Part 4: Attachment E Substance Abuse and Mental Health Residential Programs

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1 Massachusetts Department of Social Services Planning and Program Development Division Program Specifications 2006 SUBSTANCE ABUSE AND MENTAL HEALTH RESIDENTIAL PROGRAMS INTRODUCTION Historically, women with addiction problems have suffered great stigma and shame. Treatment availability and research have for the most part focused on men. The gender-specific needs of women have only recently been addressed. As more women have entered substance abuse treatment, underlying problems of mental illness and trauma stemming from histories of abuse have emerged. What was once viewed as either an addiction or domestic violence or mental health problem requiring specialized services, is now understood to be a complex array of intertwined issues. Increasingly, the incidence and connection of these problems among battered women is being recognized and documented. Abused women of all races report higher stress, less support from partners, less support from others, lower self-esteem and increased substance abuse than women not abused. They rely on drugs and alcohol to help cope with fears and manage the tasks of day-to-day living in the face of ongoing danger. Victims of domestic violence are more likely to receive prescriptions for and become dependent on tranquilizers, sedatives, stimulants, and painkillers. Research on adult women in the US reveal a direct relationship between the number of times women were victimized and the likelihood of their becoming alcoholic. Studies show that substance-abusing women suffered higher rates of childhood violence than non-substance abusing women and up to 90% of women with drug abuse problems have been sexually abused at least once in their lifetime. As adults, they continue to experience significantly more verbal and physical abuse. Of those women who enter treatment for substance abuse, 75-80% have been victims of physical or sexual abuse. SAMHSA has documented the relationship between domestic violence and substance abuse, and their Consensus Panel determined that failure to address domestic violence issues interferes with treatment effectiveness and contributes to relapse. Each year, knowledge about how violence and overwhelming trauma affects body and mind increases dramatically. Today, dual diagnosis (substance abuse in addition to another psychiatric diagnosis) is common language in the mental health and addiction fields. With the addition of Post Traumatic Stress Disorder (PTSD) as a psychiatric diagnosis in 1980, the field of trauma has flourished. Over one-third of females with problem drug use have experienced a major depressive episode in the past year, and 45% percent have experienced at least one of several mental health problems including panic attacks and anxiety disorders. Among women with current substance abuse disorders, 30-59% are estimated to have concurrent PTSD. Dual diagnosis of PTSD and 1

2 substance abuse is associated with use of the most severe drugs cocaine and opioids and PTSD is widely reported to worsen during early abstinence. Women with combined PTSD and substance abuse often suffer from extreme feelings of guilt, anxiety, self-blame, depression suicidal thoughts, and dissociation. In 1995, the DSS Domestic Violence Unit, in conjunction with Jane Doe Inc., the Massachusetts Coalition Against Sexual Assault and Domestic Violence, convened staff from battered women s programs, substance abuse services and child welfare services to discuss the unmet needs battered women with substance abuse and mental health issues. Growing numbers of women, particularly mothers, who have struggled for years to obtain assistance in finding safety and becoming sober. Many entered shelters for battered women but didn t stay due to their struggles with substance abuse. Others who attempted to get treatment for their addiction couldn t because residential programs were unable to accept women with children. Those who accessed substance abuse programs, often found safety concerns. Neither service had the capacity to meet the complex needs presented by these mothers and their children. In addition to substance abuse problems, many faced mental health issues and struggled to maintain employment, find affordable housing, and effectively protect and parent their children. These discussions resulted in a new residential program established in 1996 to specifically help substance abusing battered women and their children. The DSS Domestic Violence Unit, in conjunction with Jane Doe Inc, DSS area office staff, the Department of Public Health, and the Institute for Health and Recovery, designed the program with the primary goal of helping families get safe and sober. The program also aimed to prevent out of home placement or, in cases where a child was already in placement, help facilitate reunification. Much has been learned in the ten years since these new residential programs were implemented. The profiles of women served in currently funded DSS programs echo the above research findings and increasingly make clear the links among interpersonal violence, addiction and mental health issues. The majority of women served have experienced childhood sexual and/or physical abuse. Most often, they report multi-generational family histories of domestic violence and substance abuse. Many started using substances with they were years old, and regularly disclose poly-substance abuse. In addition to substance abuse, they enter the programs with multiple mental health diagnosis including PTSD, mood and anxiety, dissociative, somatoform, personality, and eating disorders. Frequently, they have been repeatedly involved in failed substance abuse and mental health treatment. Their partners usually are involved in using and/or selling drugs, and the majority of their relationships have been extremely abusive. Many have previously lost custody of a child due to their addiction, and enter treatment primarily to retain custody or as a last chance of reunification with their child(ren). While the complexity of these issues is better understood today, the challenge is how to effectively deliver services to substance abusing battered women, especially those with children. Traditionally these women, often among the most disenfranchised, are hard to identify, connect with and keep in treatment. Their children, however, provide one of the greatest motivations for seeking treatment. Nearly half (44%) of female drug treatment clients who have children report that they entered substance abuse treatment in order to retain or regain custody of their children. Many women report being so depressed and hopeless that they care little for what happens to 2

3 them. But their children matter greatly. However, mothers often fear losing their children if they disclose what they are going through. This worry often means women enter treatment only when there is no other choice. Programs responsive to trauma that meet the needs of mothers, and allow their children to be with them, offer real hope. Judith Herman M.D., in her seminal book Trauma & Recovery, poignantly captured the relational impact of trauma. Traumatic events call into question basic human relationships. They breach the attachment of family, friendship, love, and community. They shatter the construction of the self that is formed and sustained in relation to others. They undermine the belief systems that give meaning to human experience. They violate the victim s faith in a natural or divine order and cast the victim into a state of existential crisis. These women and their children experience a powerful conundrum. They were deeply wounded in relationships, yet need deeply connecting relationships to heal and grow. Upon entering treatment, they often convey profound despair and distrust. Given this depth of anguish plus the physical, emotional, spiritual and social consequences of violence and addiction attending to the relational needs of this population is paramount. Due in large part to the work of Jean Baker Miller and the Stone Center at Wellesley College, women s psychological development is now understood to evolve within and remain central to the experience of connection and disconnection in relationships. This understanding has led to new ways of viewing women s use and abuse of substances and gender-specific approaches to treatment. Only by recognizing and holistically addressing the physical, psychological, and relational impact of trauma, can we hope to provide services that foster healing and growth. The availability of residential programs that help women be safe, sober, enhance relationships, and effectively attend to the needs of their children is a critical component of domestic violence services to be funded through this RFR. MINIMUM REQUIREMENTS At minimum, all substance abuse and mental health programs funded through this RFR must meet the following requirements: 1. Daily on-site staffing with an emergency plan for overnights. 2. Trained staff and volunteers to answer calls directly from the statewide hotline and others for immediate information and referral. Voice mail systems are permitted when program is closed. In no circumstances are answering services or other responses permitted. 3. When the program does not have an opening staff must assist the caller in directly connecting to a program that does, preferably in the same region. 3

4 4. Trained staff to conduct intakes within one (1) business day of initial call and ability to accept individuals and families within 2-4 days of completed intake. 5. Intake and assessments using tools contained in the forms section of his RFR. 6. Shelter individuals and families locally, regionally and statewide. DSS prefers bidders who can shelter individuals and families in their own community. 7. Re-locate individuals and families to emergency shelter and/or residential program out of region when needed. 8. Update bed availability on a daily basis. 9. Provide developmentally appropriate childcare on-site (at shelter) while a parent(s) participates in the intake and/or assessment process. Such care will be provided in a physical space that is safe, welcoming, and responsive to the child s developmental needs. Childcare is also required for adult support groups and during on-site crisis intervention. DSS prefers bidders who propose creative plans to provide childcare; including but not limited to the utilization of scheduled and/or on-call volunteers, partnerships with peer and/or other child centered programs that have existing childcare services and/or access to childcare in order to maximize parent(s) participation in services. 10. Provide developmentally appropriate children s services (includes assessment, individual support and advocacy and group support) 11. Provide basic assistance (food, formula, diapers, clothing, transportation help/vouchers, phone usage, hygiene supplies) for program participants. 12. Provide on- and off-site advocacy services for program participants 13. Ensure building safety and privacy of program participants in emergency shelter/other residential programs. LOCATION: DSS expects that program participants can easily participate in services whether they be at the residential program, at the applicant s own community-based programs, or at other convenient locations through specific agreements with partnering organizations. SERVICE COMPONENTS Service components must be delivered within a framework consistent with the guiding principles set forth in the RFR. They must occur in welcoming, safe, and nurturing atmospheres. The coexistence of trauma, addiction and mental health problems can at times seem overwhelming. All must be contended with, nevertheless, for services to be effective and for women and families to 4

5 feel helped. The integration of services is fundamental to this program. DSS seeks bidders whose program can deliver synthesized services that consistently acknowledge and work to mitigate the profound depth of despair trauma engenders. Bidders must demonstrate their ability to provide the following services to adults and children, either directly or in a delineated agreement 1 with a peer program: 1. Information and Referral: Directly assist individuals and families in finding needed resources in their community and link them to the help they are seeking. Referrals could involve giving phone numbers and names to individuals, making phone calls with individuals, and/or accompanying individuals to appropriate agencies, including referral for substance abuse services (including medical detoxification), and domestic violence services. 2. Basic Assistance: Providing food, clothing, transportation/travel vouchers, phone usage, hygiene supplies, and other basic supplies, during crisis intervention. 3. Standardized Intake: A timely process by which trained staff engages with individuals, gathers basic information in order to understand a situation and determine if the program can offer help to the adult, child and/or family. Intakes are done over the phone or in-person through a specifically designed tool (see forms section) whereby program entry is determined. 4. Crisis Prevention and/or Intervention, Safety Planning: Trained staff and/or volunteers provide support, assistance, and safety planning to individuals and families to: 1) prevent a crisis 2) help individuals who are in an emergency situation with the goal of stabilizing the situation and ensuring the safety of those involved. Safety Planning is the interactive process between trained staff/volunteers and participants to create a plan designed to keep them safe. This includes relapse prevention and harm reduction planning 5. Service Needs Assessment (for adults, and on behalf of children): A process by which trained staff engages with individuals, gathers information in order to understand a situation and determine what help/services are needed. Assessments are done in-person through a specifically designed tool (see forms section) whereby recommendations, suggestions, and ways of understanding the situation are discussed with the individual. Included are trauma informed psychosocial assessment (psychiatric, psychopharmacological, clinical/therapeutic) for adults. 6. Individual Support and Case Management: Trained staff, usually one assigned to an individual/family, provides ongoing coordination of services, support, and assistance to program participants to ensure they have access and engage in needed services. This includes on-site support and case management for the following areas: Safety 1 Detailed memorandum of understanding that evidences a working relationship and how services will be organized, available and accessible. 5

6 Sobriety including relapse prevention planning Coping with trauma history and current symptoms Understanding eligibility & obtaining health and human service benefits (ex. Medicaid) Identifying and understanding individual and family strengths Parenting concerns and challenges Children s needs and help in obtaining services Medical and mental health care Time management and life skills Educational/vocational/employment skills Financial assistance resources and eligibility requirements Assistance in preserving or accessing permanent housing 7. Individual and Family Advocacy: Trained staff/volunteers actively support an individual in overcoming barriers and achieving a specific outcome they desire. Advocacy may involve the legal and child welfare systems, the Department of Transitional Assistance, schools, health care, batter intervention programs, housing, etc. Advocacy can be done on- or offsite, by phone or in-person, with or without the person present, as long as there is consent. 8. General Support Groups: Led by a trained facilitator, support groups consist of at least three victims of domestic violence. Groups may be specifically designed for adults, adolescents, and/or children, as well as for different ethnic, gender, and socioeconomic groups. Childcare is provided for parents who participate in support groups. Support groups should include an integrated trauma/ptsd and addiction psycho-educational group, in addition to domestic violence and relapse prevention support groups. Other topics for support groups should include health and well-being, eating disorders, stress management, grief and loss. DSS prefers bidders who can also provide or ensure access to peer support groups (for example, Alcoholics Anonymous, women in Sobriety, and/or Rational Recovery). 9. Parenting Support and Education Groups: Trained staff/volunteers/mentors, who model healthy, positive interactions between parents and children; providing education and support individually or in groups - that will increase empathy, promote positive discipline, and teach realistic developmental expectations. Groups include parenting support and education that engage both parents and children in learning new attitudes and skills in order to change unhealthy patterns, and, are presented within a recovery-oriented perspective with sensitivity to how trauma histories may affect parenting ability (for example Nurturing Programs) Child Care and Children s Services: Trained staff/volunteers who provide developmentally appropriate childcare during intake, assessment, crisis intervention and support groups. Children s services are defined as developmentally appropriate, trauma informed, intake, assessment, advocacy, individual and group support to children who have witnessed domestic violence. Age and developmentally appropriate educational groups for children on recovering from trauma and addiction within a family context are also required. 6

7 11. Access to Medical Care Assistance: Directly assisting an individual, adult or numbers and names to individuals, making phone calls with individuals, and/or accompanying individuals to appropriate agencies. Referral(s) for easily accessible medical evaluation and care include: gynecological, dental/oral, nutritional needs (critical for eating-disordered clients), HIV, tuberculosis, hepatitis, sexually transmitted disease exposure and/or treatment, children s immunizations, developmental evaluations, etc.; Healthcare provider partnerships are strongly encouraged, especially if screening, evaluations, and/or education can be administered on the program s premises. 12. Reunification Services for DSS involved families: In order for reunification to occur successfully, DSS and program staff must communicate and plan together regularly. The DV Unit will provide assistance to funded programs in facilitating these working relationships with Area and Regional DSS offices and Family Networks providers. These relationships are critical to ensuring consistency in working with families, as well as mutual understanding of the missions and work of DSS and domestic violence programs. Programs must identify staff to consistently work in collaboration with DSS on reunification plans and reviews. Reunification services will adhere to the following guidelines: 1. Pre-Reunification: Generally, a minimum of 30 days is necessary for mothers to be in the program prior to reunification. The focus is on stabilizing a mother, assessing her needs, and developing the therapeutic relationship. During this time program staff will meet and work with DSS staff and the mother to plan the reunification and to set up regular visits between and mother and her children. This assists with assessment and relationship building and identification of needs. 2. Transition Period: The length and structure of this visitation period (number and length of visits, increased overnight visits, etc.) will be based on each family s needs and determined through agreement of residential program staff, mother/caretaker, and DSS. 3. Placement: Program staff and DSS should work together with the family to discuss options and how reunification is working. This work also should include joint planning for provider meetings, case reviews, family group conferencing and case closings. 4. Transition to Community Stabilization: Moving on can be both a joyful and terrifying experience for mothers and children. Change is often overwhelming, and stress levels severely test newly developed coping skills. Often, a temporary recapitulation of fears and conflicts arise. Understanding, patience and support in taking each transitional step at a time is needed. 13. Continuing Care (after leaving the program): Perceived loneliness and isolation are two of the most challenging issues women face. Even when aftercare services and supports are in place, leaving a safe community where support is available 24 hours a day can be experienced as a loss of connection and confidence. Significantly, PTSD symptoms often flare up for both women and children. Progress can seem illusive and relapse a great potential. Continuing connection with and support of women and children, while 7

8 encouraging linkages and relationships within their new environments, is key to maintaining recovery. SPECIFIC POLICIES AND PROCEDURES Proposed drug/alcohol testing policies, relapse, and termination policies must be clear and reasonable and demonstrate an understanding of relapse as part of recovery. Sources Bureau of Justice Statistics. (2001). National violence against women survey. Washington, DC: U.S. Department of Justice. Minnesota Coalition for Battered Women. ( 1992). Safety First: Battered Women Surviving Violence When Alcohol and Drugs are Involved. Minneapolis: Minnesota Coalition for Battered Women. Stark, E., and Flitcraft, A. (1988a). Violence among intimates: An epidemiological review. In: Van Hasselt, V.D.; Morrison, R.L.; Bellack, A.S.; and Herson, M., eds. Handbook of Family Violence. New York: Plenum, pp Miller, B.A., Downs, W.R (1993). The impact of family violence on the use of alcohol by women. Alcohol Health and Research World, 17. Gordon, S.M. (2002). Women and addiction: Gender issues in abuse and treatment. Wernersville, PA: Caron Foundation. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (1997b). CSAT Treatment Improvement Protocol #25: Substance Abuse Treatment and Domestic Violence. Rockville, MD: HHS Substance abuse and Mental Health Services Administration. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Administration. National Treatment Improvement Evaluation Study. Retabulations from 1996 Study data by CSAT s National Evaluation Data Services. U.S. Department of Health and Human Services, National Center on Child Abuse and Neglect. (1997d). Substance Use Among Women in the United States. Rockville, MD: HHS Substance Abuse and Mental Health Services Administration. Karageorge, K., and Wisdom, G. (February 2001). Physically and sexually abused women in substance abuse treatment: Treatment services and outcomes. Rockville, MD: National Evaluation Data Services, Center for Substance Abuse Treatment. 8

9 Najavits, L.M. (2001). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. New York: Guilford Press. Najavits, L.M., Weiss, R.D., and Liese, B.S. (1996) Group cognitive behavioral therapy for women with PTSD and substance use disorder. Journal of Substance Abuse Treatment, 13(1). Herman, J. L. (1992) Trauma and recovery. New York: Basic Books Miller, J.B. (1976). Toward a new psychology of women. Boston: Beacon Press Miller, J.B. (1990) Connections, disconnections, and violations. (Work in Progress No. 33). Wellesley, MA: Stone Center, Working Paper Series 9

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