provided, planned for, and should include sustained and frequent interaction with recovering individuals who have graduated from the intensive or primary phase of treatment.

Provision should be made for graduate re-admission to more intensive forms of therapy in cases where relapse has occurred.
As women complete the intensive phase of treatment and move into the community, the effects of domestic violence, rape, and childhood sexual abuse must be addressed over time. A plan for "safety" must be developed.
Socioeconomic issues (e.g., jobs/educational deficits) require long-term remedies and must be included in relapse prevention planning.
Public assistance and housing must be addressed in the continuing care plan.
Ongoing transportation assistance must be provided for attendance at self-help groups (AA, NA, and other support meetings).
Continuing provision of primary healthcare services and medical assistance as needed for women and children.

Where to?