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Substance Abuse Treatment: Addressing the Specific Needs of Women [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 51.)
By the CSAT Women, Youth and Families Task Force
In the early 1990s, Congress appropriated funds to the newly created Substance Abuse and Mental Health Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT) to support long-term residential substance abuse treatment programs for women with children. Two separate demonstration programs were funded, including the Residential Women and Children's (RWC) program, and the Pregnant and Postpartum Women and Children's (PPW) program. Based in part on the experiences of the RWC and PPW programs, CSAT published a “Comprehensive Treatment Model for Alcohol and Other Drug-Abusing Women and Their Children” in order to help substance abuse treatment providers develop program services to meet the comprehensive needs of the women and children served by these and other programs. The model was included in a 1994 CSAT publication, Practical Approaches in the Treatment of Women Who Abuse Alcohol and Other Drugs.
This model recognized that there was an important difference between “treatment that addresses alcohol and other drug abuse only” and “treatment that addresses the full range of women's needs.” As stated in the model
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 (CSAT 1994f).
CSAT's model remains an important contribution toward describing an approach to working with women that recognizes the importance of gender in the design and delivery of services for women and their families.
Since 1994, the field has gained additional insights about critical needs of women and children and the role that partners and fathers play regarding these needs. The knowledge gained in the past decade should drive the delivery of services to women. These insights include the following:
Psychological differences between men and women and, in particular, the heightened importance that women place on relationships have a great impact on both women's gateways into addiction and relapse once in recovery. A woman's focus within relationships is often to serve as “caretaker,” a role that can result in a woman not attending to her own needs. Positive, therapeutic relationships, on the other hand, can also act as powerful tools for supporting a woman's recovery.
Women self-medicate with addictive substances to mask pain associated with underlying trauma, including past and ongoing domestic violence as well as childhood abuse and neglect. The high prevalence of a history of trauma among women receiving substance abuse treatment heightens the need for substance abuse treatment to recognize the critical impact of trauma on the woman's recovery.
The prevalence of co-occurring mental health disorders among women receiving substance abuse treatment has also come to light over the past decade and raises the need for providing coordinated services to address both substance use and mental health disorders.
Women appear to be significantly affected by the service systems they depend on, including welfare agencies and child welfare agencies, which tend to operate independently, with different timetables and perspectives on the purposes of recovery.
A new understanding has arisen about the benefits of women's economic self-sufficiency in the process of long-term recovery. This is partly a result of the pressures of society, exemplified by welfare reform and data indicating that gainful employment can be a protective influence for preventing relapse.
The field has also come to appreciate that children of women in treatment have many of their own needs that cannot simply be addressed by the provision of child care and residential living space. These needs are addressed when children are provided services directly, as well as when the needs of their parents are met.
Both mothers and fathers should receive the education and support necessary to prepare them for the responsibility of parenthood, understanding that the roles fathers play in families are diverse and related to cultural and community norms, the health and well-being of the father, and the viability of the parents' relationship to one another.
Changes in family composition play a role in supporting women and recovery. In 1960, fewer than 10 million children did not live with their fathers (U.S. Bureau of Labor Statistics n.d.). By the turn of the century, the number had risen to nearly 25 million. More than one-third of these children will not see their fathers at all during the course of a year. Studies show that children who grow up without responsible fathers are significantly more likely to experience poverty, perform poorly in school, engage in criminal activity, and abuse drugs and alcohol (U.S. Department of Health and Human Services 2000a).
This update to the model considers the needs of women, their children, and their families in the context of their community and culture.
As was the case with the earlier version, 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 (CSAT 1994f, p. 267).
CSAT's Comprehensive Treatment Model continues to reinforce that confidentiality and informed consent, as well as the establishment of universal precautions against the spread of sexually transmitted and other infectious diseases, are essential throughout all aspects of treatment (CSAT 1994e, 2000d).
In addition to incorporating the new knowledge about the common histories and service needs of women and their children, this model goes a step further by delineating the relational elements of the service continuum that have an impact on treatment for women. These elements shown in Figure B-1 below and are categorized as
Interrelated Elements in the Comprehensive Treatment Model.
Clinical treatment services: those services necessary to address the medical and biopsychosocial issues of addiction
Clinical support services: services that assist clients in their recovery
Community support services: those services and community resources outside of treatment but within a community that serve as an underpinning or support system for the recovering individual
In parallel, the model also describes clinical treatment and clinical support services for children of women in treatment.
Research has established that there are many paths to recovery from alcohol and drug problems. Some women resolve their alcohol and drug problems with individual and family supports and without any outside intervention. Others recover with support from self-help groups such as Alcoholics Anonymous and/or the faith community. Still others have found recovery through formal treatment interventions. A variety of factors can influence which of these paths is successful, including the severity of the problems and the support systems available to women with substance use disorders.
To achieve the best outcomes at the lowest cost, SAMHSA encourages the establishment of a comprehensive continuum of recovery. The full complement of these services is appropriate for many women who meet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria for substance use disorders. However, not all services and/or interventions are needed by every woman in treatment or recovery for substance dependence, and those who meet the diagnostic criteria for substance abuse may require a less comprehensive range of services than those who are substance dependent. Similarly, women with a range of family, social, and economic supports may not require a full complement of services while those who have fewer naturally occurring supports may require more services from the formal health, social, and economic supportive systems.
The array of services described below does not need to be provided by a single entity, but in most instances will be provided by a consortium of addiction treatment, health, and human service providers. The continuum is not specific to philosophies of treatment and recovery, modality, or setting. It is a generic framework within which providers can conceptualize service arrays, service capabilities, and appropriate managerial and administrative processes.
Methods of implementing each service, the manner and setting in which different services are delivered, and other ingredients of the model should be based upon an assessment and patient placement determination that considers (1) the needs of the individual, and (2) the extent to which the continuum of services is available in the community.
To better understand the model, it is helpful to view services as a series of interwoven and interdependent circles of care that are necessary to support the recovery process for women.
In the Navajo Nation, the woven basket is actually a series of concentric rings, one lying within the other, expanding outward and upward until the entire basket is shaped. By itself, one ring can hold nothing and bear no load. When bound together, the circles join, gain strength, and what before could hold nothing now holds stones for building nations and water for building bodies.
The concept of interdependence is critical to understanding the model. Each circle requires the existence of the other two and yet they are depicted as dotted lines to illustrate their permeability. The three circles together comprise comprehensive treatment, and any provider seeking to emulate the model must also ensure that there is an interdependent relationship among the three systems.
Borrowing again from the basket metaphor, the circles are also three-dimensional as a basket must be and, as such, have binders that interweave and hold the circles together. Likewise, in treatment, there are activities that weave through each circle, helping to bind the service continuum together. Housing is a good example. Some people with substance use disorders are functionally homeless and, thus, the issue of housing permeates clinical treatment, clinical support, and community support.
A final and critical aspect of how the circles are interrelated requires the inclusion of two concepts that provide the foundational support to the network of comprehensive care: cultural competence and gender competence. These concepts are graphically displayed as the handles to pick up and use the basket. For a system of care to be comprehensive in nature, it must have cultural and gender competence at all levels of treatment and support. The terms cultural competence and gender competence mean more than knowledge about culture or gender. The terms require practitioners to be knowledgeable, understanding, and sensitive to the milieu from which the woman comes regarding the issues and concerns she may bring to treatment. These include the socioeconomic context of her background; her sexual identity; the sources of potential anger, hurt, and fear; and disconnection from family, friends, and community. Both cultural competence and gender competence require recognition of the biases that may exist within the programs and practitioner that will impact treatment and relationships with clients.
As shown in Figure B-2, the fabric of the basket is interwoven with a range of clinical treatment services. These services include the following elements: outreach and engagement, screening, detoxification, crisis intervention, assessment, treatment planning, case management, substance abuse counseling and education, trauma-informed and trauma-specific services and psychoeducational therapies, medical care (including treatment for infectious diseases, women's health, and health education), pharmacotherapies, mental health services, drug monitoring, and continuing care (these services are defined and further explained in the last section of this appendix). While arguments could be made to support the addition of other core services to this continuum, experience has shown that these elements of service are typical of those that are under the core umbrella of treatment programs.
Elements of Clinical Treatment Services.
For most women in treatment, particularly those burdened with issues such as intergenerational poverty, violence, and homelessness, time-limited clinical treatment services alone will not likely result in sustained recovery. Women with multiple needs will need support from other systems, designated clinical support, and community support to achieve success in recovery.
Addiction affects women's connections and relationships, causing them to leave or abandon many of the relational systems upon which they formerly depended—family, friends, and roots in the community. Thus, for a woman to succeed in treatment, deliberate steps must connect her with the support structures that allow her to reverse the isolation and fragmentation often synonymous with addiction and reconnect with these important relationships. While some of that occurs within the context of clinical treatment itself, other aspects of the reconnection process occur as a result of clinical support and community support services.
Within this circle is an array of services that, by themselves, are not necessarily part of the treatment modality but, like ball bearings to machinery, make the treatment modality work. These support services (shown in Figure B-3) include primary healthcare services, life skills, parenting and child development education, family programs, educational remediation and support, employment readiness services, linkages with the legal and child welfare systems, housing support, advocacy, and recovery support services. Elsewhere in this appendix, similar circles are identified that relate to the special needs of children. While introduced separately, they are inextricably intertwined with those of the parenting woman.
Elements of Clinical Support Services.
Clinical support services are not ancillary services, they are a critical part of treatment designed to prevent relapse. This model suggests that these services are not enhancements of treatment but, rather, critical elements of treatment designed to promote overall well-being and prevent relapse.
Community support services are those that must be available in the community to ensure long-term recovery. These services, as shown in Figure B-4, include recovery management, recovery community support services, housing services, family strengthening, child care, transportation, Temporary Assistance for Needy Families (TANF) linkages, employer support services, vocational and academic education services, and faith-based organization support. This ring represents some areas that are not typically included in the service array for women, but women's treatment program staff and policy analysts increasingly view these elements as critical to long-term recovery.
Elements of Community Support Services.
Over the last decade, the concept of relapse prevention and aftercare evolved into the approach known as continuing care. This approach recognizes both the need to provide continuing support to a person in recovery and that treatment providers share some of the responsibility for providing this support. The concept of community support operationalizes continuing care by recognizing the systems and services that must exist in the community in order to make continuing care a meaningful reality.
Taken together, as shown in Figure B-4, clinical treatment, clinical supports, and community supports complete the basket and provide the comprehensive services needed by many women in substance abuse treatment. Implicit in the model is the responsibility of providers to look inward to their own resources as well as outward to community partners' resources to ensure that the elements of comprehensive services are made available in the community.
While it is important to provide the comprehensive array of services and supports to all women, women who are also mothers demand increased attention to their unique roles as parents and their children require additional services and supports. Treatment agencies have come to understand that, for women who are mothers, their children are a major factor influencing why they enter, complete, and/or leave treatment. Mothers in treatment are, in most instances, the custodial parent who carries out the tasks of parenting and childrearing. In some cases, the mother in treatment may not currently have custody and the daily responsibility for the care of her children. Those cases require special considerations by treatment providers to assist the woman in her efforts to regain custody if appropriate, and, when regaining custody is not an option, assist the mother as she transitions in the loss of her children.
Among mothers in treatment with custody of their children, the experience of the RWC and PPW programs is clear: Providing child care alone is an insufficient response to the needs of children whose mothers abuse alcohol and/or drugs. In many cases, the children themselves need services ranging from interventions for fetal alcohol spectrum disorders, to intervention services for childhood mental health disorders and developmental delays. Treatment programs have responded to the needs of children and have reported that treatment for women and their children requires a whole-family perspective in service delivery and in clinical practice.
Children's clinical treatment needs are depicted in Figure B-5. Their clinical needs include intake; screening and assessment of the full range of medical, developmental, emotional-related factors; care planning; residential care; case management; therapeutic child care; substance abuse education and prevention; medical care and services; developmental services; and mental health and trauma services.
Clinical Treatment Services for Children.
In addition, children need supports that reinforce their individual needs. These clinical support services are shown in Figure B-6 and include the concepts of cultural competence and developmentally appropriate services. As with the women's model, cultural competence is a critical aspect and is depicted as the handles for using the service array in the model. Needs and services for young children must be tailored to their developmental status and cognition. Clinical support services include primary health care, onsite or nearby child care, mental health and remediation services, prevention services, recreational opportunities, educational services and advocacy, advocacy in other service arenas and with legal issues, and peer supports for recovery such as self-help and mutual support groups.
Clinical Support Services for Children.
Regardless of the child's current custody status, services to address children's needs should be coordinated, and when appropriate, should be integrated with their primary caregivers' treatment and case plans to ensure that the whole family's needs are met. Ensuring that parents' and children's case plans are in harmony in terms of timing and strategies is imperative for family recovery. While children can be significant motivators for women to seek treatment, without proper planning, caring for children can also produce stress that may contribute to relapse.
Taken together, providing comprehensive services for women and their children (as shown in Figure B-7) requires treatment agencies to provide an array of direct services and to establish linkages to a wide range of supports and community resources. This is no easy feat. The need for coordination and collaborative relationships among agencies and service systems can tax scarce resources in staff time and expertise to establish those bonds. While it may seem overwhelming to consider all of the various linkages needed, treatment agencies can prioritize their most immediate need for collaboration by understanding the most immediate needs of their clients.
Interrelated Elements of Clinical Treatment and Support Services for Women and Their Children.
The elements of treatment for women, including those who are mothers, are described below. Together the elements make up the continuum of services that women and women who are mothers need to succeed in substance abuse treatment. The intensity, duration, and type of treatment will vary depending upon the assessment and diagnosis of the woman and the needs of her child or children. The manner in which services are delivered will also vary, depending on factors specific to the woman and the child, including culture, race, ethnicity, social class, age, and sexual orientation. Treatment intensity, philosophy, and methods will vary depending on the needs of the client, reimbursement policies, and treatment methods used by providers.
Clinical treatment services are generally provided directly by the substance abuse treatment provider. As such, they are considered core services. Providers recognize that providing core services without support services is likely to result in less than optimum outcomes for women and children over the longer term; thus, support services are pivotal to the successful treatment of women and children.
Outreach, engagement, and pretreatment. Activities designed to assist clients in engaging in treatment are essential elements of service, falling into the broad category of outreach, engagement, and pretreatment services. For many women, these services break the ice and help them overcome the shame and denial that often serve as obstacles to treatment. Same-day services, visits to programs, and familiarization with program staff should be facilitated whenever possible. Identification of and attention to women's immediate needs (e.g., legal, health, safety) are important aspects of engagement, even if those problems cannot be resolved immediately. When a program slot is not immediately available, services should be offered to keep women connected to the treatment organization. Outreach for women must address barriers that keep women from treatment, such as fear of reprisal from significant others and family members, fear of not being able to care for children or the loss of custody, as well as language and/or cultural barriers. Outreach must also address systemic barriers such as lack of money or insurance, waiting lists, lack of treatment for pregnant women, absence of child care, lack of transportation, inability to find sustaining employment, and need for time to address demands of other systems, such as child welfare and TANF stipulations.
Screening. Intake screening is part of the admissions process and can be an important strategy that assists in engaging a woman in treatment. As such, the interview should be relevant and sensitive to the woman's immediate needs, including the needs of her children. Intake screening should be conducted by a staff person, preferably a female, who is respectful of the complex needs of women, who is nonjudgmental, and who can determine critical immediate needs, including medical, prenatal care, detoxification, housing, safety, food, clothing, urgent dental needs, and transportation. Screening is a good opportunity to provide a complete explanation of confidentiality and represents the beginning of the treatment engagement and case management process.
Detoxification. Detoxification services are generally provided in an inpatient or residential setting and generally include close medical supervision. Although some treatment providers consider detoxification to be part of the continuum of care, others consider it a pretreatment activity. When needed, these services are critical to the comprehensive care model and offer another opportunity for a provider to engage a woman in longer-term treatment.
Crisis intervention. Women coming into treatment are often victims of violence and may be experiencing crises warranting emergency intervention. Ideally, programs would have crisis intervention specialists available or they may have established strong linkages for immediate access to crisis services. While some crises may be evident at intake, others may arise during the course of the treatment and may affect the woman and her children.
Assessment. Full assessment for women encompasses a wide range of concerns and includes a focus on her strengths; a comprehensive view of health-related needs; risks for HIV/AIDS and other infectious diseases; psychological status and screening and/or assessment for disorders that commonly co-occur in women with substance use disorders (e.g., depression and posttraumatic stress disorder [PTSD]); personal and community safety issues; understanding her significant current relationships and family-of-origin factors that may predispose her to abuse substances (such as sexual, emotional, and physical abuse, neglect, parental addiction, and parental mental illness); her current parenting and caregiving roles; responsibility and issues such as custody of children, special needs of children living with the mother; options for care of children if the mother is to enter residential treatment without her children; her housing status and the safety of her housing; financial resources; vocational/educational/employment issues; legal issues; and involvement with other health, social, and/or criminal justice service systems. Using the information garnered in the assessment process, a recommendation on the level of care and treatment placement should be made. The placement decisions should follow those promulgated by the American Society for Addiction Medicine (ASAM). Known as Patient Placement Criteria, ASAM's criteria are increasingly the standard for determining the needed level of care.
Treatment planning. Treatment planning is a collaborative process that should be done in the context of the unique needs and informed choices of women, and should be based on their individual strengths. Treatment planning should include any immediately needed services to help stabilize the family and assist the woman as she prepares for treatment. It needs to build on the internal and external resources available to the agency and should integrate the assistance offered and stipulations required by other health and social service systems. Treatment planning with women and their children requires attention to re-entry and continuing care planning as well.
Case management. Case management addresses coordination of the myriad service elements that are needed by women and their families. Case management can occur as a pretreatment activity, during treatment, and posttreatment. Among services requiring coordination are medical, housing, child care, transportation, employment/vocational preparation, educational, and legal. Coordination with child protective services, welfare, and probation and parole offices must also be managed.
Substance abuse counseling and education. Substance abuse counseling and education for women needs to address the dynamics associated with addiction in women, as well as current behavioral issues in her addiction and the interrelationship between addiction and other co-occurring disorders. These include issues stemming from family-of-origin dynamics and the importance of relationships in the lives of women. It also needs to address the physical and social consequences of substance use disorders. Programs should ensure that all counseling activities are conducted in a respectful and caring manner and should not use counseling approaches that are contraindicated for trauma survivors, such as shaming, harsh confrontation, and intrusive monitoring. Staff should work with women in a manner that builds self-esteem, using nonaggressive and nonthreatening techniques so as not to revictimize clients. In addition, relapse prevention and recovery management are important components of substance abuse counseling and education.
Trauma-informed and trauma-specific services. Given the high prevalence of histories of violence among women with substance use disorders, providing treatment in a trauma-informed environment is especially important. Staff should be trained to understand the multiple and complex links between violence, trauma, and addiction; to understand trauma-related symptoms as attempts to cope; to understand that violence and victimization play large and complex roles within the lives of most consumers in substance abuse and mental health services; and to behave in ways that are not retraumatizing to women. Trauma-specific services include individual and group services that directly address the impact of trauma and facilitate recovery and healing. A woman should not have to disclose her trauma history to receive trauma-specific services. The best practice is to enter into every treatment relationship as if the woman has experienced trauma, whether disclosed or not.
Medical care, including treatment for infectious diseases, women's health, and health education. Medical assessments and subsequent care should be provided onsite or by referral by care providers who are sensitive to gender, addiction, mental health, and trauma issues. The types of services that may be needed include primary care; prenatal and postnatal care; emergency and hospital care; chronic diseases care (arthritis, diabetes, etc.) and testing, treatment, and counseling for HIV/AIDS, tuberculosis, and sexually transmitted diseases; and gynecological care. During pregnancy, special consideration should be given to the medical management of the pregnancy. Maternal education about and preparation for delivery and postpartum needs, including postpartum relapse prevention, should be included. Methadone maintenance and medication management of opioid dependence is particularly important during pregnancy. For women with a history of mood disorder, the postpartum period should include close monitoring for psychiatric symptoms.
Pharmacotherapies. The use of methadone for treatment of opioid dependence is an accepted standard of care. Although usually provided on an outpatient basis, it should be available at all levels of care. Special attention may be needed when integrating patients on methadone and other phamacotherapies into treatment milieus with other clients who may not understand the utility of pharmacotherapies or who may have a negative attitude toward their use.
Mental health services. Provision of or linkage to psychiatric and psychological care providers is often needed, given the high prevalence of co-occurring psychiatric disorders among female substance abuse treatment clients. It is not unusual for women to need services for affective disorders, anxiety disorders (including PTSD), and somatization disorders. Services for other mental illnesses (including severe mental illnesses such as bipolar disorder or major depression) are not as common but are also needed. Pharmacotherapy is sometimes part of mental health care, and onsite staff can provide medication education and monitoring.
Drug use monitoring. Drug use monitoring, as part of ongoing assessment of the client's progress, is a component of treatment and can be used as a deterrent to relapse.
Continuing care. Continuing care is a critical element of clinical treatment services for women. Trusting relationships formed among women, their peers, and their counselors continue to provide support to women once they have completed the formal treatment period. Planning for discharge is often anxiety-provoking and counselors should be prepared for a recurrence of presenting problems and possible resistance and procrastination by the client. Continuing care takes place, ideally, in all three domains—clinical treatment, clinical supports, and community supportive services. It addresses individual needs identified in a woman's relapse prevention plan, and builds a supportive network for the woman and her family to encourage and reinforce her recovery. When possible, a mother's schedule of continuing care services and her child's prevention services should be coordinated in order to encourage maximum attendance by both mother and child. A variety of self-help support programs can also promote the integration of the woman and her family into the community.
Intake. Substance abuse treatment agencies able to serve children should establish criteria that encourage enrollment of children in the program. In providing children with developmentally appropriate services, the agency's criteria might consider the child's age, as well as the number of children who may be involved for each mother. The child's safety and well-being, including bonding and attachment issues, are paramount and any threats to these must be evaluated and considered in the intake criteria.
Screening. Screening of children is an important part of providing family-centered and family-supportive treatment. Screening of children should be done in a supportive and friendly environment conducive to open dialog. There are advantages to having the same person conduct the screening who might later perform an assessment.
Assessment. Medical, developmental, psychological, and trauma history should be assessed for all children participating in treatment with their mothers. Particular attention should be paid to issues that require immediate attention, such as methamphetamine lab exposure and physical abuse or severe neglect. As with screening, the assessment environment should be supportive, friendly, and conducive to open dialog. Determinations must be made as early as possible and should be continuously reviewed as to whether the child needs education, prevention services, intervention, treatment, or a combination of these.
The child's own support system should be assessed, including the role that the child's father and extended family plays (or could play) in the child's life.
Care planning. For children, care planning includes planning for education, prevention, and intervention services. Care planning should be conducted by professionals with particular experience in addressing the physical, psychological, and developmental needs of children whose mothers abuse alcohol and/or drugs. When age appropriate, it should include education about the treatment process that the mother will undergo and concerns about the transition that may be associated with that process.
Residential care in residential settings. Providing safe and appropriate living space and adequate services for children whose mothers are in residential care is a powerful motivating factor for women to enter and continue in treatment. It enables children to either avoid separation or be reunited with the mother when treatment is made a condition of reunification by the courts.
Case management. In addressing the service needs of children of mothers with substance use disorders, special attention should be paid to coordinating the child's services with those of the mother. Active involvement of the mother will aid in the transition from treatment program to home. Of critical importance to care for children are the dual concepts of personal safety and environmental stability. When children are not in their birth mothers' custody, engagement of the foster or kin caregiver in care management is critical.
Therapeutic child care. Children born to mothers who use substances are at high risk for poor developmental outcomes including neurological effects and alcohol-related spectrum disorders as well as consequences stemming from preterm delivery. Living with a parent with an addiction may also result in mental health issues for the children, particularly those associated with witnessing violence or separation from primary caregivers. Children with medical and mental health disabilities may need specialized child care provided by professionals with advanced training and in a setting where accommodations can be made to the physical environment that are responsive to these disabilities.
Substance abuse education and prevention. Children whose mothers have substance use disorders need substance abuse education and prevention support at an early age, in part to correct their misconceptions of what is normal adult behavior. These programs should present information about the role of substances in the mother's role in caring for her children and to put the mother's treatment in the context of the child's view of reality.
Medical care and services. In addition to a need for primary health care, attention must be given to the possibility of organic damage resulting from prenatal or early childhood substance exposure. This includes the physiological damage of alcohol-related spectrum disorders and exposure to drug production such as methamphetamine. Medical assessments and subsequent care should be provided onsite when possible or by referral when necessary. The types of services that may be needed include neonatal and perinatal care; pediatric care; emergency and hospital care; and testing, treatment, and counseling for pediatric HIV/AIDS.
Developmental services. Children who have been exposed to alcohol or drugs in utero or within their family environment may be at risk for physical and cognitive developmental delays. Physical, occupational, and speech therapy may be indicated for these children. Children experiencing developmental delays may also require behavior modification support, tutoring, and medication that will need to be managed.
Mental health and trauma services. Children who grow up in the care of adults with substance use disorders can suffer psychological distress resulting from the experience of neglect as well as emotional, physical, or sexual abuse. Some children have witnessed domestic or other acts of violence. Children of mothers with substance use disorders often benefit from psychological counseling and therapy and from having their own trauma issues addressed through individual and group modalities.
Clinical support services assist women in making the transition to independent and healthy alcohol- and drug-free living. They introduce or stabilize the woman's ability to care for herself and her family and to fulfill her role as a community and family member. For children, these services support healthy development and increase their capacity to reach their potential.
Primary health care services. Primary health care services, which are often provided at the beginning of the treatment episode, are clinical support services (as opposed to medical interventions such as detoxification and related triage services considered clinical treatment services). These clinical support medical services include obstetric and gynecologic services, HIV/AIDS counseling, general medical and dental care, nutrition counseling, eating behavior issues, family planning, reproductive health, health education, and physical and exercise therapy. Also critical to primary health care for women are medical self-awareness, personal hygiene, and self-advocacy for wellness.
Life skills. Life skills include all of the activities that support independent, healthy lifestyles. They include budgeting and banking; negotiating access to services such as housing, English as a second language, income support including access to TANF, food stamps, and Medicaid; navigating legal services and commitments; setting up and running a household; grooming and clothing; recreation and leisure; nutrition; using public transportation; and arranging for child care.
Parenting and child development education. Treatment for women with children is optimized and interaction between the mother and child is improved when the women's role as a mother is acknowledged and incorporated throughout treatment. Parenting skills are improved through education about child development and caretaking, skill building, and addressing shame and guilt over past parenting activities. Mothers who are being reunited with children will need support in preparation for and after the reunion. Fathers can also be important contributors to the well-being of their children, and when possible, should receive the education and support necessary to prepare them for the responsibility of parenthood.
Family programs. The more psychologically and emotionally healthy a woman's significant others are, the more likely they are to help her remain engaged in treatment and recovery. Significant others should be involved in understanding family members' roles in the family and how those roles may have become maladaptive coping strategies while the woman was in active addiction. When significant others are directly involved in relapse prevention planning, they are more likely to become productively involved in supporting positive efforts at recovery and intervening on relapse warning signs. Family-centered programs address all members in the family and include efforts to improve relationships with significant others, including partners, parents, siblings, children, and caretakers. These family interventions can be an important part of the woman's preparation for long-term recovery.
Educational remediation and support. Educational deficiencies may be a consequence of a woman's addiction or may be a significant contributor to her addiction. A lack of education is reflected in poor reading skills, conduct issues, illiteracy, special education needs, low family income, and psychological barriers associated with poor performance and low self-esteem. Cognitive impairments due to alcohol-related spectrum disorders and other congenital or biological origins may require significant educational supports. Establishing linkages and/or services to address these educational issues may be significant motivators for women to remain in treatment and provide hope for her to establish economic independence.
Employment readiness services. Given the relationship of meaningful employment to recovery success and societal pressures to move the unemployed to the workforce, employment readiness services are an essential element of treatment. These services include reading and numeric skills testing, literacy tutoring, GED classes, vocational assessments, pre-employment readiness training (soft skills), job referral, job retention services, and transitional employment placement. Treatment programs should establish as one of their goals the self-sufficiency of the client, seeking effective linkages with TANF and child welfare agencies.
Linkages with the legal and child welfare systems. Many women in treatment have conditions set by the child welfare system to maintain their parenting role or for reunification with children who may have been removed from the mother's custody. These requirements often include reports that progress is being made toward treatment goals, completion of parenting and anger management programs, supervised visits, drug testing, and court appearances. Communication among treatment providers, child welfare workers, the mother's legal advocate, and the dependency court helps women move toward these goals. When mothers are also involved in the criminal justice system, linkages and communication with probation and parole staff are also critical. Criminal justice requirements may include drug testing, court appearances, and documentation regarding treatment progress toward goals. Often these communications require access to the community's legal aid services.
Housing support services. For women, particularly women with children, housing represents more than just shelter. It is a crucial support for recovery. It represents safety both for her and for her children. Thus, a comprehensive care provider must address the issue of where the woman will reside when she completes treatment and make the provision for adequate housing a part of the program's continuum of care. Given the time involved in arranging for affordable, safe, drug-free housing, this service needs to be part of early planning.
Advocacy. Women entering treatment often require advocates to assist them in negotiating the various systems they may need to interact with. Although direct advocacy services provide immediate access to remediation, the goal of this process is to transform women into empowered individuals who can effectively advocate for themselves and their families.
Recovery community support services. Regardless of the treatment model or modality, women need to appreciate that they are not alone and that others have traveled the same road. It is critical for women to be supported in developing relationships with other women and persons in recovery who can be role models and provide support, friendships, and companionship in pursuing safe and sober leisure activities. Thus, early in the treatment process, providers must help women develop a gender-sensitive support network within the recovery community.
Clinical support services for children
Primary health care services. Primary health care services are an ongoing need for children of mothers with substance use disorders. Monitoring medical conditions should include screening for a range of potential medical complications including effects resulting from prenatal substance exposure and risks of HIV/AIDS and other communicable diseases. Primary health care services should also focus on wellness and prevention, including immunizations and regular medical examinations.
Onsite or nearby child care. Developmentally appropriate, quality child care is needed for children whose mothers participate in treatment. Child care should be onsite or proximate to the program and should include a full range of services, from therapeutic child care to developmentally appropriate interventions and recreational play.
Mental health and remediation services. Children whose mothers abuse alcohol and/or drugs often have developmental delays that require specific interventions. These children may experience higher rates of attention deficit disorder, attention deficit/hyperactivity disorder, conduct disorder, speech and language delays, and learning disabilities.
Prevention services. Children whose mothers have substance use disorders are at higher risk of developing a substance use disorder of their own as they enter preadolescence and adolescence. Evidence-based prevention services tailored to these children may be most appropriate when offered in the context of the parent's own history and recovery. Prevention programs that have demonstrated their effectiveness with a range of child and adolescent populations can be found at http:
Recreational services. Participation in pleasurable recreational activities helps children socialize, express themselves, relax, experience new activities, and become knowledgeable about healthful alcohol- and drug-free leisure activities. Participation in developmentally appropriate recreational activities is a critical learning experience for children. Participation in sports, hobbies, and creative outlets can also provide vehicles for enhanced self-image and self-esteem.
Educational services. The needs of school-age children, including attention to academic progress, are a necessary part of each child's service plan. Often, children in treatment with their mothers experience disruption in their academic experience because of frequent moves or other family crises. Children who were prenatally exposed to substances may have ongoing learning disabilities that require advocacy to ensure special education services are available and to ensure children's academic success. When regular reviews of individual education plans are needed, the treatment agencies must recognize the critical role that the mother may play in attending such sessions.
Advocacy. Mothers with substance use disorders may not be effective advocates for their children. Programs may need to provide direct advocacy services as well as assist mothers in developing appropriate advocacy skills to ensure that they are able to negotiate for the needs of their children. Children, as well, should be introduced to advocacy skills when developmentally appropriate.
Recovery community support services. Because of the significant impact of peers and role modeling on the development of children, there is a marked need for age-appropriate recovery support activities. By building their own community of support, children can identify with peers and learn from those who have coped with similar experiences.
Community support services are those services that extend beyond the treatment program and are found within the community. These services help to ensure that short-term treatment success can be sustained in long-term recovery. While there are additional services that women, children, and other family members may need in order to support the recovery of the family, those included below represent the more common services used by families as they progress in their recovery.
Recovery management and recovery community support services. Community-based recovery management services include activities that provide relapse prevention and continuing care. While these services may begin during treatment, they are part of the community-based network that supports recovery. Consistent with the importance of women's personal relationships, women will benefit from the availability of peer-driven recovery mutual support services, which can include Alcoholics Anonymous, Narcotics Anonymous, and Women for Sobriety.
Housing services. Adequate housing is essential both for safety and for security. While housing services are often placed within clinical support services, in the context used here, housing services are also a community infrastructure issue. In this context, housing which encourages alcohol- and drug-free living can be a vital component for sustaining recovery.
Family strengthening. Recognizing the family disruption that is common to addiction, women (particularly those who are heads of their households), need services that support the re-establishment of important family ties, including ongoing family therapy and family support services.
Child care. This is both an immediate and short-term treatment support service as well as a broader community service. As a community support, quality preschool, child care, and after-school care programs are longer-term needs that enable mothers to work outside the home.
Transportation. Accessible and reliable transportation is important given the complicated schedules of women caretakers who often have to balance the transportation needs of their children with the transportation needs of employment and ongoing participation in continuing care.
TANF linkages. With some exceptions, women from lower socioeconomic strata who progress through treatment are either TANF eligible or may become TANF eligible. TANF agencies have a role to play in providing support for recovery by serving as a bridge between the three circles of clinical treatment, with an emphasis on work preparation and sustaining employment for women going through the recovery process.
Employer support services. Communities need to create systems within employment settings that support recovery and combat workplace substance abuse. Larger employers may offer employee assistance programs and smaller employers may be able to coordinate needed job support services with treatment providers from their communities.
Vocational and academic education services. Critical to recovery success is the continuation of educational and vocational services that are begun during treatment.
Faith-based organization support. Recognizing that spirituality plays a crucial role in the recovery process, it is important that connections are established by treatment providers with faith-based institutions that can serve as appropriate resources for addressing the spiritual issues related to addiction and recovery. Faith-based organizations can play an important role in the community and can connect families in a supportive community network.
Finally, in response to the needs of providers to understand funding options for this array of services, this revision to the model allows providers to identify discrete elements of the comprehensive model and to make their own assessments of how to finance the elements through available funding streams. For some elements, funding will be readily available and sufficient to cover the full cost of services delivery. Other elements, such as continuing care and many of the services for children, are not as easily supported; providers will have to use more flexible funding to cover these services while they continue to communicate to funders that unfunded and underfunded components are critical elements in the comprehensive model of care.
Providing comprehensive services through the separate agencies serving women and their children involves connecting the multiple funding streams that flow into the various health, human service, and educational agencies serving families. The more comprehensively a continuum of care is defined, the wider the array of funding streams that is needed. The more committed an agency is to family-centered services, the more mastery is needed of all the different funding streams that can support families. No single agency has adequate funding sources by itself to achieve comprehensive outcomes; interagency funding streams are therefore critical to converting hopes for new linkages into reality.
Fiscal context always matters, and in tight fiscal climates, tapping new sources of funding is both desired and resisted. It is desired for the obvious reason that hard-pressed agencies are anxious to find alternative funding streams to support their programs; it is resisted for the equally obvious reason that agencies seek to protect their own funding streams even more when funding is tight. The descriptions of funding and suggestions that follow are made in full awareness that in most States, fiscal constraints are very significant factors at present.
Several issues affect the ability of programs to provide the comprehensive services needed by women and children affected by substance use disorders. Some of these issues are based on the nature of the collaborative relationship between the agencies, some flow from categorical funding constraints, and some are based on other Federal or State policies. Understanding which of these barriers are affecting a State's or community's ability to provide comprehensive services is a critical first step in developing its response. These concerns may include the following:
Existing categorical definitions of funding streams and eligibility restrictions can create barriers to interagency efforts, with agency officials sometimes resistant to what seems like “one more earmark” on funding streams.
Decisions by agencies to provide services directly or to negotiate for services with outside agencies are critical choices, but at times they may be made based on limited understanding of other agencies' funding streams.
Each system sees the other's funding streams as mysterious and difficult to access, and each sees its own as overcommitted and possibly threatened, leading to a debate over “your money, our money, or their money.”
A sustained, time-consuming effort is required to achieve new Federal, State, and local collaboration, which is needed to create financing responsive to the multiple needs of children and families.
As the majority of funding flows through State-level government, State systems may need specific legislation to overcome categorical requirements.
There are significant financial incentives to maintain the status quo in fragmented funding streams.
Categorically funded programs that do not apply adequate “dosage” to ensure treatment effectiveness may require additional layers of funding from additional sources to get to scale and provide an adequate dosage of services. For example, programs that do not provide aftercare services to parents may be unable to respond to relapse issues, resulting in readmission to treatment that was underfunded but that ends up with a higher overall cost due to clients' readmission.
The concept of unified fiscal planning has been introduced recently. This approach includes a variety of strategies used by States and communities to create and sustain an integrated and flexible continuum of care for children and families (Crocker 2003). Some of the more commonly used strategies include decategorization, pooled funding, blended funding, braided funding, wraparound services, and refinancing. Often the terms are used interchangeably or without clear definition; however, the following are common definitions used for these concepts:
Decategorization refers to State-level efforts to reduce or eliminate categorical requirements on how funds are spent. This reduction in requirements is often created in exchange for greater accountability for a set of negotiated outcomes.
Pooled or blended funding is generally a local-level effort that is implemented among a group of agencies that formally integrates a set of funding streams into a single source of dollars. A new funding structure is often developed that administers and allocates the funds to the participating agencies based on negotiated contracts.
Braided funding is generally implemented by an individual agency or program and refers to administrative efforts to obtain multiple funding sources to create more comprehensive services. This strategy typically works within the categorical system and administrative responsibilities for maintaining the various categorical requirements remain.
Wraparound services. The term “wraparound” came into use in 1986, in an article by Lenore Behar, who defined it as a way to “surround multi-problem youngsters and families with services rather than with institutional walls, and to customize these services” (Behar 1986). The wraparound approach is more a process than a service, in which a child's or family's individual needs are addressed by the full range of services they need, with maximum flexibility in funding.
Refinancing. “Refinancing entails aggressively pursuing monies from uncapped Federal appropriations such as entitlement funds, using these new Federal funds to pay for standard services, and then applying the freed-up local and State funds to pay for alternative programs, including… comprehensive service initiatives“ (Orland 1995).
While the Substance Abuse Prevention and Treatment Block Grant is still the largest source of publicly supported substance abuse treatment (approximately 40 percent), treatment providers should become familiar with the Medicaid-reimbursable services in their States and learn how to bill for these services. Medicaid is a joint Federal–State entitlement program and the third largest source of health insurance in the country. It makes up approximately one quarter of public funds available for treatment. Medicaid coverage varies from State to State. Nearly all States restrict services when paying for alcohol and drug abuse treatment. The types of restrictions include low payment rates for treatment providers, restrictions on the settings for treatment, low limits on the days of inpatient treatment, low limits on the number of outpatient visits, and restrictions on types of providers that can be reimbursed (Legal Action Center 2002).
The Medicaid codes published by the Centers for Medicare and Medicaid Services (CMS) are also known as the HCPCS codes (Health Care Financing Administration Common Procedure Coding System). With few exceptions, all of the services described here as clinical treatment services for women have applicable HCPCS codes. There are fewer applicable HCPCS codes for the clinical support services for women, and HCPCS codes do not apply to community support services. As noted earlier, the existence of a code does not necessarily mean that a State reimburses for a service (at any level). States are only responsible for a short list of mandatory services, whereas most services are optional reimbursable services. The CMS updates the HCPCS codes on an annual basis. Information on applicable alcohol, drug, and behavioral health HCPCS codes can be found on the Web site of the National Association of State Alcohol and Drug Abuse Directors (www.nasadad.org).
In addition to the mandatory and optional Medicaid alcohol and drug benefits, Medicaid includes a benefit known as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) to cover both prevention and treatment services for children and adolescents under age 21. All children enrolled in Medicaid are entitled to EPSDT. “Under EPSDT, States must screen and then furnish appropriate medically necessary treatment to ‘correct or ameliorate defects and physical and mental illness and conditions discovered by the screening services’” (Legal Action Center 2002, p. 10). In practice, use of this resource has been limited by States' ability to pay for the services. An additional source of funding for uninsured, low-income children is the State Children's Health Insurance Program, which is allocated by block grant formula to the States.
TANF can fund a range of nonmedical clinical treatment services as well as clinical and community support services for both women and children. The extent to which this is used varies greatly from State to State. Other additional valuable funding sources are available for many of the services described, although many are time-limited and/or specialized, increasing the time demands on the provider to seek and manage multiple funding streams.
In designing a comprehensive substance abuse treatment model for women and their children, CSAT is not attempting to articulate every element of treatment for this population. Rather, CSAT wishes to provide a standard or goal to which programs should aspire as they design and plan services that will be characterized as holistic, wraparound, and/or comprehensive. Additionally, it is not CSAT's intention to see this model adopted without reference to the context of the community in which it is used. Thus, for the model to be truly comprehensive, it should be more than adopted; it should be adapted to its community and its consumers.
In adapting this model, different communities will emphasize different aspects. For example, the American Indian and Alaska Native communities have demonstrated the special role that spirituality, culture, and historical trauma play in treatment, and for these communities, a worthwhile adaptation requires an increased emphasis on these issues. For a community of older women, an emphasis on medication abuse may also be appropriate.
This model embodies the best practices known to CSAT, as well as the agency's experience in addressing this issue on a nationwide basis.
This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.
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