Telling Their Stories: - Women, Children and Families

Telling
Their
Stories:
Reflections of the 11
Original Grantees That
Piloted Residential
Treatment for Women and
Children for CSAT
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov

Telling Their Stories: Reflections of
the 11 Original Grantees That
Piloted Residential Treatment for
Women and Children for CSAT
U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov
Rockville, MD 20857

Table of Contents
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
I. Overview, Context, and Grantee Profiles
Women and Substance Abuse: Critical Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
History of Specific Programs for Substance-Abusing Women . . . . . . . . . . . . . . . . . . . . . . . .8
Authorizing Legislation for Funding and Administering the Residential
Women and Children’s Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Requirements in the Request for Applications for Grant Awards . . . . . . . . . . . . . . . . . . . . . .9
Grantee Profiles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
II.
III.
IV.
Treatment Models
Second-Generation Therapeutic Communities Serving Women and Children . . . . . . . . . . .15
Other Common Treatment Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Population Served, Outreach, Referral, and Admission Criteria
Profile of Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Trends in Client Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Outreach Activities and Referral Sources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
Admission Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41
Questions About Having Children in Residence and Family Reunification . . . . . . . . . . . . . .49
Facilities, Staffing, Staff Training, and Retention Issues
Residential Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Staffing Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .58
Staff Development and Training Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .66
Staff Retention Problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .72
iii

V. Continuum of Services for Women
Scheduling: Time Constraints and Competing Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . .75
Collaborations With Other Agencies and Organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . .79
Continuum of Essential Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
The Timing, Intensity, and Duration of Services and the Strategies Used . . . . . . . . . . . . . .92
VI.
VII.
VIII.
IX.
Special Services For Children
A Safe, Consistent, and Nurturing Environment for Every Child . . . . . . . . . . . . . . . . . . . . .95
Providing Comprehensive Services for Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
Specific Services for Children in Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
Services for Older Children Not in Residence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .105
Relations With Child Protective Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106
The Effects on Children of Living With Their Mothers in Treatment . . . . . . . . . . . . . . . . .108
Critical Issues in Family-Oriented Treatment
Sexuality and Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109
Parenting Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115
Relationships With Family Members and Spouses/Significant Others . . . . . . . . . . . . . . . .126
Discharge and Aftercare
Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129
Continuing Care in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .138
Significant Management and Policy Issues
Working With Advisory Boards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .143
Developing a Management Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .144
Responding to New Healthcare and Welfare Regulations . . . . . . . . . . . . . . . . . . . . . . . . . .145
Preparing for the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .149
X. Evaluation Designs and Findings
Frequently Encountered Issues in Conducting Program Evaluations . . . . . . . . . . . . . . . . .151
The Quarterly Reporting System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157
Summary of Site-Specific Evaluation Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158
XI. Conclusions and Epilogue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .163
iv

Appendix A: Summary Profiles of the 11 Grantees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
Appendix B: Site-Specific Evaluation Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .201
Appendix C: Selected Publications and Presentations by Residential
Women and Children’s Grant Evaluators and Staff . . . . . . . . . . . . . . . . . . . . . . . . .229
Appendix D: Participants in the Development of This Document . . . . . . . . . . . . . . . . . . . . . . . .231
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .235
Glossary of Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .241
Tables and Exhibits
Table I-1: Key Characteristics of the Original 11 Residential Women and Children’s Grantees . . .12
Table III-1: Client Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Table III-2: Number/Age Restrictions and Timing for Admission of Children . . . . . . . . . . . . . . . . . .46
Exhibit V-1: Typical Weekday Schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
Table X-1: Summary of Treatment Outcomes for 10 Center for Substance Abuse
Treatment, Residential Women and Children’s Grantees . . . . . . . . . . . . . . . . . . . . . . .160
v

Preface
The Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health
Services Administration (SAMHSA), is proud to produce this report, Telling Their Stories:
Reflections of the 11 Original Grantees That Piloted Residential Treatment for Women and
Children for CSAT. In fiscal year (FY) 1992, CSAT was authorized to administer and support
11 new grantees that initiated demonstration residential substance abuse treatment services
for mothers and their young children. These projects allowed families to live and work together
to overcome parental substance abuse and its effects as well as to build better lives for
themselves. This report contains stories from the residential centers’ staff members about
their experiences in providing treatment to substance-abusing women and their children.
Staff members provide descriptions of treatment philosophies and practices and assessments
of clients’ needs. They offer practical advice garnered from hands-on experiences.
Telling Their Stories makes a contribution to substance abuse literature and research by
expanding the knowledge base with respect to the traumatic and troubled backgrounds of this
target population of mothers and their children, documenting their multiple service needs,
and chronicling their responses to the wide array of gender-appropriate and culturally sensitive
interventions and therapies.
Telling Their Stories also provides data on the scope and correlates of substance abuse
problems among women. It addresses the scarcity of treatment facilities, citing the legislation
under which the Residential Women and Children’s (RWC) program is funded and the requirements
of the grant awards. It also provides an overview of the RWC grant projects and their
target populations. Chapters focus on key aspects of these programs.
Significantly, the special, age-appropriate services delivered to the children who were living
with their substance-abusing mothers reflect a national interest in identifying and ameliorating
delays in early childhood development that can profoundly impede later emotional and
physical maturation as well as academic performance.
Telling Their Stories specifies some of the challenges that programs face when developing and
piloting innovative, effective, family-oriented treatment for substance-abusing mothers. CSAT
recommends it to all health and social service professionals and families who are connected in
any way with the substance abuse field. We hope that you find this resource to be rich in helpful
and practical advice, whether in creating treatment programs or in selecting treatment
services for a loved one.
We appreciate the leadership, guidance, and dedication of Maggie Wilmore, who was Chief of
the Women and Children’s Branch from its inception in October 1992 through September
1996. Under her helpful and caring tutelage, these 11 grants were brought to fruition.
Joseph H. Autry III, M.D.
Acting Administrator
Substance Abuse and Mental Health
Services Administration
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director
Center for Substance Abuse Treatment
vii

Introduction
A
s part of a larger effort by the Center for
Substance Abuse Treatment (CSAT) to
expand quality substance abuse treatment
services and to develop and disseminate knowledge
that can be useful to the field, this report
summarizes the experiences and accomplishments
of the original Residential Women and Children’s
(RWC) grantees.* This section explains the purpose
and perspective of the report, identifies
potential audiences, describes the information
sources and processes used to produce the document,
and outlines the contents of the chapters
and appendices.
Purpose and Perspective of the
Report
In July of 1992, P.L. 102–321 (the Alcohol, Drug
Abuse, and Mental Health Administration
Reorganization Act that created the Substance
Abuse and Mental Health Services Administration
[SAMHSA] and its three constituent Centers) was
amended to require Federal support, through
CSAT, to establish residential substance abuse
treatment programs for pregnant and postpartum
women (PPW).
Prior to the establishment of the PPW program,
CSAT and its predecessors developed a number of
significant products addressing the treatment of
pregnant and postpartum women. These products
helped providers, including PPW and RWC
grantees, develop state-of-the-art treatment services
for women and their children. The comprehensive
treatment model for women developed by
CSAT in 1992 was made available to grantees for
the development of their projects. In addition,
the CSAT Treatment Improvement Protocol (TIP)
publications Pregnant, Substance-Using Women
and Improving Treatment for Drug-Exposed Infants
were helpful resources for planning treatment
services for women and their children. In 1994,
CSAT published the manual, Practical Approaches
in the Treatment of Women Who Abuse Alcohol and
Other Drugs another significant contribution to
the field.
While RWC grantees benefitted from the pioneering
treatment development, resources, and leadership
of the Center for Substance Abuse Prevention
(CSAP) and CSAT, as well as these agencies’ predecessors,
the Office for Substance Abuse Prevention,
and the Office of Treatment Improvement, the 11
RWC projects described in this report also broke
new ground in the treatment of substance-abusing
women and their children.
Over the 5-year project period, grantees not only
improved the lives of those they served, but also
gained invaluable expertise and knowledge. In
Telling Their Stories, staff members share what they
discovered from their perspective and, in great
part, in their own words. Throughout the document,
quotations from RWC staff illustrate their
experiences and opinions about common challenges
and critical issues encountered in delivering
comprehensive treatment to this population.
* The grants were authorized by Public Law (P.L.) 102–141, Section 509F of the Public Health Service Act. Under the earlier P.L.
102–141, the Office of Substance Abuse Prevention (currently the Center for Substance Abuse Prevention—CSAP) was authorized to
provide support for demonstration projects permitting substance-abusing women to live with their children in comprehensive residential
prevention and treatment facilities.
CSAP awarded 11 RWC grants on September 30, 1992; the grants were immediately transferred to the Center for Substance Abuse
Treatment. Under the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA) Reorganization Act, P.L. 102–321, CSAT
was instructed to administer and support these residential treatment programs which continued for 5 years, through FY 1997.
1

Introduction
What the grantees have to say can guide and
inform future treatment programs for substanceabusing
women and their children as well as
acquaint other health care providers and policymakers
with the projects and the practices that
appeared to be successful. The report describes
what arrangements were necessary to initiate services,
how day-to-day operations were conducted,
and what resources were tapped to continue the
projects after the grants terminated.
The volume is intended to increase awareness
about problems that must be resolved in developing
and delivering substance abuse treatment services—and
general behavioral health care—for this
particular population. It also underscores the policy,
evaluation, and research questions that need
to be addressed.
Because these demonstration projects had individually
designed process and outcome evaluations,
but no overarching cross-site national evaluation,
overall findings about effective strategies cannot
be interpreted as definitive with well-supported
conclusions or recommendations. Rather, each
grantee operated a uniquely designed project with
its own treatment approach that was tailored to
the special needs of the population of participating
women and their children. Each site chose
and modified facilities to accommodate residents
and services, and each project recruited, hired,
and trained staff to implement its own customized
service.
Hence, this document reflects the variety of
approaches used to handle common issues in substance
abuse treatment program design and practice
and summarizes what the grantees found to
be the most salient service and management
issues. Of particular interest are the changes
made in services and practices as the grantees
responded to a population of women and children
that was more seriously traumatized than anticipated;
grantees moved away from more traditional
approaches to substance abuse treatment toward a
new concept of family-oriented residential care.
These projects developed imaginative and sensitive
interventions to address residents’ problems with
sexual functioning, sexual identity, physical and
sexual abuse, poor parenting skills, and damaged
relationships with family members and significant
others.
Essentially, the document is not intended to provide
a blueprint for running an effective residential
treatment program for substance-abusing
women and their children but is a first draft cookbook
of potentially successful approaches, issues
for careful consideration, and some cautionary
statements. The findings of a national cross-site
evaluation of similar RWC programs subsequently
funded by CSAT—many of which are still operational—may
shed light on the effectiveness of residential
treatment for this population.
Target Audiences
Telling Their Stories offers useful information for
policymakers at the Federal, State, and local levels
as well as for private sector agencies in the field of
substance abuse treatment. It also can be valuable
for related public and private organizations
that serve this population (e.g., child protective
services [CPS], family and welfare agencies, health
and mental health care facilities, managed care
providers, foster care programs, criminal justice
systems [CJS], schools and departments of vocational
rehabilitation).
Information Sources and
Organization of the Report
The information in this report was gathered from
a variety of written materials, informal personal
interviews, and focus group discussions. Findings
were integrated into the final document in an iterative
process. The materials used included:
• Initial grant applications and progress summaries
submitted as part of continuation
funding applications, quarterly and annual
reports from the projects, assessments of the
projects conducted by teams of CSAT representatives/consultants,
final reports at the
end
of the 5-year grant period, and publications by
2

Introduction
evaluators and other project staff at the projects.
• Data on admissions, discharges, and other
issues from CSAT’s Quarterly Reporting
System (QRS).
• Summaries of a telephone and a mail survey
conducted in the Spring of 1997 in which
grantees were asked to identify critical service
and management issues and to describe the
practices they considered most successful and
most challenging.
• Transcripts of focus groups and small-group
discussions at a 3-day meeting of grantee
administrators, project directors, clinical
directors, directors of children’s services,
and evaluators that was held in May 1997,
a few months before the grants officially
terminated.
• Brief followup telephone discussions with
grantee staff in June 1999 to garner additional
information, clarify some issues, and ascertain
the status of the projects nearly 2 years
after CSAT funding ended.
The document includes 11 chapters and 4 appendices:
I. Overview, Context, and Grantee Profiles—
describes the types of issues faced by substance-abusing
women with children, traces
the history of special treatment programs for
substance-abusing women, outlines the
authorizing legislation for the demonstration
grants, explains the grant criteria depicted in
the Request for Applications (RFA), and summarizes
the key characteristics of the 11
selected projects and their parent organizations.
II. Treatment Models—discusses how traditional
treatment models and concepts of therapeutic
communities have been modified by several
grantees, delineates common treatment
approaches adopted by most of the projects,
outlines changes made in the duration and
focus of planned phases of care, and specifies
challenges entailed in moving toward familyoriented
treatment.
III. Population Served, Outreach, Referral, and
Admission Criteria—profiles the characteristics
of women and their children at admission
for all the grantees and specific sites, depicts
changes in clients’ characteristics over the
grant period, specifies outreach activities and
referral sources, summarizes admission criteria
used by the different sites for the women
and children as well as the rationale for these
choices, and discusses some issues raised
about the benefits of having children in treatment
with their mothers.
IV. Facilities, Staffing, Staff Training, and
Retention Issues—describes the various settings
selected by the grantees for their projects
and the sites’ impact on staffing and programming;
reports on delays encountered in
renovating the facilities; summarizes staffing
patterns at the projects; and discusses recruiting
and hiring issues, types of staff training
provided, and the many problems encountered
in retaining staff at the sites.
V. Continuum of Services for Women—discusses
the grantees’ struggles with scheduling problems,
collaborations with other agencies to
provide needed services, and decisions regarding
whether services should be delivered on or
off site, and summarizes an essential continuum
of services for this population of women.
VI. Special Services for Children—documents the
critical service needs of the children who lived
with their mothers in these residential treatment
centers, discusses differences in needed
services for various age groups, specifies the
services provided for siblings who were not in
residence, and summarizes grantees’ relationships
with CPS.
VII. Critical Issues in Family-Oriented Treatment—
focuses on three programming elements that
are at the heart of familyoriented
treatment for this population of
women: interventions to address sexual
functioning, sexual identity, and violence—
including physical and sexual abuse; parenting
practices; and relationships with family members
and significant others.
VIII. Discharge and Aftercare—discusses the criteria
grantees used to assess clients’ readiness
3

Introduction
for discharge and involuntary termination for
cause; the retention strategies developed to
decrease dropout rates; and the continuing or
aftercare services offered to women who left
treatment, including barriers encountered in
finding jobs and affordable housing for these
women.
IX. Significant Management and Policy Issues—
describes the advisory boards developed by
the grantees and the projects’ responses to
external pressures from the parent agency,
managed care, and welfare reform.
X. Evaluation Designs and Findings—depicts
some issues the grantees confronted in conducting
independent evaluations, describes
the federally supported data collection system
developed by CSAT for the women and children’s
grants, presents aggregate information
about discharge status and outcomes at followup
for clients profiled in the QRS, and
summarizes several similar findings across the
projects. (Site-specific evaluation results are
included in Appendix B.)
XI. Conclusions and Epilogue—summarizes the
achievements of the grantees and reports how
most of them have managed to sustain operations
following cessation of Federal funding.
Appendix A: Summary Profiles of the 11 Grantees.
Appendix B: Site-Specific Evaluation Findings.
Appendix C: Selected Publications and Presentations
by Residential Women and Children’s Grant
Evaluators and Staff.
Appendix D: Participants in the Development of
This Document.
A listing of references and glossary of acronyms
are also included.
4

I. Overview, Context,
and Grantee Profiles
I
t is important to understand the context within
which substance abuse programs for women
and children exist. To help meet this objective,
this chapter will illustrate the types of issues
faced by substance-abusing women with children,
describe barriers to treatment experienced by
these women, review the history of special programs
for women with substance abuse disorders,
outline the legislation for funding and administering
the RWC projects, describe the requirements
for the RWC grant awards, and provide profiles of
the RWC grantees.
Women and Substance Abuse:
Critical Issues
During and since the funding of the original 11
Residential Women and Children’s (RWC) grants,
knowledge regarding substance abuse-related
issues among women has increased substantially.
Research evidence and clinical experience, including
knowledge gained from these RWC grants,
contribute to a greater understanding of the
biopsychosocial consequences of substance abuse
among women, the effects of women’s substance
abuse on their children, and the barriers to substance
abuse treatment encountered by women.
Although review of this research evidence and clinical
experience is outside the scope of this document,
a brief overview of these issues provides
context to discussion of residential treatment programs
for women and their children. Thus, the
following sections illustrate the types of issues
that are experienced by substance-abusing women
with children and by programs serving substanceabusing
women and their children and that should
be taken into consideration by service providers
and policy- and decisionmakers.
Medical Consequences of Substance
Abuse
Substance-abusing women are at higher risk than
men for developing substance-related illness, such
as liver damage, hypertension, anemia, malnutrition,
peptic ulcers, and brain and heart damage
(Reid, 1996; Howell et al., 1999). Women are
more likely than men to develop liver cirrhosis and
to develop it at earlier stages of drinking and at
lower levels of consumption (Reid, 1996;
Fingerhut and Warner, 1997). In addition, substance-abusing
women have a greater likelihood
than the general population of developing an eating
disorder (Wetherington and Roman, 1998),
and they experience such gynecological problems
as dysmenorrhea, menstrual irregularities, and
bladder or urinary tract infections. Substance
abuse increases women’s risks for unprotected sex,
sexually transmitted diseases (including human
immunodeficiency virus [HIV] infection), unintended
pregnancies, and medically difficult pregnancies
(Substance Abuse and Mental Health
Services Administration [SAMHSA], 1997a).
Among pregnant women, substance abuse can
cause spontaneous abortions, abruptio placentae
(separation of the placenta), toxemia, premature
labor, and complicated deliveries (Center for
Substance Abuse Treatment [CSAT], 1995a).
Substance abuse in pregnant women also can pose
substantial risks to their unborn children (see
Pregnancy and Substance Abuse, later in this
chapter). The physiological repercussions of alcohol
and drug abuse also may affect women’s sexual
functioning (e.g., hormonal changes, liver damage)
(CSAT, 1994).
5

Chapter I
Social Consequences of Substance Abuse
Substance-abusing women often are socially isolated
and are less likely than men to be integrated
into their family or to receive support from significant
others. At the same time, they have a substantial
level of burden related to being the primary
caretaker (Robles et al., 1998; Brown et al.,
1999). Many substance-abusing women come
from dysfunctional families in
which substance abuse and
mental illness, sexual and
physical abuse, and foster care
placements are common.
These families often do not
provide positive role models
for constructive and loving
relationships or productive
lives (Johnsen and Harlow,
1996). Many of these women
have difficulty in establishing
and maintaining intimate relationships.
In many instances,
women entering treatment for substance abuse
have inadequate financial resources; live in substandard
housing; are unemployed; and have few
or no marketable skills, little or no work history,
and a meager education (Finkelstein, 1994).
Substance Abuse and Violence
Childhood and adult sexual assault, criminal victimization,
and domestic violence are substantially
more likely among women with substance abuse
problems than among other women (Arellano,
1996; Bergman et al., 1989; Reid, 1996; Kilpatrick
et al., 1998; McCauley et al., 1997; Miller and
Downs, 1993; Worth, 1991). The risks of substance-abusing
women for experiencing physical
abuse, sexual abuse, and domestic violence begin
during childhood and adolescence but continue
throughout their lives. Research suggests that a
history of violence increases the risk of substance
abuse and that a history of substance abuse
increases the risk of violence (Kilpatrick et al.,
1998).
Coexisting Disorders
Childhood and adult
sexual assault, criminal
victimization, and
domestic violence are
substantially more likely
among women with
substance abuse problems
than other women.
Among individuals with mental illness, rates of
substance abuse disorders as high as 50 percent
have been observed, and among individuals with
substance abuse disorders, rates of mental illness
and symptoms as high as 80 percent have been
noted (RachBeisel et al., 1999; Regier et al., 1990;
Kessler et al., 1996). Among individuals with substance
abuse problems, more
women than men have a second
diagnosis of mental illness
(Anthony and Helzer, 1991;
Goodwin, 1996). The National
Comorbidity Survey estimated
that 41 to 65 percent of female
respondents with a lifetime substance
abuse disorder also have
at least one coexisting mental
disorder (Kessler et al., 1996).
Among individuals with coexisting
disorders involving severe
mental illness, women are more
frequently diagnosed with affective disorders
(Comtois and Ries, 1995). Since women with coexisting
disorders are more likely to have been physically
or sexually abused (Brown et al., 1999),
women with substance abuse disorders and a history
of physical or sexual abuse experience high rates
of posttraumatic stress disorder (Fullilove et al.,
1993; Teets, 1995; Windle et al., 1995). Substanceabusing
women are also at higher risk for having an
eating disorder than the general population
(Wetherington and Roman, 1998).
Substance Abuse and Criminal Justice
Problems
Criminal justice system (CJS) involvement is not
uncommon among women with substance abuse
problems. Among women offenders, substance
abuse is the leading behavioral health problem
(Teplin et al., 1996). In a comprehensive survey of
women in State prisons, 65 percent reported using
illicit drugs regularly, and 41 percent reported
using illicit drugs daily (Snell, 1994).
Approximately 20 percent reported drinking every
day during the year prior to incarceration. Almost
6

Overview, Context, and Grantee Profiles
one-half of the incarcerated women in the United
States had been using alcohol, other drugs, or
both at the time their offenses were committed
(American Correctional Association, 1990;
National Institute of Justice [NIJ], 1997). Women
are substantially more likely than men to serve
time for a drug-related offense than for a violent
crime, and nearly 25 percent reported committing
their offense to get money to buy drugs (Snell,
1994; CSAT, 1998; Kandall, 1998; Wilsnack,
1995).
Pregnancy and Substance Abuse
Surveys estimate that approximately 16 to 20 percent
of pregnant women have used alcohol within
the previous month, 8 percent reported drinking
on more than 5 of the past 30 days, and between 2
and 6 percent of pregnant women have used an
illicit drug in the past month (SAMHSA, 1997a,
1997b; National Institute on Drug Abuse [NIDA],
1996). In utero exposure to alcohol, nicotine, or
other drugs can lead to premature birth,
intrauterine growth retardation, low birth weight,
and other physical and neurobehavioral anomalies,
as well as to an increased risk for sudden infant
death syndrome (SIDS) and for infectious diseases,
including HIV infection (CSAT, 1995b). Babies
whose mothers consume alcohol during pregnancy
can be born with fetal alcohol syndrome (FAS) and
have coordination problems, speech and hearing
impairments, and heart defects. Babies exposed
prenatally to opiates, cocaine, and other drugs may
experience neonatal withdrawal that persists for up
to 6 months—with trembling, restlessness, agitation,
high-pitched cries, poor feeding, and inconsolableness
that challenge the most patient and
experienced of caregivers (CSAT, 1995b; Reid et al.,
1999).
Children Exposed to Substance Abuse
Children of parents with substance abuse problems—most
of whom live with their single mothers—often
experience problems related to the lack
of a safe, nurturing home environment. Chief
among these problems is neglect, as illustrated by
lack of supervision, poor hygiene, and inattention
to medical, physical, and nutritional needs.
Indeed, parental substance abuse is the primary
factor contributing to child maltreatment, death,
and child welfare cases (Reid et al., 1999; General
Accounting Office, 1994; U.S. Department of
Health and Human Services, 1998). Child neglect
can cause negative short- and long-term effects on
mental health and development, such as decreases
in intelligence scores and increases in learning
disabilities and depression (U.S. Department of
Health and Human Services, 1998). Some children
will become angry, antisocial, and aggressive
(Davidson, 1994). Also, children of substanceabusing
parents have a substantially greater risk
than children of parents who are not substance
abusers for physical and sexual assault and substance
abuse problems (Reid et al., 1999).
Barriers to Treatment
Women are underrepresented in substance abuse
treatment programs. Many women need treatment
but cannot or do not access it because of
(1) denial and stigma related to their addiction
and coexisting disorders, (2) debilitating fear that
acknowledging substance abuse problems and
treatment participation may jeopardize initial and
continued custody of their infants and children,
and (3) a shortage of treatment programs that
accept children, offer childcare services, and provide
gender-specific services.
More social stigma, anger, and blame are ascribed
to substance-abusing women than to men.
Especially when viewed through the prism of
motherhood, these women often are considered to
be weak-willed, irresponsible, sexually promiscuous,
and unkempt (Finkelstein, 1994; Goldberg,
1995). Denial on the part of these women and
family, as well as service providers, is another
major reason why treatment is not more frequently
and productively accepted as an option. Women
who need treatment may not be identified or
referred to the appropriate facility because primary
health care providers often are not well
trained to recognize the signs and symptoms of
substance abuse in women. In addition, few outreach
programs target women (Finkelstein, 1994).
7

Chapter I
In 1994, CSAT published Practical Approaches in the
Treatment of Women Who Abuse Alcohol and Other
Drugs. Designed for healthcare administrators, treatment
providers, and other social service providers, this
manual offers guidelines for using existing resources
more effectively and efficiently to design and implement
women’s programs. It includes strategies for treating
specific female populations, such as women of various
ethnic and cultural groups, women in the justice system,
and women with disabilities. The manual can be
ordered through SAMHSA’s National Clearinghouse for
Alcohol and Drug Information at http://www.health.org
or (800) 729-6686.
Among women who are socially isolated, homeless,
and the chief caretakers of dependent children,
substance abuse treatment is a low priority (Reid
et al., 1999). The fear of losing their partners or
custody of their children and the lack of childcare
services for their children while in treatment are
barriers to treatment (Young, 1996; Finkelstein,
1994). In some States, a positive urine test from
a newborn is sufficient to place him or her in the
foster care system; in other jurisdictions, illicit
drug use by a pregnant woman can lead to criminal
sanctions or civil actions. Many child welfare
agencies mandate treatment for a substance-abusing
mother as a condition of retaining or regaining
custody (Goldberg, 1995; Reid et al., 1999).
Specific data on unmet substance abuse treatment
needs are lacking for women with children, but
the experiences of the RWC grantees and of other
programs for pregnant and parenting women
repeatedly demonstrate the scarcity of appropriate
services and resources for this group. Moreover,
treatment resources are not equally distributed
across the country and are particularly scarce in
rural areas. Since residential facilities do not exist
in many communities, some women enter treatment
facilities that are 6 to 8 hours away from
their homes and families. A 1997 survey of State
child welfare agencies found that relevant treatment
services were available for fewer than one in
three of all parents with a substance abuse problem
and for only one in five pregnant women who
were using drugs. Essentially, many mothers are
not getting appropriate treatment. When referrals
are made or treatment is mandated by child welfare
agencies, clients may receive treatment based
on availablity, not necessarily what might best suit
their needs (Reid et al., 1999). Only a small proportion
of women receive gender-specific services
(Goldberg, 1995; Children and Family Futures,
1997).
History of Specific Programs for
Substance-Abusing Women
As Howell et al. (1999) note, “the history of special
programs for substance-abusing women—especially
mothers and pregnant women—is short and
sparse.” In the 1970s, the Federal government
was building a large-scale substance abuse treatment
system, and legislation gave priority to treatment
of women. By 1979, both NIDA and the
National Institute on Alcohol Abuse and
Alcoholism (NIAAA) had conducted studies and
developed and distributed extensive information
on the special treatment needs of substance-abusing
women. However, national surveys of treatment
programs in the 1980s found that few were
treating women. Most had not adopted recommended
services and did not offer the types of
assistance and quality of support needed and
desired by female clients (Reed, 1981; Finkelstein,
1994; Howell et al., 1999). In 1981, a shift to
services funding through Substance Abuse
Prevention and Treatment Block Grants to States
was accompanied by further reduced availability of
substance abuse treatment for women (and in general),
even though 5 percent set-asides (later
increased to 10 percent) were reserved for prevention
and treatment services for substance-abusing
women (Finkelstein, 1994).
Although a few innovative programs have a long
history of serving heroin-addicted and polydrugabusing
pregnant women, the particular needs of
this special population were recognized only gradually
by most facilities. Odyssey House in New
York City was among the first therapeutic community
(TC) programs both to admit women and
their children and to evaluate the impact of this
unprecedented approach. A 1979 examination of
postdischarge outcomes found unanticipated
improvements in employment, self-concept, mother-child
relationships, and parenting skills, as well
8

Overview, Context, and Grantee Profiles
as corresponding decreases in substance use and
criminal behavior (Glider et al., 1996).
The epidemic of crack cocaine use in the mid-
1980s—with its emphasis on the costly impact of
prenatal exposure—caught most States with too
few residential slots for the many pregnant women
and mothers in need of specialized care. By 1992,
only one-half the States provided Medicaid coverage
for pregnant patients in substance abuse
treatment clinics (Howell et al., 1999).
More research currently is being conducted on the
effectiveness of specialized treatment for substance-abusing
pregnant and postpartum women,
and several special projects have been funded.
The Center for Substance Abuse Prevention
(CSAP) has provided grants to more than 100
treatment and prevention programs that initiate
or enhance services and options for pregnant and
postpartum women and their infants. CSAT funded
approximately 85 residential and outpatient
programs for pregnant and parenting women and
their children since 1991. Initial evaluations indicate
that these programs have considerably
expanded the capacity of the treatment system for
this population as well as increased patients’
participation in prenatal care and decreased the
likelihood that they will have positive drug tests at
delivery (Howell et al., 1999). Although all findings
of NIDA’s Perinatal-20 project have not yet
been published, early reports by the individual
projects indicate that substance-abusing mothers
who are allowed to have their children with them
in residential care stay longer and have better outcomes
than women in traditional residential facilities
without their children.
Through these services and demonstration programs,
some consensus has developed about the
necessary components of model treatment programs
and services for substance-abusing pregnant
women and mothers of young children. Among
these are requirements to (1) provide comprehensive
and individualized treatment by addressing
multiple problems, including women’s social,
housing, vocational, medical, and mental health
needs; (2) provide parenting training; (3) offer
child care and transportation to services; (4) provide
a supportive and nurturing environment; and
(5) emphasize treatment retention and aftercare
(Goldberg, 1995; Howell et al., 1999).
Authorizing Legislation for Funding
and Administering the Residential
Women and Children’s Program
In 1992, the Independent Agencies Appropriations
Act and Section 509 F of the Public Health Service
Act authorized and appropriated initial funding for
the RWC program. This legislation called for
CSAP to receive funding for up to 10 demonstration
projects (later changed to 11) that would permit
substance-abusing women in need of longterm
care to reside with their infants and other
children in comprehensive community prevention
and treatment facilities.
In October 1992, these 11 grants were transferred
to CSAT, which administered them from their
inception through FY 1997, the official ending of
the 5-year grants.
Requirements in the Request for
Applications for Grant Awards
The proposed projects, according to the CSAPissued
Request for Applications (RFA), were
expected to build treatment capacity by annually
serving an estimated 500 women and their infants
and older children and, more importantly, to
incorporate innovative, state-of-the-art residential
services, habilitation, and aftercare arrangements.
An intergenerational focus on preventing substance
abuse among offspring of the target mothers
was another important objective in developing
these programs. These projects were to differ
from the earlier Pregnant/Post Partum
Women/Infants Demonstration Program in providing
integral residential treatment for the women’s
substance abuse, as well as an aftercare component
targeted at the women and their infants and
children. The project designs were required to
have specific strategies or interventions that
addressed identified problems to achieve specified
9

Chapter I
and desired outcomes—in a logic model. They
were to demonstrate, through a well-developed
evaluation plan, whether the proposed interventions
were effective in meeting the objectives
established by each project.
The target populations could include pregnant
women, postpartum women and their infants, and
other mothers with their children. Priority populations
included substance-abusing women who
were homeless or living in public housing, involved
with the juvenile or criminal justice system, infected
with HIV, disadvantaged,
low-income, and residing in
urban or rural areas.
Particular interest was
expressed in pregnant adolescents,
women with histories of
physical and sexual abuse, and
women with comorbid mental
illness. Grant applicants were
urged to focus on polydrug
abuse rather than any one licit
or illicit substance.
In addition, collaboration with
other Federal, State, and local
efforts related to substanceabusing
women was strongly
encouraged, including such
programs as NIDA’s Research
Demonstration on Drug Abuse Treatment for
Women of Childbearing Age and Offspring; the
Healthy Start Initiative; the Head Start program
administered by the Administration for Children,
Youth and Families; and the U.S. Department of
Agriculture’s Women, Infants and Children (WIC)
program.
The stated goal of the RWC program was "to
decrease the incidence and prevalence of drug and
alcohol use among substance-abusing women and
their children and enhance the healthy development
of the children." The demonstrable outcomes,
in addition to providing long-term (12 to
18 months) comprehensive residential treatment
and a continuum of outpatient aftercare services
for an indefinite period, were expected to
The stated goal of the
RWC program was “to
decrease the incidence
and prevalence of drug
and alcohol use among
substance-abusing
women and their children
and enhance the
healthy development of
the children.”
• Expand the knowledge base regarding what
works in residential treatment to accomplish
the stated program goal and to reduce the
effects of a substance-abusing environment on
children, including the involvement of fathers
where appropriate
• Promote the healthy development and recovery
of the women with respect to physical,
social, psychological, and economic well-being
• Promote the healthy physical, social, and cognitive
development of children in substanceabusing
families
• Provide a continuum
of services to improve parenting
skills and family relations
in order to facilitate healthy
mothering and ensure an optimal
relationship between
mother and infant
• Provide services that
improve women’s vocational
capabilities and give them
options for a productive future
life
• Assure participating
women the opportunity to
raise a family in a safe environment
by offering appropriate
residential and aftercare services
• Provide experiences that support the empowerment
of women to make decisions in their
self-perceived best interest with regard to
motherhood, parenting, career, and life functions.
Applicants also were required to address the complex
and varied needs of the target population
with a comprehensive array of services in the following
four general areas:
• Biological/physical (e.g., detoxification,
dietary, pediatric, obstetrical, acquired
immune deficiency syndrome [AIDS]/HIV, sexually
transmitted diseases [STDs],
reproductive health)
10

Overview, Context, and Grantee Profiles
• Psychological/social (e.g., self-actualization,
gender identification, comorbid psychological
conditions, relational issues, self-esteem)
• Support (e.g., housing, child care, habilitative
services, advocacy services, employment training,
medical care)
• Informational and educational (e.g., parenting,
prenatal/postpartum health, substance
abuse, nutrition, child development, resource
development).
The RFA also included extensive lists of activities
and elements that were to be evident in the grant
applications and for which support was available.
These service domains were categorized as primary
prevention, treatment for the woman, infantoriented
treatment and interventions, child-oriented
interventions, service delivery components, and
personnel. Examples of such sanctioned activities
were the building of resistance skills in young children;
counseling for HIV-positive women and those
with AIDS; comprehensive and culturally sensitive
assessments of all components of each woman’s
life, including any history of physical or sexual
abuse; appropriate medical care and mental illness
or psychiatric treatment for the women; development
and implementation of interventions with
the women to foster self-actualization, identity,
and self-esteem; primary health care for infants
and children; interventions to foster mother-infant
bonding; screening of children for signs of abuse
and neglect; peer-oriented programming for children;
developmentally appropriate interventions
for children to foster their healthy physical, cognitive,
and social development; infant and child care;
and coordination with legal services. All services
and interventions were required to be appropriate
to the ethnic, racial, and cultural backgrounds of
the target population. Finally, each applicant was
required to identify an available physical facility
that met applicable State and local childcare and
residential licensing requirements as the residential
setting for primary service delivery.
Grantee Profiles
Table I-1 summarizes key characteristics of the
original 11 RWC grantees. The projects were similar
in some respects but varied broadly in others.
The selected sites were relatively widely dispersed
across the United States—with two in Florida, two
others in the South (South Carolina and Georgia),
two in the mid-Atlantic States (Pennsylvania and
New York), and two in California. The remaining
three venues ranged across middle America—from
Wisconsin to South Dakota and Arizona. The projects
also ranged in size from Flowering Tree,
which could handle only 11 women and 15 children
at one time, to the 80-bed residential facility
at PROTOTYPES (only 40 of the spaces were funded
by CSAT). Most of the facilities served from 22
to 34 women at a time. The number of spaces set
aside for children also varied considerably. Only
one of the grantees, Families in Transition (FIT),
had sufficient room to admit all the women’s children;
most could handle 2 or fewer children per
mother, and Meta House had room for 20 children
and 34 pregnant or parenting women.
With the exception of FIT—which admitted pregnant
or postpartum women with infants under a
year old, along with older children of any age—the
projects set age limits for children who could live
in the residence. This limit was usually 10 to 12
years old, but the Watts project only accepted children
up to age 5. As noted, FIT only admitted
pregnant and postpartum women, and this policy
was also true for Desert Willow until the last 2
years of the CSAT grant. At that time, the parent
organization switched from Amity, Inc., to
National Development and Research Institute
(NDRI), and the facility began admitting parenting
women. By contrast, Casa Rita did not accept
pregnant women at all. The other projects
enrolled both women who were pregnant or postpartum
and those who were mothers.
As provided for in the RFA, all of the projects
except Georgia Addiction, Pregnancy, and
Parenting (GAPP) initially expected that women
would stay in the residence for approximately 12
to 18 months and in continuing care for another
11

Chapter I
year. As the later chapter on evaluation (Chapter
X) reflects, the actual length of stay in the different
projects often was considerably shorter, even
for those who graduated from the program. The
characteristics of the women and children who
enrolled in the projects were very similar in many
ways, which are described in more detail in
Chapter III. Some of the major differences among
the residents reflected the referral sources that
were used. The majority of clients in all but three
sites were African American. Whites predominated
at Desert Willow and Parental Awareness and
Responsibility (PAR) Village, whereas all the
women at Flowering Tree were Native Americans.
Hispanics (Latinas) constituted as many as 19 to
24 percent of enrollees at three sites—PROTO-
TYPES, Casa Rita, and Desert Willow. Most of the
women at seven projects came from inner-city
areas. Chrysalis and PROTOTYPES classified a
majority of clients as coming from rural areas,
Table I-1. Key Characteristics of the Original 11 Residential Women and Children’s Grantees
Casa Rita
New York, NY
Chrysalis Center
Florence, SC
Project Grantee Beds for Women
and Children
Women In Need,
Inc. (WIN)
Circle Park
Associates
16 Women
36 Children
(any age girls, boys
to age 13)
16 Women
24 Children
(through age 10)
Target Population
Homeless women with
children
Pregnant or parenting
women with multiple
problems
Expected
Stay in
Residence,
Aftercare
12 mos.,
15 mos.
6–12 mos.,
12 mos.
Client Race/
Ethnicity
70% African American
23% Latina
7% White
80% African American
18% White
2% Other
Clients’
Geographic
Source
100% Urban
66% Rural
34% Urban
Desert Willow
Tucson, AZ
Amity, Inc.
(currently NDRI)
20 Women
40 Children
(through age 8)
Most referrals from
Child Protective Services
(CPS) or CJS
12–15 mos.,
9–12 mos.
53% White
19% Latina
18% African American
10% Native American
85% Urban
15% Rural
Families in Transition
(FIT)
Miami, FL
The Village South,
Inc.
20 Women
60 Children
(all ages)
Only pregnant and
postpartum women
12 mos.,
12 mos.
68% African American
22% White
10% Latina
100% Urban
The Flowering Tree Project
Pine Ridge, SD
GAPP* Family
Enrichment Center
Atlanta, GA
Interim House West
(IHW)
Philadelphia, PA
Meta House
(Project MetaMorphosis)
Milwaukee, WI
Parental Awareness &
Responsibility (PAR)
Village
St. Petersburg, FL
PROTOTYPES
Women's Center
Pomona, CA
Oglala Sioux Tribe
Georgia
Department of
Children and
Youth Services
Philadelphia
Health
Management
Corporation
Our Home
Foundation, Inc.
Operation PAR,
Inc.
PROTOTYPES
11 Women
15 Children
(through age 10)
24 Women
36 Children
(to age 10)
22 Women
50 Children
(through age 12)
34 Women
20 Children
(through age 12–13)
27 Women
33–34 Children
(through age 10)
80 Women
25–50 Children
(to age 12)
Young Lakota pregnant
and parenting women
with alcohol problems,
referred by the Tribal
Court and the DSS
Pregnant and parenting
women, mostly
unemployed
Pregnant and parenting
women, nearly one-half
with high school
degree or general
equivalency diploma
Over one-third
pregnant or
postpartum, two-thirds
categorized as high
psychiatric severity
Over 70% referrals
from CPS or CJS
Over one-half of clients
referred from CJS or
CPS
12 mos.,
6 mos.
6 mos.,
12 mos.
12–18 mos.
for both
phases
9–15 mos.,
24 mos.
12–14 mos.,
6 mos.
12 mos.,
6–12 mos.
100% Native American 100% Rural
Reservation
93% African American
7% Other
94% African American
4% Latina
2% White
76% African American
18% White
6% Other
50% White
46% African American
4% Latina
43% African American
31% White
24% Latina
2% Other
100% Urban
100% Urban
100% Urban
100% Suburban
30% Urban
30% Suburban
40% Rural
Women and Children’s
Residential Program
Lynwood, CA
Watts Health
Foundation, Inc.
30 Women
30 Children
(to age 5)
Inner-city pregnant and
parenting women, 30%
referred by courts
10–12 mos.,
12 mos.
84% African American
13% Latina
3% White/Other
100% Urban
*Georgia Addiction, Pregnancy, and Parenting (GAPP) Project
12

Overview, Context, and Grantee Profiles
PAR Village described its residents as suburbanites,
and most of the women at Flowering Tree
came from Indian reservations.
Almost all of the parent organizations that
received the RWC grants had long histories of providing
substance abuse prevention and treatment
services. At least four of the grantees (Operation
PAR, PROTOTYPES, Our Home Foundation,
Village South) had been delivering relevant substance
abuse–related services for more than 20
years, and seven grantees had experience in residential
treatment. Most of these agencies already
had demonstrated leadership capabilities in establishing
innovative, gender-sensitive programs—
often for minority women. Two of the sites, PAR
Village and Desert Willow, had participated as
therapeutic communities in the NIDA-sponsored
Perinatal-20 research project. These were forerunners
of the RWC grants designed to determine
whether long-term, gender-specific, residential
treatment for pregnant women and their children
would help participants remain in treatment
longer and have better outcomes than did counterpart
women who did not have their offspring
with them during treatment. Women In Need
(WIN) had received funds in the late 1980s from
NIAAA to develop a special outpatient program for
women, and the GAPP project had a 3-year
Pregnant/Post Partum Women/Infants demonstration
grant from the Office of Substance Abuse
Prevention for outpatient treatment, which ended
in 1992.
Not only was the experience of these parent agencies
valuable in designing and implementing
appropriate, gender-sensitive services for the population
of substance-abusing women and their children
to be served, but the facilities, staffing, and
other resources already available through these
seasoned organizations enhanced the benefits that
could be offered immediately to the new projects.
For example, the health programs and medical
clinics operated by the Watts Health Foundation,
Inc., were valuable resources for this effort, as
were the extensive physical facilities and existing
campuses of Operation PAR, Amity, and Village
South. Most of the grantees had preexisting and
well-tested linkages with local hospitals and clinics
that treated women’s special health problems.
Our Home Foundation, Inc., and the Philadelphia
Health Management Corporation both had consid-
13

erable experience in running residential treatment
facilities for women, and WIN already was linked
with the New York City shelter system that would
refer clients to Casa Rita. Circle Park Associates,
too, already had developed linkages with many
other resources in Florence, South Carolina, that
assisted in delivering special services for women
and their children.

II. Treatment Models
S
erving mothers and their children together
in residential substance abuse treatment settings
is a novel concept that was pioneered
by the 11 RWC grantees. Although all of the
grantees had extensive experience in working with
women in recovery, and the majority had also
operated residential facilities for substance-abusing
women, the family-centered treatment model
was new—or just being developed. Several projects
had experience treating pregnant and postpartum
women. However, helping these women to
deliver healthy infants and to bond with these
babies, and admitting mothers with young children
who had not necessarily been residing with
them immediately before treatment entry, raised
new and challenging issues.
In their grant applications and focus group discussions
at the conclusion of the projects, the
grantees described a variety of eclectic treatment
models or philosophical approaches to delivering
services for the target population. No single
model predominated, although a majority of the
sites spoke of strategies that originated in therapeutic
communities. A number of elements were
mentioned repeatedly as being important to successful
outcomes, including comprehensive care,
staff and peer support in a nurturing environment,
individualized and flexible treatment plans, longterm
and phased treatment, case management,
group processes, and culturally and gender-appropriate
interventions.
Although the basic treatment models apparently
remained constant throughout the 5-year duration
of the grants, specific program elements had to be
adjusted as staff discovered that many of the
women and their children were more troubled and
traumatized than originally anticipated. Moreover,
the new vision of family-centered treatment was
difficult to achieve—requiring integration and reconciliation
of sometimes disparate interests and
perspectives of not only the women and their individual
children but also of significant others, family
members, staff, and the community agencies
that work with this population.
This chapter discusses how traditional concepts of
TCs were modified by several of the grantees to
meet the needs of this new population, delineates
the common elements or approaches adopted by
most of the grantees, outlines some of the
changes and modifications made in the duration
and focus of planned phases of care, and specifies
some of the challenges entailed in moving toward
a family treatment focus. Later chapters provide
more details about several of these themes—
staffing patterns, criteria for admission of children,
and factors that affected the length of stay.
Second-Generation Therapeutic
Communities Serving Women and
Children
The majority of the projects mentioned the influence
of TCs on their theoretical models for treatment,
stressing the emphases in this approach on
self-help, group dynamics, and providing comprehensive
services to address multiple problems, not
simply addiction. Three of the projects that
adapted TC treatment models (PROTOTYPES,
Desert Willow, PAR Village) have written interesting
pieces on this topic (Brown et al., 1996;
Coletti et al., 1995; Stevens et al., 1997; Glider et
al., 1996), specifying what aspects of the original
TC model were kept and which concepts were
modified or discarded to make this approach more
suitable for the specialized needs of women, especially
the vulnerabilities and parenting responsibilities
of mothers.
15

Chapter II
The early TCs—modeled after the original
Synanon program that was incorporated in 1958—
were designed for men, although coeducational
programs were established later and a few allowed
children. Initially, these learning communities
were self-help alternatives to more conventional
medical or mental health approaches and took
great pride in employing recovering
persons as responsible role
models for new enrollees.
Addiction was viewed as a disorder
of the whole person, requiring
comprehensive treatment
over a prolonged period with a
goal of major lifestyle changes.
The primary therapeutic tool
was direct confrontation by the
group—targeted at breaking
down addicts’ denial, pathology, and street code
that prohibited both self-disclosure and reporting
on anyone else, whatever the provocation.
Competitiveness, individualism, and selfishness
were to be replaced by trust in the collective. The
community was viewed as an extended family in
which helpfulness and positive peer relationships,
not independence, garnered approval and social
support. Openness and self-revelation during
group discussions were valued measures of engagement
in the therapeutic process that was deemed
essential for recovery. A system of privileges and
punishments, as well as a carefully structured and
graduated series of treatment phases, was
designed to move residents toward more responsible
participation in the program and, eventually, a
return to society. The first TCs were completely
self-contained with no professional staff; all residents,
whether newcomers or old-timers, performed
explicit job functions in a communal
model.
The newer, second-generation TCs developed for
substance-abusing women and their children still
focused on the whole person, not primarily on substance
abuse, and offered comprehensive, individualized
treatment. Emphasis remained on peer
support and modeling by longer term, more
responsible TC members, not solely on individual
recovery. Residents in a TC were still part of an
Grantees found that
most women needed
a range of services
in addition to
remediation of their
substance abuse . . .
extended family in which participants were working
members, and there were explicit incentives
for approved behaviors and disincentives for undesirable
activities. The expected length of stay in
the residence was usually 12 to 18 months, with
graduated phases of care that had specified criteria
and anticipated timeframes for completion.
Although treatment professionals
generally were incorporated
into these more recent TCs, staff
in recovery were often a vital
part of these programs, serving
as positive role models with
authority that came from their
personal experiences.
Programming was also genderspecific
and culturally competent
(i.e., program components
were structured around the culture of the target
population). The majority of staff members in residential
facilities that treated mothers and their
children were women. A variety of therapeutic
techniques (e.g., cognitive-behavioral strategies,
individual counseling, social learning) replaced
the original reliance on group confrontation.
Comprehensive and Holistic Services
All of the RWC projects aimed to treat the whole
person, not just the addiction. Grantees found
that most women needed a range of services in
addition to remediation of their substance abuse,
including physical and mental health care, education
and job training, instruction in basic life
skills, and help in facing and resolving problems
stemming from traumatized childhoods as well as
domestic violence, physical and sexual abuse, and
sexuality issues. These women also required a
great deal of assistance in taking care of their
children and learning how to be adequate parents.
Most of the grantees reported that their initial
philosophy and vision—to provide comprehensive,
holistic services to women and their children within
a supportive family environment—did not
change as the projects evolved, although the definition
of comprehensive was broadened.
16

Treatment Models
It wasn’t the vision and philosophy that changed.
We all wanted to take an approach that said
women are whole human beings, not just their
addiction. (PAR Village)
Our vision, when we wrote the proposal, was to
address some of the issues of women and children
and drug and alcohol use. We then expanded it to
address other issues, such as trauma, mental illness,
and HIV. We wanted to see if integrated
services could be successful. (PROTOTYPES)
[As] in traditional TCs, . . .
drug abuse is viewed as a disorder
of the whole person,
affecting some or all areas of
functioning. Addiction is a
symptom, not the essence of
the disorder. A global change
in lifestyle remains the [treatment]
goal, not just a reduction
or cessation of drug use.
(Desert Willow)
Consistent with the concept of
a TC, [our program] seeks to
address the needs of each participant
in a holistic and comprehensive
manner (i.e., treatment
of the whole person, not just the addiction) .
. . and [to offer] culturally relevant interventions.
. . .The most effective treatment approaches for
these clients focus on changing negative patterns
of behavior . . . as well as promoting the development
of educational, vocational, and social skills
that will enable them to lead productive, drug-free
lives. (GAPP)
Some of the greatest benefits of these [residential]
programs include the demand for responsible
behavior and the teaching of social values and
specific skills, including parenting, which will
enable the women to function successfully outside
the treatment center. (Interim House West [IHW])
Poor, homeless women have multiple problems
(e.g., housing, child care, employment) that
impact their lives and may trigger the onset or
escalation of addiction problems. These other
“The most effective
treatment approaches
for these clients focus on
changing negative
patterns of behavior . . .
[and] the development
of . . . skills that will
enable them to lead
productive, drug-free
lives.” (GAPP)
problems must be addressed in conjunction with
the addiction. (Casa Rita)
A Nurturing Environment With
Appropriate Peer and Staff Support
In the emerging TC models for treating women
and their children, a nurturing environment
superceded confrontation because this approach
proved particularly detrimental to substance-abusing
women with traumatic histories of sexual and
physical abuse. Rather than
motivating them to change,
confrontation merely exacerbated
these women’s feelings
of powerlessness. Instead of
deconstructing women, the
emphasis in these enhanced,
second-generation TCs was on
empowering the mothers, helping
them take responsibility
for themselves and their minor
children, and encouraging
them to be appropriately
assertive. This entailed supportive
supervision in a structured
environment that struck
a balance between too restrictive regulation and
too permissive lack of control.
[We recognize that] reliance on aggressive confrontation,
toughness, and unrestrained anger
results in premature dropout among drug-addicted
women who are highly likely to have been victims
of physical and sexual abuse in childhood
and rape and other forms of violence as adults.
Treatment methods that exacerbate a woman’s
sense of powerlessness may discourage her from
revealing and exploring such key issues and also
inhibit expression of her more tender emotions
and feelings of sadness, pain, grief, warmth, nurturance,
and protectiveness. The treatment environment
in a TC for women needs to promote
healing. [The interventions used in our program]
are less confrontational, more nurturing, and supportive
of women’s particular needs for affiliation
and support. Groups and counseling focus on
grief and loss, as well as sexual abuse, and facili-
17

Chapter II
tate women’s efforts to explore their experiences.
(PROTOTYPES)
PAR Village focuses on identifying women in need
and finding reasons to accept them in treatment,
rather than rejecting them for poor motivation. . .
. The majority of women entering PAR Village suffer
from low self-esteem, have already been devastated
by years of physical and sexual abuse and
dysfunctional relationships, and are too fragile for
the intense confrontation common in male-oriented
TCs.
. . . PAR Village has adopted a nurturing philosophy
. . . and uses a teaching model, based primarily
on social learning, that attempts to create and
strengthen residents’ skills and abilities in an
atmosphere that accepts individual
shortcomings and psychological
disabilities. [We]
empower women by building
on their personal strengths,
teaching proper parenting and
child development, and providing
health care and other psychosocial
interventions. PAR
Village replaces the traditional
tear down, build up approach
of a traditional TC with a model that supports,
educates, and guides. (PAR Village)
Casa Rita recognizes that traditional TC
approaches must be modified for effective treatment
of homeless women who have experienced
difficult and often dehumanizing circumstances in
association with this crisis. Hence, confrontational
techniques are not used, positive urine tests are
considered to be a treatment issue [not a cause
for expulsion], and a balance is sought between
the need to develop and practice necessary skills
for making choices and the need for a structured
environment. The philosophy guiding this program
is that a family-based residential community,
coupled with extensive, supportive counseling
and other services, can best address the needs of
drug-addicted, homeless women. (Casa Rita)
Our approach incorporates elements of TCs to
provide a structured, non-permissive, corrective
milieu with legal, ethical, and moral boundaries.
The fundamental TC concept [we included] is
“[A] multidisciplinary
team approach assures
a nurturing, supportive,
empowering, and
safe environment . . .”
(PAR Village)
change through self-help and a communal living
environment. The extended family concept generates
healthy social interactions. [We also] emphasize
self-empowerment to change and solve problems.
Mothers must be active partners in their
own recovery [even though] the family as a whole
is the client, not just the individual woman.
(Watts)
Use of Professionally Trained Staff
Newer TCs that admitted pregnant or parenting
women with their children were no longer selfcontained
communities but incorporated professional
staff to deliver a variety of specialized services,
notably medical care and health education
for the mothers and therapeutic
daycare for their infants
and young children.
Additionally, consultants often
were hired to run groups, to
provide individual psychotherapy,
or to lead educational sessions
on such relevant but sensitive
topics such as parenting
practices, domestic violence,
healthy family relationships,
and sexuality and sexual abuse (also see Chapter
IV, Facilities, Staffing, Staff Training, and
Retention Issues).
While [the program] does maintain the basic
structure of a TC, staffing has been enhanced with
professionals. [Our program] combines
. . . the expertise of trained professionals from
many disciplines and the strengths of social model
recovery programs where participants learn
healthy behaviors and attitudes from other participants
while building support networks and learning
to handle stress in a positive way. (PROTO-
TYPES)
Our philosophy is to facilitate the physical, psychological,
and social development of women and
their families by providing a variety of therapeutic
experiences. . . . Thus, the traditional team of
treatment providers has been expanded to include
vocational counselors, family members, employers,
foster care workers, and medical and psychiatric
providers. This multidisciplinary team
18

Treatment Models
approach assures a nurturing, supportive,
empowering, and safe environment . . . [that
encourages] these women to open up more easily
with staff and one another. (PAR Village)
In addition to staff members who are recovering
addicts, [we have hired] many academically
trained persons who have specific . . . expertise.
[For example], the therapeutic daycare for infants
and young children [is provided by] . . . trained
staff whose educational and employment background
allow for the delivery of specialized services
for children. Some of the children, particularly
the newborns, have special medical needs
[resulting] from substance exposure in utero.
Consequently, medical staff include a full-time registered
nurse who works with mothers and the
children. (Desert Willow)
Individualized and Flexible Treatment
All of the grantees emphasized individual treatment
planning to meet the specifically assessed
needs of the women and children who were admitted
to the facility. Project staff recognized that
some clients were more seriously troubled than
others and that treatment could neither be standardized
nor delivered in a specified order. Each
woman had to be allowed to progress at her own
rate and be offered relevant services that she
could use to her best advantage. This kind of flexibility
sometimes proved difficult to achieve in a
residential facility, where it would have been easier
to require that all clients attend the same groups
or receive the same training. (The complications
entailed in scheduling individualized treatment
and meeting personal appointments are further
elaborated in Chapter V, Continuum of Services
for Women.)
PROTOTYPES offers a complex program that
seeks to provide needed services to a woman
when she is most ready to learn new skills, attitudes,
and coping strategies. While there is a core
program, women’s individual trajectories through
the program vary, as do the environments they
face after they leave. (PROTOTYPES)
[Our program] . . . provides a comprehensive
range of flexible and easily accessible services
that allow self-prioritization of needs and . . .
involve all children, significant others, and relatives
who can be part of an extended family unit
in the treatment plan. (Casa Rita)
Although core elements of a TC are retained, the
women’s treatment plans are largely individualized
. . . to maximize psychosocial learning.
Personally customized treatment is also flexible,
rather than rigid, and responsive, rather than preordained.
(PAR Village)
The Importance of Long-Term Treatment
in a Residential Facility
Another firm belief shared by all the grantees was
that long-term residential treatment was necessary
to help substance-abusing women—particularly
those with little social or financial support as
well as those with multiple physical, emotional,
and mental problems—achieve a lasting recovery
and reintegration into the community as individuals,
productive citizens, and adequate mothers.
Although all of the projects insisted that the
length of treatment should be tied to individual
treatment needs and progress, the expected duration
of residential treatment (not including aftercare)
varied from 6 to 18 months (see Table I-1).
By the end of the grant period, several projects
were facing the realities of managed care and its
impact on shortened lengths of stay. They also
had more experience with women who dropped
out of treatment, not only in the critical first 30
days, but also after 6 months of relatively successful
participation. Chapter X, Evaluation Designs
and Findings, presents additional information
regarding the actual length of stay in the different
programs and the ways in which some programs
have accommodated.
I’m convinced it takes a good 90 days before people
[in treatment] even think clearly. (Meta
House)
Six months is too short [a time] to deal with the
environmental and financial problems they come
in the door with. I think 6 months should be
thought of as primarily stabilization. (GAPP)
Our data show pretty clearly that there are significant
differences in outcomes between women who
19

Chapter II
stayed 6 months or more and women who stayed
less than 6 months. Women with multiple needs
should really stay at least 12 months. (PROTO-
TYPES)
You need to be able to set up these woman financially
[through vocational training] so they don’t
go back to abusive relationships. They also need
to understand and become resolved not to have
those relationships, and that’s going to take a
year of emotional and psychological
work. To get these kids
and the moms situated together
so that the children are
overcoming some of their
obstacles and are working
with the mother is also going
to take a year. I don’t think
moving the kids around [too
frequently] is good for
them . . . they need to be in one
place for at
least a year so they aren’t
pulled in and out of school.
(Desert Willow)
Programs found that many of these women already
had tried outpatient or shorter term residential
programs with little or no success.
They’ve been there and they’ve failed. By the time
they come to us, most of our women have had
two or three treatments already. (Chrysalis)
Phased Treatment
Eight of the grantees that adapted a TC model
(Chrysalis, Desert Willow, FIT, GAPP, IHW, PAR
Village, PROTOTYPES, Watts) also specified three
or four different phases of treatment, lasting for
varying lengths of time with separate criteria for
progression through each phase. Responsibilities,
independence, and privileges generally increased
with time and progress in treatment. The focus of
treatment also changed by phase, moving from
assessment and orientation immediately after
admission to handling women’s and children’s
issues separately, and then as a family unit, before
preparation for reentry into the community and
aftercare. The timing for initiating particular
“Our data show pretty
clearly that there are
significant differences
in outcomes between
women who stayed
6 months or more and
women who stayed less
than 6 months.”
(PROTOTYPES)
interventions depended, in some programs, on the
phase of treatment (e.g., vocational training or
parenting and child development classes were
sometimes delayed until the women had dealt with
major health and other substance abuse–related
problems).
The TC model insists that all women learn to take
responsibility for themselves and the residential
community. The responsibility, in the early phases
of treatment, is primarily
focused on self-care, care of
one’s own children, and physical
tasks for maintaining the
facility. As the women
progress through treatment,
their responsibilities increase,
particularly regarding the functioning
of the community. They
are expected to take responsibility
for such specific tasks as
receptionist, resident leader, or
house manager. In addition,
they gradually assume more
responsible roles outside the
TC, as college or trade school students or as a
workers in the wider community.
(PROTOTYPES)
Although the specific activities, foci, and restrictions
in each phase differed among the grantees,
the following composite description captures the
most usual components and anticipated durations.
• Phase I: Orientation/Initiation (30 days)
focused on assessments of physical, psychological,
recreational, educational/vocational,
recovery, and legal needs; the development of
an individualized treatment plan; remediation
of acute problems; and structured substance
abuse education and orientation groups.
Women usually were restricted to campus and
were expected to adjust to/bond with the program,
staff, and other residents.
• Phase II: Stabilization/Integration (60 to 90
days) concentrated on chronic personal problems
of the individual woman and her children,
with separate treatments and objectives
for each. Intensive groups covering such top-
20

Treatment Models
ics as physical and sexual abuse, relationships,
life skills, health education, stress management,
parenting and child development, and
addiction/relapse were initiated. The women
had assigned household tasks and responsibilities
for child care and babysitting others’ children,
and they participated in exercise classes
and other leisure activities under close supervision.
Community passes sometimes were
given for brief, out-of-residence trips or
appointments if the women were accompanied
by a responsible buddy or staff member.
Children also participated in age-related activities
in a structured and nurturing environment.
• Phase III: Transition/Family Unit (up to 90
days) emphasized the mother-child dyad in
the residence and the development or reestablishment
of healthy relationships with significant
others, older children who are not in residence,
and family members. More attention
was given to adult education or vocational
training and planning for independent living.
The women were expected to take on more
household responsibilities
and to demonstrate leadership
capabilities with
peers and sound decisionmaking
skills as well as
appropriate parenting.
Overnight passes sometimes
were given.
• Phase IV: Community
Reentry/Reintegration
(90 to 160 days) focused
on independent living—
with women acquiring
jobs or going to school in
the community, making
appropriate childcare
arrangements, securing
reliable medical care,
obtaining safe and affordable housing, and
demonstrating time management and budgeting
skills as well as participating in outside
Alcoholics Anonymous (AA) and Narcotics
Anonymous (NA) meetings or church activities.
The women sometimes had weekend
Even a program
espousing a traditional
disease model
emphasized the
importance of treating
the whole person with a
comprehensive range of
services and also
perceiving the recovering
woman within her family
context.
passes. They were required to demonstrate
their ability to practice healthy lifestyles while
still under some supervision and guidance.
After program initiation, one of the grantees,
Chrysalis, discovered that its carefully constructed
four phases, modeled after Gorski’s Developmental
Model of Recovery (Gorski, 1989), were not tailored
to the extremely limited household management
skills and practical experiences of the
women being admitted. These clients did not
know how to parent or even operate a washing
machine, vacuum cleaner, or stove. Instead of
waiting to emphasize parenting in Phase II and life
skills in Phase III, these important competencies
had to be addressed in Phase I, immediately after
the mothers were admitted. Staff felt that more
knowledge about parenting was critical to ensure
the safety and well-being of the children.
Similarly, it was impractical to delay training in
critical life skills. Since these changes left only
vocational training as a primary emphasis for
Phase III, the final Phase IV was eliminated altogether.
The initial orientation and assessment
phase after admission was
shortened from 30 to 15 days
after experience demonstrated
that the proposed tasks
and activities could be accomplished
in one-half the time.
The anticipated duration of
treatment also was shortened
from 12 to 18 months to 6 to
12 months. This shorter,
more intense program
seemed to work well at
Chrysalis, and premature
departures after 6 to 8
months in treatment fell dramatically.
Many of the
women became ready to graduate
after less than a year of
residency. The continuing care component of
Chrysalis concurrently was strengthened with a
dedicated counselor and a network of referral
resources.
21

Chapter II
Other Common Treatment
Approaches
Not all of the projects offered a detailed description
of their treatment models. Rather, they mentioned
approaches that had proven effective with
the target population. None of these conflicted
with the elements found in the modified TCs.
Most seemed to complement the approaches
already noted and were used by many of the projects,
whether explicitly reported or not. Even a
project espousing a traditional disease model
emphasized the importance of treating the whole
person with a comprehensive range of services and
also perceiving the recovering woman within her
family context.
We consider addiction to be an
illness and, therefore, provide
treatment interventions within
a disease-model framework.
[Although our]
. . . fundamental goal is assisting
families to achieve abstinence
from alcohol and other
drugs, . . . we concurrently
recognize that a supportive,
structured environment acts
as a stabilizing influence . . .
and that treatment should fit
the environmental, social, and
psychological needs of women
as well as be consistent with
the racial, cultural, and class characteristics of
the [target] population. This means viewing
chemical addiction among the new homeless (i.e.,
women and children) as a . . . response to such
larger problems as lack of housing or employment
or the stresses of single parenting and poverty.
This holistic, family-based approach . . . makes a
connection between sobriety and an enhanced life
situation and sees the redress of these problems
as an essential part of treatment. (Casa Rita)
Case Management
Several sites employed case managers to obtain
and coordinate community-based services for the
As grantees implemented
and refined their
projects designs, the
importance of a large
and functional network
of community resources
that could deliver
necessary services
without duplication
became paramount.
women and children—during residential treatment
and also in the continuing care phase after graduation
from the residence. Case management was
viewed as necessary to ensure the delivery of comprehensive
services for both the women and children.
Securing offsite arrangements for such
needs as medical and psychological assessments
and specialized treatment, education and vocational
training, recreational programs, and legally
required attention. Case management was particularly
important in the later phases of treatment
and in aftercare activities as the women transitioned
back into the community. As grantees
implemented and refined their project designs, the
importance of a large and functional network of
community resources that could deliver necessary
services without duplication became paramount.
Targeted families were often
involved with numerous social
service agencies at admission
and received similar and overlapping
assistance from them.
As one site noted about a particular
family:
. . . Different clinics were providing
parenting classes,
vocational assessments and
training, developmental
assessments, and case management.
The State social
service agency was also
involved with the family, . . .
providing parenting classes
and case management. Yet another agency furnished
case management and medical care for the
children, while another offered only child care and
parenting classes. This was obviously not an
integrated service delivery system, and coordination
was needed among these different agencies in
order for the family to receive valuable, unduplicated
services. Hence, FIT, as the [residence] site
. . . became the lead case manager for enrolled
families. Through [its] board and outreach . . .
FIT actively recruited referral sources, social
service agencies, and . . . medical clinics to form .
. . partnerships and minimize service duplication.
. . . [As a] result of this networking . . . each fam-
22

Treatment Models
ily’s needs are assessed along with the community
services that [they are] receiving.
Subsequently, appropriate referrals are made to
other agencies that may benefit the family. . . . All
[helping] agencies . . . are kept informed about
the mother’s progress and
involved with any clinical
interventions that help retain
her in treatment. Close coordination
of efforts—through telephone
contacts and joint
staffings—is emphasized. Of
course, this is time-consuming
and requires a staff position
solely dedicated to case management
of the families in residence.
Since many of the
mothers and their children were clients of these
various agencies long before being admitted to
FIT, and will continue to be served by them for
some time after discharge, keeping these agencies
involved eases the transitions out of—as well as
into—residential treatment and provides continuing
support during recovery. (FIT)
An Emphasis on Groups and Group
Dynamics
Another site, Meta House, did not model its treatment
on TCs but nevertheless emphasized the
value of group participation—a critical element in
all of these projects.
No particular model of treatment was initially
chosen. We worked on principles of group
dynamics and watched the model develop through
trial and error. If we had to put a label on [our
philosophy], I would say that it is a combination
of a cognitive/behavioral and a relational model.
Actually, I did not discover writings about the
relational model until after we were already using
it. However, our approach relies heavily on
groups, since consensual validation is the most
salient experience in group process. . . . Each
woman [is] encouraged to develop a sense of
belonging that will motivate her to stay in treatment
and mitigate the pain associated with therapeutic
exploration. The cohesive group offers
“The group process
allows each person to
risk experiencing longdenied
and powerful
feelings with acceptance
from others . . .”
(Meta House)
women unconditional acceptance no matter what
their histories or behaviors prior to coming [into
treatment]. Support and emotional warmth provide
the psychological glue that encourages risktaking
for self disclosure. . . . Rules and standards
develop as part of being
a group that exerts social pressure
on its members to change
their views or behavior. . . .
Groups strongly influence how
each member views herself,
others in the group, and the
group as a whole. The group
format provides insight and
understanding, helps attribute
meaning to life circumstances,
and thereby defines a consensual
reality for each person. The group process
allows each person to risk experiencing longdenied
and powerful feelings with acceptance
from others . . . [and] to realize that feelings are
not overwhelming and do not produce the imagined
[negative] consequences of release. . . .
Groups offer new possibilities for feeling, processing,
and behaving. (Meta House)
Culturally and Gender-Appropriate
Interventions
All of the grantees agreed on the importance of
culturally and gender-appropriate interventions
but took different paths to ensure that this objective
was met. All sites employed staff, to the
extent possible, who reflected the racial/ethnic
backgrounds of the clients. Most projects opted
for an all-female staff, although some employed
men who could serve as positive role models, especially
for the children. (Also see Chapter IV,
Facilities, Staffing, Staff Training, and Retention
Issues.) Understanding and speaking the clients’
language, including dialect, also were viewed as
important. Primarily, the treatment addressed
topics of particular relevance to women and to different
cultures. Spirituality, for example, was an
important component at several sites (e.g.,
Chrysalis, GAPP, FIT, Flowering Tree)—interpreted
not as a particular religious perspective but as
part of a search for spiritual growth, moral mean-
23

Chapter II
ing, and belief in a Higher Power. Other culturespecific
components were included at some sites.
Every effort is made to maintain a culturally and
ethnically diverse staff that is composed mostly of
women who serve as successful female role models.
Male staff members are carefully chosen and
supervised to ensure that they understand the difficulties
of working in a women’s treatment program.
Male staff are never left alone on duty at
night. All staff are trained on issues pertaining to
boundaries, sexuality, and abuse. [We also
attempt] to coordinate and
deliver services in the context
of women’s lives—their psychological,
familial, social, economic,
medical, and spiritual
[aspects]. One cannot talk to
women about drug abuse without
also talking about health,
relationships and dependency,
family, violence (including physical
and sexual abuse), and
love and loss. (PROTOTYPES)
Another key factor in designing
and implementing a successful
treatment program is that attitudes
about race, class, and
culture must be made relevant.
. . . Conscious or unconscious attitudes displayed
by service providers towards poor [women] and
minorities too often have resulted in a lack of
trust or the inability of clients to bond with the
providers. . . . It is extremely important to the
engagement process for people to be addressed in
their own language, for them to be treated with
patience and respect, and for service providers to
take the time to understand the specific implications
of working with a particular population.
(Casa Rita)
In developing a gender-specific program for
women and their children, . . . programming was
designed to address not only substance abuse and
relapse prevention issues but also such genderspecific
topics as assertiveness, sexual behavior,
emotional/physical/sexual abuse, HIV infection,
parenting, relationship problems, nutrition for
“Since . . . every
woman’s needs are
uniquely different, a
continuum of services
must be available to
meet her diverse needs
and reflect her cultural
background, values,
and beliefs.”
(PAR Village)
adults and children, appropriate play with children,
mother-daughter issues, codependency, and
other ethnic/cultural issues. (FIT)
Since . . . every woman’s needs are uniquely different,
a continuum of services must be available
to meet her diverse needs and reflect her cultural
background, values, and beliefs. Drawing on previous
research and theories published within the
past 15 years, PAR Village assumes that women’s
substance abuse is directly linked to family drug
abuse, childhood sexual trauma, and depression.
Consequences of illicit drug use
for women include mental and
physical illness and violence.
Additionally, women are more
likely to have an anxiety or
affective disorder that antedates
their drug abuse. . . . The
lifestyles of our clients at admission
reflect their heavy use of
crack cocaine as well as their
multiple social problems, including
unemployment, involvement
with the criminal justice system,
child neglect, sexual degradation,
violence, and homelessness.
(PAR Village)
We try to get women to understand
their own culture and reinforce what it
means so they can overcome any negativity
regarding their different racial/ethnic heritages.
For example, a father of one of our Native
American clients built a sweat lodge on the campus
for "spiritual cleansing and awareness." To
learn the positive aspects of their own cultures,
we’ve also encouraged Latina women in the program
to research and celebrate Cinco de Mayo,
and African American women, Juneteenth [which
honors the day, June 19, when enslaved Africans
in the South and West first heard about their
emancipation after the Civil War.] (Desert
Willow)
Our philosophy is to provide a holistic, culturally
based [approach] to empowering Lakota women
to live healthy, productive lives [and] follow in the
footsteps of our ancestors. A wide range of theo-
24

Treatment Models
ries are applied through counseling that is cognitive-behavioral,
reality-oriented, person-centered,
and existential. Therapy centers on the basic conditions
of human existence such as choice, selfdetermination,
and the freedom and responsibility
to shape one’s life. [Treatment is based on] nurturing
the four sacred directions of the self: spiritual,
emotional, mental, and
physical. Our culture has
seven rites [that] the women
participate in after they deal
with issues of sexual abuse
and grief. The "Wiping the
Tears Ceremony" is provided.
Since part of our culture is
taught through bead work, each
client completes a beaded doll
and has a naming ceremony
for it in which she reclaims her
spirit as well as her hurt, abandoned inner-child.
All staff members are of Native American descent
and female. (Flowering Tree)
Family-Focused Treatment
The most important change in the emerging treatment
models adopted by the grantees was the
shift from building relationships among residents
to a new focus on women not only as individuals
but also as mothers and family members. This
required a therapeutic emphasis on parenting and
the mother’s relationship with her children as well
as the inclusion of other functional members of
the family of origin, the children’s fathers, or the
women’s significant others in the treatment plans.
The women were encouraged to build relationships
with these persons, not to exclude them unless
they were detriments to their positive functioning.
Addiction was addressed in the context of being a
mother as well as a woman, with family reunification
and/or child custody usually—but not
always—a desirable outcome. Achieving and maintaining
this family focus were not easy, however,
since it required that project staff and representatives
of many community agencies work together
to help identify and reconcile the often disparate
needs and desires of women as individuals and
“All of the women
enrolled . . . are
encouraged to examine
their family dynamics
and rearrange or rebuild
family relationships . . .”
(Desert Willow)
mothers with those of their individual children
and other family members and relatives.
All of the women enrolled . . . are encouraged to
examine their family dynamics and rearrange or
rebuild family relationships so they are functional.
Family members are invited to attend groups. . . .
Family dynamic issues and patterns of behaviors
in child raising are even more
important in a mothers and
children treatment setting since
the mothers need to learn
appropriate and healthy parenting
skills and practices.
(Desert Willow)
[We] initially thought that the
best way to impact the child
was through the mother,
[believing that] a healthy parent
would produce a healthy child. We no longer
believed that [after] we realized that the population
of women and children coming to Meta
House was more traumatized than expected.
[These women had more difficulty meeting] basic
survival needs, and fewer services were available
for their education and nurturance. . . . The children
had experienced years of parental neglect following
the crack epidemic in Milwaukee. . . .
[They] had more emotional and developmental
problems and increased antisocial behavior, and
they were less likely to have received well-baby
care [than we had anticipated]. We had to design
some serious programming for children that we
had not initially planned and focus more on parenting/child
management and the family. (Meta
House)
A whole-family focus is difficult to establish and
maintain in an outpatient setting but feasible in
residential care if all services are offered to all
family members at the same time and intensity.
Little has been written about fully integrating services
for the whole family, including a full range of
alcohol and other drug (AOD) prevention
approaches. . . . [Our] conceptualization deepened
as a result of initial operations which were
too focused on the mother. The demands and
rewards of parenting were not fully appreciated,
25

Chapter II
nor were the effects [of addiction] on children
and on fathers. [At FIT], the family unit is the
primary client, not the mother. Drug treatment is
only one component of family habilitation. [We’ve
taken] a systems approach to treatment, [recognizing
that] changes in one part impact all others.
A mother’s abstinence makes parenting possible,
but success in this role and a positive response by
children improve the mother’s self-esteem and
motivation to remain abstinent. (FIT)
Children need to be part of treatment because they
are at high risk for future addiction, and mothers
are often willing to take actions [engage in treatment]
they would not take for themselves if they
think these will benefit the children. (Casa Rita)
The reality of having women and children in treatment
together presents us with unique opportunities
to facilitate emotional growth of
the mother and increase her bonding/nurturing
activities with the children. Literally, the
mother gets on-the-job training in parenting while
incorporating a drug-free lifestyle and dealing
with the emotional issues surrounding addiction.
The mothers are learning new
coping strategies as they go along, which can be
frustrating for both the family and the program.
We are literally seeing a work in progress.
(GAPP)
26

III. Population Served,
Outreach, Referral,
and Admission Criteria
T
he population of substance-abusing women
and their children who were served by the
original 11 RWC grantees had many of the
characteristics at admission that were identified in
Chapter I. The women had multiple and serious
treatment needs, limited education, and were
unemployed, unmarried, receiving public assistance,
and suffering from physical health problems
or co-occurring mental disorders. More than half
were victims of sexual or physical abuse as children
or adults. Most were polydrug users with a
preference for crack cocaine; many had been convicted
of a drug-related crime or had a claim
against them of child abuse or neglect. Most also
had received previous treatment for substance
abuse. One-third of the children admitted to the
residences with their mothers were newborns or
toddlers up to 2 years old; a preponderance of
these babies had older siblings who were living
with relatives or in foster care placements.
This chapter profiles the characteristics of women
and their children at admission for all the
grantees and specific sites; depicts changes in
client characteristics over the grant period; specifies
outreach activities and referral sources; summarizes
admission criteria for the women and children
used by the different sites, as well as the
rationale for these choices; and discusses some
questions raised about the benefits of having children
in treatment with their mothers.
Profile of Participants
Admission data for 1,168 women and 1,113 children
who were treated by 10 of the 11 grantees
during a 2 1 ⁄2-year period between April 1995 and
the official end of the projects in September 1997
provide a composite but apparently accurate characterization
of the participants in residential care.
The statistics were compiled from CSAT’s
Quarterly Reporting System (QRS)—an automated
information system to which CSAT grantees submitted
data on a quarterly basis, beginning in
1995. (See Chapter X, Evaluation Designs and
Findings, for a more detailed description of this
system.) The period covered is only one-half the
5-year duration of the original grants—a number
of the projects did not actually admit clients until
FY 1994 or later because of delays in facility renovations
and other start-up problems. Because of
these delays, the number of admissions reported
by all these sites for the entire grant period totals
only 2,086. Moreover, the numbers of women
clients for whom admission data on their demographic
characteristics, problems, and current status
were collected and analyzed by grantees over
the course of the projects totaled 1,627 compared
to 1,168 from the QRS. Although data from
Flowering Tree are not included, and data from
Casa Rita were only collected through the third
quarter of FY 1997, the available summary statistics
seem to reflect a credible sample.
Information from the separate projects on client
characteristics at admission is included at the end
of this chapter to compare and examine individual
variations across sites. All grantees were apparently
successful in reaching the target population
specified by CSAT. Most of the pregnant women
and mothers admitted to treatment at all sites
had troubled, traumatic histories, with serious
current problems related not only to substance
abuse—primarily crack cocaine—but also to symptoms
of mental disorders, involvement in the criminal
justice system, and unemployment. Because
the grantees did not all collect the same information
at intake, direct comparisons cannot be made
27

Chapter III
on many variables. However, the clients at the
separate sites do seem remarkably similar—to the
extent reported—with respect
to age, minority group identification,
single status, poverty,
unemployment, dependence
on welfare, previous treatment
failures, prior or current
involvement in the CJS, and
number of children. Among
the noticeable differences
across the grantees are the
comparatively high rate (45
percent) of married women at
Casa Rita (all of whom were
homeless) and the large numbers referred to treatment
by the courts at Watts (59 percent) and
Desert Willow (50 percent).
A disquieting similarity across the sites is the very
high percentages of women reporting a history of
childhood or adult physical and sexual abuse.
These rates of abuse range from 88 percent of the
women at Meta House and 42 percent at FIT who
acknowledged a history of physical abuse, to 81
percent of the women at Meta House and 32 percent
at FIT who experienced sexual abuse at some
point in their lives. At Chrysalis, 81 percent of
clients had a history of domestic violence. At
Casa Rita, 68 percent of the women had been
physically abused, and 45 percent had been victims
of sexual abuse as children. Similarly, 62 percent
of women at PROTOTYPES reported physical
abuse during childhood, and 23 percent were
raped as youngsters.
More encouraging, the percentages of women
entering treatment who had completed high school
or obtained a general equivalency diploma (GED)
were remarkably high in several of the programs—
55 percent at GAPP, 49 percent at Meta House, 42
percent at Watts, 35 percent at PAR Village, and 32
percent at PROTOTYPES. While this level of education
appears to increase the potential for
employability earlier, the program director at one
site noted that the grade level attained in an era of
"social promotion" does not necessarily correlate
with literacy or other academic skills.
A disquieting similarity
across the sites is the
very high percentages
of women reporting
a history of childhood or
adult physical and
sexual abuse.
Asking, at admission, about grades completed is
misleading. Some of these women may have
actually finished the 10th grade
but are functionally literate at
the 3rd grade level and have
2nd grade level math skills.
The clients are too embarrassed
about their actual abilities
to be accurate about the
grade completed, or, if they are
truthful, they don’t say they
skipped most classes and were
already doing drugs, so they
never really learned much. It
is important for programs to
know clients’ functional intelligence level so that
expectations about reading and participation
[and employability] can be based on that. (PAR
Village)
Women at Admission (QRS Data: N = 1,168)
• Nearly 50 percent of the clients were between
the ages of 26 and 34 years.
• Sixty four percent were African Americans; 25
percent were white; 9.2 percent were
Hispanic; 1.2 percent were Native American;
and .08 percent self-identified as multiracial.
Socioeconomic Status
• Almost all of the women (94.6 percent) were
living below the poverty level prior to admission;
two in five (39.9 percent) were homeless;
nearly three in five (59 percent) were
receiving public assistance; and about one-half
(45.8 percent) were Medicaid recipients.
• Three-quarters of the new admissions (75.1
percent) were unemployed; 12.5 percent were
either disabled or institutionalized or were
students; and 3.3 percent were employed—
either full- or part-time. Further, nearly three
in five (59.6 percent) had not completed high
school.
• More than two-thirds of the women (67.1 percent)
were single mothers; fewer than 1 in 10
(9.4 percent) were married.
28

Population, Outreach, Referral, and Admission
Types of Drugs Used
• Crack cocaine was the primary drug of choice
for almost two-thirds (64.2 percent) of all
women clients. Among those who did not
report a primary problem with either cocaine
or crack, 18.5 percent acknowledged using
cocaine, and 11.6 percent had experimented
with crack.
• Alcohol was the next most frequently reported
primary drug of choice—by 11.7 percent of
the women, although more than one-half
(51.5 percent) of the women claimed to be
drinkers.
• Cocaine, stimulants (including methamphetamines
and amphetamines), and heroin were
the next three primary drugs—reported by
8.2, 5.9, and 4.5 percent of the women,
respectively.
• Nearly 40 percent of these clients used marijuana
in addition to other drugs.
• More than three-quarters (77.1 percent) used
nicotine more than five times in the 30 days
just prior to admission to this project—a
particularly important factor, given the
associations between prenatal smoking
and birth outcomes and between parental
smoking and childhood asthma and other
bronchial illnesses.
Involvement With the Criminal Justice
System or Child Protective Services
• At admission, about two-fifths (41.3 percent)
of the women were currently involved with the
CJS and almost one-half (49.7 percent) had a
criminal record.
• Nearly one in four (22.6 percent) had a record
of formal government action resulting from a
finding of child abuse or neglect.
Physical and Mental Health Status
• Almost four in five (79.4 percent) of the
women had received previous treatment for
substance abuse.
• Almost one-third (31.8 percent) of the women
had a physical health problem, and nearly two
in five (39 percent) had a co-occurring mental
illness—primarily depression (21.1 percent)
or an anxiety disorder (9.3 percent).
• More than half of the women (55.5 percent)
reported being victims of some type of abuse.
Of this group, 60 percent were victims of sexual
abuse, and 23 percent were victims of
incest. Less than one-quarter of these victims
(22.5 percent) had received any previous
counseling for their abuse.
• At admission, 2 of 10 women (20 percent)
were pregnant. Of the 232 women entering
treatment while pregnant, close to 80 percent
did so during the second or third trimester
(40.5 percent in the second, 37.5 percent in
the third), wheras slightly more than 20 percent
(21.9 percent) entered during their first
trimester.
Children in Residence With Their
Mothers (QRS Data: N = 1,113)
• The children in residence with their mothers
were evenly divided between boys and girls.
• Nearly one-third (32.9 percent) were newborns
or toddlers up to 2 years old.
• Although the racial/ethnic characteristics of
these children reflected those of their mothers,
6 percent were identified as multiracial.
• Just prior to admission, more than three in
five (61.5 percent) of the children were living
with their mothers; 14.6 percent with grandparents;
12.6 percent with relatives other
than their fathers; and 6.1 percent with their
fathers. Given this data, it would seem that
less than 6 percent of the children were living
in foster care.
• Exposure to drugs or alcohol during their
mother’s pregnancy was reported to have
occurred for nearly two-thirds (63.1 percent)
of the children.
Trends in Client Characteristics
Several grantees commented that the women
entering treatment had more serious problems
than initially anticipated and that the level of burden
borne by this population seemed to increase
29

Chapter III
over the course of the projects—requiring additions
and modifications to planned programming
as well as changes in staffing patterns.
As time went on, the population of women and
children coming to Meta House changed. [They]
appear to be more traumatized . . . [as] it has
become more and more difficult to meet the basic
needs of survival in our community. . . . Fewer
services are available that
address education, nurturance,
and other skills that help build
stability for the future. Women
are receiving less primary
treatment prior to entering
Meta House . . . [with] the
result that some may still be
toxic [at admission]. They
may have little understanding
about the commitment they will
need to make toward the
recovery process. There is
also a higher incidence of diagnosable
mental health problems
among the women. . . . As a
result of the 1986 crack influx
into Milwaukee, the children
coming to us have been
exposed to years of parental
neglect . . . [with the] result
that [they] are exhibiting more emotional and
developmental problems and increased antisocial
behavior and are less likely to have received wellbaby
care. (Meta House)
We are seeing much more severely impaired
women being admitted to the program. The
women are being referred through the departments
of health and rehabilitation services and
corrections and have had multiple failed treatment
experiences, severe histories of [physical
and sexual] abuse, and children who have been
in the foster care system for 5 to 7 years. These
children’s behaviors are representative of children
who are emotionally disturbed and have, themselves,
histories of abuse and neglect. We are also
seeing more severe neglect of the children’s health
and hygiene. We are not adequately equipped to
deal with many of the needs of the older children.
“The women are being
referred through the
departments of health
. . . and corrections and
have had multiple failed
treatment experiences,
severe histories of
[physical and sexual]
abuse, and children who
have been in the foster
care system for
5 to 7 years.”
(FIT)
. . . Many of the mothers are dually diagnosed,
more are coming into treatment on medication, and
many have borderline intelligence and substance
abuse histories beginning at 6 to 10 years of age.
Additionally, at admission, these mothers lack parenting
skills and motivation to change these behaviors.
[They] also appear to have a tremendous
sense of entitlement. . . . This is a much more difficult
population to treat, to motivate to remain in
treatment, and to teach effective
parenting techniques [to use]
with their children. We are
experimenting with new methods
of intervention that are
much more concrete. (FIT)
Several plausible explanations
were offered by one of the
grantees for a notable trend
toward identifying multiple
serious treatment needs
among the women and children.
New admissions appear to be
more traumatized and troubled
over time, not because the
referral sources have changed
but because of the following:
• Localities have
developed a broader continuum of care for
substance abuse and ordained that placement
criteria be followed in referring clients
to appropriate treatment. Hence, residential
facilities are now serving a population with
multiple, serious, and difficult-to-ameliorate
problems that is truly in need of intensive
treatment, rather than the worried drinkers
and abusers of other drugs who [were former
residents, although they] might have
made it in AA or other self-help programs.
• The onset of addiction now occurs at a much
younger age (8 to 9 years old) than in the
1970s–80s when it was about 18 to 21 years
old. As a result, today’s drug abusers have
developed fewer skills and have more arrested
development than was true 20 years ago.
30

Population, Outreach, Referral, and Admission
• Residential programs are now seeing the second
or third generation of violence, incest,
sexual abuse, neglect, and addiction in families.
[These problems] are even more traumatizing
and difficult to handle [than they
were for the grandmothers
and mothers].
Because this generation of
mothers had no role models
for appropriate behavior,
they have almost no
skills and deteriorate even
faster. Women are also
entering the CJS at
greater rates. (PAR
Village)
State and local laws also have
affected the numbers and types of women referred
to treatment for substance abuse.
New laws in California assume that parents
under the influence of alcohol and other drugs are
endangering minor children who can be taken
away and placed in foster care by the Department
of Child and Family Services. Our program is
getting more and more referrals from this source.
(Watts)
In our State, women who fail treatment more than
once have their parental rights terminated, so
there’s been a huge need for us to bring women in
with their children, not only to help women learn
recovery, but also to learn parenting skills.
(Chrysalis)
Table III-1 displays the general
client characteristics
across each of the 11 grantee
programs.
Outreach Activities
and Referral Sources
“Residential programs
are now seeing the second
or third generation
of violence, incest, sexual
abuse, neglect, and
addiction in families.”
(PAR Village)
“Outreach services may
be provided to a woman
for extended periods of
time (months) in order
to [make a] successful
referral.” (PROTOTYPES)
Grantees conducted outreach
activities, especially during
the early phases of program
development, to ensure a steady stream of referrals
into treatment. However, most of the projects
had, or soon developed, referral sources and referral
processes that resulted in more applicants than
could be admitted. Decisions then had to be
made about how to handle this overflow––whether
and how to maintain waiting
lists or refer these women
elsewhere for immediate care.
The grantees’ success in generating
larger-than-needed
numbers of appropriate referrals
seems to confirm the continuing
need for RWC programs.
[Our agency] has extensive
street . . . outreach services for
women. The outreach centers
are located in communities known for a high rate
of indigent drug-using women. These communities
often lack resources for providing treatment
services. Our outreach workers actively participate
in the community to identify women in need
of services, educate [them] regarding substance
abuse, advocate for care, and work to refer.
Outreach services may be provided to a woman
for extended periods of time (months) in order to
[make a] successful referral. The agency also
works closely with the network of [substance
abuse treatment] service providers and with the
CJS to identify women in need of and ready for
[our residential treatment] services. Finally,
print and electronic media are occasionally used
to inform the community of the services available.
(PROTOTYPES)
[Minority clients] were recruited
by flyers to potential referral
sources (e.g., Maricopa County
Tribal Social Services). Flyers
[about our program] generated
referrals from eight additional
sources, including Public
Defenders, Department of
Corrections, University Medical
Center Social Services,
Metropolitan Ministries, Urban
League, and private attorneys. [Additionally, we
31

Chapter III
Table III-1. Client Characteristics
32

Population, Outreach, Referral, and Admission
33

Chapter III
Table III-1. Client Characteristics (continued)
34

Population, Outreach, Referral, and Admission
35

Chapter III
Table III-1. Client Characteristics (continued)
36

Population, Outreach, Referral, and Admission
37

Chapter III
Table III-1. Client Characteristics (continued)
did] some cross-training with staff at CPS to
increase referrals. (Desert Willow)
The admissions coordinator . . . has scheduled
site visits for representatives from the more than
seven referral sources that have already contacted
IHW. These site visits will include the distribution
of admissions criteria and an overview of the
program design. The coordinator also met with a
probation officer . . . to discuss the IHW program
and appropriate referrals from the judicial system.
(IHW)
Between February 1, 1993, when the automated
telephone screening system was instituted, and
March 1997, PROTOTYPES received 2,567 calls
from [prospective] clients . . . who answered
questions that take between 5 and 15 minutes
. . . 25 percent of the referrals were from the client
herself or a family member, 19 percent
. . . were referred by another substance abuse
program, 20 percent . . . by the CJS or the courts,
and 15 percent . . . by the Department
of Social Services. Three-fourths (75 percent) of
the women screened were not admitted into treatment.
The most frequently cited reason for not
admitting a client was that she did not show up
for the initial interview. One-quarter (25 percent)
of the callers were admitted to treatment—13 percent
of these entered the residential program.
(PROTOTYPES)
Waiting Lists
A few of the grantees maintained waiting lists and
offered support and other services to these
women; most sites referred them to other
providers for more immediate assistance.
While a woman is on our waiting list, we have
developed a system to provide her with support
and to monitor her motivation. First, we make a
referral to an interim support service (i.e., outpatient).
In addition, we require that she call in
weekly to let us know how she is doing.
(Meta House)
38

Population, Outreach, Referral, and Admission
Women who are waiting for services at PAR
Village are contacted by admissions staff
weekly. Women who are not
incarcerated and living in the
community are linked with outpatient
or day treatment services
and case management while they
wait for residential services.
(PAR Village)
Sometimes a waiting list is maintained
for [applicants] who do
not meet the criteria for priority
admission. . . . While on the waiting
list, women must maintain
contact with intake staff and participate
in efforts to begin treatment for sobriety.
This usually increases attendance at a 12-Step or
other support group meeting. (PROTOTYPES)
. . . The project has remained at full capacity with
an average waiting list of 10 women. (Desert
Willow)
Referral Sources
When queried about major referral sources, almost
all of the grantees mentioned four primary categories:
courts, child protective or family welfare
services, substance abuse treatment providers, and
prenatal or perinatal medical facilities. Although
most of the grantees did not report or estimate
the percentages of residents coming from each
“While a woman is
on our waiting list,
we have developed a
system to provide
her with support
and to monitor her
motivation.”
(Meta House)
source, departments of family
and child services or CPS were
mentioned as a major source by
seven grantees, and CJS components
(e.g., probation, courts)
were named as a primary
source by six projects. Three of
the sites specified central
intakes, and another named the
Alcohol and Drug Commission
as the major referral source.
Three additional grantees listed
substance abuse treatment
providers as sources for 13 to
20 percent of referrals.
Perinatal units or obstetrical services and hospitals
were mentioned as referral sources by three
grantees. This was the only type of referral source
used by the FIT program, which
admitted only pregnant or perinatal
women. All women who
enrolled in Casa Rita already had
qualified for New York City’s
homeless shelter program.
Other community and self-referrals
also were reported by several
grantees.
From the data provided and the
discussions with the grantees, it
appears that the trend is toward
more referrals from agencies
with authority to mandate treatment as a condition
of continuing or restoring child custody or in
lieu of more punitive criminal sanctions.
Client Flow Issues
. . . the trend is toward
more referrals from
agencies with authority
to mandate treatment
as a condition of
continuing or restoring
child custody or in lieu
of more punitive
criminal sanctions.
Over the course of these projects, intake was
stopped or delayed at several sites for various reasons.
The major problem at all facilities was that
they were operating at or near their stated capacity
in terms of bed space and staffing arrangements.
Space was further restricted at one location
by a Florida law prohibiting two children of
the opposite sex from sharing a bedroom—even if
they were siblings. This meant that same-sex children
from different families sometimes had to
sleep together in the same bedroom
at PAR Village. At GAPP,
there was only room for six
infants at any one time; when
these beds were occupied, an
applicant with a baby might
have to wait until space
became available or be referred
elsewhere.
A reason to delay admission for
the Meta House program was
Wisconsin’s requirement that
clients entering residential
treatment be certified as free
of communicable disease
before admission. In other States, facilities were
39

Chapter III
allowed a short period after admission to conduct
physical examinations of the women and children
and determine whether the children had all their
immunizations.
When women had no primary physician or had
inadequate medical records, contractual medical
services or staff doctors conducted the intake
examinations. Some creative solutions, using
retroactive billing, had to be devised at some sites
to secure the needed physicals on a timely basis.
The major reason that prevents referrals to the
program is that we are always at capacity. The
other major . . . [delay in] admissions is that [the
women] do not have the necessary paperwork. . .
. State regulations require that medical personnel
obtain a complete psychosocial history, conduct a
physical examination, and provide a statement
that the applicant is free of communicable disease
before any admission to a residential program.
While these [women] are trying to get the paperwork
from the referring agency, we advocate for
them . . . to facilitate the process. (Meta House)
The major obstacle to maintaining the expected
utilization rate . . . involved admission delays
[because] a Department of Health and
Environmental Control (DHEC) standard requires
a history and physical within 30 days prior to
admission. . . . Physicians were also refusing to
see patients who did not have Medicaid coverage,
but [we] could not take steps to activate this until
after admission. . . . An agreement was finally
reached to resolve this issue. The Chrysalis
physician now performs a history and physical
before admission. When the new resident’s
Medicaid becomes active, the fee is billed retroactively.
This seems to be an effective solution.
(Chrysalis)
At FIT, intake was closed during an outbreak
of chicken pox among the children that could have
endangered other pregnant women or adults with
HIV infection who had compromised immune systems.
[One] significant barrier to admissions occurred
when [there were] outbreaks of contagious illness,
specifically, chicken pox, among the children.
Because this outbreak persisted over a period of
months as new cases developed, and because FIT
is in physical proximity to the rest of [the
agency’s] adult services, admissions of all pregnant
women, children, and other immunocompromised
adults were stopped immediately. . . .
Because some adults had never had, or didn’t
know whether they had been exposed to chickenpox—or
whether they were pregnant or immunocompromised—we
subsequently renewed admissions
for adults who could prove they were antibody
positive for the [chicken pox] virus. To
facilitate this, the agency, in conjunction with the
health department, arranged testing for program
applicants. A total of four cases of chicken pox
were reported and all remained among the children.
Nonetheless, this outbreak affected not only
admissions but the daycare and clinical staff at
FIT, mothers, visitation of outside family members
and other agency personnel that work with The
Village, and the immediate reunification of two
mothers with their newborns. Offsite activities
for the children were severely curtailed. Care for
the children who were infected with chicken pox
was provided by the mothers and selected daycare
staff who were not at risk of infection. . . .
The school-aged children were allowed to attend
school as long as they did not have an active
case. In sum, the program had to operate at less
than capacity throughout the outbreak, placing
prospective mothers and children who had not
been previously exposed to the virus on the waiting
list. (FIT)
All grantees had to plan for a program shutdown
at the end of the fourth year of funding because
CSAT notified them that there would be insufficient
funds to continue the projects for the final,
fifth year. Although this problem was averted at
the last minute by Congressional language requiring
that they be funded, most of the programs had
laid off some of their staff and had limited client
intakes. This disruption affected program continuity
and development. It negatively affected
some clients’ behaviors when only a few experienced
peers remained in the program to model
appropriate ways of community living.
Another critical event in the program’s history
was the threat of funding discontinuation by
CSAT after Year 4. . . This imminent danger
40

Population, Outreach, Referral, and Admission
caused anxiety among both staff and participants,
leading to staff resignations and reductions in
intake. . . . [One-]half of the staff and [one-]half of
the families actually left the program during the 6
months of uncertainty. The effect was to create
two different RWC programs and to destroy the
natural evolution of the program. . . . FIT essentially
had to start all over in FY05 with inexperienced
staff and a rapid influx of new patients.
The potential threat of shut-down also destroyed
the balance of old-to-new patients and role modeling,
resulting in an increase of behavioral incidents
and discharges against medical advice
among the residents. (FIT)
Admission Criteria
Aside from the project-specific criteria already
mentioned (e.g., homelessness at Casa Rita, pregnant
or postpartum at FIT), most of the grantees
adopted similar admission criteria for women with
respect to age limitations, capabilities for functioning,
and medical/psychiatric health. That is,
they accepted adult childbearing-age women,
usually 18 to 45 years of age or older, who could
function successfully in the project and understand
and comply with the rules. They uniformly
rejected (and referred elsewhere) women who were
actively psychotic, too physically ill to participate
or in need of
constant medical care, or too intellectually challenged
to understand the program.
This was done on a
case-by-case basis, and the
decisions largely rested with
the individual projects. The
admission criteria pertaining
to several other factors,
including priorities for enrollment,
geographic source, medications,
and need for detoxification,
varied more by site.
Criteria for Women
Priorities for admission were explicitly mentioned
by only two of the sites.
. . . most of the grantees
adopted similar
admission criteria for
women with respect to
age limitations, capabilities
for functioning,
and medical/
psychiatric health.
Women who are pregnant, intravenous drug
users, and those infected with HIV are given priority
for admission. (PAR Village)
Priority is given to pregnant women, HIV positive
women, and homeless women. (PROTOTYPES)
Geographic Source
While many of the grantees restricted admissions
to women who lived in a defined geographic area
(e.g., county) close to the facility—with homes
and families nearby—several accepted women
from anywhere in the State or from anywhere in
the country. Desert Willow, for example, not only
admitted women from Arizona but had a few residents
from California and would accept women
from anywhere in the country. Chrysalis accepted
women from anywhere in Georgia; PAR Village
accepted any resident of Florida, but in practice,
most women came from the Tampa–St.
Petersburg– Clearwater area. Flowering Tree
admitted women from all over the country: 60 percent
of the residents came from out of State.
Since the tribe requires that Sioux children in
non-Indian foster care placements be returned to
the jurisdiction of the Oglala Sioux and placed
with families on the reservation, many admissions
to the residential treatment program involve Sioux
children who were under the custody of departments
of child and family services in States other
than South Dakota.
Detoxification
Because the majority of
women admitted to the original
11 RWC programs had a
primary problem with cocaine
or crack, medically supervised
detoxification was seldom necessary.
Many of the sites had
nursing staff who could determine
whether women with
alcohol problems or, in a very
few cases, heroin dependence
needed detoxification before
entering residential care. Most of the grantees
had arrangements with offsite facilities that would
detoxify women. Flowering Tree sent women who
41

Chapter III
needed alcohol detoxification to Nebraska for a
15-day inpatient program.
Since resources for detoxification are so limited in
Atlanta, we did accept women, even those with
primary alcoholism, who needed this care.
(GAPP)
Although we used to require that women be drugfree
for 5 days before admission, we now admit
active drug users. The nurse evaluates whether
they need detoxification for alcohol and refers
them, if necessary. (IHW)
may be prescribed psychotropic medications.
(PAR Village)
Candidates who are violent, suicidal, or dangerous
to themselves or others will not be considered
for admission. Women and children selected for
admission who have experienced a recent psychotic
episode or severe depression must be evaluated
by a psychiatrist. Residents must be physically
and mentally able to participate in scheduled
rehabilitative and therapeutic activities that are
part of the . . . program. (IHW)
Co-Occurring Mental Illness
Grantees found it necessary to screen women for
co-occurring mental illness and to examine their
preparedness to handle these problems. While
some sites had contractual arrangements with psychologists/psychiatrists
or
staff who could adequately
assess and care for clients
with psychiatric diagnoses,
others acknowledged difficulties
and challenges.
Dual diagnosis is tough to
screen. We ask, ‘Is this someone
we can handle in our center?’
Unfortunately, we’ve had to discharge some
women or find a different program for them.
(Desert Willow)
We’ve learned through trial and error what we
can handle. We had one woman who came in
with a dual diagnosis. She’d been in jail. She
was not only addicted to drugs and alcohol, but
she also had a schizophrenic diagnosis. She had
a baby less than 1 month old. She was so paranoid
that she knew everyone in the building
was trying to sexually molest her child. We
couldn’t deal with her; we weren’t set up to handle
that type of diagnosis. (Chrysalis)
Women in treatment can’t be incapacitated by
psychosis, but [one-]third or more of the women
we admit have dual or multiple psychiatric diagnoses
in addition to substance dependence and
“. . . [one-]third or more
of the women we admit
have dual or multiple psychiatric
diagnoses . . . “
(PAR Village)
Prescription Medications
Two projects initially resisted admitting women
who were prescribed psychotropic medications,
finding that heavy medication use in early treatment
had a negative impact.
They’re on so much medication,
they can’t function. They
can’t stay awake through a
group, meet their time requirements,
participate in the community,
or be a part of the
community. (Chrysalis)
This site ultimately contracted
with a physician who specialized
in addictions to examine women and reassess
their medications so that they could fully participate
in and benefit from treatment.
Another grantee initially decided that its treatment
model precluded accepting women on psychotropic
medications but later revisited the issue
and admitted women on antidepressants if they
were stabilized and functional.
We’re a therapeutic community and do not have
the resources to care for people on medications
such as Prozac. (Desert Willow)
The grantees uniformly agreed that a well-stabilized
woman taking medications for her psychiatric
disorder(s) could participate in and benefit
from the residential program. Most made arrangements
to have nursing staff onsite who could
administer these medications as well as others for
42

Population, Outreach, Referral, and Admission
diabetes, hypertension, or common medical illnesses.
Psychotropic medications prescribed by a physician
were mostly acceptable, but the program did
not accept women on medications for manic
depression. Most of the women voluntarily went
off psychotropic medications while in treatment.
They could, however, be taking iso nicotine
hydrazine for tuberculosis. (Flowering Tree)
If a woman with a psychiatric diagnosis can be
stabilized on medications and participate in the
program, we will admit her. We work with a
number of other facilities to get women stabilized
so we can admit them. (GAPP)
We accept women who have prescriptions for psychotropic
medications for depression and other
psychiatric disorders, but no one on methadone.
(Casa Rita)
We do administer medications and have lots of
clients on psychotropics for psychiatric diagnoses.
(IHW)
Physical Disabilities
All the grantees were willing to admit women and
children with physical limitations or medical problems
if the facility could accommodate them and
they were not too sick to participate in the program
without putting too much of a strain on staff
resources.
We accepted two hearing-impaired women and
arranged for sign language interpreters so they
could benefit from the program. Mostly, we don’t
take women who need constant medical supervision.
(Desert Willow)
We had to turn away one woman with AIDS
whose medical problems couldn’t be managed in
the facility. (GAPP)
Women must be able to get out of the facility unassisted
for us to admit them. (Meta House)
Women . . . with severe handicaps or medical
problems that would interfere with participation
in the program may not be admitted. Criteria for
denial include (1) inability to perform chores, (2)
inability to provide self-care, or (3) necessity for
continuous emergency medical attention for nondrug-related
illnesses. (IHW)
Medical Screening To Rule Out
Communicable Diseases
Although only one site (Meta House) reported
ongoing delays in admissions because of difficulties
in obtaining necessary documentation that
applicants were free of communicable disease,
other grantees had to augment their medical staff
or make special contractual arrangements with
physicians so that physical and laboratory examinations
could be conducted promptly before or
during the admission process. All were concerned
that women be tested for tuberculosis, hepatitis,
and HIV status. Some States also required a
physician’s confirmation of substance dependence/addiction.
In one center, initial intake and
screening forms were revised to ensure that all
essential medical history data were obtained,
including HIV status if a woman entering treatment
knew she was HIV positive.
Intellectual Functioning
Although intelligence quotient (IQ) level was not
a specified criterion for admission, several
grantees noted an increase in the number of
women entering treatment who were illiterate.
PAR Village found that 43 percent of women residents
had below-average scores on the Kaufman
Brief Intelligence Test at admission.
Several women at Chrysalis suffered from alcoholrelated
disabilities that negatively affected intelligence.
As already noted, many of the women who
had graduated from high school functioned at a
much lower grade level in terms of literacy and
other academic skills. Those with even less formal
education—more than one-half the admissions in
most sites—were even less well equipped to understand
written materials or instructions. The low
levels of intellectual functioning affected the programming
that could be used and the vocational
training that could be offered. One program (FIT)
simplified its written materials and made its edu-
43

Chapter III
cational program more concrete to accommodate
this finding.
[IQ level] has raised a lot of questions about who
can benefit from treatment programs and who we
can work with. (Meta House)
Some of the treatment terminology is way over
their heads. It takes a lot of effort on the part of
the staff and requires more time on a one-to-one
basis to deliver the services. When you do an
intake, there are certain things you assume and
you think that everybody fits like a peg.
(Flowering Tree)
A number of adult residents have signs and symptoms
of FAS or related birth defects. The therapeutic
approach, as a result, must be more concrete,
more directive, and more repetitious than
that originally implemented. Basic skills for life
functioning and parenting need to be the focus of
the life skills training curriculum,
and more individualized
treatment planning must be
developed to avoid disrupting
the overall community milieu.
(Chrysalis)
Motivation for Treatment
Another less objective criterion
for admission to some of the projects was motivation,
including attitudes toward residential care
and a willingness to follow rules and cooperate
with other women
and their families. Some of the grantees initially
assumed that women with young children would
be motivated by a concern for their welfare and a
desire to have custodial rights continued or
restored. The degree to which external motivation—by
the courts or child protective agencies—
influenced women’s entrance into and success in
treatment was a debatable issue among the
grantees.
The fact that women come into treatment
"because of their children" is absolutely not a
deterrent or predictor of negative outcomes.
However, it is also the case that some women
have no bond or attachment to their children
“A number of adult
residents have signs and
symptoms of FAS or
related birth defects.”
(Chrysalis)
whatsoever and, therefore, the children provide little
motivation for treatment. Identifying when this
is the case has been important to a better assessment
of what the women’s motivation is based
on. Obviously, understanding motivational factors
is a key clinical issue that requires staff training
and supervision to prevent angry reactions
when a women doesn’t display motivation based
on her children.
(Meta House)
While children are a motivating factor, they will
not always keep a woman in recovery if she has
not made a commitment to change. Other motivating
factors include the impact of having CPS
being actively involved in the cases. The stigma
and grief involved in losing custody of their children
will make potential clients seek treatment.
Another motivating factor is the influence of the
CJS. (GAPP)
Women who come into treatment
"because of their children"
are not usually successful in
completing the program.
Women who are court-ordered
to complete treatment as a
requirement to have their
parental rights restored to them
are not always successful.
Most of the women who enter treatment at
Flowering Tree had a desire to quit, as well as
being court-ordered or being threatened with permanent
loss of parental rights. This is secondary
to why they remained in treatment. (Flowering
Tree)
Child custody issues and criminal justice issues
are the key determining factors that bring women
into residential treatment at PAR Village. The
majority of women who enter treatment are
referred by the Florida Department of Children
and Families and the Florida Department of
Corrections (FDC). The increase of women being
referred by FDC is partly due to recent changes in
criminal justice policy and growing public intolerance.
The war on drugs has resulted in much
stiffer crime policies, and now women are incarcerated
for all crimes, especially crimes involving
drugs. Mandatory sentencing laws require the
44

Population, Outreach, Referral, and Admission
women to serve longer terms behind bars and
complete the last year of their sentence in a residential
treatment setting. (PAR Village)
Verification of Admission Criteria
In several instances, grantees came into conflict
with community agencies that wanted to refer
women who did not meet the established admissions
criteria of the program. FIT, for example,
was funded to serve pregnant and postpartum
women. When a local university hospital wanted
to refer women who had young children but were
not pregnant or postpartum, the project had to
explain the admissions criteria to pediatricians as
well as to their own evaluators.
During the first few years of CSAT funding, Desert
Willow also limited admissions to pregnant and
postpartum women. This site learned from experience
that it was essential to administer a pregnancy
test to women claiming eligibility on this basis.
We’ve had situations where the women lied to us
and told us they were pregnant. They were desperate.
Now we do pregnancy tests before bringing
them onto the property. (Desert Willow)
Criteria for Children
The fundamental assumption of these innovative
projects was that allowing children to be in residential
substance abuse treatment programs with
their mothers was worthwhile for a number of
reasons that could be objectively studied and verified.
Treating children with their mothers was
expected to achieve the following:
• Encourage women to enter treatment, especially
if they might otherwise lose custody of
their children, fear that their offspring would
be abused by others, feel shame and guilt
about being a neglectful or abusive parent,
or accept primary responsibility for the
children’s well-being
• Prompt women to remain in treatment longer
and to complete the program because they
are not worried about the whereabouts and
welfare of their children
• Facilitate the identification and reduction of
children’s medical, psychological, cognitive,
and developmental problems
• Assist women, through guided observation of
their children’s activities and emotional reactions,
to remember and reveal their own childhood
traumas and to work through these
intrusive and continuing issues
• Assist pregnant women to give birth to healthier,
drug-free babies and to form a strong
bond with these newborns under the tutelage
of project staff
• Provide assessments of mother-child relationships,
improve the mothers’ parenting skills,
and lower the stressors associated with
motherhood that can contribute to relapse
• Improve the overall functioning of the women
for leading a productive lifestyle that includes
providing an emotionally and physically
adequate environment for raising children
• Help reunify mothers with their children,
especially when the children have been in
foster care placements, and also promote reconciliation
with significant others and family
members who can provide positive support
• Interrupt the intergenerational cycle or
transmission of substance abuse with its
correlates of familial violence and child abuse
and neglect.
Restrictions on the Age, Number, and
Gender of Children Admitted to the
Residence
Despite these strong convictions about the multiple
benefits of allowing children to live with their
mothers in residential treatment facilities, all the
grantees set limits—for practical reasons—on the
ages and numbers of children who could be admitted.
Serving women and children together both
takes more time and complicates treatment, espe-
45

Chapter III
cially when the needs of the mothers and children
are disparate and are emotionally divisive for staff.
The grantees found, through experience, that
mothers, especially those who had not been living
with their children or who had neglected them
while engaged in substance abuse, were so overwhelmed
by parental responsibilities that they
could not focus on their own recovery. This was
even more of an issue with older children who
were angry with their mothers and resented living
in an institutional setting. Because of the intense
needs of these children, mothers of several youngsters
had difficulty responding to their children’s
multiple needs and simply could not cope. The
grantees made provisions to have older children
and siblings who were not in residence visit their
mothers on weekends—or for longer periods during
vacations (see Chapter VI, Special Services for
Children).
Table III-2 displays the restrictions set by the
grantees on the number of children each mother
could have living with her in the residence and
additional age limitations. As discussed in a later
section, a few projects also delayed admission of
the children until the mother was considered stable
or until permission could be obtained for
release from CPS that had official custody and
responsibility for many of the children.
The reasons given by the grantees for these age
and number restrictions were similar.
Three children seems to be the upper limit in
terms of reasonable expectations of a mother in
treatment. Limiting the ages to 10 years old
seems to work well. Children older than 10 may
be physically developed to the point of being seen
as young adults. This has caused problems with
older boys in that some women react in a sexually
provocative manner toward boys. Problems
with older girls have typically been seen with
women involving girls in their adult peer group
with inappropriate boundaries for the child.
(Meta House)
It is difficult for mothers to adjust to residential
treatment by themselves, and there is an added
burden when [they are] caring for children. We
recommend that a mother not have more than
three children with her, and that the age for boys
be limited to 12 years and under. (Casa Rita)
We have found that there needs to be a realistic
age limitation and restriction on the number of
children that a mother has in the program. Childrearing
without an addiction can be overwhelming.
It is important that the mother therapeutically
process these issues. The goal of regaining custody
of the children is not the same as being capable
of parenting four children without adequate
support. (GAPP)
Table III-2. Number/Age Restrictions and Timing for Admission of Children
Grantee Number Restriction Age Restriction Timing for Admission
Casa Rita
Up to three, mostly two; limit depends on
age
Boys to age 13, any age girls
Children required to enter with their mother
Chrysalis Up to two 10 years and younger Most children admitted with their mother
Desert Willow Up to two, with exceptions 8 years and younger Case-by-case decision based on what is best for
the family
FIT
No limit on numbers; usually under six
per family
No exclusion
Most entered with their mother; 30- to 45-day
delay for foster care
Flowering Tree Up to four 10 years and younger 30- to 90-day delay if not living with mother
GAPP Up to three, with exceptions 10 years and younger Case-by-case decision; only a few were admitted
with their mother
IHW Up to three, with exceptions 12 years and younger Most entered with their mother; 30-day delay if
under CPS supervision
Meta House Up to three 10 to 11 years and younger Most entered with their mother; unspecified delay
if under CPS supervision
PAR Village Up to two, with exceptions 10 years and younger 30- to 45-day delay for all children
PROTOTYPES Unclear 12 years and younger Not specified; many only visited their mother
Watts Only the youngest child admitted 5 years and younger Most children were in foster care and had
admission delayed
46

Population, Outreach, Referral, and Admission
It is our experience that children in the residence
should be newborns to about 9 years old. After
that age, the child has probably been taking the
mother role with other siblings, and this can
cause a power struggle between the mother and
child. The mother is frequently unable to set limits
and boundaries due to her own
guilt and her lack of parenting skills. (Flowering
Tree)
Although our program allows mothers to bring up
to three children into treatment at any one time,
our experience has shown that this is a stressor
for the mothers. Women with one or two children
in treatment are more successful. Moreover,
mothers of younger children are also more successful.
In families with older children, the trauma
of the mothers’ substance abuse as well as
their having to live in "institutions" is very uncomfortable.
The children have difficulty adjusting to
the structured setting of the program, seldom have
many peers within the program to play with, and
are often angry with their mothers for forcing
them into this situation because of their substance
abuse. The older children are likely to present
with anger and behavioral problems. (IHW)
Children between the ages of birth and 10 years
may live with their mothers. The program
attempted to have older children live with their
mothers, but found that the children’s developmental
issues precluded successful integration
into the communal aspects of the residence.
(PROTOTYPES)
PAR Village serves children between birth and 10
years old. Women are allowed to bring two children
who meet this age restriction to live with
them. Older children are permitted to stay
overnight with their mothers on special occasions,
[but] are restricted from living in the residence
with their mothers because [our program] is not
equipped to handle adolescent issues. We try to
be flexible and make exceptions when necessary,
but the majority of children in the residence are 5
years old and younger. (PAR Village)
We discovered from our outcome data that we
could not handle more than two children for each
mother. Most of the mothers can’t handle all of
their children. (Watts) (This site later restricted
child admissions to only the youngest member of
the family.)
Timing of Children’s Admissions
Different opinions were held by these projects
about when children should be admitted to the
treatment facility. All agreed that this decision
should be made individually for each family. Only
one grantee (PAR Village) was adamant that
admission of almost all children should be delayed
for at least 30 to 60 days. This position was partially
inspired by the deaths of seven children in
Florida who should not have been released from
State supervision and returned to homes with
substance-abusing mothers. These tragedies
made the Department of Children and Families
reluctant to relinquish children from foster care
placements for even longer periods—until they
could be assured that the mothers were doing well
in treatment.
However, many projects apparently believed it was
better for the mother’s recovery if her children
delayed joining her for some time between 14 and
90 days, although they made decisions on a caseby-case
basis. This delay gave the mother time to
achieve physical stability and to begin her personal
therapy before having the distraction and responsibility
of caring for her children. This delay also
allowed staff more time to assess stability and any
co-occurring mental illness that might become
evident only after the mother was abstinent.
Some of the sites reported that having
children wait before joining their mothers
increased the mothers’ retention in treatment by
lowering her stress level at that crucial early
stage, a time when many women leave.
In addition, some grantees thought it better not
to uproot the children until the mother’s motivation
for treatment could be evaluated. In several
locations, the local child welfare agency itself
insisted that the mother be stabilized and demonstrate
motivation for treatment before their case
workers were willing to disrupt a foster care or relative
placement. In addition, it was important for
the children to have all of their immunizations, or
47

Chapter III
a record of them, before they could be admitted to
the treatment center.
All grantees agreed that there were times when
children should not have to wait before being
admitted with their mothers. Exceptions were
made for homeless families, infants who needed to
bond with their mothers, and older children who
might be put in foster care because there were no
acceptable childcare alternatives.
Women must first prove a commitment to treatment
and be considered emotionally and mentally
stable before counselors can reunite mothers with
their children. Reunification usually occurs following
60 days of treatment. However, all infants
and children needing emergency placement are
allowed to join their mothers immediately. As
soon as a mother is reunited with her children,
they seem to all move along together as a family.
(PAR Village)
It is vital for women entering treatment who have
not had custody of their children
for the past 6 months to
have a 90-day adjustment period
before the children join
[them]. If the family is reunited
earlier than that, the mother
and child(ren) will have a lot
of problems. (Flowering Tree)
While some sites thought it
beneficial to admit children
subsequent to admitting their
mothers, others admitted both
at the same time. Some
believed this was preferable
and found that women seemed
capable of having their children with them from
the start. Casa Rita insisted that children come
with their mothers into treatment.
“It is vital for women
entering treatment
who have not had
custody of their children
for the past 6 months
to have a 90-day
adjustment period before
the children join [them].”
(Flowering Tree)
To ease the transition for mothers and children
who entered treatment at the same time, one site
added a pretreatment phase during which the
schedule was not as rigid. This allowed women to
spend time with their children while adjusting to
their new surroundings. Unfortunately, this practice
was discontinued because of pressures from
managed care to shorten the treatment period.
Children With Behavioral Problems
Grantees faced many challenges in deciding
whether children with behavioral problems should
be excluded from entering treatment with their
mothers.
We’ve had a heck of a time dealing with some of
the children. We have criteria that allow children
up to the age of 11 to enter treatment with their
mothers. We’ve had some children who were
very, very difficult to deal with. A major problem
with the older children was anger
control. They were violent and frightened even
the staff. (Meta House)
We would exclude a child who is a known arsonist.
(IHW)
It was not always possible to screen extremely violent
children before admission. Some needed a
longer period of time for
observation. If a child’s behavior
problems were impossible
to manage, referrals were
made to more qualified
resources. The sites provided
support for the mothers
through this painful process.
The need to improve the initial
assessment of children was
another learning experience.
It became necessary to hire
more highly skilled staff for
both the assessment process
and for night and weekend shifts. One center
screened children by having them visit before
admission.
We try to have children visit on weekends before
they move in, and [we] really observe the child
playing and the mother interacting with the child.
(PROTOTYPES)
48

Population, Outreach, Referral, and Admission
Questions About Having Children
in Residence and Family
Reunification
With experience, several of the grantees began to
question whether having children in residence
with mothers or aiming toward restored custody
and family reunification was always in the best
interest of either the mother or child.
Through trial and error, we’ve learned that moms
and kids may not always need to be together.
We’re doing a disservice to those kids if we don’t
know whether mom is going to make it, especially
if we’re her sixth place for treatment. (Chrysalis)
Simply put, there are some women who would do
much, much better if they were not given the
responsibility of [being] parents.
(PAR Village)
Staff had to learn how to
accept the fact that not all of
the women were cut out to be
or wanted to be "good mothers."
They had to learn how to
accept diversity and reconcile
differences between wanting
the women to have more time
for themselves and their recovery
without parenting responsibilities
and wanting them to be
super moms. It was often difficult
to integrate these diverse
points of view, but controversy
was allowed to surface and be
worked through. (GAPP)
At the Philadelphia site, women had a choice
between entering a residential facility with their
children (IHW) or without them (Interim House
[IH]). Focus groups were conducted with clients
to evaluate women’s motivation and reasoning
for entering treatment and, specifically, how
having young children influenced the decisionmaking
process regarding treatment enrollment and
retention.
“[Staff] had to learn how
to accept diversity and
reconcile differences
between wanting the
women to have more
time for themselves and
their recovery without
parenting responsibilities
and wanting them to be
super moms.” (GAPP)
Many women at IHW expressed guilt about leaving
their children with friends or relatives or in foster
care.
I don’t want my mom to be all boggled down. I
mean, she lived her life and she raised us and
now I’m gonna leave mine on her. That’s one of
the reasons why I looked for a place that took children.
My major motivation was not to lose my last
baby. My family has custody of three of my kids
and they didn’t want my last baby.
I put them [the children] through a whole lot too,
not takin’ ‘em to school, not keepin’ up with their
clinic appointments, and lack of takin’ care of
them. So I wanted them with me. For them [to]
learn and understand my rehab problems, I [am]
coming in here to help myself . . ., and for them to
get help too.
I feel bad about having to bring
my kids here, but it also gives
me a chance to learn my kids
and for my kids to learn me.
Makes me know this is not
something that I want to do
again.
By contrast, women at IH were
very clear about not wanting
to bring their children into
treatment with them.
The first time when I went into
rehab I wanted my children
with me. . . . That was one of
the reasons why I left. This time around I found
out that it would be better if I did some of my
recovery alone so that I can build a foundation
and then gradually work them [my children] into
my recovery program. It’s hard, I know I need to
build a foundation for me first if I’m gonna be any
good for them.
I was lookin’ for it for myself. She’s being taken
care of and so I have to take care of myself before
I can take care of her. When I leave here I’m goin’
to another facility and I’m not thinkin’ about
takin’ her with me.
49

Chapter III
I am thankful for my mother [who has the children]
because dealing with my children and my
recovery would be too much.
Once the women decided to enter treatment with
their children at IHW, they were torn between
wanting their children with them in treatment and
wanting to concentrate on their recovery. They
found out quickly that the demands of being a
consistent parent are very challenging. Many of
the families were being reunited after long
separations. The children as well as the mothers
required support during this transition.
Developing new, nonviolent parenting techniques,
testing limits, and building trust were all issues
that the mothers were trying to master while
maintaining sobriety and
learning a new way
of living.
I know for me when I first
came here I was glad my kids
was with me and then after the
fog lifted, oh my God, it was a
struggle because I didn’t realize
who these little kids were. I
hadn’t had them for so long . . .
some days are better than others
but they still give me a run
for my money besides trying to
get this thing of recovery so I
won’t go out and relapse . . . .
Some women who had older children expressed
their concerns regarding teenagers who were not
permitted to live at Interim House West because
they were over the age limit.
I wasn’t fully focused on being here because
I worried about her [my teen-aged daughter].
I didn’t feel whole.
It [has] been affecting me terrible. [My teen-age
daughter who can’t enter the program has] been a
part of my addiction, and she should be here with
me. She shouldn’t be excluded.
Although the clients reported difficulties coping
with children, the children represent a motivation
Developing new,
nonviolent parenting
techniques, testing
limits, and building trust
were all issues that the
mothers were trying to
master while maintaining
sobriety and learning
a new way of living.
to remain sober. The women were able to cite
improvements in their children’s behavior, school
performance, and emotional development. On
some level, the ability to see this progress in their
children served as an incentive for the mothers to
persist in their recovery program.
I came in here and my children really regressed
when I first came. It’s like now the difference in
my children, like my daughter she’s had surgery
on both her ears after I came here because I didn’t
even know she had a hearin’ problem. (IHW
client)
He was real insecure. Since I’ve been there for 10
months, he’s not as insecure. He’s willing to venture
off—before he used to be real clingy, now he
ventures off and he’ll come
back and I’ll still be here and
he’s happy. (IHW client)
My daughter was [doing] terribly
in school. She [could]
hardly read, and now [she’s]
makin’
C’s.. . . (IHW client)
The staff at IHW concluded
that substance-abusing
women’s personal and family
histories and coping skills are
varied and complicated, as are
the dilemmas they face when
entering drug treatment.
Thus, women need the option of taking
children into treatment with them and assistance
in determining whether that is the best choice.
The administration at PAR Village reached a similar
conclusion. Women in that program were
allowed to decide whether their children would
join them in treatment. Some women chose not
to bring their children into treatment because
they felt the children were in a safe, stable environment
and it was in the children’s best interest
to remain there. Other women felt they needed to
focus solely on their recovery. These women wanted
their children to remain in the community or
50

Population, Outreach, Referral, and Admission
have them visit regularly. Allowing women to
make these decisions fostered a healthy self-awareness
of personal needs and the development of
sound decisionmaking capabilities. Most of these
women had never had the opportunity to do this.
Some women would not have entered treatment if
they could not have had their children with them.
Others would have left the program prematurely
to meet their children’s needs. Regardless of the
decision, it was vital that counselors in the program
supported the women and set aside personal
opinions and beliefs.
51

IV. Facilities, Staffing, Staff
Training, and Retention Issues
A
s grantees planned and implemented their
programs, the settings they chose and the
staff they employed critically influenced the
services delivered and the client responses. Some
of the sites already had operational residential
facilities for women and children, wheras others
needed to confirm arrangements for space and
complete extensive renovations. Most of the projects
also needed to recruit, hire, and train all or
some additional staff. The staffing and facility
resources already available from the parent agencies
affected the types of staff and the amount of
space for services, child care, and recreation—as
well as housing—that needed to be added.
This chapter describes the various settings the
grantees selected for their programs, including
the impact of the locations and living arrangements
on staff and programming. Some of the
delays and frustrations encountered in renovating
facilities are also discussed. With respect to
employees, this chapter summarizes staffing patterns
at several sites, recruiting and hiring issues,
types of staff training provided, and problems
encountered in retaining staff.
Residential Facilities
Location
In describing their facilities, all the grantees
found more advantages than disadvantages to the
locations selected. At four sites (PAR Village,
Desert Willow, FIT, PROTOTYPES), residences are
situated on or near already-established treatment
sites of the parent agency that have extensive
recreational facilities and other services that could
be used by the women and children. Operation
PAR, for example, has 8 acres with 30 buildings on
its main campus, whereas the PROTOTYPES residential
facility is located on a 3.4-acre site that
formerly housed a Christian school program for
500 children and includes a large church building
that is used for conferences and meetings. The
PROTOTYPES site also features extensive recreational
space, with a recently added swimming
pool and gardens. All of the projects emphasized
the importance of a peaceful setting and homelike
surroundings for motivating the residents.
Our facility is located on a former dude ranch
outside the Tucson metropolitan area. The environment
provides a homelike atmosphere with
areas for privacy and community interaction.
Fountains, trees, and desert plants create a peaceful
setting, decorated with many symbols and art
works from the various cultural/ethnic groups
represented in the target population. (Desert
Willow)
[The Village South, the parent agency for FIT] is
within 20 blocks of . . . two of the most economically
depressed and crime ridden areas in [downtown
Miami]. Within this depressed neighborhood,
however, the Village sets an example of a
stately looking, well-kept center with lush gardens
and play and meditation areas, as well as a full
spectrum of recreational amenities (e.g., pools,
volleyball and tennis courts, gymnasium with
weight room). Most people who visit think this is
a private agency—in reality, the Village reflects a
philosophy that people who are treated well in
comfortable surroundings do better and have
more incentive to work toward a productive,
healthy lifestyle. (FIT)
In selecting location, the grantees had to consider
the needs of the children and the mothers. They
looked for nearby parks and schools, proximity to
53

Chapter IV
hospitals and health clinics, and access to public
transportation. These became assets that not only
made it possible for the women to get to appointments
and jobs in the later phases of care, but
encouraged visits by older children, family members,
and significant others. Meta House is particularly
proud that they were able to create a safe
and affordable treatment environment a few
blocks away from the inner-city, drug-affected
neighborhood where many of the women formerly
lived. IHW occupies a restored five-story, handicapped-accessible
Victorian mansion and a nearby
row house in a stable residential neighborhood
facing a very large urban park with many recreational
and cultural activities for residents.
Rehabilitation of the buildings was supported by
the Parkside Historic Preservation Corporation,
one of the grant partners.
Only three sites, Desert Willow, Chrysalis, and
Flowering Tree of the Lakota Sioux Reservation,
reported that they are not easily accessible by public
transportation, and this caused some programming
inconvenience and complaints by residents
about the lack of offsite activities.
Having locations not
close to collaborating agencies
and other places where many
of the residents had appointments
(e.g., offices of CPS,
adult probation, welfare, medical
clinics for women and
children) also meant that
more staff time was consumed
in transporting the residents
and supervising their attendance
at these engagements.
Although other grantees
expressed satisfaction with the
residences’ proximity to parks
and recreational facilities,
GAPP cited the lack of
grounds around their former
apartment house as a decided disadvantage that
caused residents to complain about feeling "too
confined"; the lack of green space for an outdoor
play area also prevented licensing of the childcare
center. Flowering Tree has only a big field outside
its second-floor facility in a former hospital.
Although the children walk through the downstairs
offices of other agencies and an ambulance
service to reach this play area, this "free space" is
suitable for the children’s exercise.
Selection of the facility and location was the
responsibility of the grantee, and several grantees
could only find facilities that were some distance
away from the parent agency. Some did not have
sufficient space to conduct all the desired services
for women (e.g., multiple group meetings) or to
provide appropriate onsite daycare for children. It
was not uncommon for administrative offices or
space for other treatment services to be located at
a separate site, several blocks away (e.g., Casa
Rita, Chrysalis, IHW, Watts, PAR Village).
Living Arrangements
Housing the families
in separate quarters
made it more difficult
for staff to supervise the
residents after daily
activities were finished,
but these arrangements
promoted normal,
family-style routines
for rising, eating
together, and putting
children to bed.
The facilities occupied by the grantees include an
old convent built for communal living (Meta
House), converted schools (Casa Rita, PROTO-
TYPES), renovated nursing or convalescent homes
(Chrysalis, Watts), apartment buildings (FIT,
GAPP), an Indian Health
Service (IHS) Hospital
(Flowering Tree), and multiple-family
residences (PAR
Village, Desert Willow, IHW).
The configuration of the living
space in the residences both
affected and reflected the
planned programming.
Almost all of the projects
chose apartment-style living
arrangements so women could
learn important skills such as
how to manage a home, cook,
clean, and safely care for their
children. PROTOTYPES, however,
found that the more traditional
dormitory setting
used in TCs facilitated better
monitoring and support of women and children by
both staff and peers; this was particularly helpful
in the early phases of treatment. IHW initially
planned to use a communal setting for women and
54

Facilities, Staffing, Staff Training, and Retention
children who were entering treatment, but the
facility selected for this purpose (next door to the
apartment-style residence) was never renovated.
Housing the families in separate quarters made it
more difficult for staff to supervise the residents
after daily activities were finished, but these
arrangements promoted normal, family-style routines
for rising, eating together, and putting children
to bed. Staff also were able to observe the
routines families established and provide needed
assistance in natural, not classroom,
environments.
In most of the residences, women and their children
had private bedrooms (sometimes sleeping
together in one room per family) but shared a
bath with another family and used larger communal
living, dining, kitchen, and laundry areas.
Several families might share the smaller houses,
with each mother and her children having one or
more private bedrooms. At PAR Village, where
State law prohibits opposite sex children from
sharing sleeping quarters, girls or boys of similar
ages from different families sometimes occupied
one bedroom while their mothers shared another.
Meta House never assigned more than two persons
per bedroom, but the occupants might be two
children, a mother and child, or two mothers.
Privacy and personal space seemed to be very
important to the clients. Several projects
(Flowering Tree, Watts, Casa Rita) reported that
the women took great pride in decorating their
own rooms and making them homelike.
We chose to locate in an old convent . . . [that
was] built for communal living. We are near the
central city, but not directly in it. We also established
the residence for women and
children in a neighborhood [that has] proved conducive
to helping mothers use neighborhood
resources for recreational purposes.
(Meta House)
Since the program was established on the reservation,
we were not required to have licensing by
the State. The program is situated in an old IHS
hospital where [we have] all the second floor. The
old rooms for patients are large enough to make
individual little homes for each client. The choice
rooms share a connecting bath; the others have
access to communal showers. (Flowering Tree)
With the commencement of this project for families,
an 18-unit apartment building was renovated
to provide single-family, one- and two-bedroom
efficiency apartments. Each woman resides with
her children in a unit consisting of a private bathroom,
two living areas, and a kitchen. Each
mother is completely responsible for the cleanliness
and upkeep of her family apartment.
Furniture for families, such as cribs and beds for
small children and dressers, was purchased.
Since this project allows a mother to bring all of
her minor children into her residence, the furniture
needed by each new family has to be determined
at admission. (FIT)
Finding a proper facility was an accomplishment.
Different physical layouts were tried, including
several apartment buildings. It took over a year
to find the current facility, which was then extensively
renovated and enlarged. In the current
facility, women and children live in large dormitory
rooms. We have found that dormitories provide
for closer monitoring of women and their
children, particularly in the earlier phases of treatment.
Women often need the added monitoring of
peers to help them control any impulses to use
harmful drugs or disobey rules. Another woman
in the dorm may work with the woman having
problems around parenting issues or may get a
counselor on duty to assist the mother. In addition
to the dormitory, there is a large communal
dining room, a large play area for the children,
and separate rooms for the children’s programming.
For security, only the front door is accessible
to visitors. It is locked and opened by a receptionist
who can identify the visitor before allowing
entrance. All other entrances are accessible only
by a key or electronic gate opener. The entire multiple-acre
site is surrounded by a high wall.
(PROTOTYPES)
PAR Village . . . consists of 14 houses that are separated
from the main grounds of the original TC
by a small pond and a short walk. Seven of the
houses have been renovated for women who have
children with them in treatment, and two to three
55

Chapter IV
families live together in these residences. Most of
the mothers have private bedrooms with their children
in an adjoining room, but they share a common
kitchen and bathroom with at least one other
family. The families eat together as a household,
fixing their own breakfasts but having dinner
brought in. This integrated services design . . .
has caused a few tensions among families in residence.
For some women, the stress of being a
parent, coupled with the responsibilities of sharing
a home, is difficult to handle. Additionally, these
women are not used to living in a structured environment
governed by program rules and regulations.
. . . Some of these stressors have been
partially alleviated by having staff provide individualized
counseling and hands-on parenting
interventions in the women’s homes.
(PAR Village)
[NDRI, formerly Amity,] operates two TCs in
Tucson with a total capacity of 220 beds. The different
programs are located on two former guest
ranches separated by a road, allowing some joint
[co-educational] programming and special community
events. Gender-specific activities have
been added for women. Several buildings in the
women’s facility were renovated
for mothers living with children;
these had several configurations.
In some, two
women share a bedroom, and
their children share adjoining
bedrooms. In others, a
woman and her children share
a single bedroom, but several
similar families in the same
house share the kitchen and
bathroom. A developmental learning center for
the women’s facilities provides specialized services
throughout the day, after school, and on weekends
for children in residence and those who only
visit their mothers. (Desert Willow)
The families at all the sites ate at least some
meals communally in large or small groups with
their children. Learning how to socialize at mealtimes
and include children in the experience—as
an important ingredient of normal family life—was
a critical part of the therapeutic program. All the
Learning how to
socialize at mealtimes
and include children in
the experience . . . was a
critical part of the
therapeutic program.
projects also provided staff supervision and assistance
at mealtimes and bedtimes to teach and
model appropriate behavior. This was not always
an unqualified success, especially when eating
together in a large dining room.
One disruptive kid among 20 mothers, 35 other
children, and a couple of staff members can set
off the whole dining room and frustrate everyone.
We did think about some alternative possibilities,
and clients did complain.
(Desert Willow)
At IHW, however, women in the later phases of
treatment were expected to cook for and eat with
their own families and manage their independent
apartment units by themselves as they would be
doing when they left the program and returned to
the community.
In the majority of projects, household management
was part of therapy and a practicum for
teaching life skills such as house cleaning, budgeting,
meal planning, nutrition, careful shopping,
and even washing laundry. At minimum, all the
women were responsible for cleaning and maintaining
their own rooms as well as babysitting
their own children during designated
periods (mealtimes
and bedtime). At eight sites
that incorporated elements of
TCs, jobs in the residence
were assigned according to the
client’s treatment phase or
responsibility level and also
were a part of individual treatment
plans. At sites that
employed cooks or food service
managers, the women nevertheless helped
cook for all the residents and children. FIT was
the only site where all the meals except snacks
were prepared for the residents. The women at
Casa Rita and Watts, however, did not regularly
cook meals; those at PAR Village only fixed breakfast;
and Meta House residents assisted with the
preparation of buffets for breakfast and lunch.
Union specifications at Watts and Casa Rita
required that
maintenance staff clean common living areas at
the residences.
56

Facilities, Staffing, Staff Training, and Retention
Problems With Renovations
At the time of grant award, the majority of
grantees already had residential facilities and only
requested funding for minor renovations that
could be completed in 6 to 7 months. The residences
at five sites where new facilities had to be
acquired were typically not ready for occupancy
for at least a year.
A building for the project was found in November
1992. After lengthy negotiations, a lease was
signed in March 1993. [We] took occupancy on
May 1, 1993. After extensive renovations were
completed, equipment purchased, and necessary
inspections conducted, the building was ready for
occupancy on September 30, 1993. The first residents
were admitted on October 5, 1993—over a
year after funding began. (Chrysalis)
The repairs made at Watts—and contemplated and
never completed at IHW—affected programming
substantively. As already noted, IHW originally
planned to house the TC and continuing care
treatment phases in separate, next-door mansions
that are connected by a playground for the children.
When the rehabilitative funding to be provided
by a cooperating partner never materialized,
IHW had to decrease the number of bed spaces
offered and lease an alternative, much smaller site
in a nearby row house that could accommodate
new admissions as well as administrative offices.
Communal eating for new Phase I residents in the
already-renovated building that had separate efficiency
apartments for each family could only be
arranged by dining in shifts—an unsatisfactory
accommodation that persisted for too long and
caused many complaints from residents.
At Watts, delays in finding and renovating an
appropriate facility that was separate from the
existing coeducational, traditional, social-model
TC ultimately meant that the project was evaluated
as two independent programs; the women and
children admitted to the new facility in Lynwood
after August 1995 (the end of the fourth year of
funding) were compared with those exposed to the
earlier program in the House of Uruhu.
Licensing Issues
Most facilities were licensed by their States as
residential substance abuse treatment centers and
were inspected annually for complience with fire,
health, and safety laws. Some also decided to
obtain licenses for their children’s daycare components.
This process was not without difficulties.
We’re licensed by one State agency for daycare of
children and by another for the treatment of
women. Because our parent agency was used to
dealing with treatment programs, by far the hardest
part was becoming licensed as a daycare center.
(Chrysalis)
The PAR Village Developmental Center is licensed
by the Juvenile Welfare Board of Pinellas County.
This Center has separate classrooms and indoor
and outdoor play areas for infants through
preschoolers. The childcare licensing division
requires separate playgrounds for children who
are under 2 years old and those who are 3 to 5
years old. Similarly, the regulations require that
each classroom has 35 square feet per infant and
25 square feet for every child who is 1 year old or
older.
(PAR Village)
The projects where childcare facilities met State
or local licensing requirements recommended
this as a worthwhile objective, not only to ensure
the safety and appropriateness of the care offered
to children in residence, but because these
approved onsite centers became revenue-producing
assets that could attract Medicaid and other
forms of reimbursements—rather than remaining
costly liabilities.
Even those grantees that used offsite childcare
facilities and other programs for children found
they needed adequate play space and equipment
onsite.
Because our daycare is funded by external
sources, it is a revenue center, not a cost center.
(FIT)
Our license allows us to capture childcare revenue
that’s coming in through welfare reform, foster
care, and other sources. (Meta House)
57

Chapter IV
Reactions From the Community
During the planning stages, grantees that were
opening new facilities developed strategies to
address prejudice against this population of poor,
addicted, minority women and to gain acceptance
by the community. One project reported community
hostility, expressed as "not in my backyard"
(NIMBY), with respect to opening a new residence.
One suggestion for offsetting such negative reactions
is to portray the facility as a family-oriented
program.
Public relations efforts in the planning stage [and
thereafter] should focus on providing
services for children and families. It’s one thing
to say you house drug addicts; it’s quite another
to say you have a nice family center.
(Meta House)
Staffing Issues
Although their grant applications outlined appropriate
staffing complements for delivering specified
services, the new projects were nonetheless
challenged by the tasks of recruiting, hiring, and
training program-sensitive employees. The
process of getting ready to open a new residential
facility, including hiring and orienting new staff,
took up to a year. The grantees also had to provide
regular and ongoing staff training on topical
issues and to build an integrated, multidisciplinary
team of workers who understood and were
committed to the new model of family-oriented
treatment. This required
blending perspectives of staff
who were knowledgeable
about addiction and familiar
with women’s issues with
those who specialized in child
development and children’s
issues. Finding strategies to
retain qualified staff was even
more difficult. The projects
had to overcome staff aggravations
about low salaries and
long hours, the frustrations of
working with clients who have
serious treatment needs, and the obstacles inherent
in building an innovative program.
Staffing Patterns
In designing their programs for substance-abusing
women and their young children, the grantees
were required to provide a broad variety of
medical, psychological, social, recreational,
vocational/educational, preventive, and support
services as well as more traditional treatment of
substance abuse problems. These programming
plans required a broad array of qualified staff or
linkages/partners who could offer not only a multidisciplinary
approach but also incorporate the
personal recovering perspective of the particular
program model. Outreach, treatment, and retention
success required that professional and management
staff reflect the diversity of populations
served.
If you have a comprehensive program, you have
to have a comprehensive staff. (PROTOTYPES)
Mix of Disciplines
“Public relations
efforts . . . should focus
on providing services for
children and families.
It’s one thing to say you
house drug addicts; it’s
quite another to say you
have a nice family
center.” (Meta House)
Staffing patterns were dictated by program design
and the needs of the target population. Projects
drew from a variety of disciplines: clinical psychologists,
pediatricians, registered and licensed practical
nurses, social workers, case managers, certified
substance abuse counselors, family therapists,
vocational counselors, teachers, child development
specialists, house parents, and childcare aides. As
the programs evolved and matured, changes in the
staffing complement were
made—mostly to reflect the
findings from local evaluations
and feedback as well as new
requirements of Temporary
Assistance for Needy Families
(TANF) for addicted women,
an increasing emphasis on
continuing care services in the
community, and the recognition
that many of the women
and their children had mental
illness, addiction, and behav-
58

Facilities, Staffing, Staff Training, and Retention
ioral problems that were more severe than anticipated.
Since each of the grantees used community
resources and collaborating partners as well
as volunteers to deliver services, the staffing
pattern did not necessarily provide an accurate
picture of the scope or intensity of services
provided by the grantees. Further, the titles
given to employee positions in the different sites
could be misleading in terms of their actual
duties, since each grantee established its own
organizational structure. Nonetheless, a review of
the staffing patterns for the 11 grantees found the
following commonalities:
• All of the projects hired staff to fill administrative
roles, to deliver needed services to the
women, to provide care and age-appropriate
education/interventions for the children, to
work with the family as a unit, and to add necessary
support services (e.g., cooking, driving,
maintenance, security). When these programs
were initiated, staffing components
were often regarded as separate units, sometimes
in physically different locations, rather
than as one integrated team.
• Nearly all projects apparently had separate
directors (also called supervisors, coordinators,
managers) of the women’s and children’s
components of the residential facilities in
addition to an overall project director. More
coordinators of the children’s services had
master’s level degrees (usually in social work
or education) than did the counterpart clinical
directors of the women’s services,
although most of those positions were filled
by persons with at least a college education.
• Although all grantees were required to
arrange for physical assessments and medical
care of the women and children, nine projects
hired medically trained staff, usually registered
and/or licensed practical nurses, parttime
physicians, physician’s assistants, pediatricians,
and psychiatrists. Casa Rita contracted
with both a psychiatrist and an
acupuncturist. Two sites also hired health
educators. The medical personnel provided
an array of different services, including physical
examinations at admission, preventive and
acute medical care, medication administration,
and referral for prenatal care and other
specialty medical treatments needed by the
women and children. Other services included
group discussions or classes on nutrition,
birth control and reproductive health, caring
for sick children, STDs, and other issues.
Many of the sites also had formal or informal
arrangements with community-based hospitals,
clinics, prenatal care facilities, and other
physicians to provide needed medical care.
Only one of the projects, GAPP, mentioned
having a consulting psychologist on staff,
although all grantees were required to
arrange for mental health assessments and
any needed treatment with community-based
clinics and practitioners.
• Eight sites used certified addiction specialists
as primary counselors for the women. Many
of these counselors were college trained
and/or in recovery. At Chrysalis, the counselors
were required—as a condition for the
program to qualify for Medicaid reimbursement—to
have bachelor of science degrees in
a health-related field as well as substance
abuse certification. Two projects, IHW and
FIT, hired therapists with master’s or bachelor’s
degrees. GAPP used case managers to
assist women in developing and implementing
individual treatment plans. The staff-to-client
ratio for these front-line counselors ranged
between 1:6 and 1:11, with most of the projects
reporting approximately one primary
counselor or caseworker for every eight
women in treatment. The staff to infant and
children ratio varied by State. As one grantee
commented, residents experienced a resourcerich
environment.
• Eight grantees employed specialists in family
therapy or family services. Most of those individuals
held advanced degrees, often in social
work, and worked primarily with the mothers
and children to assess family needs, improve
mother-child relationships, monitor potential
child neglect/abuse, and lead groups for family
members or couples. Some also assisted
the women with practical living skills.
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Chapter IV
• Seven sites listed case managers as part of the
staff for women’s services. These employees
were most often used in both the residential
treatment and continuing care components to
help the women find and use collateral community
resources, such as safe, affordable
housing, vocational training or special schooling,
and daycare for their children. The case
managers also helped the women make and
keep appointments with child welfare workers,
probation officers, physicians and other
healthcare workers, and psychotherapists.
PAR Village assigned a separate case manager
to work with the children.
• Six projects employed full- or part-time vocational
training specialists who assessed the
women’s skills and previous work history, provided
counseling about job and educational
possibilities, coordinated training opportunities
in word processing centers and other
types of businesses operated by the parent
agencies, and helped the women find appropriate
employment and handle job-related
stresses as they transitioned back into the
community.
• Four sites hired or contracted with recreational
specialists who coordinated or led leisure
activities, including exercise classes and a
variety of other low-cost, drug-free forms of
family entertainment. In many sites, one of
the counselors or other primary care- workers
organized offsite trips and other recreational
activities—separately for the women and children,
as well as together as families.
• Three projects (Casa Rita, Chrysalis, Desert
Willow) designated staff members for their
aftercare components. Chrysalis also had an
outreach specialist, and Desert Willow
assigned a part-time staff member to client
enrollment.
• Two grantees employed specialists to provide
training and hands-on coaching to the
women in such life skills as routine household
chores, banking and bill paying, time
management, use of public transportation,
personal hygiene, and assertiveness/stress
management.
• One site (PROTOTYPES) had a part-time legal
advocate on staff to assist clients in their relationships
with the CJS; another (Casa Rita)
had a housing specialist; and Flowering Tree
employed a cultural mentor for its Native
American project.
• All of the grantees employed some combination
of licensed or degreed teachers or child
development specialists and certified,
although not necessarily college-educated,
childcare workers or aides in their therapeutic
nurseries or daycare centers for young children.
Most of the teachers also worked with
the older children in the residence to offer
afterschool tutoring and recreational programs.
Two sites specifically mentioned foster
grandparent programs; PROTOTYPES had a
designated staff member to coordinate this
volunteer effort.
• Six grantees employed individuals as house
parents, milieu coordinators, night supervisors,
or house/facility managers. These workers—who
rotated shifts and were usually high
school graduates or college students—had
special responsibilities for ensuring the safety
and security of the residences, obtaining any
necessary emergency assistance, and ensuring
the maintenance of a therapeutic environment,
particularly on evening and night shifts
and during weekends. Most had to keep a
report log of unusual incidents. Some also
helped enforce house rules, assigned and
supervised household tasks that the clients
performed, and monitored supplies and physical
conditions in the facility.
• All grantees also employed or contracted with
other support services, such as janitorial and
housekeeping work, maintenance, van driving,
security, and cooking or food services.
For all positions, the criteria for hiring were analogous
in that what we sought was the highest relevant
credentials accompanied by substantial
experience with the participant population.
Additional criteria included efforts to match the
overall staff to the participant population in terms
of gender and culture. (FIT)
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Facilities, Staffing, Staff Training, and Retention
A number of issues were considered in the selection
and hiring criteria for staff. Education and
experience in the field were certainly important,
but not to the exclusion of someone who was
enthusiastic about working with this population
and open to learning the project’s treatment philosophy.
Also, State certification for substance
abuse counselors is an Arizona licensing requirement
for unsupervised service delivery.
Fingerprint clearance had to be obtained for staff
to work with the project’s children. A past history
of certain felonies, especially child abuse and neglect,
would disqualify prospective candidates.
(Desert Willow)
Staff should be as diverse as possible. In order to
comply with State substance abuse program regulations,
it is best to have as many degreed and
licensed staff as possible. (Casa Rita)
About 90 percent of the staff in the Developmental
Center have certificates as Child Developmental
Associates (CDA), and all have at least 2 years of
childcare experience. Most staff have some college
and/or experience and training in addiction
and other women’s issues. All staff have strong
human relation skills.
(PAR Village)
Balance of Professional Training, Practical/
Personal Experience, Race/Ethnicity,
and Gender
On the basis of program experience, grantees were
encouraged to recruit competent and appropriate
staff who would best work with the target population
and who understood the dynamics of substance
abuse, culture, and gender, as related to
the treatment and recovery needs of prospective
clients. The projects also tried to maintain a
balance among staff who were qualified by their
professional credentials or programmatic experience
and those with personal histories of recovery
from substance abuse problems and co-occurring
disorders. At least two sites that served many
women who had been or were currently involved
with the CJS hired staff who formerly had been
incarcerated.
The percentage of staff estimated by the grantees
to be in recovery ranged from a low of 2 percent
at GAPP to 100 percent at Flowering Tree. Most
of the grantees judged that 30 to 45 percent of
their staff were in recovery; Desert Willow related
that 75 percent of its employees were in recovery,
and Meta House reported this figure as 60
percent. Several grantees required staff in recovery
to have a minimum of 2 years of sobriety or
clean time; other sites hired project graduates and
found them excellent when given training and
proper supervision.
Our program, with a mix of professional mental
health/substance abuse specialists and a preponderance
of recovering, nondegreed substance
abuse specialists, provides a broad spectrum of
resources and models for clients. Management
staff also represent a mix of training and experience
and reflect the ethnic and sexual orientation
of the clients and other employees. Sometimes the
tensions and natural tendencies toward hierarchy
with this mix of staff must be addressed and alleviated
by management [who are sensitive to these
issues]. (PROTOTYPES)
Several of our program graduates were hired in
staff positions as milieu coordinators, childcare
aides, and prevention specialists in another CSATfunded
program. Another program graduate
served as a consumer on the advisory board.
(FIT)
[Staff in recovery] must have been sober for 2
years and have a support system in place. They
have their breath and urine [specimens] monitored
regularly for signs of drug or alcohol use.
They are also released for an hour each week for
counseling and get 2 weeks of paid mental health
leave each year. (Flowering Tree)
Although there was universal agreement among
the grantees that the staff should reflect the cultural
diversity of the clients, some centers found
this easier to accomplish than others. Six of the
grantees reported that they succeeded quite well
in matching the diversity of staff and clients.
However, more staff at IHW were Hispanic than in
the client population, whereas Watts was not able
to recruit as many Hispanic and white staff as
desired. Desert Willow, Meta House, and PAR
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Village related that they were unable to hire
sufficient numbers of qualified minority staff, especially
African Americans.
It appears from [our] experience that the most
effective staffing pattern is one that is racially/ethnically
diverse; our experience is that this is superior
to a staff made up of a single racial [group],
even when the vast majority of families are from
a single racial or ethnic group. (FIT)
PAR Village attributed its difficulties in matching
the characteristics of staff and clients to the low
pay scale, which could not attract qualified African
Americans to commute "across the bridge" in the
congested area where the project is located.
The grantees held different opinions about having
men on staff. While four sites hired men in only
low-level positions—as security guards, drivers, or
maintenance workers—most of the other grantees
found that male staff could serve as positive role
models and help offset the unhealthy relationships
with men experienced by so many of the women in
treatment. However, grantees cautioned that male
staff must be carefully screened. The men who
worked at Desert Willow, for example, tended to
be older and well known to the project director.
They proved to be important influences on and
supportive friends to the women in treatment.
IHW had several male employees; Meta House
hired only two males and was more skeptical about
their value as staff members in the programs for
women and children.
We had a very dynamic guy in his mid-twenties
[as a member of the childcare team] who had
seven little boys following him around on tricycles.
Their mothers were able to see some of his
interactions with the children in a very positive
way. (PROTOTYPES)
Our treatment director was male and so was one
of the counselors. Men also worked in
the residential care specialist positions.
(Chrysalis)
The male counselor who runs our family program
is in recovery, and he’s been very helpful in
attracting male members of families. Information
from client focus groups has indicated that some
of the most valuable groups for these women have
been led by male counselors. In terms of outcomes,
however, a comparative analysis of client
retention by case manager gender did not find any
relationship between these variables. (GAPP)
Total Staff Complement
Another difficulty faced by the grantees was hiring
sufficient numbers of staff to provide the selected
services, supervise the residence at all times, and
meet licensing requirements for staff-to-client
ratios, particularly in the childcare components.
Sites that were part of large parent agencies had
obvious advantages in being able to use—or
share—employees from other programs and components
(e.g., administrative personnel, maintenance
workers, recreational therapists, psychiatrists,
psychologists). Some projects used temporary
or backup workers to cover positions with
high turnover or where experience and willingness
to learn were needed more than specific skills
(e.g., milieu coordinators, childcare aides).
Fluctuations in the numbers and ages of the children
admitted made it difficult to predict how
many staff would be needed to work in the daycare
center and provide afterschool programs or special
therapy for older children.
Depending on our admissions and discharges, the
numbers [of children] are constantly changing.
At one time, we may have 20 infants and toddlers
and 5 preschoolers. Three weeks later that may
shift. We have to constantly make sure we have
enough staff. (IHW)
Other Personal Characteristics
All projects believed staff members should be team
players, since treatment was provided by a multidisciplinary
group. In addition, grantees looked
for individuals who were flexible, shared a common
vision or philosophy, and could adapt to a constantly
changing environment. Particularly sought
after were staff who could fill more than one role;
such individuals helped "get the job done," were
more aware of what other staff members were
doing, and were less likely to "burn out" as they
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Facilities, Staffing, Staff Training, and Retention
took on multiple responsibilities. The grantees
found that dependable contributors to the program
at any level of the organization had to be
willing to grow and change as the program
evolved.
The key to the retention of a core staff who’ve
been with us from the beginning [of the grant] is
that they’ve been flexible enough to accept all the
changes that have come—including staff turnover
and our growth from one building to two. The
staff who’ve managed to stay can deal with the
changes and with the fact that somebody may
have to stay until one o’clock
in the morning or get called
about something on the weekend.
(IHW)
[Our program] employs staff
who have the highest credentials
and field experience. In
order for staff to remain effective
with this population,
supervisors [must] make certain
that counselors embrace
a nonjudgmental, nurturing
attitude while continuing to
uphold the program’s model
philosophy based on empowerment,
self-sufficiency, and independence. Staff
must also be willing to participate in a multidisciplinary
team approach. (PAR Village)
Recruitment and Hiring
The grantees tried a variety of approaches to
recruit staff with diverse skills, experience, and
backgrounds. They advertised vacancies in major
metropolitan newspapers, local inner-city gazettes,
and professional journals; they placed notices in
the bulletins of schools of social work and education
and teachers associations; and they made
announcements to specialized professional
organizations, such as the National Association of
Black Social Workers or the Association of Black
Psychologists. These traditional strategies,
however, had varying degrees of success. In some
locations, recruiting a diverse staff was made easier
by having a large pool of qualified candidates
The factors deemed most
critical to successful staff
recruitment were the
program’s reputation,
community networking,
and competitive salaries,
especially to attract
minority members to
management positions.
residing in the area (e.g., Los Angeles, New York
City). The factors deemed most critical to successful
staff recruitment were the program’s reputation,
community networking, and competitive
salaries, especially to attract minority members to
management positions.
We placed numerous ads in the classified sections
of major local newspapers, including one with a
large circulation in the African American community.
We also posted positions internally [with the
parent agency] and mailed some to our partners
[collaborators on the grant]. In addition, several
members of [our] Board
brought postings to their work
places, and we contacted such
specialized resources as the
School District of Philadelphia
and the Delaware Valley
Association of Black
Psychologists in order to ensure
a comprehensive and thorough
search process. We received
more than 150 applications in
response to these solicitations
and conducted approximately
30 interviews. (IHW)
As part of the recruitment and
hiring process, all grantees believed that prospective
employees should be given a realistic picture
of the project, clients, and job demands. In thinking
back, some grantees believed they could have
improved staff retention if, in the interviewing
process, they had been clearer about the rigors of
each job. Since these were innovative programs,
however, no pool of already-trained and experienced
personnel existed.
Some of the required positions were foreign to this
traditionally client-centered residential treatment
facility. For example, the clinical staff, including a
childcare director, needed to have knowledge of
children’s needs, family dynamics, parenting
skills, and the specific mental health issues associated
with substance abuse clients. However,
most individuals with experience in addiction
treatment have not had to deal with mother-child
interaction issues, including parenting skills, and
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Chapter IV
most individuals experienced in childcare have
not had to consider their work in the context of
the mother’s therapy and recovery issues. Job
applicants for the childcare positions had little
knowledge of addiction, recovery, the dynamics of
family addiction, and developmental delays and
needs of cocaine-exposed infants. In fact, no professional,
family-centered, residential treatment,
clinical staff pool existed from which to recruit.
(FIT)
Comprehensive orientation and cross-training of
all staff were necessary. This
training of clinical staff is
ongoing and includes such topics
as health and safety issues
for children, detection of child
abuse or neglect, assessment
of the quality of interaction
between mother and child,
dual diagnoses, HIV, the effects
of cocaine on infants and small children, [and]
culturally specific issues around parenting in the
African American community. Additionally, the
childcare staff, who had never worked in a setting
such as this, had to be trained in addiction and
personality characteristics frequently found
among addicted mothers. They also had to be
trained to work effectively with, and to meet the
specialized needs of, substance-exposed newborns
and small children, including how to deliver cardiopulmonary
resuscitation (CPR) and attend to
cardiorespiratory monitors prescribed for premature
infants at risk for apnea. (FIT)
Orientation
All grantees provided some orientation for new
staff. This might be minimal if additional handson
training and observation followed. At startup,
however, the grantees used staff retreats and more
intensive approaches to introduce all employees to
each other and the goals and philosophies of the
program. Training for new employees also
addressed the program’s specific policies and procedures,
recordkeeping requirements, and participation
in the evaluation research. Much of this
training was ongoing, repeated not only for new
“. . . no professional,
family-centered, residential
treatment, clinical
staff pool existed from
which to recruit.” (FIT)
staff members but to refresh or enhance staff
skills and to correct noted deficiencies among
some long-term employees.
All new employees attend an 8-hour orientation
session that reviews personnel policies and procedures
and also covers operational policies and
job-related responsibilities. (Desert Willow)
All new staff members attend a day-long orientation
sponsored by Circle Park Associates and a
departmental orientation provided by their component
supervisor. (Chrysalis)
As part of orientation at one
site, new staff and interns
attended groups and workshops
before taking on any job
responsibilities.
For the first week, they shadowed
other staff without having
one-on-one client contact,
since they needed to know what the program was
like, what the activities were, and who the staff
were. (IHW)
A particular challenge was the training of staff
who worked the evening and weekend shifts or
who were responsible for maintaining a desired
decorum in the residences and fairly enforcing
program rules and regulations. Although they
often had fewer skills or experience and were seldom
well paid, these staff were expected to be professional
in their approach and also to be peer
counselors and role models for the women.
Ongoing training for this staff usually focused on
such issues as teamwork, concepts of a TC, ethics
for treatment professionals, program protocols,
conflict resolution, and other job-related tasks.
It is important to have clinical staff with experience
and "sophistication" who can effectively and
dynamically manage the therapeutic milieu. This
is a critical issue for women-specific treatment
because of what we know about the relational
needs of women, compounded by the dysfunctional
socialization of women to view other women
as untrustworthy.
(Meta House)
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Facilities, Staffing, Staff Training, and Retention
Team Building
A major issue that needed to be resolved at all the
sites was related to disagreements and misunderstandings
between staff who had primary responsibility
for the women and those who worked almost
exclusively with the children. Cross-training and
team-building efforts were needed to teach the
staff of the children’s and women’s components
about one another’s missions, work, and challenges
so they could cooperate, instead of operating
at cross purposes. For instance, it was not
uncommon for the children’s staff to become very
angry with mothers when they saw them mistreat
their children. Staff of the children’s component
often did not realize or understand that the mother
was going through her own painful therapy and
was feeling incapacitated, without adequate
resources to give necessary attention to her children.
By contrast, the women’s staff could overreact
to what the children’s staff said to or about
the mothers.
The integration of women’s and children’s services
has been extremely important. It’s necessary
to develop, nurture, and maintain a treatment
team of individuals with specific expertise and
accountability who also recognize the importance
of integrated and coordinated service delivery.
This especially requires a change for [substance
abuse] counselors who have traditional treatment
experiences, since this model demands comprehensive
family case management. (Meta House)
Issues also arose among staff about their different
roles at the centers. For example, childcare
specialists at one center felt devalued and as if
they were viewed as babysitters rather than as professionals.
Other staff would say, "The childcare staff is over
there playing all day." But play is educational—
it’s how children learn to make decisions and
socialize. I think our biggest struggle has been to
help each staff member feel he or she has something
to bring that is valuable and different.
(Casa Rita)
Various approaches were used to help staff in these
different components work together more cooperatively.
At some sites, the women’s staff were
required to spend time in the children’s program,
and vice versa. Other grantees held regular multidisciplinary
training, case conferences, and meetings.
Staff were frequently counseled by their
supervisors or management to work as a team. In
one center, a single supervisor was assigned to
both staffs for the sake of unity. Conflict resolution
and mediation techniques were used to
resolve problems among staff and between staff
and the women. Some projects used
overlapping shifts and logbooks to facilitate communication
among staff about important daily
events or incidents that affected the women and
their children.
Other staff training areas that deserve more
emphasis are team-building as well as management
and clinical supervision of senior staff.
(GAPP)
I can’t emphasize enough the critical need for staff
training and supervision with regard to [familyoriented]
treatment in a women and children’s
program. It’s very easy to establish therapeutic
rapport and an empathic relationship with a
woman when you see her in isolation. When, however,
staff actually witness women routinely
neglecting and abusing their children, they react
with a great deal of anger and judgment—not to
mention acting out their own countertransference
issues. I believe the staff burnout potential in an
RWC program is exponentially higher for that reason.
There must be an environment where staff
can talk freely about their personal biases and
values; otherwise, these issues will certainly surface
and possibly sabotage treatment. For example,
some staff are unable to tolerate a woman
who is considering [relinquishing her child for]
adoption, [having an] abortion, or not appealing
an order for termination of parental rights. These
issues need to be discussed and worked through
openly. One of our challenges was [recognizing]
. . . the fact that what’s good for mom is not
always good for the child, and vice versa.
Coming to an agreement about what is good for
the family as a unit is sometimes quite difficult.
Some staff seem to always look after the children
while others are concerned with the adults.
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Chapter IV
Often, they’re in conflict with each other.
(Meta House)
Staff in the . . . RWC programs experience . . .
stress beyond that normally experienced by residential
drug abuse counselors. The reasons are
multiple. [The first is] the complex nature of the
task. Therapists must concern themselves with
the mother’s immediate in vivo relation to and
behavior toward her children in
addition to the expected substance
abuse and mental health
issues; childcare staff must concern
themselves with the mother’s
parenting attitude, stress,
and skills [in addition to providing
appropriate interventions
for developmental delays in the
child]; case managers must
concern themselves with the
numerous ongoing medical, legal, educational,
and housing issues, [which are] more numerous
the more children the mother is allowed to have in
treatment with her. [The second reason for added
stress is] the need for close coordination among
childcare, therapy, and milieu/environmental staff
and the demand to operate as a team . . . with a
very high level of clear, concise communications
as well as cooperation and dedication. [The third
cause of stress is] the emotional attachment of
staff to the infants and children. While this certainly
brings rewards unknown to traditional
drug treatment service delivery when habilitation
of the family is successful, it can be emotionally
wrenching when a mother leaves prematurely or
returns to drug use and the children must be
abruptly placed in the care of the State. (FIT)
Staff must come to see themselves as a single
interdiscipinary team. [This requires that] the
women’s treatment staff and the children’s developmental
staff exchange perspectives and learn
not to see the kids as merely baggage brought
along by the mothers. When mothers drop out of
treatment, the trauma is felt by the staff and the
other women and children at the center. We actually
brought in grief counselors to talk about this
so that staff would not take out their frustrations
on other women and so that the remaining
women and children could talk about their feelings.
We even had staff and residents write letters
to the women and children who left. (PAR Village)
Staff Development
and Training Activities
“One of our challenges
was [recognizing] . . . the
fact that what’s good for
mom is not always good
for the child, and vice
versa.” (Meta House)
All the grantees provided extensive, ongoing staff
training that covered many
different content areas and
took advantage of the expertise
available in the program;
the parent agency; and other
community or State agencies,
institutions, and organizations,
such as
• The Red Cross
• Schools of nursing,
psychiatry, and medicine
• Maternal and child health agencies
• State substance abuse authorities
• Departments of public health or child and
family services
• The Child Welfare League of America.
Training helped to enhance the personal skills of
staff and motivate them to take continuing interest
and pride in their jobs. Training also helped to
build a cooperating team of employees who could
develop and share individualized treatment objectives
for each mother and child and reconcile
these into a family-oriented focus. Staff came into
these residential centers with their own life experiences
and concerns, and they worked with women
and children who had complex histories and
needs. To cope with the range of issues involved,
grantees offered training on many diverse but relevant
topics. One site (PAR Village) found that
staff exchanges among the CSAT-funded RWC programs
worked out well; the expertise available at
the different sites was usually well known and
respected so that reciprocal benefits could be
found at low cost when staff taught each other
their most successful strategies in particular
areas.
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Facilities, Staffing, Staff Training, and Retention
Not all staff members attended every course; most
training was specific to the job responsibilities of
designated participants. Onsite classes and offsite
courses usually lasted from several hours to several
days or more. A few staff members were sent
out of town to attend schools of alcohol studies; a
Harvard Medical School course, Addiction: What
Works?; or other professional conferences. Some
of the training sessions were scheduled regularly
as weekly or monthly in-service meetings, other
classes on such topics as emergency medical care
or case management were repeated with some frequency,
and still other special staff development
opportunities occurred only once. The projects
varied in the levels of onsite, in-house training
that were offered as opposed to reliance on offsite
resources.
Staff training addressed a variety of topics, many
of which pertained to generic substance abuse
treatment issues and each project’s own policies
and procedures. Other staff development
activities concentrated on particular problems
and challenges facing different service
components, such as
• Infant care and child development
• Women’s issues
• Medical and health problems
• Parenting and other family activities
• Milieu management
• Administration.
Much of the staff training was didactic in nature
and was delivered to small groups. Skilled trainers
often augmented their presentations with roleplays,
case examples, videos or slides, and handouts
of written materials.
Some hands-on training and supervision were
offered to individual staff members who were
changing positions or learning new skills. All the
grantees scheduled regular—often weekly—staff
meetings for all employees or for different service
components of the project. Many organized special
retreats away from the normal routine and
program environment, where staff members could
review past and present goals, reflect on accomplishments
and issues, plan future activities,
improve morale, and renew commitment.
[Our] staff retreats benefit all participants by fostering
a sense of comradeship and revitalizing
commitment to our mission. (GAPP)
We use community development retreats to review
services for children and adults, elicit the problem-solving
skills of staff participants, discuss
alternative strategies, and agree to try selected
suggestions for change. We’ve made many program
improvements as a result of staff ideas.
(Desert Willow)
The most frequently mentioned staff development
activities in routine quarterly reports from the
projects included the following categories and
examples.
Addiction Treatment and Counseling
Training in this area addressed many traditional
concepts of addiction treatment and a variety of
counseling techniques. The broad array of course
titles included the following:
• Duties of Case Managers
• Group Therapy Techniques
• Improving the Clinical Skills of Alcohol and
Addiction Counselors
• Counseling Theories
• Relapse Prevention
• Breaking the Cycle of Addiction
• Integrating 12-Steps Into Treatment
• The Basis of Addiction
• Useful Tools for Treating Substance Abuse
• Transference/Countertransference and Other
Defense Mechanisms
• Rationale Emotive Therapy
• Motivational Enhancement Therapy
• Psychodrama
• Using Humor in Therapy
• Sensitive Issues and the Clinical Record
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Chapter IV
• Integration of Information from Multiple
Assessments
• Individualized Treatment Planning and
Documentation
• American Society of Addiction Medicine
Patient Placement Criteria
• Client Rights and Ethics.
Special Issues for Women
The grantees also provided staff training on many
issues specific to substance-abusing women.
Among the titles of the many similar and relevant
training sessions offered in this area were the following:
• Violence Against Women
• Assertiveness for Women
• Working With Victims of Childhood or Adult
Physical and Sexual Abuse
• Stress, Anger
Management, and
Violence
• Managing Grief and Loss
• Sexual Functioning and
Sexual Orientation of
Substance-Abusing
Women
• Women’s Sexuality in the
Context of Substance
Abuse Treatment Services
• Low-Income Housing
Loans and Tax Credits
• Spirituality
• Strategies To Enhance Self-Esteem
• Issues of Incarcerated Women
• Gender Issues in Treatment of Substance-
Abusing Women
• Women’s Reality in an Addiction Society:
Recovery, Depression, Spirituality, and
Sisterhood
• Clinical Treatment of Eating Disorders:
Anorexia and Bulimia Nervosa.
Staff problems in dealing
with mental health
issues were identified
as a major reason for
women leaving
treatment against
medical advice, for being
discharged prematurely,
and/or for having poor
treatment outcomes.
Psychopathology and Co-Occuring Disorders
Training about basic psychopathology was considered
important by all the grantees and a necessary
step to successful integration of treatment for
mental illness and substance abuse problems.
Staff problems in dealing with mental health
issues were identified as a major reason for women
leaving treatment against medical advice, for
being discharged prematurely, and/or for having
poor treatment outcomes. Two-thirds of the
grantees reported that program disruptions
occurred if symptoms of co-occurring psychiatric
disorders were ignored. Staff members needed to
develop sufficient clinical judgment to be able to
discriminate between women’s acting-out behavior
and the beginning of a psychotic decompensation.
The training sessions addressing this topic had
titles such as:
• Working With Clients With Dual Diagnoses
• Diagnostic Classification of Mental Health
Disorders in Infants and
Toddlers
Women
• Anxiety Disorders
• Psychiatric Manifestations of
HIV Infection
• Classification of Mental
Disorders Using the Diagnostic
and Statistical Manual of
Mental Disorders, 4th Edition
• Community Treatment of
Women with Co-Occurring
Disorders Who Are Involved
With the CJS
• Dual Diagnosis Among
Minority Substance-Abusing
• Post-Traumatic Stress Disorder Among Victims
of Sexual and Physical Abuse.
Women’s and Children’s Medical and
Health Problems
The topics most frequently addressed by training
in this area were procedures that staff needed to
68

Facilities, Staffing, Staff Training, and Retention
know for handling medical emergencies, monitoring
medications, preventing HIV infection, and
responding sensitively to women in the residences
who were HIV positive or had AIDS diagnoses.
Almost all of the grantees relied on local chapters
of the Red Cross to train staff about community
first aid and CPR for adults and children, including
how to perform rescue breathing, respond to
choking, care for conscious and unconscious victims
of life-threatening emergencies, and prevent
and treat other injuries. Other training classes
mentioned by the projects included the following:
• Bloodborne Pathogens
• Universal Precautions and Communicable
Diseases
• Prevention of Cardiovascular Health Disease in
Women
• The Relation of Substance Abuse to HIV
Infection, Tuberculosis (TB), and STDs
• Counseling and Treating Patients With HIV
Infection or AIDS Diagnoses
• Risk Factors for HIV Infection and
Transmission Among Women
• Nutrition
• Management of Usual Childhood Illnesses
• Caring for Our Children: Health and Safety
Standards for Out-of-Home Care
• Smoking Cessation
• Fetal Alcohol Syndrome
• Bio-Magnetic and Touch Healing
• Management of Psychotropic Medications and
Pharmacotherapy for Dual Diagnoses
• Monitoring Drug Therapy in a Residential
Facility.
The latter included topics such as
• The use and effectiveness of antibiotics
• Adverse reactions and drug interactions
• Medication dispensing issues
• Appropriate use of over-the-counter
medications
• Withdrawal symptoms for some medications
• The pros and cons of methadone
• Effective medications for attention deficit
hyperactivity disorder (ADHD).
Use of Apnea Monitoring Equipment for Sick Babies: A Case Example 1
When a premature infant with an intercurrent viral respiratory illness suddenly stopped breathing, he had to be
resuscitated by the program nurse and transported by emergency medical services to the hospital for admission to
intensive care. The mother had been fully involved in the earlier treatment of this premature infant during his initial
stay in the hospital’s neonatal intensive care unit and accepted full responsibility for his care at the RWC program.
When the infant was discharged from the emergency hospitalization, the physicians prescribed apnea monitoring
and deemed the mother fully capable of managing this equipment at home after complete instruction and training
in apnea monitoring and cardiopulmonary resuscitation. However, the mother was overwhelmed by this responsibility
and her potential culpability if the infant developed further problems. The staff were near panic-stricken about
accepting responsibility for this infant’s care and considered placing him in shelter care. After extensive discussions
with the hospital and clinic pediatricians and nurses, the decision was made to train staff so they could support the
mother’s efforts. In a short time, the mother was confident, proud of her accomplishments, and closer with her
son. The infant’s second serious respiratory illness was handled more smoothly by both mother and staff. The case
exemplifies the need for close communication between residential treatment staff and medical care providers before
the first admission so that the staff will be educated regarding routine and emergency medical complications in substance-exposed
infants, especially those who are at high risk due to other conditions such as premature delivery.
[ 1 The programs providing the case examples in this document are not disclosed in order to protect client confidentiality.]
69

Chapter IV
Of course, much staff learning resulted from
practical experience on the job rather than
from formal training. The case example in the
text box describes how staff at one site were
convinced they should learn to use sophisticated
apnea monitoring equipment for newborns with
breathing problems.
Children’s Services
Through special training, the teachers, child development
specialists, childcare aides, women’s counselors,
and clinical staff increased their knowledge
about such topics as
• Stages of child development
• Age-appropriate play and discipline
• Substance abuse as a precursor to child
maltreatment
• Effects of substance abuse on infants and
families
• Recognizing and reporting child abuse and
neglect: CPS requirements
• Sexual abuse of children
• Sand play therapy
• The role of poverty in child development
• Working with behaviorally challenged
children, make and take: Suggestions for
preschool teachers
• Cherishing our children: Behavior management
for children with ADHD
• Cognitive, language, and physical development
of infants
• Social and emotional development of children:
Infants to age 3 years
• Winning ways to talk to young children
• Jump-start curricula for children
• Education of the exceptional child
• The magnificent kingdom of children: What to
do with infants, toddlers, and twos
• Child sexual abuse and incest: Symptoms,
detection, and therapy
• Keys to success with children who show
aggressive behavior
• Anger control training for children
• The etiology of developmental delays
• Speech pathology
• Transforming the difficult child
• The experience of pain from the child’s
perspective
• Perinatal effects of substance abuse.
Parenting and Family Services
Project staff with responsibilities for helping substance-abusing
mothers become better parents
and reconcile with family members attended training
related to such issues as
• The design and delivery of effective services
for children and families affected by alcohol
and drug abuse
• Developmental and disciplinary issues for
abused and neglected children
• Systematic Training for Effective Parenting
(STEP)
• Minuchin family therapy
• Family systems
• Couples in recovery
• Multiple family therapy
• Marriage and family counseling: Solutionoriented
therapy.
Cultural Issues
Grantees paid special attention to training staff
about cultural issues and how sensitivity to others
might be manifested. The projects brought in outside
consultants to handle diversity issues; help
staff examine their own and others’ cultures, cultural
biases, and stereotypes; and understand the
implications of these on behavioral expectations.
Grantees encouraged openness to and acceptance
of others, lectured on cross-cultural concepts and
practices, and addressed cultural issues through
role modeling, openness, and individual counseling.
We tried to get staff to examine their own belief
systems to see what messages they responded to
as children and what their overt and covert
beliefs are now. We’ve found that gender shame
70

Facilities, Staffing, Staff Training, and Retention
leaks out [rather frequently] and that staff have
strong, often unexamined, beliefs about mothering,
minorities, religion, and other sensitive issues.
(PAR Village)
The formal in-house and offsite training that pertained
to cultural issues and was mentioned in
grantees’ quarterly reports addressed such topics
as
• Valuing cultural diversity
• HIV infection and the Hispanic/Latino and
African American communities
• Color me human: A cultural diversity
workshop
• Guiding principles for African American
children
• How to relate to African American clients
• Understanding Recovery for Native American
women
• Community initiatives for persons with
African American or Southeast Asian ancestry:
Culture, symbols, traditions, and art
• Family workshops on Native American and
Hispanic traditions and values.
Management and Supervision
Project staff in administrative and supervisory
positions often attended training sessions of relevance
to their special roles. The types of training
offered to this group addressed such topics as
• Staff burnout
• Clinical supervision and performance
evaluation
• Stress reduction
• Conflict resolution
• Effective communications
• Team-building and team management
strategies
• How to handle difficult people
• Humor in healthcare professionals
• Management skills
• Violence management and empathy training
• Chart audits and case conferences.
Some employees in the offices of program
directors also attended classes on bookkeeping/
accounting, grants management, personnel
records, computer programs, and using
the Internet.
Cross-Training
Most grantees participated in cross-training with
other community organizations that also served
this population of women and children—offering
information about substance abuse and residential
treatment services in exchange for training on
issues such as domestic violence, mental health,
sexual abuse, and, in some cases, reproductive
health issues. When providing cross-training, projects
found it important to get to know the staff
who really see the clients—those who are on the
front line, rather than administrative personnel.
The grantees also provided information about the
program and developed relationships with personnel
such as teachers in local schools or daycare
centers that the children attended or caseworkers
in child protective services to facilitate ongoing
communications.
Staff Retention Problems
One-half of the grantees acknowledged that staff
turnover was a large problem affecting program
operations and effectiveness, particularly in the
first years after startup. Staff members with different
levels of responsibility left the projects for
varying reasons. In general, there appeared to be
more frequent turnover among the lowest
level/paid employees, particularly shift workers
such as milieu coordinators, who had less investment
in the program and might see the job as a
temporary way to get through college or gain
experience in preparation for a better opportunity.
However, all programs but one reported changes
in top management or administrative positions
71

Chapter IV
over the course of the grants. Six projects had
changes in their program/project directors, and a
director of evaluation and a clinical supervisor
resigned at two other sites. The parent agency for
Desert Willow changed during the grant. Political
appointees were a problem at Flowering Tree,
where there were seven project directors during
the first
2 years of the grant. After the program settled
down, staff turnover diminished dramatically, and
most of the staff at the end of the grant had
3 years of tenure in the project.
The intensity and demands of
working for low pay with
women and children in a residential
setting were major reasons
for staff turnover in other
positions. Most employees who
left complained about too
much to do and too many
errands. However, the reasons
for staff turnover and the positions
in which it occurred varied
by project. At one site, the
change in program philosophy
to a family-oriented focus
could not be assimilated by the existing employees.
At the start of the Village South’s grant, the existing
staff were very resistant to having children in
a residential treatment facility. They repeatedly
expressed concern about potential liability, medical
management, and safety issues—almost to
the point of being immobilized. We had never
before admitted entire families into residential
treatment, and staff were also concerned with the
potential impact of treatment on the children, and
vice versa. Many of the staff were hesitant about
engaging themselves in the program’s development
or implementation. In fact, all existing staff
at the time of startup resigned or transferred from
their positions. (FIT)
The intensity and
demands of working
for low pay with
women and children in
a residential setting
were major reasons for
staff turnover in other
positions.
Similarly, the existing staff at PAR Village who had
been associated with more traditional long-term
TCs left in the early part of the grant. Once the
program settled down and staff developed common
beliefs and philosophies, turnover became
less of a problem. At IHW, resignations seemed to
result from very demanding work with a sometimes
difficult population. Staff who left were not
really prepared to work in residential treatment
facilities and were not very adaptable.
Burnout with overload. That’s the reason we lose
so many staff. (IHW)
Some of the turnover at all the sites, however, was
attributed to normal attrition—moving, maternity
leave, or opportunities for promotion or better pay
somewhere else.
At Casa Rita, the biggest
turnover was among support
staff, whereas counselors
seemed to be more committed
to the program. Similarly, the
residential services staff at
Chrysalis were most likely to
leave the project for better
opportunities. However, several
counselors at this site left
because they did not meet new
State credentialing requirements
for a bachelor of science
degree. Desert Willow had the most difficulty in
filling and retaining line staff positions in the children’s
component; these employees found the children
difficult to work with and differed among
themselves as to how the children should be handled.
By contrast, FIT found that professionals
were more likely to leave for better pay; staff with
less responsibility remained because they were
unable to find better jobs. GAPP reported high
turnover rates among counselors and case managers
who found higher paying and more secure
positions elsewhere.
Strategies for Retaining Staff
Grantees made a concerted effort to retain staff by
improving working conditions, offering training
and educational opportunities, and including staff
in program planning and decisionmaking.
Opportunities for promotion from within and hir-
72

Facilities, Staffing, Staff Training, and Retention
ing program graduates were also incentives for
many staff. FIT, Desert Willow, Flowering Tree,
and Chrysalis proudly cited the numbers of staff
persons who were promoted to more responsible
positions in the program over the course of the
grant. Not all rewards were tangible; many of the
staff who worked in these programs were highly
invested in their jobs and in the success of the
women and children they treated.
A key determining factor in retaining staff and
minimizing turnover is an adequate salary.
(Casa Rita)
Our program had few problems with staff
turnover. The staff are very familiar with the population
in treatment, since there are promotions
from within the program and many of our graduates
are hired. Twenty percent of the staff in the
RWC project are graduates of some component of
the parent agency, and they are excellent role
models. Since the residents do well in treatment,
there are many rewards for staff and little
burnout. Also, because the agency was established
by and for women, we have very good personnel
policies for women, with reasonable pay
and raises if you stay. Moreover, staff are given
lots of flexibility and room for creativity. (Meta
House)
We try to [keep staff happy] by recognizing their
birthdays, organizing parties at holidays, and
involving them in the social activities of the residents.
We’ve found that staff take great pride in
what they’re doing and are very motivated by any
recognition they get [or sense of accomplishment]
at residents’ commencements. They often get
accolades from residents’ families and testimonials
from the women themselves. Getting to share
in the women’s pride and struggles strengthens
staff commitment and is often a greater motivator
than simply pay. (FIT)
Staff Discipline and Terminations
Resignations of staff were far more common than
termination for cause at all the sites. Employees
who were terminated had, unless the violations
were extreme, been counseled or reprimanded
before firing occurred. Most of the terminations
were due to repeated tardiness, unexcused
absences, lapses in following security or safety precautions,
harshness toward clients, or asking
favors and accepting gifts from women in treatment.
Sometimes the employees simply did not
perform their duties adequately; one staff member
falsified time sheets. Only one case of potential
sexual inappropriateness was noted, and this was
self-reported by a male employee after a woman in
treatment made advances.
73

V. Continuum of
Services for Women
A
s described in Chapter III, women in these
projects entered treatment with a wide range
of problems that needed to be addressed. In
addition to their substance abuse, they had other
health, medical, or dental problems; co-occurring
mental disorders; histories of violence and sexual
abuse; unresolved relationship issues with family
members and significant others; limited parenting
skills; little or no employment experience; inadequate
education or functional literacy; and poorly
developed capabilities for managing many routine
aspects of daily life. In many cases, they were
involved with the CJS or CPS.
Pregnant women had special
needs for prenatal supervision
and instruction as well
as for bonding with and caring
for their newborns after
their births. The special services
needed for toddlers and
older children are described
separately in Chapter VI,
Special Services for Children.
As they designed programs
for this population, the
grantees had to decide which
services were necessary for every mother and child
and which services might be needed by only a few.
They subsequently had to decide who could best
deliver such services and whether they could most
efficiently and effectively be provided onsite with
hired staff or consultants or offered elsewhere
through existing or new collaborations with other
agencies. In addition, the projects had to resolve
scheduling questions and balance the multiple,
sometimes conflicting, needs of the mothers and
children. Because of competing demands for the
women’s time, daily activities had to be juggled to
In some projects, the
intensity of treatment
activities had to be
reduced and more
flexible arrangements
had to be made to meet
the women at their own
functional levels.
address their personal, therapeutic issues as well
as to establish sound family relationships and
meet numerous offsite appointments. All of these
decisions involved difficult choices and tradeoffs.
Scheduling: Time Constraints and
Competing Needs
All grantees had to adjust their proposed schedules
for working with the women and children separately
and face the challenge of serving mothers
in the context of their families—both
onsite and offsite.
Each project had to determine
how best to fit an impossible
number of desirable activities
into the limited time available.
The pressures arose from several
sources. To begin with, there
were now two or more separate
clients instead of one—the individual
woman—whose needs
had to be met. Moreover, the
population admitted was more
severely traumatized than initially
anticipated and required
more intensive services. The women’s capabilities
for participating were handicapped, in many cases,
by low literacy levels; intrusive medical, mental
health, and legal problems; and the added stress of
parenting responsibilities. In some projects, the
intensity of treatment activities had to be reduced
and more flexible arrangements had to be made to
meet the women at their own functional levels.
Further, the needs of each different family unit
had to be assessed and addressed separately from
each person’s individual requirements.
75

Chapter V
[Although] women without children in treatment
have a relatively fixed treatment schedule, women
with children in treatment constantly need to reorganize
and prioritize treatment schedules to meet
[their] individual needs and the needs of their
children. Also, what we could do in any given
day completely changed over time. All the wonderful
things we planned to do would take a 48-
hour day because of the lower functioning level of
our women—their educa-tion level was lower
than we anticipated, and the children were more
traumatized. Staff would spend a great deal of
time dealing with one tiny matter. (PAR Village)
Our vision or philosophy changed as we incorporated
the needs of the children into treatment; the
needs of moms and children sometimes appeared
to be contradictory. For instance, a woman may
need to be in an intensive counseling session, but
her child may be acting out or be sick and in need
of his or her own mother. We faced such challenges
daily and tried to make sure that the needs
of both were addressed without discounting one
or the other. It’s been a very big issue between
staff who work with children and those who work
with women. (Desert Willow)
We thought we had great services for women and
great services for children. We forgot that we had
them all booked from 6 o’clock in the morning
until 8 at night. We forgot that we needed services
for the family as a unit. One of our biggest
changes has been surrendering control over the
schedule. (IHW)
Women needed time alone to relax as well as time
together with their children to be—or become—a
family. More unstructured time had to be allowed
for women in the early stages of treatment, when
many were adjusting to having their children with
them. Sick children in the residence had to be
cared for, as did newborns. Someone had to
babysit the children after school hours, in the
evenings, and on weekends as well as when the
mothers found jobs or participated in vocational
training. Therapeutic time for the women was frequently
interrupted by offsite appointments to
resolve legal problems or to get medical or dental
treatment for their children or themselves. Each
site had to figure out schedules that considered
these constraints.
The philosophy and program design had to reflect
the fact that women must be emotionally and
physically available to their children in the late
afternoons and evenings. Clinical intensity is
often taken for granted in treatment, perhaps even
more so in women’s programs. This can cause a
serious conflict with the women’s roles as mothers.
The program design and staffing pattern
must reflect the fact that children are present in
the late afternoons and evenings. The women’s
primary counseling, psychological evaluations,
and other clinical services specific to their needs
must occur in the mornings and early afternoons.
(Meta House)
Our clinical team complained that they were not
able to conduct high-quality groups because of
intermittent attendance. Most of the residents
were attending only one or two of the scheduled
clinical groups each week. Some women with
several children could go weeks without attending
groups because their children had so many doctor’s
appointments. Then the women complained
that they were not getting enough clinical services.
Since we couldn’t influence the appointment
schedules, which were determined by the hospital
and other clinics, we shifted our treatment schedule.
The clinical team recommended that groups
be shifted to evening rather than afternoon hours.
Activities such as AA and NA groups, usually held
in the evenings, were moved to the afternoons.
Additionally, each clinical staff member began
conducting weekly workshops during the day in
order to provide the women with one additional
clinical activity each day. Attendance at the
evening clinical groups increased by 80 percent
over a 3-month period. (FIT)
We had some group sessions in the evening, and
then Tuesdays and Thursdays were set aside for
all medical and dental appointments, except, of
course, for emergencies. The medical issues are
huge. We have had an average of 150 medical or
dental appointments per quarter for the [20]
moms and the [40] kids. If we scheduled these
for 2 days followed by groups and education on
76

Continuum of Services for Women
the other 3 days and some evenings, it was workable.
(Desert Willow)
Scheduling treatment groups, house meetings, and
vocational training is a critical issue vis à vis the
consistent need for child care. Because of each
mother’s participation in child care and responsibility
for her own children, groups and activities
must be scheduled at staggered times so that there
is always adequate woman power to supervise
the children. (PROTOTYPES)
A big issue in scheduling has been babysitting. If
an hour is scheduled for groups, does that mean
that [one-]half of the women attend an hour of
group [therapy] while the other [one-]half babysit,
or does it mean that all the
women attend 30 minutes [of
therapy] and also babysit for
30 minutes? These issues
need to be resolved while keeping
in mind requirements to
provide a specific amount of
therapeutic services per day
and to allow time for bonding
and attending to daily living
activities. (Chrysalis)
The way we accommodate the
needs of women who have
children living with them . . .
is to train all women as certified
babysitters. These certified babysitters care
for children while
their mothers participate in school, support
groups, vocational training, and other necessary
treatment activities. This model promotes a
neighborhood concept similar to what these mothers
will encounter once they return to the community.
(PAR Village)
These internal scheduling constraints were frequently
heightened by pressures from external
sources, including Medicaid reimbursement
requirements that women receive a certain number
of continuous hours each day of uninterrupted
treatment. Pressure was also felt from the new
welfare-to-work legislation that emphasized rapid
reentry into the workforce and an earlier emphasis
on vocational training, and custody conditions by
. . . the length of
treatment authorized by
managed care providers
or Medicaid was being
shortened, temporarily
or permanently. This put
tremendous pressure on
the sites to rush women
through the program.
CPS that dictated the levels and timing of parenting
courses or groups. At the same time, the
length of treatment authorized by managed care
providers or Medicaid was being shortened, temporarily
or permanently. This put tremendous
pressure on the sites to rush women through the
program.
The amount that women are expected to do keeps
increasing. They feel more and more pressured:
"Now we have to find a job, and now we have to
learn good parenting." They’re not only expected
to do twice as much, but in [one-]half the time.
It’s almost becoming a situation where we can’t
win. (PAR Village)
Working with women and children
together requires more
time than just working with
women individually. With
managed care and [other]
funding entities wanting us to
shorten the treatment time, I’ve
become increasingly concerned.
(Desert Willow)
Flexibility and resourcefulness
were key to successfully balancing
these competing
demands and developing daily
and weekly schedules that
might change with the phase
of care. For example, several centers were persistent
enough to get the health department or medical
clinics that the women attended regularly to
batch appointments so that several women could
go together in one van at a specified time during
the week. Other sites were somewhat successful
in convincing stakeholder agencies (e.g., child welfare,
probation) to send representatives to the site
on designated days for multiple, back-to-back
appointments with clients who were scheduled
during a single block of time.
Although each site established its own daily and
weekly schedules, as well as phases of treatment,
some commonalities emerged. A typical daily
schedule might contain the activities and approximate
times portrayed in Exhibit V-1, although
these could vary by day of the week. Most of the
77

Chapter V
projects scheduled at least 1 hour per week for
individual counseling to address personal issues
and 16 to 20 hours of additional structured therapeutic
activities in groups. Family counseling
might be scheduled separately, and most of the
projects also encouraged participation in traditional
self-help, 12-Step groups to support recovery.
In some sites, different days of the week were set
aside for specific activities. For example,
Flowering Tree devoted the mornings on Monday
and Tuesday to the women’s substance abuse and
mental health issues, Wednesday mornings to
classes on health and nutrition and domestic violence,
alternate Thursday mornings to unresolved
relationship issues and fundraising events to pay
for women’s recreation and entertainment, and
Fridays to learning Lakota traditions. Specified
afternoons were allocated for offsite appointments
and for learning parenting skills. The weekends
were filled with shopping in Rapid City, church,
self-help meetings, and visitors. Although daily
schedules at Meta House had to be individualized
to make certain that women got to important
offsite appointments, the focus of scheduled educational
groups shifted by day of the week from
vocational issues to parenting, family issues, and
other special topics. Desert Willow set aside two
afternoons a week for offsite appointments.
Schedules also changed as the women moved
through different treatment phases. Women, during
the initial months of treatment at PROTO-
TYPES, were intensely involved in groups focusing
on maintaining abstinence, building self-esteem,
developing coping skills, breaking through gender-
Exhibit V-1. Typical Weekday Schedule
Time
6:00–7:00 a.m.
7:00–8:00 a.m.
8:00–9:00 a.m.
9:00–11:30 a.m.
11:30–12:30 p.m.
12:30–3:00 p.m.
3:00–3:45 p.m.
3:45–5:30 p.m.
5:30–6:30 p.m.
6:30–7:30 p.m.
7:30–9:00 p.m.
9:00–10:30 p.m.
Activity
Women wake up and participate in exercise program
Women prepare children for school or daycare and eat breakfast together
Meditation and morning meeting for mothers to plan day
Individual counseling, therapy groups, and educational studies; in some sites,
one-half the women worked at job assignments
Lunch; in most sites, this included small children
Groups and educational studies; some mothers worked in daycare under
observation, others went to offsite appointments
Personal time before children return from daycare or school
Women greet children with snacks and supervise homework; family play time or
assigned household tasks, including cooking
Dinner with the family
Family activities (may include visitors on some days); special groups and on- or
offsite AA and NA meetings
Bedtime routines for children, depending on age; special groups for mothers if
babysitting was arranged
Personal time and lights out
78

Continuum of Services for Women
role stereotypes, and understanding the impact of
drugs on the family and on women’s roles as mothers.
In subsequent phases, more emphasis was
placed on parent training and supporting the
mother-child unit as well as vocational planning
and household responsibilities. By the final phase,
women were preparing for independent living by
finding housing, jobs, child care, and positive
social networks. Similar changes were evident at
GAPP, where the focus shifted from substance
abuse education and self-care in the initial phase;
to life enhancement classes on nutrition, drug-free
leisure activities, parenting, and traumatic childhood
experiences in the intermediate phase; and
family reunification, vocational preparations, housing,
and other requirements for independent living
during the final stage.
At IHW, newly admitted women participated in
individual and family counseling, GED and vocational
training, physical fitness activities, and parenting
and life skills classes, as well as house
meetings and childcare and play groups. By the
transitional phase, they were living as separate
family units in efficiency apartments, preparing
their own meals, and concentrating on vocational
opportunities rather than therapeutic activities.
More time was spent offsite, and the daily and
weekly schedules became even more flexible.
Collaborations With Other Agencies
and Organizations
Before they established the RWC programs, most
of the grantees or their parent agencies had long
histories of delivering services to addicted women,
using their own resources and those available from
other community organizations to provide comprehensive
outpatient and residential care. As the
projects got under way, continuing or new collaborations
with a variety of relevant agencies and
organizations expedited the provision of some critical
services and the enhancement of others.
The major factors that helped facilitate the establishment
of this program were the long- standing
relationships with other substance abuse, mental
health, criminal justice, and children’s services.
(PROTOTYPES)
One of the most valuable planning actions taken
prior to the program’s implementation was the
special attention given to building community linkages.
(Casa Rita)
The most valuable planning factor was the collaboration
with specialized health and social service
agencies, which began at the proposal development
stage of the project. We included three collaborating
partners in the grant application, and
although the nature of the work these partners
have performed has changed substantially over
the course of the project, the collaborative application
process assisted the rapid development and
execution of subcontracts and the implementation
of specialized program components. (IHW)
In order to provide family-centered treatment to
substance-abusing women and their children, a
large community network had to be established in
which resources were used efficiently without
duplicating services. Through our advisory board
and outreach to these agencies, [we] actively
recruited referral sources, social service agencies,
and various medical clinics to join in a network
that would encourage the formation of partnerships,
appropriate referrals, and the minimization
of service duplication. (FIT)
These relationships made it possible to provide the
comprehensive range of services needed for
women and children without having to offer all
services onsite or to use project staff.
Partnerships with community-based organizations,
a requirement in the original RFA, were formalized
through cooperative agreements.
While we would like to provide all services inhouse,
it is necessary to contract with other support
services in the community to obtain, for
example, psychiatric assessments for children
with behavioral and emotional problems. It is
crucial to participate in collaborative efforts with
other agencies that provide ancillary supportive
services (e.g., medical, physical, recovery-related).
(GAPP)
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Chapter V
It is a vital part of the program to have a network
of service providers available for the clients and
the children. (Flowering Tree)
Projects were resourceful and inventive as they
developed collaborative relationships with medical
and mental health facilities, health education
groups, social service agencies, the CJS, educational
institutions, vocational training facilities,
women’s shelters and advocacy groups, childcare
and well-baby services, churches, recreational
agencies, and other community organizations and
businesses.
We had to network with people in the community
to get the services we needed, and there weren’t
always dollars in place to get those services, especially
for the children. We found that there was
very little out there. We participated in every network,
went to network breakfasts, and served on
other providers’ teams so we could get to know
each other. (PAR Village)
The original hope of the
grantees for community cooperation
was sometimes challenged
as they sought to
establish additional services.
Our vision didn’t change at
all. What changed was our
understanding of the difficulties.
We had a very idealistic sense of how we would
pull the community together to create a holistic
type of treatment, and it was a lot tougher
than it looked when we wrote the initial grant
application. (Chrysalis)
Typical Services Provided by Collaborating
Agencies and Organizations
“We got judges to visit
our center periodically.
. . . and their ideas about
treatment started to
change.” (PAR Village)
Grantees were resourceful and successful in reaching
out to a variety of community agencies and
organizations, both public and private. Although
the specific collaborators are too numerous to list,
the following are a few examples of the types of
services provided.
• Medical and other healthcare services for the
residents and their children were delivered
primarily by contracted physicians, community
hospitals, specialty perinatal facilities, medical
and dental clinics, healthcare centers,
ophthalmologists, and public health departments.
In one site, a local university hospital
provided obstetrical services and parenting
classes to the program participants and pediatric
care to the children. Departments of
public health offered testing and treatment
for STDs and TB. AIDS crisis centers and networks
provided HIV education, counseling,
testing, supportive care, housing, and staff
training. Dental clinics took care of long-neglected
dental problems for both the women
and the children, and speech and hearing clinics
were used to evaluate children and to provide
needed therapy. A local ophthalmologist
offered free eye examinations and glasses to
residents at one center. Community healthcare
agencies gave lectures on breast-feeding,
childbirth, birth control, and safe sex.
• Social service and benefit
programs sent staff onsite to
complete eligibility paperwork
for food stamps and welfare as
well as for the Women, Infants
and Children (WIC) program, a
Federal food program. All of
the grantees established relationships
with local family services
or CPS. One project even
designated a staff person to work full-time
with CPS case workers (see Chapter VI).
• Mental health services, including psychiatric
assessments and therapy, were provided to
women and children through community mental
health clinics and staff from private centers.
• CJS representatives cooperated with several
projects by sending probation officers onsite
to meet with the women and to conduct interventions
if residents threatened to drop out
prematurely. Project staff also tried to educate
representatives from the CJS about the
importance of the program for helping women
turn their lives around.
We got judges to visit our center periodically. This
was very important, especially for our criminal jus-
80

Continuum of Services for Women
tice clients. We invited the judges to tour our facilities,
and their ideas about treatment started to
change. (PAR Village)
• Educational institutions assigned their students
of nursing, social work, medicine, psychology,
or psychiatry to onsite practicums
that augmented services for the grantees.
Local community colleges offered special
courses (e.g., computer skills) for some residents,
as well as adult literacy and GED programs.
Centers for adult education also
assisted with GED, tutoring, and literacy
classes. College students volunteered at several
sites. Local elementary schools collaborated
with the projects in providing afterschool
activities for their students who lived
in the residences and in encouraging the
mothers to become more involved in their
children’s academic progress.
We work closely with the elementary school, which
awards us grants to fund summer programs for the
[older] children. The teachers work with the mothers
to help them become more involved with their
children. (Desert Willow)
The Wisconsin School of Professional Psychology
provides testing, consultation, and individual and
family therapy. (Meta House)
• Departments of vocational rehabilitation delivered
and paid for vocational training services
and transportation, particularly
as the welfare
reform act required more
rapid job placements.
• Women’s advocacy centers
and family resource centers
conducted educational
sessions and counseling on
anger management and
how to survive sexual abuse and domestic violence.
A local hospice provided a grief counselor
to help families with their grieving
processes and to assist the grantee in developing
a series of workshops on dying, death, and
grieving.
• Religious organizations and churches provided
holiday gifts, recruited volunteers to help with
“We’ve . . . recruited
16 churches to adopt
and help decorate the 16
rooms in our facility.”
(Chrysalis)
the children, offered transportation, hosted
parties and fundraising events, and made
donations for special activities and summer
camp scholarships for the children. Some
special ministries made low-cost housing available.
Local ministers also provided spiritual
counseling for the women.
We have a church that supplies us with Christmas
presents and summer volunteers for the project.
We’ve also recruited 16 churches to adopt and help
decorate the 16 rooms in our facility. When the
woman living in the room adopted by a specific
church leaves the project, the congregation provides
her with utensils and dishes to get her started with
independent living. It has worked very well; some
of the churches have even become competitive.
(Chrysalis)
• Legal aid societies offered consultation and
representation.
• Local departments of recreation and other
private organizations augmented the recreational
activities available to the projects. A
local Young Men’s Christian Association
(YMCA) waived fees for summer camp and
swimming lessons for children living in one
residence. A council for the arts gave dance
and art lessons to the residents at another
site. Other community organizations contributed
tickets for special entertainment.
• A variety of businesses
assisted the projects with
basic needs and teaching the
residents life skills. Food was
donated to one grantee by
area restaurants and stores.
Banks helped women open
savings accounts and sent
speakers to the facilities to
teach women about credit
and budgeting. Cosmetic Executive Women, a
sponsor of Casa Rita, gave workshops on
appropriate dress and makeup for employment.
The country club down the street has big buffets
and then sends all the extra food over to us.
(Desert Willow)
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Chapter V
• Volunteer associations, such as the Reserve
Senior Volunteer Program (RSVP) and Foster
Grandparents, provided personnel to work
with the children at several sites.
Offering Onsite and Offsite Services
Another challenge in program development was
for grantees to decide whether services could—or
should—be delivered onsite at the residential facility/parent
agency or provided offsite at the collaborating
agency’s location. All grantees agreed
that it was beneficial to deliver the majority of
services onsite, particularly in the early phases of
treatment, when women were expected to spend
most of their time at the residential program.
Onsite services helped build trust between staff
and clients, were more convenient, and reduced
the need for providing costly transportation and
having staff accompany the women and children to
offsite destinations.
A preferred option to having the women and children
leave the residence for services was to
arrange for staff from the collaborating agencies
to come to the site at specified times to teach special
classes, provide therapy, confirm eligibility for
benefit programs, or deliver other direct services.
The grantees were persistent in finding well-qualified
individual consultants or agency representatives
and in convincing them to deliver services at
the residential program. Bringing outside
resources and expertise onsite augmented existing
staff skills, minimized disruptions to the schedule,
and facilitated prompt interchanges among
providers about the effectiveness of the services
delivered. The resources typically brought onsite
included physical and psychological assessments,
counseling for special mental illness and other
problems, therapy for childhood or adult sexual
abuse and trauma, special classes in relevant subjects
by experts in the field, and determinations of
eligibility for benefit programs such as food
stamps, Aid for Families with Dependent Children
(AFDC), and WIC.
When existing staff expertise and funding constraints
made onsite services impossible, the projects
did their best to arrange appropriate services
for the women and children at offsite locations.
Sometimes the professional expertise and technology
(e.g., medical or vocational training equipment)
available only at these agencies offset any
inconveniences entailed in arranging appointments
and getting the women and children to
them.
I don’t think our substance abuse treatment counselors
are specialists in sexual abuse therapy, and
they don’t think so either. We refer to specialists
who have that expertise. It’s important to recognize
what you’re good at doing, and to let others
handle different areas.
(PAR Village)
When one grantee found that women who had
been sexually molested were reluctant to discuss
this issue in groups, even when the groups were
led by an outside expert, a linkage was developed
with an offsite sexual assault center, where each of
the women with a history of abuse was assigned to
an individual therapist.
Factors That Discouraged a Full Range of
Onsite Services
Although the grantees preferred to deliver all services
onsite, they were constricted by a number of
factors, chiefly cost, space, and concern about
women becoming too dependent on the convenience
of having readily available services at a single
location.
If we had enough money, I would say all the services
should be brought onsite. We brought medical
services, psychiatric services and vocational
training onsite, and I think it really helped. That’s
why we had the outcomes we did. But it’s costly
to bring all those services here. (PROTOTYPES)
Ideally, all these services need to be onsite. The
reality is, you can’t always afford it. (GAPP)
One program, however, insisted on offsite services
because it was not cost-effective to duplicate
services already available from other community
agencies.
Some centers simply did not have sufficient space
to offer all services onsite. This was particularly
true of services for children of different ages who
82

Continuum of Services for Women
could not easily be accommodated together. The
grantees sent older children offsite when they had
no room for afterschool programs and other recreational
activities.
Several grantees were concerned that mothers
might become overly dependent on the residential
program and not learn how to access offsite
resources for themselves and their children. One
reason was the perceived need for these women to
have a daily schedule during later treatment phases
that approximated a realistic, community-based
routine so they could be prepared when they left
residential treatment. This routine included going
to work; taking children to daycare or school;
shopping for food; meeting with CPS workers or
probation officers; and keeping other appointments
with doctors, dentists, or school counselors.
Designating a Point of Contact With
Outside Agencies
Grantees stressed the need to develop and maintain
relationships with specific individuals at service-providing
agencies to which they referred the
women and children, not simply with the organization’s
administration. Sites that collaborated with
numerous agencies and organizations designated a
case manager to coordinate these contacts and
keep them up to date.
We try to have one contact person so an agency
can get to know us and remember us through this
person. Then there’s more likely to be communication.
(Meta House)
Moving from an agency-to-agency approach to a
person-to-person and case-by-case approach is
crucial to success. (Chrysalis)
The most effective way to manage these coordination
tasks is to identify one person in the program
who is responsible for coordination with another
community organization. Likewise, one identified
staff member in the other organization helps to
facilitate communication. Coordination is a critical
and sometimes daunting task for the success
of linkages. It requires continuous and focused
effort on the part of management and staff. (PRO-
TOTYPES)
One project reported initial difficulty with foster
care workers who were not willing to let children
come to a place where there were "addicts and
criminals." After extensive efforts to diffuse this
image and build a positive relationship, the project
now considers the development of trusting
partnerships with foster care workers, as well as
with other agencies and systems that work with
children, critical to their success.
Limitations of Collaborations With
Community Agencies
Not all of the formal and informal collaborations
with community agencies worked out to the
grantees’ satisfaction. Sometimes there were frustrating
waiting lists for services. One site found
that the only community resource for conducting
emergency mental health assessments and therapy
for poor women had a 6-month waiting list.
Ultimately, this site had to find other placements
for these women.
Some women were deteriorating so rapidly that
we couldn’t keep them in treatment while they
waited. And we couldn’t endanger the other
clients and children by keeping them. (PAR
Village)
A local community hospital in another location
had a system for urgent care that differed from
emergency care.
Women and children from the treatment center
often had to wait for up to 11 hours to receive
urgent care [at this hospital]. (FIT)
Sometimes the promised services did not materialize.
For example, one project was frustrated by a
community system’s inability to process paperwork
for food stamps and WIC services for women
and children in a timely manner. Yet another
grantee was disappointed that the Department of
Developmental Disabilities (DDD), which had the
capability to test infants and toddlers for developmental
delays and design therapeutic treatment
plans, did not always meet its commitments.
There were numerous occasions when DDD caseworkers
assigned to work with the project’s children
who had developmental delays did not follow
83

Chapter V
through with scheduled appointments. (Desert
Willow)
Residency requirements and other qualifying limitations
hampered the delivery of some needed
services. Although the public health departments
in some locations offered free dental services in
emergencies involving severe toothaches or
abscesses and private dental clinics sometimes
offered to reduce fees for needed care, these
arrangements were not without problems. PAR
Village, for example, found that waiting lists were
long and that women who did
not reside in the local county
had to be seen at the public
health department where they
lived. Moreover, the local dental
clinic that reduced its fees
insisted on proof of income
and full payment in cash at
the time of the appointment—
conditions that could not
always be met by the residents.
At other sites, staff changes in
the collaborating agency led
to deteriorating services or
unmet expectations with
respect to the number or
quality of services.
. . . a core of
interrelated, sensitive,
and crucial issues was a
major focus of treatment
services at all sites—
parenting skills, family
dynamics and
relationships, and
histories of sexual abuse,
physical trauma, or
domestic violence.
Continuum of Essential Services
Grantees generally agreed on the continuum of
essential services for all the women in treatment.
Briefly described in the following paragraphs, the
continuum included medical and mental health
services; health education; addiction treatment;
training in life skills; educational and vocational
services; recreational and leisure activities; legal
assistance; and special groups or therapy, which
were used to address recurrent
or emerging issues, such as
low self-esteem and empowerment
or grief and loss. In
addition, a core of interrelated,
sensitive, and crucial issues
was a major focus of treatment
services at all sites—parenting
skills, family dynamics and
relationships, and histories of
sexual abuse, physical trauma,
or domestic violence. Since
these issues are central to the
delivery of family-oriented
treatment, the approaches
developed by the grantees to
address them are described
separately in Chapter VII,
Critical Issues in Family-Oriented Treatment.
We have experienced some difficulty with our subcontractor
. . . in providing the full array of services
they are contracted to provide. Most notably,
they have had extreme difficulty in retaining staff
for the project. We are currently working with
[the subcontractor] to resolve these concerns. If,
during the remainder of
this contract year, they are unable to provide the
types of services required on a consistent basis,
we will not renew the contact for the next year.
(IHW)
Assessment and Treatment of Medical
and Dental Problems
All of the grantees obtained medical histories and
conducted physical examinations of the women
and children at—or prior to—admission. This was
usually done by a primary-care physician in a
Medicaid-supported health maintenance organization
(HMO), by a contracted physician onsite, or
through a medical clinic with which the facility
had established a formal linkage. As already
noted, most followup referrals for needed medical
treatment were made to collaborating physicians
or medical facilities.
84

Continuum of Services for Women
The projects all found an overwhelming need for
medical and dental care because the women did
not have private insurance and
had neglected their own and
their children’s physical health
while using drugs. Medical
appointments averaged almost
one per month for each
woman at Desert Willow. Meta
House reported that 83 percent
of the women who stayed
beyond the first month of
treatment received regular and
preventive health care instead of the emergency
room visits they had relied on in the past. Many of
the medical problems diagnosed were gynecological
in nature. Additional common health problems
included various sexually transmitted diseases,
cystitis, stomach problems due to poor
nourishment and stress, chronic back pain, high
blood pressure, orthopedic problems, diabetes,
seizure disorders, and injuries resulting from physical
abuse.
Nursing staff in most of the projects provided
some treatment onsite for minor ailments, administered
medications, and made necessary referrals
for additional care or consultations. All sites that
admitted pregnant women had provisions for preand
postnatal care as well as pediatric supervision
of the newborns. In addition to arranging care for
pregnant women, most of the sites admitted
women who were HIV positive. At PAR Village,
these women were referred to the AIDS Coalition
of Pinellas for case management and support
groups. Those in later stages of the disease
received financial assistance from the Ryan White
Foundation and other AIDS sources for necessary
medical, pharmaceutical, and emergency healthcare
expenses.
Assessment and Treatment of Co-
Occurring Mental Disorders
All centers agreed that it was important to provide
thorough psychiatric assessments of the women
entering treatment, since the number with
co-occurring mental disorders and substance
All centers agreed that
it was important to
provide thorough
psychiatric assessments
of the women entering
treatment . . .
abuse disorders seemed to increase over the 5-
year period of CSAT funding. Some projects
found it necessary to conduct
these psychiatric evaluations
before admission to screen
out anyone with severe psychoses
who could not function
in the program or who
required stabilization on psychotropic
medication before
entering the residential facility.
Others found that psychiatric
assessments were likely
to be more accurate after the women had been in
the residence for some period of time and were
no longer using drugs or showing withdrawal
symptoms.
A variety of arrangements were made to conduct
psychiatric assessments and provide ongoing care
for women with co-occuring disorders. Several
sites had contracts with private psychologists, psychiatrists,
or licensed social workers to provide
individual psychotherapy for women with significant
levels of psychopathology. At least three sites
that tried to use community mental health clinics
or departments of mental health were frustrated
by long waiting lists for services, delays in receiving
the results of consultations, and disputes over
payments.
Counselors refer certain women for a comprehensive
psychological assessment and medication
monitoring. Women suffering from mental disorders
as diagnosed by [our medical director] are
reevaluated once a week. The program also provides
community referrals for mental health counseling
services whenever necessary.
(PAR Village)
I wish psychiatric services could be part of what
we offer. I would like all "intimate" services to be
provided onsite. (FIT)
One of the things that we have been able to show
in our data is that outcomes are definitely a function
of whether or not the woman has bonded
with at least one staff member, and some of our
women have bonded with the psychiatrist. She
comes only once a week, but she’s a very sensi-
85

Chapter V
tive woman—and women who hated psychiatrists
in the past, or were afraid of them, feel close
to a psychiatrist for the first time. (PROTO-
TYPES)
Medication Management
Several of the projects that traditionally had
refused to admit anyone who was not totally drugfree
had concerns about women who were prescribed
psychotropic medications for their mental
disorders. One of the sites worried that women
might become overly dependent on prescription
medications and warned that this was an important
treatment issue. Another site limited the
type of psychotropic medications that could be
used for treating depression. Although most of
the grantees understood the benefits of psychotropic
medication—particularly for treating
the affective disorders most frequently diagnosed
in this population of women—they reported that
women did not always take the proper doses of
these medications at prescribed times.
Treating women who were prescribed psychotropic
medications presented practical issues for the
grantees. These concerns were principally about
the nursing support necessary
to dispense medication and to
monitor medication routines
to achieve compliance.
Grantees agreed that it was
important to closely monitor
both the amount of medication
women were given and
the length of time women
were on specific medications.
They also discovered that clinical
staff did not always understand
the problems women
might encounter if they did
not adhere to prescribed medication
regimens, and these
staff members needed training.
Many staff members had no understanding of the
importance of taking the [psychotropic] meds regularly,
as prescribed. They viewed them like
aspirin—take one or two when you don’t feel well.
“It’s important to
remember that
compliance with
medications is a difficult
issue for many people . . .
We need to be sensitive
to this issue and help our
clients take prescribed
medications correctly.”
(PROTOTYPES)
Also, there was very limited understanding of side
effects, the time it takes before antidepressants are
effective, and so forth. (Meta House)
Another issue was the cost of the medications.
Some sites used major pharmaceutical companies’
indigent medications programs to offset these
costs for women who did not have prescription
coverage as part of their HMO plans.
Several grantees made medication compliance a
condition for continued participation in treatment.
At least one site reported that the clinical
treatment team might determine that a woman
was unable to maintain appropriate behavior in
the community unless she took her medication as
prescribed.
It’s a challenge for us to convince women through
education about the importance of following
through and complying with medication [instructions].
They’ve typically had many years of varying
crises, going through our
county system, seeing a different psychiatrist at
each appointment. These different psychiatrists
have frequently changed the women’s dosages
and/or medications, with resulting confusion,
noncompliance, and a low level of trust in that
whole system. [Also,] we’ve
learned the importance of case
management or advocacy in
terms of helping the women
navigate the medical/psychiatric
system. (Meta House)
It’s important to remember
that compliance with medications
is a difficult issue for
many people—even us. It is
difficult to get people to take
antibiotics the way they are
prescribed. However, psychotropic
medications may
need to be taken for a long
time—even a lifetime. We need
to be sensitive to this issue and help our clients
take prescribed medications correctly. (PROTO-
TYPES)
86

Continuum of Services for Women
Health Education and Physical Fitness
The grantees also used nursing staff, as well as
counselors and outside consultants, to provide
both health education and practical interventions
to improve the women’s physical condition and fitness.
Over several years of the grant, IHW contracted
with a specialist who directed weekly exercise
classes; Desert Willow used a counselor to
encourage women to hike, jog, swim, and go on
extended camping trips; GAPP initially tried aerobics
but settled for dance classes that were more
popular with the women; PAR Village not only took
advantage of the on-campus sports facilities but
used an offsite exercise course made available by
Honeywell, Inc.; and PROTOTYPES included team
sports and physical fitness in its program because
of the well-known contribution of regular exercise
to stress relief and overall well-being. Some sites
also offered special instruction in relaxation techniques
and stress management as part of wellness
programs. All of the grantees prohibited smoking
in the residential facilities, and some offered
smoking cessation programs.
Courses or instruction about health-related topics
were provided by the nursing staff in most sites
and also by specialists from a variety of community
organizations (e.g., WIC, student nurses, health
department representatives, planned parenthood,
AIDS coalitions). Some were single sessions;
other lessons or group discussions were held at
regularly scheduled times over a designated number
of weeks. Among the topics most frequently
mentioned by the grantees were HIV and other
STD prevention and testing; women’s health
issues—including female reproduction, birth control,
prenatal care, alleviating symptoms of premenstrual
tension, and breast self-examination;
eating disorders and good nutrition for women
and children; basic hygiene; recognizing and caring
for sick children; and child safety issues.
Treatment of Substance Abuse and
Prevention of Relapse
All of the sites made provisions for detoxifying
women under medical supervision, if necessary,
but most of the newly admitted women were not
using drugs (e.g., alcohol, heroin) that required
this level of intervention. Hence, few referrals
were made to offsite detoxification centers by
the onsite nursing staff, who did monitor women’s
symptoms and provide some medications for
their relief.
All of the grantees incorporated education about
addiction and relapse prevention into their programs.
Most used a 12-Step approach as the basic
framework for individual and group counseling,
although Desert Willow used 3-hour encounter
groups facilitated by peers and staff to handle
issues arising in the therapeutic community and
to build relationships among the women.
Interestingly, Casa Rita provided once-a-week
acupuncture sessions to aid women in remaining
sober and to reduce their stress. PROTOTYPES
specifically modeled its 10-week relapse prevention
group on the principles of Marlatt and
Gordon (1985) to increase women’s ability to
identify and avoid high-risk situations and triggers
by managing thoughts about drugs, learning to
relax, controlling anger, resisting negative thinking,
and coping with persisting problems. At
Chrysalis, two local clergy members ran a popular
weekly group on spirituality, where women faced
and overcame the guilt and shame associated with
addiction, got in touch with a Higher Power and—
most important—gained some hope. This ultimately
helped women rebuild self-esteem and feel
better about themselves.
Generally, recovery groups met at least twice a
week for 2 hours, but they met more frequently at
sites such as Watts, GAPP, and Flowering Tree that
stressed a 12-Step program. Other recovery-oriented
groups focused more on understanding
addiction and the personal dynamics involved.
Self-help support groups were organized on site,
and the women also attended AA, NA, or Cocaine
Anonymous (CA) groups in the community, especially
in the later phases of treatment. Some centers
insisted that women have sponsors and attend
fellowship groups in the community as a condition
of satisfactory program completion.
The incorporation of 12-Step recovery support
groups into the program schedule, as well as
87

Chapter V
using [AA] principles to teach the residents how
to work and live together, is essential. The principles
of trust, honesty, and forgiveness are applied
on a daily basis. (GAPP)
The program provides three 12-Step programs
onsite, and women also may attend additional offsite
meetings. The program also provides 12-Step
study and an introduction to 12-Step [principles]
as part of its regular services. (PROTOTYPES)
[We] rely on self-help support groups to assist
women in dealing with their recovery once they
return to the community. The women attend AA,
NA, or CA support groups both on- and
offsite throughout the course of their treatment.
They may also take part in other self-help groups,
such as Overeaters Anonymous and Gamblers
Anonymous. Women are welcome to continue
attending self-help support groups at PAR Village
after completing treatment. Transportation is
provided when necessary. (PAR Village)
Training in Life Skills
A major part of treatment in all of the sites was
some combination of formal instruction and
hands-on training in what was loosely termed “life
skills”—capabilities for functioning independently
in today’s world. The grantees did not include all
of the same skills under this rubric, but they generally
focused on developing some proficiency in
such everyday activities as budgeting and money
management; personal hygiene and self-care;
cooking, cleaning, and caring for a household;
home maintenance; use of public transportation;
time management; and accessing and working
with community resources to secure needed
access to education, social services, legal assistance,
employment, recreation, and medical care.
The bulk of this training was incorporated into
everyday living, using curricula developed and
taught by onsite staff who also observed the
women in their residences and provided individual
coaching to improve their skills. Maintenance personnel
did not simply fix the plumbing, but
showed the women how it was done. Cooks or
food service managers also involved the women in
meal planning and shopping, as well as in preparing
meals. Efficiency was encouraged in such
everyday acts as getting to appointments on time
and getting children up, dressed, and fed in time
to meet the school bus.
Basic tasks, like learning how to use a microwave
without starting a fire and practicing safety rules
in the home, especially when there are children,
are a big issue. We discovered through the years
that most of the women have no idea how to care
for themselves or their children. We have a life
skills instructor who goes into the women’s apartments/homes,
observes them, and teaches them
the basics for themselves and their children. The
other staff and counselors also assist. [We] also
found that most of our women have never budgeted
their money. It’s one thing to learn these skills
in a safe environment, but when the [women]
leave and no longer have the safety net, it’s a
whole different world. At followup, we find
women are still having a hard time budgeting
money. (PAR Village)
A specific challenge was helping women learn how
to save money during the residential treatment
stay so they would have sufficient funds to support
themselves and their children after they left. One
grantee invited a representative from a local bank
to visit the treatment site once a month and speak
to the women about credit and budgeting.
Women opened bank accounts, and the project
mandated that women save a certain amount of
money before discharge. Case managers worked
closely with the women to help them reach their
savings goals. In another center, women were
required to fill out requests for funds they needed
on the weekend, and these requests were closely
monitored.
Learning to prioritize expenditures was also an
issue.
They’ll go out and spend $50 on shoes for a
6-month-old baby who won’t be able to wear the
shoes 2 months from now. Learning [spending]
priorities is critical. (Chrysalis)
Two centers insisted that women learn the skills
necessary to negotiate with community agencies
for the information and services they and their
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Continuum of Services for Women
children will need. These women often felt
stigmatized by their past addiction and needed
help to build self-confidence and practice
assertiveness in their contacts with institutions
and organizations.
We really want them to take from our treatment
center ways that they can negotiate with outside
agencies; we want them to become more assertive
and practice self-esteem. It’s amazing how little
they know as adults. It is said in the substance
abuse treatment world that
development stops whenever
you start using alcohol and
other drugs. Some of our
clients started using drugs at
age 13 or 14; thus, they have
very limited life skills, and they
have much to learn about normal
development. (Casa Rita)
Adult Education and
Vocational Training
All of the projects voiced concern
about the implications of
welfare reform and the challenge of preparing
women to meet the job requirements outlined in
recently passed State and Federal welfare-to-work
bills. Although staff, as well as the women in
some sites, apparently had initial difficulty believing
and accepting the scope and potential effects
of the legislation, several of the projects began
conducting vocational assessments and incorporating
job training into the women’s treatment plans
earlier in their residential stays. One site asked
staff to brainstorm for changes that would be
needed to accommodate welfare reform. Staff also
assessed when in treatment to begin vocational
training and considered making employment a
condition for women graduating from the project.
[Welfare] reform became very real when women
[at our program] got the letter in the mail that
said, "Unless you report by this date, you’re not
getting a check anymore." (Meta House)
It’s just overwhelming. We did a 3-hour staff
training. We had Community Legal Services
come in and talk about welfare reform and what
was happening so we could assert ourselves and
“We had Community
Legal Services come
in and talk about
welfare reform . . . so
we could assert ourselves
and advocate on
behalf of our clients for
specific rights and
entitlements . . .” (IHW)
advocate on behalf of our clients for specific rights
and entitlements that were still theirs. (IHW)
Even before the new legislation, however, all of the
sites provided some on- or offsite assistance with
improving women’s literacy, helping them obtain
high school diplomas or GEDs, preparing them for
the world of work, helping them with vocational
testing and training, securing employment, and
retaining a job.
IHW had a contract with Jewish Employment and
Vocational Services to provide
onsite GED preparation and
vocational readiness classes
for women as soon as they
entered treatment. By the
fourth year of the contract,
these classes had increased
from three to six per week. A
career preparedness curriculum
was conducted weekly for
12 weeks to help women identify
and develop career goals.
Residents also participated in
offsite vocational and educational
training programs (e.g.,
secretarial, computer skills, community college
courses). Residents also were encouraged to volunteer
in community organizations, schools, and
healthcare facilities to brush up on previously
learned skills that would improve employment
opportunities.
We had a job fair—a career day—with morning
workshops . . . on vocational preparedness, how
to dress for an interview, and how to search for a
job. . . . Employers had booths and [handed out]
job applications. The clients really enjoyed this.
(IHW)
At PAR Village, all women without a high school
diploma were assessed for educational needs . . .
during the first phase of treatment. Two full-time
teachers provided a comprehensive educational
program, and mentors from the community
offered additional tutoring when appropriate.
[We] were actually successful in raising participants’
academic performance by two grade levels.
[We also established] a working relationship with
the Department of Vocational Rehabilitation (DVR)
89

Chapter V
to assist women in finding part- or full-time
employment. These women also received onsite
training in the use of office equipment. Residents
who needed more formal vocational training were
referred to a vocational school or a community
college. [We’ve also been innovative] in getting
women to explore nontraditional jobs such as
welding that pay more than those usually open to
women. Since the WAGES [Work and Gain
Economic Self-sufficiency] requirements took
effect, and the women are approved for shorter
lengths of stay, vocational activities are offered
earlier in treatment. (PAR Village)
GAPP initially used the DVR program, Project
Leap Forward, to provide
vocational training. Later,
funding from the Department
of Family and Child Services
supported the Professional
Opportunities for Women
Entering Recovery (POWER)
program, which provided individual
and multifamily vocational
counseling, job readiness
support, motivational
lectures, and training in
other life skills. POWER was
augmented by a program
sponsored by the Computer
Curriculum Corporation, Essentials for Living and
Working, which increased participants’ keyboard
skills and familiarity with WordPerfect and
Windows applications.
At Desert Willow, women studied for GEDs with
staff members or volunteers or attended twice-aweek
tutoring sessions at the local probation
office. Twelve women received GEDs while still
enrolled in treatment, and two were awarded
scholarships to the local community college.
Women in treatment, also were administered a
vocational interest inventory and referred to offsite
agencies for further vocational testing and
training. Several residents enrolled in a workshop
on resume writing and job interviewing at the
local career center.
In addition to the training and practice that all
PROTOTYPES residents received in managing the
household and serving as receptionists, training
PROTOTYPES . . . thought
carefully about suitable
types of vocational
training for this
population of women
that would engage their
attention; validate their
self-esteem, skill mastery,
and dignity . . .
was offered for them to become food service
supervisors or assistants at the childcare nursery.
As part of routine programming, the women also
attended a group on job readiness that helped
them obtain and keep jobs. PROTOTYPES also
thought carefully about suitable types of vocational
training for this population of women that
would engage their attention; validate their selfesteem,
skill mastery, and dignity; and allow them
to work in a standard office setting or in small,
home-based operations where appropriate childcare
arrangements could be secured. This grantee
had a full-time vocational counselor; offered five
popular 10-week courses (6 hours per day) in computer
operations, data entry, and word processing
skills; and operated a small
word processing center where
the women could be paid for
work contracted by area businesses,
independent professionals,
and college students. PRO-
TOTYPES staff believed strongly
that substance-abusing
women needed jobs that paid
sufficient wages to support a
family—and that included a
daycare component—to compete
with high-paying prostitution
and other illegal activities
associated with a "street life."
Recreation and Leisure Activities
Another important and often overlooked program
focus at the different sites was helping the women
find low-cost, drug-free recreational activities that
they could enjoy by themselves, with peers, or with
their children and other family members. Many of
the centers involved the women in planning and
raising money to pay for special outings to movies,
sober dances, Renaissance fairs, music and arts
festivals, church services and other functions,
parks, nature walks, sports events, beaches and
boardwalks, and malls.
[We place particular emphasis on] respite care—
the opportunity for mothers to spend time away
from their children, knowing they are safe and
well, and to engage in recreation, reflection, and
completion of tasks that might not have been pos-
90

Continuum of Services for Women
sible without this break from the constancy of
child-rearing. The family services coordinator
involves mothers in planning these respite activities,
which are scheduled for some evening hours
and one Saturday a month. (FIT)
Women also learned how to have affordable fun
with their children—taking part in special activities
at the child care center and at the playground,
going to the zoo, taking nature walks,
exploring museums, hearing stories read or taking
books from the library, and attending puppet
shows or other community entertainment events.
All of the grantees provided family-oriented activities
on the weekends and sometimes invited other
relatives or significant others to accompany the
mothers and their children.
Special attention was given to
celebrating major holidays
that involved the children in
making decorations or preparing
simple food. A recreational
therapist at one site,
and counselors/case managers
or child care specialists
at other
projects, helped plan these
celebratory activities and
supervised the mothers and
children on their outings.
Legal Assistance
A majority of the sites reported
linkages to legal assistance
for the women in treatment.
Most were referred to
resources such as legal aid
societies or legal staff of the
parent agency. One site used
a local community law program to lead seminars
on family law, domestic violence, and financial
counseling. At Desert Willow, staff accompanied
women to numerous meetings with CPS caseworkers
throughout Arizona and in California and also
attended meetings that CPS staff conducted
onsite at the residential facility. This attention to
relations with CPS workers resulted in nearly onehalf
(45 percent) of the women successfully closing
CPS cases by the end of the first year after discharge.
Many also regained custody of children as
a result of participating in the program.
Other Special Services
“[We place particular
emphasis on] respite
care—the opportunity
for mothers to spend
time away from their
children, knowing they
are safe and well, and to
engage in recreation,
reflection, and
completion of tasks that
might not have been
possible without this
break from the
constancy of childrearing.”
(FIT)
As noted in the introduction to this chapter, several
central issues in family-oriented treatment
required considerable program development attention.
Services addressing sexuality and violence,
parenting practices, and relationships with family
members and significant others are described separately
in Chapter VII, Critical Issues in Family-
Oriented Treatment.
However, the grantees also
established special groups to
focus on other relevant issues.
At some sites, these involved
all women in a particular treatment
phase; at other projects,
women were assigned to appropriate
groups as issues
emerged. One topic addressed
in these groups at several sites
was grief and loss—to help
women express their feelings
regarding the loss of sexual
partners, family members, children,
or friends to death, substance
abuse, divorce, or dropping-out
of the program.
Other sites developed curricula
or ran time-limited groups on
such topics as feminine roles,
empowerment, prejudice, mediation
and conflict resolution,
goal-setting, and communication
skills.
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Chapter V
The Timing, Intensity, and Duration
of Services and the Strategies Used
In delivering some services to women in the residential
facilities, grantees also had to consider
when in treatment they should be offered, at what
intensity, over what time period, and the most
appropriate approaches or techniques that would
ensure that the content was fully understood and
absorbed. Chapter IV already
has described how many of the
sites targeted certain services
for different phases of treatment—focusing
initially, in
general, on women’s and children’s
separate, personal problems;
then on the needs of the
family unit; and finally, on the
financial, housing, and other
social supports that need to be
in place before the family could successfully
return to community living. The grantees all
found that women entering treatment were too
needy in too many areas for services to be delivered
in discrete and sequential units.
Nevertheless, different types of services usually
were initiated at different points in the treatment
process and were delivered at varying intensities
over the course of the residential stay.
Some services for women, such as medical treatment,
prenatal care, or psychotherapy, however,
were obviously only offered when the need
emerged, although assessments and monitoring
were ongoing. The educational and vocational
services provided by the grantees often entailed
formal instruction or tutoring in particular skills
(e.g., typing, reading, food services management),
where knowledge and progress could be measured
by standardized tests. These services, moreover,
often were delivered by professional teachers or
vocational instructors who used already-developed
and tested curricula with defined lesson plans and
course outlines. It was in other areas of personal
growth that approaches to helping residents
acquire new knowledge, change attitudes, and try
more functional behaviors had to be developed
All of the sites relied on
some combination of
individual counseling,
group therapy, and more
formal instruction in
small groups . . .
and/or tailored by the grantees to this particular
population of substance-abusing women. All of
the sites relied on some combination of individual
counseling, group therapy, and more formal
instruction in small groups to teach such important
concepts as relapse prevention, anger management,
healthy relationships, and many other
valuable life skills.
The importance of individual counseling and the
positive therapeutic relationships these women
developed with staff members
were consistently acknowledged
in surveys of client satisfaction
with the treatment
programs. At one site,
indepth exit interviews with
residents—who were either
completing treatment or terminating
against staff
advice—revealed their opinions
that one of the most positive aspects of the
treatment experience was clinical staff support.
The commitment of the therapists and staff is
wonderful. They believed in me when I didn’t
believe in myself, and for that I will always be
grateful to them. (FIT client)
Another woman at this facility who was about to
graduate reflected on positive changes she saw in
herself over the course of her stay in treatment
and attributed these changes to skills she learned
in treatment, including how to handle her anger
and temper and how to improve her relationships
with her mother and two grown sons. She further
explained that she had acquired self-insight for the
first time in her life through working with her
staff therapist and case manager.
Although each woman received individual counseling
about her participation and progress in treatment,
a great deal of treatment took place in
groups. The leaders of therapy groups tried to
involve all members and to evoke feelings and personal
responses. Participants were encouraged to
identify their own, and confront their peers about,
maladaptive attitudes and behaviors, as well as to
learn and practice new, positive ones.
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Continuum of Services for Women
The grantees all used structured groups to communicate
important information to participants
and elicit their responses on particular topics.
These groups were conducted by clinical staff and
medical personnel who often used lesson plans—
either developed by themselves or borrowed from
relevant published materials. Most groups of 10
or fewer participants met for an hour or two, once
a week or more often, and continued for a specified
period—usually 12 to 16 weeks. Some outlines
of curricula submitted by the grantees in
quarterly reports contained learning objectives;
timeframes for covering specific material; suggested
handouts, videos, and activities to involve the
participants; and even pre- and posttests and text
for the instructor to use. Other curricula materials
were not so structured, focusing on the content
to be covered but leaving the presentation
style and time needed for delivery more flexible.
Although many topics were taught in classes or
courses, the grantees agreed that these women
learned best if didactic instruction was kept to a
minimum and was followed with practical, handson
experience and coaching in real-life situations.
Interactions among the women and with program
staff in discussions and problem-solving
group sessions also
were considered helpful in
changing the residents’ attitudes
and behaviors.
Staff often took advantage of
teachable moments, such as
meals or bedtime routines with
the children or cooperative
activities involving several residents,
to observe behavior,
intervene, demonstrate new
behaviors, and then get the women to practice
these new behaviors. Many household skills and
safety precautions were taught in practical, reallife
situations in the residence—how to use a
microwave for particular cooking tasks, how to
prevent infection transmission, or how to "childproof"
a room. Staff at Desert Willow emphasized
the provision of immediate critical feedback,
either individually or in a group setting, for behavior
displayed. Particularly important was positive
reinforcement for appropriate behavior or the
incorporation of new skills into previously troublesome
situations. Role modeling, especially by staff
who had made positive changes in their own lives,
also encouraged women to improve themselves
and remain in treatment for a sufficient period.
Interestingly, although the observations made by
staff were not always positive and the demonstrations
were not always successful, this approach
was still useful for identifying issues for further
clinical interventions and skill-building. At one
site, for example, a particular weekend group session
focused on helping mothers work with their
young children to make holiday decorations for
the residence.
. . . household skills and
safety precautions were
taught in practical, reallife
situations in the
residence—how to use a
microwave . . ., how to
“childproof” a room.
The mothers did not want to interact with their
children, and the mothers did not want to take
responsibility for their children participating in
this activity. The deficient mother-child interactions
in the . . . group, in spite of [the attempt to
provide] a medium to foster bonding, are consistent
with frustrations regularly reported by staff.
Parental responsibility, attachment, and bonding
are still clinical, as well as parenting skill, issues.
(FIT)
One site, Desert Willow,
wrote most thoughtfully
about the learning styles residents
brought with them into
treatment and tried to develop
an appropriate curriculum
with materials every participant
could use without feeling
"left out or left behind."
Hence, staff took into
account the women’s differences
in cultural and ethnic backgrounds as well
as their varying levels of literacy. Materials also
focused on empathic content as well as more cognitive
concepts. Workbooks for participants incorporated
a variety of techniques, including reading,
listening to tapes, writing, acting in skits or roleplaying,
watching videos, and participating in
interactive exercises.
93

Chapter V
Additionally, staff at this facility discovered that
many of the women in treatment responded most
positively to intensive 2-day (or longer) workshops
that dealt with such difficult, clinically challenging,
and sensitive issues as childhood sexual abuse,
grief and loss, relationships, shame and guilt, and
violence, including that which is self-inflicted.
Evaluation of participants’ perceived helpfulness of
these workshops indicated that an average of 80
percent of women found them to be "quite or very"
helpful in their recovery process, although some of
the workshops were rated as more helpful than
others. When compared to other treatment components,
workshops were perceived by many participants
to be the most helpful activity in overcoming
addiction and resolving underlying issues
surrounding substance abuse.
Topics for workshops are based on the clinical
needs of the women in treatment. Several standard
workshops are built into the ongoing curriculum,
but others address such recurring issues
as grief pertaining to the loss of loved ones to
drugs and violence. While working on these
issues in short, 1-hour, individual sessions or in
2-hour therapy groups is helpful, more intensive
interventions are needed to achieve deeper understanding
and greater
resolution. . . . These workshops last approxi
mately 2 days. Some . . . address topics in a general
sense; others are tailored to more specific
aspects of the issue. For example, a workshop on
violence may cover a variety of issues, such as
child molestation, victimization, perpetration of
child abuse, and partner abuse. The 2-day format
allows the topic to be addressed from many
angles (i.e., intellectual, emotional, problem-solving,
identification of patterns, prevention).
Various presentation strategies (i.e., video viewing,
[posting] of data/information, art therapy,
group discussion, movement, role-playing, ceremonies)
target differences in learning and processing
styles and facilitate integration and synthesis
of materials. Before the participants engage
with their children again during the time scheduled
for mother-child interactions, the intensity of
the workshop is lightened, and some sense of resolution
is obtained so that any "spillover" of the
women’s emotions is minimized. Additionally,
during the last several hours of the workshop, the
focus is on positive reinforcement, integration of
the material, commitment, and resolution. It is
important that enough time be allowed for the
"wrap-up" so that women can process their workshop
experience and feel good about their accomplishments.
(Desert Willow)
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VI. Special Services
for Children
M
any of the children who came to live with
their mothers in these residential treatment
centers had serious problems of their own.
Because of their substance abuse and other related
problems, most of the mothers had not attended
to the ordinary needs of their children or had
not been living with them for some period of time
before admission to treatment. As a result, many
of the children’s medical, emotional, and developmental
problems had not been previously identified.
As the projects evolved, grantees realized
that incorporating children with special needs into
the residential facilities would be no easy task.
Meeting the needs of the older children, whether
living on- or offsite, was particularly challenging.
This chapter documents the projects’ intentions to
provide all the children in their care with a suitable
environment in which to thrive as well as
comprehensive services targeted to their varying
ages and problems. Also described are the specific
types of services offered by the sites to children
residing with—or visiting—their mothers.
Another section depicts the special linkages developed
with local offices of CPS, where mothers frequently
had pending custody cases or might be
reported for neglecting or abusing their children.
A Safe, Consistent, and Nurturing
Environment for Every Child
In all of the centers, the children, regardless of
age, benefited from a structured, safe, consistent,
and nurturing environment that reinforced a sense
that the world was trustworthy. Many of them had
come from homes that did not provide for these
very basic human needs. The children liked having
their mothers nearby and fully available to
them each evening and on weekends, and they
flourished when given attention and love by their
mothers, staff, and teachers.
A staff member spoke of a little girl carrying
around a box of crackers and not wanting to let
that box go for a long, long time, just because she
was so afraid she wouldn’t have something to
eat. We worked on assuring her, "You will get fed."
It’s important to provide nutritious meals at consistently
scheduled times so the children come to
know that their basic needs will be met. It’s also
important to have structured days for all the children
and to separate children by age levels to prevent
aggression and inappropriate behaviors.
(Desert Willow)
Children need a sense of safety. However you
create that, they need to feel like they can relax
and be kids. They need structure and boundaries.
They also need stimulation. It can be verbal interaction,
being read to, being given things to play
with, being played with, being treated like normal
children. But I think we cannot underestimate the
need for verbal interaction. Staff must immediately
start talking to every child who comes in the
door. Children who have stayed for extended
periods have really bonded with staff they know
and trust. The benefits for the children in the
treatment program are immeasurable. (Meta
House)
Our experience is that a majority of children coming
into our program have a history of poor
attachments and lack of trust. . . . It is a major
priority . . . to establish a strong relationship with
each child and family. Teachers’ modeling [of]
concerned, nurturing, and predictable interactions
[respectful of] feelings can teach a lesson far more
important than numbers, colors, and
95

Chapter VI
. . . letters. That is: adults can be trusted; needs
will be met; and children are valued. (FIT)
[One child’s response to a question about why he
liked being a resident was,] "My mom is at home
with me and she eats with me and she’s there
when I wake up in the morning." That was
enough for me to see just how important it is to
treat moms and their children together and to
have the child care onsite. (GAPP)
Sometimes the children were in foster home placements
or in relatives’ care for so long before the
mother’s treatment that the
children and their mothers
were strangers to one another.
In these cases, the children
did not relate to their mothers
as their parents because they
did not know them.
A number of women entering
treatment have not been with
their children for months, even years. Others
have been with their children but have not been a
stable influence in their lives. We have learned
that consistency on the part of the mothers and
staff works best with the children. Once the children
realize that the mother is going to be a permanent
and authoritative figure in their lives, they
begin to trust and respect her as such.
(Chrysalis)
Providing Comprehensive Services
for Children
Grantees tried to provide comprehensive services
that were tailored appropriately to the ages and
developmental needs of the children. These sites
found it necessary to identify and develop linkages
with other child-serving professionals and agencies
to supplement the services they could offer onsite
with their own staff.
It is very important to provide a comprehensive
array of services for the children who are in the
residential facility with their mothers. The most
utilized service is health care; the benefits of providing
and coordinating healthcare services are
“My mom is at home
with me and she eats
with me and she’s there
when I wake up in the
morning.” (GAPP)
apparent, even for families that remain in
the program for a short length of time. In addition,
onsite, developmentally appropriate child
care, as well as recreational and educational programming,
are key to meeting the needs of children.
Finally, onsite clinical support services for
the children assist with identifying and ameliorating
any emotional, developmental, or psychological
difficulties. (IHW)
Services at the PAR Village Developmental Center
address children’s comprehensive needs, considering
physical, emotional, educational,
cognitive, and social
factors. The Center is a
licensed, therapeutic preschool
providing developmental testing
and assessments; speech,
physical, and occupational
therapies; and community
referrals. Staff and mothers
work hand-in-hand as they discuss the children’s
developmental competencies and learn methods of
overcoming gross motor, speech, or social delays.
Additionally, developmental staff use individual
Educational Development Plans (EDPs), skilltracking
charts, and interaction forms to monitor
the care and progress of the children. Although
this documentation takes time, it has proven
invaluable in guaranteeing and delivering quality
care for all children. The results are discussed
thoroughly with the women, and they are taught
developmental exercises to use with their children
at home. An onsite pediatric nurse also teaches
mothers about their children’s healthcare needs
and helps them become advocates for their children
within the public healthcare system. To meet
the mental health needs of the increasing number
of children in [treatment] who have been sexually
abused or neglected, staff at the Center make necessary
community referrals for family therapy,
mental health counseling, and more. (PAR
Village)
As a result of incorporating children into residential
treatment with their mothers, grantees had to
develop referral linkages, formal contracts, and
other agreements with a variety of child-serving
agencies and organizations that did not usually
96

Special Services for Children
deliver ancillary services to clients in traditional
substance abuse treatment programs. In addition
to special relationships with CPS, which are discussed
separately in a later section, the most frequently
mentioned collaborating
resources were the following:
• Pediatricians who accepted
Medicaid reimbursements
• Local speech and hearing
clinics
• Physical therapists for children
• Specialty clinics at local
hospitals
• Healthy Families programs
• Healthy Start programs
• Head Start programs
• The Red Cross
• WIC programs
• Councils on early childhood
• Departments of developmental disabilities
• Child guidance clinics or psychiatric centers
• Task forces or councils on child abuse and
neglect
• Diagnostic and learning centers
• Foster care agencies.
Specific Services for Children in
Residence
The grantees all provided professional assessments
and treatment/interventions for the various needs
of these children. Bonding between the mothers
and their infants, a crucial priority, was fostered in
onsite, therapeutic daycare facilities under the
tutelage of trained child development specialists,
who also showed mothers how to provide children
with age-appropriate stimulation. The developmental
and socialization needs of toddlers and
preschool-age children—many of whose language,
Bonding between the
mothers and their
infants, a crucial priority,
was fostered in onsite,
therapeutic daycare facilities
under the tutelage
of trained child development
specialists.
motor, and social skills were delayed or underdeveloped—were
the focus of childcare workers in
these centers as well as in the Head Start and
other community daycare programs that some
attended. Working with older
children was more complicated
because they exhibited
anger, violence, and a host of
conduct problems and mental
illness. Most of the grantees
referred more troubled older
children to expert help,
although many communities
did not have adequate
resources for this population.
Grantees also addressed older
children’s educational and
recreational needs and provided
some services for siblings who were not residents
in treatment in order to keep them connected
to their mothers and prepare for family reunification,
when possible.
Professional Assessments
All sites conducted physical examinations of the
children at admission, tested the developmental
status of the younger ones, and observed symptoms
of emotional distress or behavioral problems
among older children who might need further
assessment by experts in these fields.
Physical Examinations
In some States, physical examinations of the children
at admission were a licensing requirement
for residential care. The majority of sites had
pediatricians on staff or under contract; others
referred children to Medicaid providers in the
community or to private physicians the women
already used. Nurses at the sites made certain
that the children had necessary immunizations,
either by bringing these up to date onsite or by
referring the children to clinics where vaccinations
could be obtained for little or no cost. The
WIC program provided well-baby checkups for
babies at Desert Willow.
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Chapter VI
Grantees often were hampered in their initial
assessments of the children because there was so
little information (e.g., immunization records,
birth certificates, and other documents necessary
for enrolling children in daycare or school) available
before they were admitted. One site speculated
that such information was missing because
many of these children were too young to have
been involved in other social service systems.
Evaluation of Developmental, Emotional,
and Cognitive Problems
Initial developmental assessments or screenings of
young children—from birth through 5 years of
age—were usually conducted by program staff who
had degrees in early child development or related
fields. Several sites used instruments such as the
Denver Developmental Screening Test Revised
(Frankenburg and Dodds, 1978) or the Battelle
Developmental Inventory (Svinicki, 1984).
Chrysalis relied on the standard EPSDT (Early and
Periodic Screening, Diagnosis, and Treatment)
program conducted by the Department of Health.
The DDD sent an employee to the Desert Willow
site to test children for delays in fine and gross
motor skills.
At most sites, children with suspected developmental
delays were referred to a specialist for a
more thorough assessment. Ongoing observations
of children at the treatment center were thought
to improve the accuracy of assessments. At PRO-
TOTYPES, for example, children were observed
routinely by the childcare specialists for signs of
any delays in affective, social, and cognitive functioning.
If problems were noted, the child might
be referred for further assessment. In any case, a
remedial plan would be designed for participation
in appropriate groups, tutoring, or other treatment
by specialists.
Staff at PAR Village came to prefer the Hawaii
Early Learning Profile (HELP) (Furuno, 1979) for
developmental assessments because it yielded subtle
results that could be displayed graphically to
convince mothers that delays were real. HELP
also had an accompanying kit of interventions that
the mothers and staff could use to ameliorate any
identified deficiencies. Both mothers and staff
witnessed the impact of these early interventions
and were proud of the competencies they developed
in working with the children to correct their
language and motor skill deficits.
Psychological assessments by trained professionals
were considered necessary for older children who
exhibited behavioral or emotional problems.
Usually, these were conducted through offsite
referrals. Casa Rita, however, had a pediatric
social worker who both evaluated children and
provided counseling for them and their mothers.
The family therapist also was involved. IHW had a
contract, as part of the grant, with the
Philadelphia Child Guidance Clinic to evaluate and
provide weekly individual counseling for children
with behavioral problems or emotional disturbances.
Understanding and Accepting Test Results
Some of the grantees reported problems in communicating
the results of formal developmental or
psychological evaluations by offsite clinical professionals
to the program staff and to the mothers.
Inexperienced staff, as well as the mothers, did not
always understand the language used or the implications
for treatment and feared that results
might be unnecessarily stigmatizing rather than
helpful. It seemed that mothers sometimes
blamed themselves for the child’s deficits. In
most cases, neither mothers nor staff realized they
would be asked to take an active role in constructive,
remedial interventions.
Both staff and the mothers were concerned about
the possible negative implications of labeling children
with emotional or cognitive difficulties as a
result of assessments.
There’s a cultural issue in our neck of the woods.
If you’re going to come in and do an assessment
of the children that says, "Developmentally you’re
here, or mental health– wise, you’re really not
there," the mothers really hate that. The staff
don’t like it either. It would be better if there was
something in between that talked about the child’s
needs for treatment related to the mother’s issues
without turning it into a mental health problem
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Special Services for Children
that could carry through into the school system
and their entire lives. (Meta House)
As we do our assessments, many kids qualify for
special education. And there’s been a lot of discussion
among staff as to whether or not this
child is truly "special ed" with all of the connotations
this carries, or whether the child will catch
up if we just work with him/her intensively.
(GAPP)
One site reported a way to
bridge these clinician-to-staff
and clinician-to-client communication
gaps regarding the
children’s assessed needs:
The staff [at the program] who
needed to communicate with
the offsite clinical professionals
didn’t necessarily understand
psychological language. They
kept coming back to me and
saying, "What does this word
mean?" I finally told the professionals,
"I want you to talk in
lay language and just tell the
staff what they need to do to
work with this child." And that
has worked out. Another part
of this is also interesting. If one of the mothers
hasn’t a clue what the professionals are talking
about, it’s an opportunity for us to say, "Let’s
write down all the questions that you have. Do
you think this is the right thing to do with your
child?" If we develop good relationships with the
clinical professionals, they don’t see this as an
affront, but rather as a family process. (Meta
House)
Medical Care
The infants born while their mothers were in treatment
or just before admission often required medical
interventions, although their health problems
usually were not attributed to prenatal drug exposure.
Although the popular media has published numerous
stories about the deleterious effects of in utero
Some of the more
frequently reported
health or medical problems
of the young children
included lack of
immunizations; respiratory
problems; HIV/AIDS;
failure to thrive; dental
caries; hearing, speech,
and language problems;
and ear infections.
exposure to drugs, particularly cocaine, [we]
found that prenatal cocaine/crack exposure
resulted in very few cases of mild developmental
deficits, mostly associated with prematurity, that
could be managed in the residential treatment center
with planning and staff training. (FIT)
Some of the more frequently reported health
or medical problems of the young children included
lack of immunizations; respiratory problems;
HIV/AIDS; failure to thrive; dental caries; hearing,
speech, and language problems;
and ear infections.
Onsite pediatricians and/or
nurses treated minor infections
or illnesses (e.g., colds,
ear and throat infections), but
children were referred to outside
specialists for medical
services that were beyond the
scope of program staff. One
site utilized a mobile pediatric
unit and also had a doctor and
nurse on staff.
Problems similar to those
experienced with the women
were noted in getting children
to offsite appointments and
rearranging treatment schedules for the mothers
who accompanied their children on frequent visits
to doctors’ offices. Desert Willow reported an
average of 64 medical appointments each quarter
for the children alone. Centers that did not have
onsite medical care tried to coordinate children’s
visits to pediatricians and medical clinics by asking
clients to use a limited number of facilities
and to batch appointments to save time and
reduce the inconvenience.
Several grantees reported that medical treatment
for the children was not always easy to obtain.
Desert Willow experienced delays in getting
approvals through the State provider for surgery
on a child’s clubfoot as well as for vision and hearing
problems diagnosed in other children.
Another site reported that hospitals had closed in
the area, leaving a serious gap in available medical
care.
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Chapter VI
Treatment of Emotional and
Developmental Problems
Significant developmental delays were found in
some of the youngsters, although FIT reported
that screening with the Denver Developmental
Scale II did not uncover any significant deficits
among the children tested at that facility. In
other sites, young children were most frequently
identified as needing speech or physical therapy,
special education, and interventions for attention
deficit disorders. Individual lesson plans were
developed regularly at each site to ensure that
all of the identified problems of each child were
being addressed. These plans also involved
the mothers in providing recommended stimulation
or remediation and consistently reinforcing
expected behaviors.
If I were going to pick one kind
of developmental delay that I
think would cause the most
problems throughout real life, it
would be language delays . . .
In 1, 2, and 3 grades, they
can’t compete because their
language is so delayed. In
addition, the mothers sometimes
treat the kids as objects
and talk at them, rather than to them. They do
not have conversations like those you see in a
healthy-parenting household. (PAR Village)
[About] 25 percent of our children have attention
deficit disorders as well as alcohol-related birth
defects or FAS diagnoses. (Flowering Tree)
Many of the children admitted to [our program]
have histories of parental neglect or abuse.
Twenty percent had developmental delays, and a
majority lagged behind their peers academically.
These children are at high risk for emotional,
developmental, and behavioral problems that
early identification and intervention can ameliorate.
(GAPP)
The developmental needs of toddlers and preschool-age
children were largely addressed in the
therapeutic daycare or early childhood programs
attended by the children, either on- or offsite.
All the grantees
emphasized the value
of mother-infant
bonding in preventing
future developmental
problems . . .
At some sites, children who were 3 years old and
older were enrolled in local Head Start programs;
the onsite nursery was reserved for younger babies
and toddlers. Other projects had different
arrangements with respect to the ages of children
kept at the program or sent offsite to preschool
and other daycare facilities for varying numbers of
hours each day.
All the grantees emphasized the value of motherinfant
bonding in preventing future developmental
problems in very young babies. Desert Willow
taught mothers how to use massage therapy for
soothing young infants.
[We believed that] if bonding occurred between
the mother and child, everything else would fall
into place, and the baby’s future developmental
needs would likely be met by the mother. (Desert
Willow)
Among the mental illnesses
commonly found in children
who were usually over 5 years
old were depression; behavioral
problems, such as destroying
property and stealing; sexual
acting out; social isolation;
violence; and trouble in relationships
with peers, adults,
and other authority figures. These problems were
believed to result from years of exposure to
parental addiction, witnessing and/or experiencing
sexual and physical abuse, and abusive treatment
in foster care placements.
Two children who were aggressive and acting out
[in the childcare center] were referred to the
Children’s Psychiatric Center for therapeutic daycare
and therapy. These were older children, 5-
and 11-year-old boys, who had been exposed to a
very dysfunctional lifestyle prior to the treatment
stay of their mothers. . . . It is believed that [the
5-year-old] has been exposed to inappropriate
sexual behavior and may have been sexually
abused. (FIT)
Older children often had problems with having to
act as the parent in the family when their mothers
were using drugs or alcohol. Staff focused on
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Special Services for Children
these issues in therapy, helping children to act as
children.
The role reversal has to be pointed out when you
see it happening, and you have to help the mother
learn the role her child is in and help her identify
her need to have the child in that role. Mothers
who see all these behaviors believe that they’re
doing great all the time, with no problems. It’s
hard to convince them that this behavior can
affect children in negative ways. (PAR Village)
All of the grantees initially tried to address children’s
disruptive or disturbed behavior by working
with the mother to change her parenting practices
while simultaneously addressing the child and suggesting
how inappropriate conduct might be
improved. If responses were not positive and the
behavior continued, referrals were made to outside
specialists. Exceptions were made if a child’s violent
behavior threatened others. All the sites
agreed that older children could be discharged
separately from their mothers if their behavior was
too predatory or dangerous. Both Meta House and
FIT had children whose behaviors were not
amenable to repeated interventions. This repeated
acting out ultimately warranted exclusion of
the children from the childcare centers.
The first approach to dealing with emotional or
behavioral problems [of children] is for the childcare
staff, counselor, and/or mental health professional
staff to address the issues with the mother.
Suggestions are made about approaches to parenting
the child that might remediate the problem.
Childcare staff also address the issues directly
with the child, utilizing behavioral and supportive
approaches. If these interventions are not effective,
then the director of the parenting program (a
social worker) may try further assessments and
interventions. The mother and team may also
decide to refer [the child and mother] for mental
health services at a community-based mental
health center. This local mental health center
works more intensively with the child and mother.
(PROTOTYPES)
Full evaluations utilizing community resources
are offered to children at PAR Village who are
exhibiting emotional and behavioral problems.
Family and individual therapy is provided by
community referral for children suffering from
sexual and physical abuse and/or trauma issues.
Staff [at the childcare facility] are responsible for
observing and identifying the need for these services.
At times, children exhibit emotional and
behavioral problems because of their mother’s
inability to handle the stress of parenting. In these
situations, keen observation is also required.
Staff observe the mother-child interaction and provide
feedback to the women to help them develop
healthier relationships and learn appropriate parenting
skills. (PAR Village)
One grantee assigned a staff person who was not a
clinician to work with the older children, giving
them a separate group in which to vent their
anger and frustrations. They responded well to
the open, supportive, and nonjudgmental style of
this individual.
She doesn’t do a lot of therapy with them, but she
does listen and talk and teach, so that she’s somewhat
separate from the clinical staff. The children,
who seem to have adapted to the environment
very quickly, are carrying all this rage that
comes out in subtle ways. Allowing them to be
angry, to grieve, and to talk about all these things
is important, as is trying to reduce the mothers’
exposure to their children’s anger. The mothers
are already full of guilt and shame. The older kids
always come to the special group. [Trying to
maintain a] balance between secretiveness and
sharing is hard. You need to reassure them that
this is "their private place." However, they also
have to know that if they say something that
should be shared with their parents, we can do
that. The key is that they’re involved in the
process, not eliminated from it. (PAR Village)
[At our program], children participate in a weekly
fitness class that . . . also helps develop their
social skills. Children have family therapy with
their mothers on a weekly basis, and school-age
children participate in a children’s group [where]
they can express feelings about being in a treatment
program with their mothers, concerns they
have about their families, and how to interact
with other children in a positive manner. (IHW)
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Chapter VI
Emerging Needs for More Professional
Staff in Childcare Components
Several sites did not anticipate the extent of the
emotional problems seen in these children.
Because they found it very difficult to access mental
health services for young children, they would
have preferred to have had child psychologists and
other professionals on staff. One site had so many
sexually abused children who were acting out sexually
that they hired a sexual abuse treatment specialist
to work with both the children and mothers
and to train the staff.
It is very important to have qualified professionals
provide services for children. Recommended
staff positions would include a psychiatrist, pediatrician,
pediatric social worker, and licensed
early childhood teachers. A specific goal should
be to develop individualized child and family
assessments and prevention and treatment plans.
(Casa Rita)
Staff required a great deal of training and supervision
to work effectively with the emotional and
behavioral problems exhibited by the children. It
is very common for children’s acting-out behavior
to increase after they’ve been in the residence a
short time and a level of trust has been established.
Without an understanding of these behaviors
and specific direction on how to respond,
many staff react angrily and view the children as
"naughty" or "disrespectful."
During supervision, many staff
members have talked about
their feelings of incompetence
and impotence in working with
acting-out children. . . . We’ve
learned that the original plan
for staffing the children’s program
(including staff qualifications)
was inadequate, and the
severity of the children’s problems
was underestimated.
We’ve had to rely on psychology
professionals much more
than I originally expected, and two positions are
being added with an eye toward fully addressing
the children’s (and family unit’s) needs. (Meta
House)
Therapeutic Daycare
“Staff required a great
deal of training
and supervision to
work effectively with the
emotional and behavioral
problems exhibited
by the children.”
(Meta House)
All of the grantees ultimately provided some form
of onsite daycare, whether conducted and supervised
by child development specialists in a licensed
facility or operated with the assistance and cooperation
of trained mothers who were responsible
for their own children.
Initially, the children attended a community child
care center. [Unfortunately], efforts to influence
this provider to meet the children’s treatment
needs were largely unsuccessful. As a result, we
opened our own daycare center which can integrate
the women’s and children’s needs into its
programming. (Meta House)
The Women’s and Kids Center opted for a model
of supplementary child care in which the mother
has primary responsibility for her children, but is
assisted by child worker staff. Supplemental
childcare is provided by women in the facility who
are provided with parenting education and are
supervised by childcare staff. This model simplifies
licensing issues because the mother is responsible
for her own children and, thus, a childcare
facility license is not needed. (PROTOTYPES)
The childcare programs at the centers served multiple
purposes: allowing uninterrupted time for
mothers’ individual and separate
treatments; providing a
laboratory where mothers’
interactions with their children
could be observed and
appropriate parenting practices
modeled or directed; and
offering age-appropriate learning
experiences to foster the
youngsters’ emotional, social,
cognitive, language, motor,
and self-help skills. Daily
activities included games, arts
and crafts, music, stories, and
other structured play. At least two sites (PROTO-
TYPES, PAR Village) installed computer-assisted
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Special Services for Children
learning programs that mothers could use with
their children to stimulate cognitive growth.
In addition to being learning environments, these
daycare centers were places for the children to
have fun. Sometimes children went on field trips,
with or without their mothers, to local zoos,
libraries, Chuck E. Cheese or McDonald’s restaurants,
playgrounds, museums, and special events.
Activities for Older Children in Residence
School-age children living with their mothers in
the residences were enrolled in local schools.
Many were performing below grade level in at least
some subjects and had specific educational deficiencies
requiring remediation and coordination
with the schools. Most centers provided some
afterschool tutoring and supervision as well as
recreational activities that involved these older
children. Several of the grantees tried to involve
the mothers in supervising homework, with varying
degrees of success since the mothers’ academic
skills were not always sufficient to provide constructive
help. One center instituted reading
competitions and gave prizes to children who read
the most books in the summer. The women and
their children were taken to the library so mothers
would encourage and participate in their children’s
reading. In one center, mothers were
expected to read to each of their children for 30
minutes a day.
These sites also encouraged the mothers to attend
parent-teacher conferences and Parent-Teacher
Association (PTA) meetings to help them feel
more comfortable with and involved in their children’s
schooling. One site formed a PTA of its
own, and the women practiced talking to teachers
about their children. They were encouraged to
ask teachers questions and get progress reports.
Educational terms were explained so the women
had a vocabulary for speaking with the teachers.
Other sites sent staff to accompany mothers on
school visits.
Our program provides special services for the
[older] children, including an afterschool tutor
who helps with academics. This tutor also works
with the mother and child regarding homework
issues. Additionally, a male, after-school activities
director oversees the recreational program for
all the older children. (PROTOTYPES)
All of the school-age children participate in afterschool
tutoring on a daily basis. For those children
who are experiencing educational delays, the
teachers at our program work closely with the
school to develop and identify strategies to assist
the child. The mothers are included in this as
much as possible and are encouraged to spend
time with their children focusing on educational
activities. (IHW)
The school children at our center attend [the elementary
school] that is located directly across the
street from the facility. The staff have learned that
keeping open lines of communication among
teachers, parents, and children is the key factor in
successfully working with the school system. The
Children’s Services Coordinator and the
Afterschool Counselor at our program work closely
with the school teachers and guidance counselors
concerning any behavioral problems displayed
by the children. Staff from Chrysalis’ Child
Development Center initially meet with each
child’s new teacher to share information related
to the child’s social and emotional history and
progress in school. The Center staff also make
presentations and conduct in-service [training]
for the [elementary school] staff concerning the
effects of alcohol and drug use on children. This
insight helps the school staff better understand
why some of our children are acting out. The collaborative
efforts of these two groups have helped
to decrease the number of discipline notices
received and to increase the academic performance
of our children. Also, the school principal is
a member of our advisory board. (Chrysalis)
The school linkage we have established has
proven to be a viable component to our program;
it plays an important role in the lives of the
women and children. The mothers and their children
actively participate in many of the school’s
activities. Some of the mothers have served on
various committees, volunteered for special
events, acted as chaperones for field trips,
become classroom moms, and read stories to the
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Chapter VI
children in their classrooms. The principal and
faculty members have also served as volunteers
at GAPP and assisted with special events.
(GAPP)
[We] provide tutoring and other academic support
for the children in elementary school, encouraging
mothers to get involved and collaborate
with the schools. [We’ve found] that kids thrive
academically while in the residence because the
staff value education, and the mothers are also
involved in learning by enrolling in literacy and
adult education courses as well as participating
in their children’s education. The school attendance
of the children improves radically while
they are in residence, and their failing grades
come up, too. (FIT)
Some of the older resident children had a difficult
time when school friends wanted to come and visit
them at home or exchange
phone numbers with them.
Some of the children wanted
to hide the fact that they were
living in a substance abuse
treatment center, although
GAPP reported that children
at that site actually brought
friends home from school and
wanted to enroll them in some
of the center’s most popular
activities. Most projects were
ambivalent about this issue—wanting both to protect
the privacy of the children in residence and to
avoid any stigma or shame they might feel while,
at the same time, wanting them to make friends
and to live as normally as possible. One compromise
was to encourage the children’s participation
in community activities (e.g., Boy or Girl Scouts,
Boys and Girls Clubs), where they could interact
and have fun with peers and get away from the
treatment center.
A lot of our children don’t know how to have relationships
with their peers. They do better with
adults because that was their environment. They
don’t know how to have appropriate attachments
and relationships. If we don’t overcome those
barriers, the chances of them being successful in
“The school attendance
of the children improves
radically while they
are in residence, and
their failing grades
come up, too.” (FIT)
school or in the world or wherever they go after
they leave us are pretty slim. (IHW)
At most sites, donations and scholarships were
solicited so that older children could attend local
summer day camps or take swimming lessons.
Both Casa Rita and IHW ran their own summer
camps, finding that some of the children were
reluctant to stay away from their mothers and that
their own staff and college volunteers could easily
organize appropriate activities.
These centers also found it important to have positive
male role models for the older boys. When
male workers or volunteers were present, the boys
gravitated to them.
These boys are just dying for a man [to be a role
model and friend]. (Chrysalis)
It has been very difficult for [us] to find consistent
community partnerships that would work
with the older children and
boys in the [treatment] program,
so we had to be
resourceful. We started two
[of our own] programs. [In
the] first, adult men residing
in a Village South residential
treatment program who had
minor children and needed
parent training were given the
opportunity to volunteer in the
childcare center and to work under staff supervision
with older children, especially boys. These
men became mentors to the boys and, in addition
to talking with the boys regularly, took the boys
fishing and involved them in maintenance tasks
around the facility, such as washing cars, landscaping,
and repairing the building. This proved
to be therapeutic for both the men and the boys.
Additionally, the male teenagers
residing in the Village’s adolescent dual diagnosis
treatment program who were in their last phases
of treatment were given an opportunity to serve
as "Big Brothers" to the boys in the FIT program.
These teenagers assisted childcare workers in the
center, tutored the boys after school, took the boys
on hikes, and played
basketball and went swimming with them. Again,
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Special Services for Children
this proved to be therapeutic for both
the adolescents and the boys in the RWC
program. (FIT)
Prevention of Future Substance Abuse
One specified program objective of most grantees
was to prevent or interrupt intergenerational substance
abuse among the youngsters whose mothers
were admitted to treatment. Sometimes this
was achieved by structuring specific prevention
activities, such as teaching refusal skills and the
dangers of alcohol and other drugs. Some
grantees recommended that older children participate
in drug and alcohol awareness and education
groups or clubs (e.g., Alateen). The discussion
groups organized at Chrysalis for older children
not only provided information on the nature of
addiction and taught refusal skills, but absolved
these children of any responsibility for their parents’
involvement in substance abuse. It also
taught them options to follow if their mothers or
other close relatives relapsed to drug abuse.
Staff engage children in drug-free recreational
activities as well as specific programs to
develop their [drug] resistance skills. [We] use
the "Breaking the Cycle: Recovery for Kids"
curriculum and conduct other prevention activities
for the children on a weekly basis. These
activities provide children with an opportunity to
speak about how their mothers’ drug use has
affected them and their families and what they
can do to keep from getting involved in drug use
themselves. (IHW)
At other sites, more general programming was
expected to produce similar results. PAR Village,
for example, involved older children in groups
where they could address such issues as arguments
with parents, divorce, using alcohol and other
drugs, and prevention of HIV infection.
Our childcare curriculum emphasizes the development
of self-esteem and efficacy in the children
with the intent to prevent their own abuse of substances
in the future. (FIT)
Services for Older Children Not in
Residence
The grantees also provided limited services to older
children who were not living with their mothers in
the treatment center. Some of these children felt
resentful that their younger siblings were with
their mothers when they were not. They were,
however, invited to spend time at the project on
designated evenings, weekends, and school holidays
and to participate in field trips and recreational
activities with their mothers and other family
members. Several sites allowed out-of-residence
children to stay at the facilities for overnight or
longer—up to 60 days at PROTOTYPES. Out-ofresidence
youngsters who had troublesome histories
or evidence of emotional disturbances also
were referred to community resources or were provided
counseling by staff at the treatment centers.
Many participated in family counseling with the
objective, when possible and reasonable, of family
reunification. Efforts were made to work with
these children’s foster care parents.
All resident school-age children, along with their
siblings who are not in residence, are invited to
participate in the Chrysalis Club on a weekly
basis. On an informal level, these children participate
in discussion groups that focus on
drug/alcohol use, its effects, and how to respond
when confronted with drug use. All visitors,
including older siblings, are asked to complete a
3-hour Family Education Program and three
Multi-Family Therapy Sessions offered at the
Chrysalis Center weekly. These meetings provide
siblings who are not in treatment with knowledge
and understanding, not only about how the disease
has affected their mothers’ and their own
lives, but about what they can do for themselves.
Through collaborative efforts with the Department
of Social Services, some children not in treatment
received transportation to the center for visitation
with their mothers and other siblings. (Chrysalis)
Children who do not reside with their mothers are
permitted to visit the residence on weekends and
holidays. We realize these visits are important for
the families and that, at times, they help to keep
the mothers in treatment. For children who do
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Chapter VI
not reside with their mothers but need psychological
or support services, IHW staff assist in identifying
appropriate resources and in arranging and
coordinating appointments. (IHW)
Older children who are not living with their mothers
in the program may visit on weekends, holidays,
and vacations, according to the needs of the
mother and of the child. Additionally, children not
living in the program may be referred by the mother’s
case manager or counselor for needed services.
(PROTOTYPES)
We looked in our State for pockets of money that
would allow us to [provide] services for what we
call "community-based children"—the older siblings
who were in foster care placements or were
living with relatives and wanted a chance to be
reunited with their family. The funds don’t have
to be large to be adequate—they can literally be a
$1,000 or $5,000 grant. We [used these monies]
for COSA (children of substance
abusers) programs. We
get in our vans three or four
times a week and pick up all
the kids who live in the community
from their schools.
They take part in age-appropriate
peer support groups, drug
prevention discussions, life
skills training, other educational
and recreational activities,
and family interventions, and
they eat supper with their mothers or fathers—
because we do the same thing in the men’s program.
Sometimes the children come and spend
Saturday night. We do whatever we can so they
have contact with their parents. It’s as good as
we can do because they can’t come to live [here].
We only have so much space, and besides, some
of them don’t want to live with their moms.
They’re in middle school, they have other friends,
and they don’t really want to live here. They just
want to see their moms. (PAR Village)
Relations With Child Protective
Services
All of the treatment
centers recognized their
duty to inform CPS of
any suspicions that
mothers or others were
abusing or neglecting
the children.
Extensive working relations were developed by all
of the grantees with the local CPS or child welfare
agencies. Many of the referrals to the residential
treatment programs were mothers who had lost
custody of children or had pending cases.
Working with CPS entailed not only regular
reports to the agency about mothers’ progress in
treatment, but decisions about when and under
what circumstances children under State custody
could reside with their mothers in the residential
facility or be reunified with them following their
mothers’ successful treatment. A more sensitive
issue was the reporting of a mother’s suspected
abuse or neglect of a child. Although there were
occasional problems—children not wanting to be
reunified with their mothers, overwhelming paperwork,
and inattention to grantees’ recommendations
that a family not be reunited—these sites
generally had productive relationships with the
child welfare agencies.
All of the treatment centers
recognized their duty to
inform CPS of any suspicions
that mothers or others were
abusing or neglecting the children.
CPS sent workers to
train treatment staff regarding
the signs of abuse and neglect
as defined by State laws and
how to recognize and report
them. On a few occasions,
mothers had to be reported. This was a potential
cause for turmoil in the treatment facility, because
the women feared losing custody of their children.
However, all women were informed at admission
that the program had a duty to report abuse, and
most respected that authority.
With regard to family reunification, the sites advocated
both for and against family reunification,
depending on the mother’s individual parenting
abilities and behavior. To the surprise and frustration
of the grantees, the CPS agencies sometimes
ignored their recommendations that families not
be reunited, even when abuse or neglect had been
noted. This was attributed to the high caseloads
and overwork among CPS caseworkers.
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Special Services for Children
IHW has been very much involved with child welfare
issues. We provide documentation to courts
regarding a mother’s progress in treatment. In
addition, when incidents of abuse have occurred
within our facility, we have reported the incidents
and worked with the child welfare system to provide
additional supports for our families. (IHW)
Our program has ongoing relationships with CPS.
All staff are mandated to report [suspected child
abuse or neglect]. The staff present the need for
reporting to program management and/or professional
staff and are supported in the process.
Our program provides support for reunification
efforts; we frequently work with CPS in assessing
a family’s readiness for reunification. Program
staff often participate with the mother in advocacy
for reunification when assessed as appropriate.
This may involve letters to the court, appearances
in court, and other contacts with the CPS
workers.
(PROTOTYPES)
Staff members maintain excellent working relationships
with representatives from local child
protection agencies. All social workers are invited
to participate on the women’s treatment team.
Staff from the Developmental Center attend custody-related
hearings with clients and assist the
women in understanding custody-related issues.
Family reunification remains the primary shared
goal between agencies, whenever appropriate.
(PAR Village)
Involvement of the program with the child welfare
system is a delicate issue that requires sensitivity
and vigilance. There are several facets to this
issue. One is that many of the women enter treatment
distrustfully, viewing the program as part of
"the system." Another issue occurs when staff
have to report an abuse case; the ramifications to
the program because of residents’ reactions are
enormous. Still another issue is the splitting
among staff that can occur when there are truly
conflicting interests between the child and the
mother. Somewhat more subtle is the potential for
conflicting interests between the client’s role as
woman and mother. For example, do we discharge
a mother from treatment because she
repeatedly hits her children and refuses to comply
with the program rules, despite the fact that this
woman is in desperate need of treatment? (Meta
House)
While it was unpleasant to file reports [with CPS]
on women in aftercare who were suspected of
abuse or neglect, this action was ultimately therapeutic
for the mothers and their children. (GAPP)
A critical agency that FIT approached early . . .
and with which [we] have nurtured an important
relationship is CPS. CPS has three types of linkages
with our program:
• Staff from CPS have been extremely effective
partners in interventions with mothers who
are thinking of or asking to leave treatment
prematurely.
• CPS authorities and the courts are often reluctant
to disrupt the children’s present custody
placement even though the mother has agreed
to enter residential treatment. Courts may be
willing to release the children to custody of the
mother after she has "proven herself" by completing
a month [or more] of treatment. In
such cases, the treatment center is not the legal
custodian and the mother assumes full
guardianship responsibilities. If the mother
leaves prematurely, she may take her children
with her, even if staff feel that this is not in the
children’s best interest. Alternatively, a formal
arrangement can be made in which the treatment
center, the mother, and the courts share
custody rights. This agreement can encourage
the court to be more lenient, since the treatment
center has authority to retain the children
if the mother leaves prematurely or is expelled
from the facility. In such a case, however, the
program must be prepared to care for the children
until the State agency removes them. FIT
operates in both scenarios; each offers certain
advantages, and both require good working
relationships with CPS and the courts.
• Another linkage we have forged with CPS
entails decisions about how to determine
whether suspected or observed child abuse or
neglect is occurring and when a report to CPS
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Chapter VI
is necessary. What usually
triggers such a
report is a mother’s
repeated misuse of physical
punishment with her
child/children that
proves unresponsive to
repeated interventions.
Before an abuse report is
made, the project director
and therapist conduct
a meeting with the mother
about whom the report
is to be made, explaining
the circumstances, reasons, and legal requirements
and ramifications. After the report is
filed, we have a group session with the mother
and other clients to inform them and discuss
the action. As a result, no "dirty secret" is
maintained between the staff and the mother,
and the mother cannot misinform and manipulate
other clients as to what she herself was
told. After a report of abuse is registered, the
mother’s conduct usually improves, because
she has been believably threatened with loss of
custody, and she has also seen the staff stand
firm and act on their beliefs. At no time have
problems with the client population increased
because staff reported child abuse. (FIT)
The Effects on Children of Living
With Their Mothers in Treatment
“The children in the
residential facility come
out of their shells while
they are here. They
appear happier, are
more participatory, and
have better verbal
skills.” (Casa Rita)
Grantees offered informal comments about the
positive effects on children of being allowed to
reside with their mothers in residential substance
abuse treatment facilities as well as the most critical
aspects of programming for
these children.
The children in the residential
facility come out of their shells
while they are here. They appear
happier, are more participatory,
and have better verbal skills.
(Casa Rita)
[We saw] significant improvements
in all the children who had
developmental delays in language,
fine and gross motor coordination,
and social-personal skills. All of the 18
babies born to mothers who were in treatment
were drug-free at birth. Of the 130 children
served, 120 were reunited with their mothers.
(Desert Willow)
108

VII. Critical Issues in
Family-Oriented Treatment
M
uch of the programming in the projects
focused on three critical and interrelated
issues that are the core of family-oriented
treatment but are not always traditional elements
in comprehensive substance abuse treatment: sexuality
and violence, parenting practices, and relationships
with family members and significant others.
The vast majority of women entering treatment
had histories of physical and sexual abuse
during childhood or as adults; many had been battered
in domestic assaults and
had traded sex for drugs as
part of a current or past
lifestyle. Because the women
had not previously disclosed
these issues or examined feelings
about them, their attitudes
spilled over into their
parenting practices. Most of
these women had no role models
for, or experience with, loving
and trusting relationships,
and they did not know how to
discipline or express affection
for their children. They did
not understand the dynamics
of family relationships and had
to make decisions about not
only their roles as mothers but how they would
relate to family members and significant others.
This chapter describes the problems the women
had in each of these areas and the interventions
grantees developed to address them.
Sexuality and Violence
All of the grantees structured interventions to
deal with the profound and universal problems the
Almost all of the mothers
admitted to residential
care had been emotionally,
physically, or
sexually abused as children,
and few had
received any previous
counseling to confide,
understand, and resolve
their feelings of shame,
anger, and victimization.
women in treatment had with sexuality and violence.
Almost all of the mothers admitted to residential
care had been emotionally, physically, or
sexually abused as children, and few had received
any previous counseling to confide, understand,
and resolve their feelings of shame, anger, and victimization.
Many had recently been involved in
abusive sexual relationships, both as the abused
and the abuser. Their unexpressed and unresolved
anger often carried over into relationships with
their family members, including
their children. Also, a
number of these women traded
sex for drugs and engaged
in sexual behaviors that
seemed inappropriate as they
became abstinent. While in
treatment, they struggled with
their views of themselves as
sexual objects, with limited
understanding of what else it
means to be women—to feel
good about themselves and
also to be assertive and selfsufficient.
Some of the
women substituted sexuality
for positive self-esteem.
Others were confused about
their sexual orientation because of past experiences
in jails and prisons or because they felt
betrayed by men or mistook initial feelings of
trust and cooperation with other women with sexual
longings. Many had surprisingly little factual
information about reproductive issues and safe
sex. Healthy sexual functioning in loving relationships
was almost unknown to them.
Sexuality [for these women] is very much related
to drug acquisition and issues around incest and
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Chapter VII
violent relationships. All of our women have been
sexually active and have children, but many of
them have never experienced pleasure in sex or
known anything about their bodies. (Meta House)
There’s a lot of sexual confusion, especially with
crack cocaine, trading sex for drugs, and all of
the things that go along with these. (PAR Village)
When, Where, and How To Address
These Issues
The centers had different opinions about when and
how to bring up such sensitive issues and intervene
with women who had histories of abuse and
trauma. Whereas some programs thought it
important to address these problems early in
treatment, many urged waiting until women had
stabilized their recovery, were comfortable with
their surroundings, and had developed some trust
in the staff.
All of the projects agreed that women needed a
comfortable and safe environment in which to discuss
their past abuse and their current sexual
issues—a climate of openness and trust where
they would not be stigmatized, shamed, or
ridiculed by other clients or staff. The projects
tried to impart effective coping skills that would
help women manage the overwhelming feelings
that arose from exploring their pasts. Staff had to
be trained to deal with clients’ reactions, including
anger and violence, as well as withdrawal.
These services were developed because there was
a gap in services for women, but there was also
the fact that women needed a safe place to discuss
issues of sexuality, violence, and other
abuse. [We have discovered that] women tend to
self-disclose their experiences with prostitution
and domestic violence in the course of discussions
about women’s health. (Casa Rita)
Sexual abuse issues are addressed with the
clients as they arise. During the intake process,
we identify whether or not a client has been affected
by emotional, physical, and sexual abuse.
Within 72 hours of admission, we administer a
Trauma History Checklist. At that time, clients
are informed that additional counseling can be
obtained to address these issues if they so desire.
(GAPP)
Sexual abuse issues are assessed from the time of
admission. Treatment may be provided throughout
the woman’s stay. However, the timing and
intensity are determined by the woman’s readiness
for treatment, her mental status, and other
factors. (PROTOTYPES)
Staff have determined that women dealing with
sexual abuse should only address these issues
after they reach a certain comfort level in treatment
and are ready to cope with the trauma and
get necessary ongoing mental health counseling.
Thus, sexual abuse and incest issues are
addressed at various times in treatment, depending
on established individual needs. (PAR Village)
Two sites (FIT and Desert Willow) noted that
mothers tended to ignore or overreact to sexual
acting out by their children in the childcare center
or the residence. Some overlooked inappropriate
sexual exploration by their children; others
became hysterical. Their reactions were influenced
by their own guilt, shame, and past experiences.
Both sites took advantage of these occasions
to help mothers explore their feelings and
get special counseling. Desert Willow also enlisted
a trained social worker to teach mothers about
the warning signs of sexual abuse, age-appropriate
sexual play, effective intervention strategies, and
the importance of working on their own sexuality
issues and interrupting the intergenerational cycle
of sexual and physical abuse.
Because alcohol and drug use and sexuality can be
entwined, staff members must be knowledgeable
about and comfortable with discusing sexuality
and intimacy issues with women in individual and
women-only group sessions. If staff members are
unable or unwilling to talk openly about these
issues, a woman’s fears and concerns will only be
exacerbated, and the possibility of a healthy recovery
may be limited (CSAT, 1994).
Finding appropriately trained staff to work with or
run groups for women who had been sexually
abused or had other issues around sexuality was an
ongoing problem. Some staff were uncomfortable
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Critical Issues in Family-Oriented Treatment
working with lesbians in treatment. Some projects
hired gay and lesbian staff who were open
about their own sexual orientation. However,
most agreed that prejudice and discomfort among
staff about working with openly lesbian clients
were major issues that had to be addressed.
The staff of the program is diverse in sexual orientation.
All staff are well trained in issues of sexuality
and sexual orientation. (PROTOTYPES)
Because of the limited availability of mental health
services and the pervasiveness of the identified
[sexual] abuse, [we needed] to hire two full-time
licensed clinical social workers to work with the
women and children on a continuous basis.
Another . . . need was to add a curriculum on
sexual addiction that would be taught by a
trained therapist who specialized in addiction and
sexual disorders. (PAR Village)
Interventions and Approaches Used
A major challenge for these centers was to develop
realistic treatment goals and effective interventions
for the many women who had experienced
abuse and trauma. All offered some combination
of structured education, group discussions and
therapy, and individual counseling.
Education About Women’s Health
One discovery experienced by most of the projects
was how little the women knew about their own
bodies, personal hygiene, reproduction, sexual
functioning and development, and STDs.
Although the women were "sexually experienced,"
they seemed eager to learn and were very attentive
to and appreciative of lectures by the onsite nurses
and other staff about women’s health issues.
They needed to learn "the facts" for themselves
and to talk with their children about sex. A variety
of approaches were used, including groups,
classes, and guest speakers.
Several sites commented that most of the women
knew nothing about mammograms and did not
always practice safe sex to reduce the risks of contracting
STDs and HIV. Some of the clients knew
little about their menstrual cycles and the biological
realities of becoming pregnant. Providing family
planning information, including information
about condom use and how to negotiate with a
partner to use one, was important to give women
more choices about future pregnancies.
They didn’t get this education growing up. (Casa
Rita)
If we’re really going to empower women in terms
of sexuality, [we have] to start with some basic
facts and education that focuses on acceptance of
their own bodies, not what the media portrays as
the new "heroin chic." (Desert Willow)
One center held a weekly women’s health group
that focused on safe sex practices, the menstrual
cycle, and helping women learn to respect their
bodies. Another used nursing students who were
interning at the facility to teach women about
basic hygiene and medical care. Yet another incorporated
a "history of women" class into its basic
sex education curriculum. Several sites looked at
the impact of culture on sexuality and the differences
among cultural groups regarding what is
considered healthy and what body images are considered
attractive. Some sites also addressed eating
disorders as they relate to sexuality and body
images.
Therapeutic Groups That Focus on Sensitive,
Interrelated Issues
Several of the grantees used groups on such topics
as victimization, anger, guilt, and shame to help
women not only understand how common these
feelings are, but to encourage them to disclose
their personal experiences, gain insight, and get in
touch with their own feelings and reactions.
Desert Willow, for example, facilitated groups on
such interrelated issues as anger and violence,
physical and sexual abuse, shame and guilt, childhood
messages, and rape.
[At our facility,] a woman’s survivor group meets
for several hours each week for 12 weeks to focus
on issues of sexual and physical abuse from childhood.
The participants are encouraged to understand
and express their feeling about being vic-
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Chapter VII
tims and to examine the impact of these experiences
on their roles as mothers. (PROTOTYPES)
Many of the projects turned to trained experts in
the community to run onsite groups related to
sexuality and violence or enrolled women in
already-existing offsite groups led by professionals.
For example, Chrysalis used a staff member from
the local Coalition Against Domestic Violence and
Sexual Assault to run a weekly class on this
subject, and at Watts, a therapist from the Rosa
Parks Assault Center counseled women about
sexual abuse and assault. At PAR Village, a
counselor from the Center Against Spouse Abuse
led weekly groups on domestic violence, a staff
member from the SAFE Center provided onsite
staff training and ran groups for survivors of
incest, and a representative from the Women on
the Way Challenge Center facilitated a group on
healthy relationships.
As noted elsewhere, staff at Desert Willow strongly
believed that intensive workshops lasting several
days gave women sufficient time and an environment
in which to explore sensitive issues at a
deeper level. Here, the women disclosed and
processed disturbing events and articulated how
they were affected by these events. Participants
reported that such workshops helped them to
understand and resolve issues from the past and to
develop positive, alternative ways of behaving. The
workshops were conducted in a safe environment
away from the intrusion of daily routines, used a
trained facilitator, involved a group of peers who
knew and trusted each other, and excluded anyone
who had harmed a member of the group. The
multiple activities at the workshops usually included
video presentations followed by group discussions,
dissemination of research findings or other
factual information, art therapy, role playing, ceremonies
(e.g., letters of amends, a gift for a survivor),
and commitments by the participants.
One particularly helpful workshop developed and
tested at Desert Willow addressed the violence
that had been experienced by so many of the
women admitted to these residential facilities and
that if untreated, could lead to posttraumatic
stress disorder. This site noted the cycle of violence
that persists when women with childhood
histories of violence aggress, as adults, against
their own children. Explorations of childhood
abuse in these intensive workshops helped participants
identify patterns and make positive behavioral
changes. The staff at Desert Willow found
that work on violence also must address the issue
of women as perpetrators, including the resulting
shame and guilt that should be dealt with by making
amends to those who were abused. In a survey
conducted at Desert Willow, 77 percent of the
women acknowledged emotionally abusing a partner,
and 61 percent said they had been physically
abusive toward a sexual partner. The discussions
of violence also examined women’s personal experiences
in terms of the degree/level of their victimization
(e.g., assault, rape, molestation),
aggression (e.g., hate crimes, child abuse, verbal
abuse), or witnessing (e.g., gang rapes, murders,
child torture). If the women in treatment who
participated in this workshop persisted in violent
behavior, they were referred to special counseling
to learn new, less aggressive ways to communicate.
Groups To Build Self-Esteem
As an antidote to negative experiences with sexuality
and violence, many of the sites tried to help
women become empowered, practice assertiveness,
improve self-esteem, and search for ways to
develop healthier and more intimate relationships
that include love, trust, and friendship, as well as
sex. These groups stressed the importance of
helping women to develop healthy sexual identities
and believe in their ultimate worth. One center
insisted that helping women upgrade their vocational
and educational skills is an integral part of
this issue—by enabling women to see themselves
as whole human beings with skills and dimensions
beyond their sexual functioning.
[These women] look for anything that will validate
them. And the easiest thing they may know
how to do is have sexual relationships. We do a
lot of women’s groups on self-worth. I think that
projects that have a more feminist bent accelerate
women’s recovery a little more than those that
are hesitant to look at self-esteem. When you have
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Critical Issues in Family-Oriented Treatment
worth, you have worth—with or without your
partner. (PAR Village)
Acceptance through sexual behaviors—that’s
what the women learned in their drug-using culture.
We have to unravel their sexual practices
and help them to develop a healthy personal sexuality.
They all seem to become infatuated with getting
a [sexual] partner—whether heterosexual or
lesbian. We have a group on healthy relationships
and sexuality in which we try to get women to
examine why they do whatever a man wants and
then try to empower them to stand up for themselves.
(FIT)
[Our program includes] group discussions about
what the women expect in a man and how to
build healthy relationships. Most of these
women’s partners are in prison, so they have no
relationships at all after a few
months in treatment.
(Flowering Tree)
[We try to help women] figure
out what to look for in a mate
and how to find love and intimacy.
(Watts)
[Our program] runs weekly
groups on women’s health and
sexuality, relationships, and
empowerment training. (Casa
Rita)
Several grantees used groups
to help women learn to trust
each other; many of them had engaged in prostitution
and had little confidence in the honesty and
integrity of others. Groups also helped women
explore the implications of culture on their comfort
level in discussing sexuality and sexual orientation.
Education, openness, and respect for individual
backgrounds and beliefs were essential.
Being a woman out on the street, you don’t trust
other women. Then, in the group process, women
build relationships with each other and learn that
they’re talking about the same issues and feeling
the same feelings. (Desert Willow)
They discover so many commonalities in group
and it’s therapeutic. (PAR Village)
Desensitization
“Acceptance through
sexual behaviors—that’s
what the women
learned in their drugusing
culture. We have
to unravel their sexual
practices and help them
to develop a healthy personal
sexuality.” (FIT)
One site, GAPP, offered an experimental program
of desensitization for women in treatment who
self-identified as survivors of trauma. These
women were recruited as volunteers to reprocess
and transform this past experience so as to reduce
its impact on their social functioning. They were
offered eye movement desensitization reprocessing
(EMDR) therapy that was conducted by a trained
and licensed social worker. Participants in EMDR,
who had to be in Phase II of the program, received
one to four 90-minute sessions. The EMDR therapy
guided these women to revisit and process traumatic
events while identifying feelings associated
with them. Following EMDR, the participants
seemed to feel better about themselves and to be
more emotionally stable, less anxious, and less
psychologically distressed. According to data collected
at GAPP, only 28.5 percent
of the 14 women who
received EMDR dropped out of
the residential treatment program
before graduation.
Individual Therapy
In addition to other interventions,
many of the grantees
found that sensitive issues pertaining
to sexuality, promiscuity,
sex for drugs, and domestic
violence were best addressed
through intensive, individual
therapy with a trained professional. Women who
had been severely traumatized were more likely to
reveal their past histories and acknowledge their
pain and guilt in individual sessions than in
groups.
Weekly counseling [sessions with each woman]
focus on emotional, sexual, and physical abuse.
(GAPP)
[We found] that prostitution and sex for drugs
were acceptable parts of the drug-using lifestyle
when the women discussed these issues in a
group format. They were more likely to express
their pain and acknowledge the connection
between past molestation as children and current
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Chapter VII
prostitution when counseled in individual therapy.
(Watts)
Sexual Behaviors During Treatment
Nearly all of the grantees reported that inappropriate
sexual behavior in the residential facility was
not a major problem or concern. A few of the
women did act inappropriately while on passes or
if they came into contact with men at AA meetings
or at treatment sites that had programs for
men. Coeducational GED classes were disbanded
at one site because of sexual activity between male
and female students. Lesbian activity also presented
an occasional problem at some sites, and
newly admitted women sometimes had to be counseled
about inappropriate clothing.
Dress Codes and Rules
All the grantees had some form of dress code that
prohibited provocative clothing. Women, for
example, could not lounge around the facility in
bathrobes and nightgowns, go without bras or
underwear, wear shorts that were not a certain
minimum length, or dress in clothing that was
"too tight." Mostly, clients were counseled individually
if they violated established dress codes, and
the matter was viewed as a therapeutic issue. At
some sites, inappropriate dress was dealt with at
community meetings, and clients could be "called
up" and asked to change clothing.
When the women first come in, they become familiar
with what they should or shouldn’t wear.
While in treatment, they also learn how they define
themselves and their relationships, and they begin
to understand why they’re dressing the way they
are. (PAR Village)
[We try to convince the women that] we care
about modesty so people can see the real you, not
focus on your clothes. (FIT)
Sexual Activity in the Treatment Facility
All of the grantees agreed that sexual activity in
the treatment facility, whether the woman was lesbian
or heterosexual, was inappropriate. Most of
the grantees had curfews and were more or less
strict about women being out of their rooms after
a specified hour. Sometimes, the grantees relied
on honesty for enforcement. IHW reported that
lesbian activity was alleged in the residence but
was never verified by staff; FIT said that lesbian
relations in the residence were only a problem
episodically. At Flowering Tree, women had to
take passes out of the facility in groups of three to
avoid pairing off as couples. Not all the projects
agreed about how to handle sexual behavior in the
residence. Some believed that women could be
terminated from treatment for such behavior.
Most reported that they did not discharge women
but addressed sexual acting out as a treatment
issue in therapy groups or transferred one of a lesbian
pair to another room or treatment facility, if
necessary.
Partnering is not allowed in the program, and
women are discouraged from establishing exclusive
friendships as well. Partnering and exclusive
friendships often impair the woman’s progress
toward recovery and are disruptive to the house.
(PROTOTYPES)
Sexual Activity in the Community
Restrictions also were imposed by all the grantees
on passes to leave the residence. The time limits
of these restrictions varied by project. Casa Rita,
for example, allowed weekend passes after 30 days,
whereas clients at Desert Willow generally could
not have home visits for 2 to 9 months, and those
at Flowering Tree were only allowed home visits on
major holidays. Women at Meta House usually
were in treatment for 6 to 18 months before they
earned pass privileges.
What the women did while on passes usually was
regarded as their own business, although projects
tried to counsel them about getting involved
with—or resuming relationships with—inappropriate,
enabling, or abusive sexual partners. Sites
that postponed home visits stressed that women
had entered treatment for recovery, and sex was
not everything. However, GAPP reported that
many women did drop out of treatment because of
unresolved relationship issues with males who
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Critical Issues in Family-Oriented Treatment
were still in the drug culture. Most projects
expected the women to be honest about whom
they were seeing while on passes and to discuss
their relationships in therapy. Two sites reported
that clients became pregnant while on weekend
passes, and one woman became infected with HIV.
We try to relate the issue to recovery and to
relapse. We used to be a lot stricter. Women
know that sexual acting out is not acceptable, but
we equate their behaviors with alcohol and other
drug-seeking behaviors and addiction. I don’t
think a lot of staff really understand sexual addiction.
With crack cocaine, it’s very hard to understand.
They’re out of control. While we think we
really have a very good understanding of sexual
addiction, we will terminate women who will not
stop the behavior. (PAR Village)
For some women, discussing sexual acting out
can be a real learning opportunity. It’s a chance
to understand the precipitating factors that led a
woman to have sex with a guy when she didn’t
even enjoy it. (Desert Willow)
Parenting Practices
Because most women entering treatment either
had been separated from their young children for
some time or had been living with their children
but not attending to all their needs, improving the
mothers’ parenting skills was a major goal of all
11 grantees. The projects developed a variety of
parenting education programs, including both formal
instruction and an array of experiential activities,
to help women overcome guilt about their
previous neglect of children, understand the
impact of their childhoods on their roles as mothers,
discover new ways of parenting, practice less
harsh forms of discipline and more expressive
forms of affection, and bond with and enjoy their
offspring. All the grantees encountered thorny
issues in their attempts to assist the women in
parenting their children. Major disagreements
arose when mothers competed with their children
for staff attention, when parenting practices and
styles were linked to cultural differences, and
when mothers chose to—or programs were forced
to—turn over custody of children to the State.
These sensitive situations provoked useful and
open dialog among the staff, between staff and
clients, and among the mothers involved.
In many respects, the parenting program became
the "hub" of treatment. This was due to the
[women’s] extreme deficits in parenting skills and
also the therapeutic issues triggered for the
women as a result of their parent training, including
the abuse they experienced as children. Except
for keeping their kids clean and well fed, parenting
was a foreign concept for most of the women.
They didn’t know how to nurture or enjoy their
children or what were age-appropriate behaviors.
(Meta House)
Parent Training Programs
Although all the sites provided extensive education
and training about parenting, no two programs
were exactly alike. The basic approach, however,
involved some combination of formal parenting
education classes, modeling or coaching by
trained staff, experiential learning through active
interventions, and peer support groups. The different
parent training components evolved as the
centers gained a fuller and more specific understanding
of the women’s parenting styles and the
influences of their childhood experiences and cultures
on their parenting. The grantees also had to
deal with the staff’s expectations and values about
parenting. For instance, many staff members were
appalled at what they interpreted as unruly and
disrespectful behavior by the children, particularly
sexual acting out.
Formal Parenting Education Classes
In parenting education classes, mothers primarily
were taught age-appropriate expectations for their
children. These were based on formal knowledge
about the different stages of child development
and how this knowledge could be translated into
practice. For example, the women learned appropriate
times and ways to introduce toilet training
to their children and the age at which they might
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Chapter VII
expect the children to "sit still" or "behave" on
shopping trips or social visits in the company of
their mothers.
All the sites made arrangements for regular parenting
classes, which either were conducted onsite
by staff members with the assistance of special
guest speakers or were held in nearby agencies
with expertise in the area. The amount of time
spent in formal classes also varied by project.
Mothers at Chrysalis, for example, attended 45-
minute parenting sessions taught by staff 3 days a
week and attended another class taught by a representative
from the Adult Education Center. At
FIT, the women were expected to attend 12 or
more sessions a year at a 6-week, hands-on
program conducted by the Linda Ray Intervention
Center or a 15-week multicultural class conducted
by the Baby Steps Clinic. IHW provided both
onsite parenting classes on such issues as
discipline and safety and also sent mothers with
children under 5 years old to a Healthy Beginnings
program held at a nearby church once a week.
Desert Willow conducted its own 2-day parenting
program that combined discussions of past
family experiences with present parenting issues
and styles.
Since some child welfare agencies or CPS required
that women they referred to these residential
centers attend and graduate from parenting
education classes as a condition of continuing
child custody, several sites developed and distributed
certificates that the women could use as
proof of their participation.
The sites also used a variety of curricula and other
materials for these classes. One of those was The
Parent’s Handbook: Systematic Training for
Effective Parenting (STEP) (Dinkmeyer et al.,
1997), mentioned by Desert Willow. Chrysalis was
impressed by materials from the Hazelden
Foundation that focus on the three biggest issues
for these women: handling anger, setting limits
and boundaries, and being consistent. Several
projects noted that most parenting education
materials were written at a much higher reading
level than the women could understand. At some
sites, staff revised the curricula to be comprehensible
at the second or third grade level.
Mothers also learned how to care for their different-aged
children, both emotionally and physically.
In some sites, pediatric nurses taught the women
about their children’s healthcare needs: when to
go to the doctor, how to take the temperature of a
baby or child, what immunizations are necessary
and when, how to dress children for different
weather conditions, and the nutritional needs and
preferences of different-aged children. Women
often had misinformation about health and parenting
issues and needed to be reeducated. For
example, many of the children ate a diet consisting
primarily of carbohydrates (e.g., cereal, cookies)
and whatever the oldest child could prepare
for all the rest when the mother was not around.
These women also had to become empowered and
encouraged to be advocates for their children with
healthcare and social agencies. At some sites, the
nurse accompanied the mothers to the doctor’s
office for their children’s appointments. In general,
however, it was considered preferable for the
women to learn how to approach healthcare professionals
with their own questions and to advocate
for themselves and their children.
Our pediatric nurse taught the mothers how to
negotiate the Medicaid system and insist on
Board-certified pediatricians for their specialneeds
children. (PAR Village)
Hands-On Help With Parenting
It was universally believed that classroom-style
training alone was insufficient for these women to
improve their parenting skills. The women
seemed to learn better from repeated, hands-on
coaching and interventions in their residences, in
the daycare centers, and during directed recreational
activities with their children. Because the
women were usually with their children in the
early mornings, in the late afternoons after daycare
or school, at all or most meals, at bedtime,
and for longer periods of time on weekends, there
were plenty of opportunities—teachable
moments—for counselors and childcare staff to
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Critical Issues in Family-Oriented Treatment
observe the women’s parenting styles and to suggest
more effective practices.
At PAR Village, for example, parent education
classes were followed by evening demonstrations
in the women’s homes. An instructor helped the
mothers set up routines and rituals for bath, bed,
meals, and other times—such as just before dinner—when
the children were most difficult. The
instructor sat down with each mother and made a
list of recommendations for establishing practical
routines and schedules and for dealing with her
children’s difficult behaviors. During the week
that followed, the woman recorded the recommendations
she had implemented and the outcomes.
If the recommendations did not work, they were
modified; if the woman had not tried any of the
recommended behaviors, she was asked for an
explanation. The instructor, who was like a second
mother to the women in the program, gained their
trust for being both available and approachable.
They felt comfortable asking her questions and
confiding in her.
This approach is by far the most effective we have
found—more so than support groups, skills classes,
handouts, and all that stuff. It’s just getting in
the house and [working alongside] the mom.
(PAR Village)
The grantees also took advantage of the onsite
daycare programs by insisting that mothers spend
designated time in class with their children to
observe staff-child interactions and to apply skills
they witnessed there or learned in other more formal
parenting courses. The mothers were expected
to play with the youngsters, supervise them,
and guide their behaviors. Watching clinical staff
and teachers work with children in real-life situations
was an important component of parent training;
mothers were expected to imitate these effective
approaches to parenting. Staff not only modeled
ways of handling and disciplining children,
but showed mothers how to enjoy them and reinforce
positive behaviors.
When childcare is onsite, a woman can spend
part of her day in the center with the staff where
we can do hands-on modeling, hands-on parenting,
and observe her interactions with the child.
These observations are also reported to the mother’s
clinical team, who are concerned about her
comprehension of the parenting class lessons and
how her behavioral changes, from anger management
to age-appropriate expectations, are affecting
her children. (PAR Village)
In the mom’s treatment plan, we incorporate time
for her to be with the child in the classroom. She
gets support and the teachers can say, "This is
something good you can do, and these are suggestions
you can try." (IHW)
At most sites, mothers of newborns and mothers
being reunited with children who had not been
living with them before admission were excused
from all regular activities and expected to spend
significant periods of time—all day for at least 2
weeks at Desert Willow and up to a month at PAR
Village—in the therapeutic childcare center.
Here, they learned, for example, how to hold and
feed babies and massage them or how to play with
older children by reading and talking to them.
Staff at PAR Village noticed that mothers bonded
more closely with their babies who were born
while they were drug-free in the treatment center
than they apparently had to their older children.
These mothers had a more sensitive understanding—almost
instinct—about their new infants’
well-being and emotional need than they had for
their older children, whom they did not seem to
know as well and did not so naturally observe.
At another site, staff brought in their own children
to model parent-child interactions. This had an
instant effect.
Women noticed that the head teacher’s 2-year-old
was acting like any 2-year-old, but the way
she handled it made a difference. Afterwards,
some of the mothers said, "Wow, your son acts
just like our kids, but you don’t go off yelling at
him." (Casa Rita)
However, some of the sites were concerned that
staff had very authoritarian relationships with
their own children and doubted that all of them
would model suitable parenting practices. In fact,
differences among staff with respect to proper par-
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Chapter VII
enting led to many staff discussions and training
so all could agree about what was being taught.
Grantees also helped these mothers learn to have
fun with their children by enjoying recreational
activities together. Every outing or party at the
site was an opportunity to model and coach
women about how to communicate with their children
more appropriately and how to show real
affection.
Many of our parents do not know how to play
with their children or do not know of games and
activities in which to participate as part of their
child’s development. But "play" assists with parent-child
bonding. (IHW)
The sites offered different explanations for why
women had difficulty playing with and talking with
their children. For example, many women did not
have parents who played or talked with them when
they were children. Also, some women were raised
to believe that parents and children belong on two
different levels; it is disrespectful for a child to
play with or speak back to his or her mother. One
center described this behavior on the part of the
mothers as "objectifying" the children.
The [mothers] are emotionally detached from the
[children] and have not established a bond. So,
they can hit them and say, "I told her to do this
and she didn’t, so what else could I do?" (FIT)
A related issue noted by all the grantees was the
mothers’ inability to express affection naturally
and convincingly. Although staff at Casa Rita
reported that the homeless mothers from shelters
in that program were very proud of their children
and kept them well dressed and groomed, these
women still needed to be encouraged to enjoy
their children and express affection for them physically.
Mothers at FIT had to be taught how to
cuddle their children and comfort them when they
were hurt or tired. A Harvard-trained volunteer at
Flowering Tree taught mothers how to massage
their children and help them relax.
Most of our clients were raised in boarding
schools and had no real nurturing; issues of bonding
had to be addressed in treatment because
these were abandoned children who lived with a
norm of "no touching" and never saying "I love
you." (Flowering Tree)
To help mothers learn how to enjoy interacting
and conversing with children, one grantee
required the women to hold their children in a
rocking chair and talk or read to them for a certain
length of time. Until they became accustomed
to this ritual, the women felt awkward.
Another center required the women to spend
1 hour a week in the developmental center, feeding
and talking to their children. In both
instances, the staff observed the mothers’ behaviors
so they could evaluate their parenting abilities
and the assimilation of what they were learning.
Another grantee filmed parent-child interactions
with a video camera. At first, the women thought
that they looked silly talking to their children
when they watched the videos, but they eventually
became excited about this approach. In some centers,
twice-weekly parent-child activities were
organized to ensure "quality time" for mothers and
their children. Most of the projects planned birthday
parties, recreational outings, and social gettogethers
so the women could learn to have fun
with their children. As one center observed, when
mothers enjoy their children, it’s much easier to
parent.
More experienced peers in the TCs also modeled
appropriate parenting behaviors, both naturally
and by design. Sometimes women in later phases
of treatment simply reached out and took new
admissions under their wings. Or, staff would pair
a newcomer with a veteran client in a "buddy" system,
expecting the more experienced mentor to
model appropriate behavior toward the children,
watch for problems, and act as a peer counselor.
Parent Support Groups
Most of the centers also incorporated peer support
groups into the parenting program. These groups
provided opportunities for the mothers to brainstorm
for ways to handle difficult parenting problems.
One center had women keep a weekly journal
about their parenting experiences and then
share their frustrations and progress with the
group. At PAR Village, women organized a support
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Critical Issues in Family-Oriented Treatment
group known as the "Lunch Bunch" to talk about
their common problems with children.
It’s empowering for women to learn that some of
what they’re going through, all moms and dads go
through. Not being able to handle children can be
a huge relapse trigger. I don’t think you can treat
a woman without knowing what’s going on with
the child in the center and what’s going on in that
[parenting] part of her life. (PAR Village)
These treatment centers stressed the importance
for the women to discuss their own childhoods,
the way they were parented, and their reactions.
Many women did not initially
see the connection between
how they were brought up and
how they were raising their
own children. These issues
were integrated into the
women’s own individual,
group, and family therapy sessions.
Women needed much
reinforcement to talk about
any negative feelings they had
toward their children. For
example, some women needed
to hear a staff member or
another mother talk about her own frustrations
with her children’s behavior before they could
acknowledge their anger. Perhaps most importantly,
the support found in peer groups allowed
women to express some of their negative feelings
about their children without acting on them.
Another common problem was the women’s reluctance
to acknowledge the effects of their substance
use on their children. Discussions about
this issue evoked feelings of guilt and shame and
were sometimes a trigger for relapse. Women had
a full range of reactions to these discussions, from
denial of the impact of their addiction on their
children to hypervigilance about their children’s
emotional and physical health. In these situations,
peer support was helpful in getting women
to acknowledge problems they were having with
their children and to explore positive ways to react
without becoming defensive with staff or angry at
their children.
“I don’t think you can
treat a woman without
knowing what’s going
on with the child in the
center and what’s going
on in that [parenting]
part of her life.”
(PAR Village)
Parent support groups often used role-playing as a
way of helping mothers really understand how they
were parenting their children and reacting to disruptive
behaviors. The women often could not see
beyond themselves to understand and empathize
with how their children might be feeling or reacting
to their mother’s behavior. One site had
mothers play the role of the child at 1, 2, and 3
years old so they could envision what timeout
might mean at different age levels and when this
form of discipline might—and might not—be
effective.
Role-playing is very strong. It’s concrete, they
can see it. The [mothers] sit
back and see how they look to
others. More importantly, they
tend to believe it, if it’s what
their peers are saying.
(Chrysalis)
Difficult Parenting-
Related Issues
Several issues related to parenting
were not
easily resolved. All of the
grantees struggled with ways
to involve the mothers in their children’s activities,
to assure them that they had ultimate
responsibility for the care of their offspring, to
provide culturally competent and sensitive parent
training while maintaining prohibitions against
violent disciplinary practices, and to recognize
that some women may lack the capacity for
effective parenting.
Competition for Staff Attention
One common problem faced by the projects was
that women often were jealous of the attention
that staff paid to their children. The mothers
often would compete with their children for staff
attention or withdraw into their own concerns.
This seemed to be a manifestation of the women’s
lack of intimate and loving childhoods, as well as
guilt about their failures as mothers.
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Chapter VII
We have noticed very real tensions created by providing
services for both mothers and their children
in one treatment setting. The mothers frequently
respond in a jealous manner to the attention
given to the children, commonly
complaining that staff
care more about the children
than about them. This comes
up with every young woman
who comes in because of her
need to focus on her own personal
issues. It’s been difficult
to ameliorate staff tendencies to
judge the women as merely selfcentered
rather than recognizing that this is a predictable
dynamic, given the fact that most of the
women experienced childhood abuse and neglect
themselves and, therefore, are extremely vulnerable
and in need of nurturing. All the staff, of
course, go goo-goo over how cute all the kids are.
So, when a mother has to be confronted because
of a parenting problem, what almost always
comes up is, "You just care about the kids around
here, and you don’t care about us women." This
therapeutic conflict can be very positive, but it
was sometimes an interesting challenge. (Meta
House)
Competitive behavior was thought by some to be
a manifestation of the guilt the women felt for not
providing adequate care for their children. A lot
of moms go back to "I remember when I bought
my child this and then I sold it for drugs." There’s
a lot of guilt around that issue. (Chrysalis)
This competition for attention was addressed in
counseling by encouraging the women to talk
about what they did not receive as children. Some
centers also gave birthday parties and gifts to the
women to help them feel that they were as special
as their children. When women observed their
children having fun and making things, they often
wanted to be involved in these activities themselves.
Sometimes they would openly compete
with their children for the staff’s attention and for
an opportunity to be involved in the same "fun"
activities.
“Because of the
residents’ addiction, they
have not had the opportunity
to be mothers to
their children.” (GAPP)
We had arts and crafts projects for awhile, and
the moms wanted to get involved. They wanted
to paste the macaronis on because they never did
that. And when I would interview them in their
apartments, they were proud
of the artwork that they had
done. It’s then that you realize
that they didn’t have a
childhood. They have a lot of
catching up to do. (IHW)
This competitiveness also was
addressed by insisting that
mothers take responsibility
for their own children and by reassuring them that
they were competent to do this.
Because of the residents’ addiction, they have not
had the opportunity to be mothers to their children.
When they enter treatment, they have this
chance but don’t know exactly how to exercise it.
The kids attend our therapeutic nursery where
they receive love, discipline, and nurturing from
experienced childcare providers. This sometimes
causes tension between the mother and child.
Our staff are trained to promote understanding,
not competition. They accomplish this by recognizing
and acknowledging competitive issues and
constantly placing the responsibilities for mothering
on the residents. (GAPP)
Mothers were considered to be the primary caretakers
of their children while in treatment. The
role of the staff was to assist them in their
parental roles, not to usurp this obligation. The
goal was to empower the mother to be a good parent,
especially if she had not exercised her
parental responsibility in the past or had used it
inappropriately. Mothers dealt with childcare
duties and decisions, and staff encouraged and
taught appropriate behaviors.
A major issue that must be addressed . . . is the
reconciliation of the image of the immature and
irresponsible newcomer in treatment with that of
a mother who must take care of her children.
Because of the need to enforce the mother’s
parental authority with her children, staff must
also be careful not to undermine her role, espe-
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Critical Issues in Family-Oriented Treatment
cially when there is an intervention regarding her
own behavior. (PROTOTYPES)
Ideally, the women were active participants in
(1) the development of their children’s individual
service plans, (2) communications about the children’s
progress, (3) the children’s health and education,
and (4) caring for the children during
hours when they were not involved in their individual
treatment.
The program ensures parental involvement by
making certain that women are kept informed and
understand their children’s service needs. All
mothers are directly involved with staff in developing
and selecting educational goals for their
children. If specific needs are not provided directly
by the program, families are linked with necessary
community services. This assists staff in
gaining parental cooperation and support. (PAR
Village)
In some sites, another way that
women were given responsibility
for children—and learned
techniques for taking care of
them—was to have them
become babysitters for the
children of other mothers who
were ill or were going to doctor’s
appointments, attending
groups or counseling sessions,
or working in the community.
The mothers were usually
trained for this responsibility
and were certified as capable.
Sometimes the babysitting arrangements resembled
the voluntary, cooperative exchanges among
mothers of small children in community neighborhoods.
At other sites, all mothers were expected
to work a certain number of hours in the childcare
center, assisting with all the children, not only
their own, and thereby learning more about the
individual and developmental differences and
responses of children of various ages.
When women are attending special group meetings
or school in the evenings, childcare is provided
by peers who have completed childcare educational
classes and are certified babysitters. On
“A major issue that must
be addressed . . . is the
reconciliation of the
image of the immature
and irresponsible newcomer
in treatment with
that of a mother who
must take care of her
children.” (PROTOTYPES)
some occasions, it may be necessary to hire a
paid babysitter from the community. (PAR
Village)
Illness and hospitalizations of pregnant and postpartum
women require alternative care arrangements
for their children. For short-term hospitalizations
and illnesses in the FIT program, a team
of senior client volunteers under staff supervision
assume nighttime care for
the children, much as they might aid a neighbor.
The children attend their usual childcare/preschool/public
school activities during the day.
Prolonged or frequent maternal absences due to
hospitalization may necessitate placing the children
in the care of family members or with a foster/shelter
care provider. (FIT)
Not all the mothers were willing to take responsibility
for supervising others’ children. At Desert
Willow, extra evening staff
were hired to ensure that the
children were being given adequate
care. In addition,
schedules were rearranged so
that any group activities for
women began after their children
were safely in bed and
could be watched more easily
by others.
Parenting Styles Attributed
to Cultural Differences
Another challenging issue for
grantees was the perception among staff and
clients that culture strongly influenced parenting
styles, determining the type of discipline used and
the way affection and nurturing were expressed.
The differences that caused the most disagreements
entailed the role of parental authority, corporal
punishment and harsh discipline, food preferences,
the designated disciplinarian, and the use
of home cures for treating illnesses. When cultural
clashes occurred, they either could divide the
residential community and undermine the project’s
goals for the children or be positive in opening
honest dialog among both clients and staff.
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Chapter VII
One controversy pertained to the role of the child
in the family and the community. Several projects
became aware that there were at least two points
of view about the role of children. In child-centered
cultures, children are the center of attention.
In other cultures, children are valued
peripherally, and adults make no eye contact with
them. This difference had implications for how
children were expected to behave. Cultural differences
also were seen in how people handled each
other’s children, whether the children were seen
as belonging to the community or to the parent.
This most often came up when discipline was
needed or a child or baby in distress needed help.
Among Native Americans, for example, different
tribes have different expectations for children
at different ages. In some tribes, you are never
without a parent because the role of parent can be
passed on to an aunt or uncle.
(Flowering Tree)
I grew up in the housing projects where everybody
disciplined everybody else’s child, and everybody
looked after everybody else’s child, and you didn’t
speak back to anyone who was larger or older
than you. It could be . . . any alcoholic or addict
in the village. Regardless, you just didn’t disrespect
the culture of the neighborhood. That had
as big an impact as anything on how I parented.
(FIT)
One important factor in addressing these issues
was helping staff members look at their own culture
and biases as a way of sensitizing them to cultural
differences among the families who were in
treatment.
When staff started cultural/ethnic competency
training, they often used a lot of words and
stressed learning the dogma. In other words,
African American people do it this way, Hispanic
people do it that way, and so on—which was
very unproductive. One of the things that worked
best was to spend time in staff training, not looking
at other people’s culture, but looking at one’s
own. (PAR Village)
Several of the sites addressed the differences in
parenting styles by implementing culturally specific
components.
[We] engaged grandmothers to teach the mothers
and the children about their roles and expectations
and to teach them names and purposes of
cultural ceremonies (e.g., vision quests). This
helped clarify the different roles of daughter, mother,
grandmother, aunt, and others. (Flowering
Tree)
[We] enrolled mothers in a multicultural parenting
group because different cultures parent in different
ways. All parents must take part in this group so
they can understand the differences in parenting
styles and parenting philosophies. (FIT)
[We] ensure that culturally competent parent
training is provided to parents of racially mixed
children, drawing on diversity as a strength.
Different backgrounds can be shared, including
having the mothers talk about their heritage or
background with their children. Also, children are
included in all celebrations. (Desert Willow)
[We] offer a Black parenting program that encourages
the parents to accept and understand their
culture. (Watts)
The most problematic issue that clients and staff
attributed to cultural differences was discipline,
particularly physical punishment. All the grantees
reported that the mothers in treatment routinely
hit and yelled at their children or jerked them
about. Some mothers walked out on the children
when they misbehaved. FIT reported that women
arrived at the residence insisting that they were
good mothers, that they did not need to be told
what to do, and that they did not want to hear
criticism. Confrontations about discipline were
sometimes very serious and difficult.
One of the thorniest things we have dealt with is
when the women say [we are] not respecting
their culture by telling them it is not okay to
spank. (Meta House)
All the sites ultimately agreed that physical punishment
was not allowed and could not be turned
into a cultural issue. Parenting seemed to have
less to do with ethnicity or religion than how the
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Critical Issues in Family-Oriented Treatment
women were brought up and the fact that they
did not really know how to control their children
without hitting them. Women who were physically
hurt as children when they misbehaved almost
instinctively treated a misbehaving child the same
way.
[Our] rule is no acts of violence,
no matter where you
came from and no matter how
it was done in the generations
before you. (PAR Village)
While the women were
required to follow program
regulations regarding the punishment
of children, they had
to be taught alternative and
more productive ways to discipline their children.
The more success the mothers experienced with
positive disciplinary practices, the more willing
they were to practice these approaches and to try
other variations. In general, parenting practices
that were taught in the various programs were
derived from the current child development literature.
These practices (1) encouraged close and
openly affectionate relationships between mothers
and children, (2) recognized the mother as the
primary caregiver, (3) gave mothers a major role
in promoting their children’s learning and education,
and (4) insisted that mothers discipline their
children in a nonviolent manner, without any
spanking or derogatory name-calling.
In addition to timeouts, several other positive disciplinary
strategies were used.
Provide a structured environment. Children do
better with more structure in their lives. (Meta
House)
Teach mothers to constantly
remind themselves of their own
control problems and of their
potential to become angry,
which could result in physically
hurting their children.
Constant repetition of these
reminders finally convinces
mothers that they are true and
Women who were physically
hurt as children
when they misbehaved
almost instinctively treated
a misbehaving child
the same way.
Probably the most
difficult issue faced by
these centers was how to
deal with mothers who
were not interested in
their children.
makes it easier for them to control their anger and
discipline their children in other ways.
(Chrysalis)
Use "the look," which varies by race/ethnicity.
For many African Americans, "the look" means
"we do not want to go there,"
or "we’re not going to have
that discussion. I didn’t ask
for any feedback, I simply
asked something of you."
(Watts)
For Native Americans, a raised
eyebrow by a grandparent is
"the look" and means, "you’d
better chill or you are going to
get it." (Flowering Tree)
Several projects also noted the importance of
accepting women who have practiced physical punishment,
rather than judging them as bad mothers.
I think it’s important to try not to be judgmental
about what you see in the women when they come
into treatment. That also relates to the culturalethnic
issues. Start with the dialog. "Okay,
you’re doing it one way. Have you ever tried it
this way?" rather than, "This is what you need to
do to be a good parent." (GAPP)
Custody and Family Reunification Issues
Probably the most difficult issue faced by these
centers was how to deal with mothers who were
not interested in their children. Although it was
not common for women to have to give children
up for adoption or for them to refuse to take or
keep custody of their children, almost all grantees
had some experience with
these occurrences. These sites
initially had assumed that all
mothers would want to keep
their children, whether or not
this involved a reunification
from foster care or relative
care. Yet, some mothers consistently
tried to avoid any
contact with their children by
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Chapter VII
making excuses to have other women look after
them or by ignoring or openly rejecting their children.
They say, "I love my child," but you don’t really
see the nurturing and the caring. (Casa Rita)
Projects also had to address the tragic fact that
some of these women had their children as a
result of rape or prostitution
and really had no desire to be
mothers. Others had been
away from their children for
such long periods that they
did not know them at all.
You really question the women
who relapse, especially after
they get their children back.
When you face them with
"What’s going on? What happened?"
they say they just
couldn’t handle it. So you
start all over again, basically.
We know it’s by sheer accident
that many of the women have
their children anyway. In one case, a woman
who begged for her child exclaimed when he was
brought to her, "It’s a big boy." She thought he
was going to be an infant. When she remarked, "I
don’t want him, he’s too big," we were stunned.
But we were not going to give the child back. So
we had a co-mother work with him and we kept
him in order to observe what was going on.
About 3 days later, the mother asked for him;
today, she is reunited with all four children and it
is working very well. (Watts)
Not all of these cases were so successful. Several
sites reported that they had children removed
from their mother’s custody because of inappropriate
mothering; some were returned to grandparents,
others to foster care.
One of our women got custody of a 6-year-old son
she had not seen since infancy, and she took out
her frustrations on him. The damage to this child
had already been done, and his mother wasn’t
able to repair it. We finally had to ask CPS to
intervene. (Desert Willow)
“Relapse . . . can be
significantly more
emotionally charged in a
program for women and
children . . . because the
children are present,
and everyone witnesses,
firsthand, the devastation
of the children.”
(Meta House)
FIT brought in CPS on several occasions in the
first years of the grant to revoke custody and pick
up children whose mothers had walked out of
treatment. Word got around rapidly, and the
mothers now know the program will take action if
necessary. The project is better prepared, and the
mothers tend to stay longer, once they understand
treatment. (FIT)
However, mothers’ rejection of
their children, as well as program
reports of abuse to CPS,
caused tremendous tension
and conflicts among staff.
Relapse . . . can be significantly
more emotionally charged in
a program for women and
children for both the staff and
the residents, because the children
are present, and everyone
witnesses, firsthand, the devastation
of the children.
Processing the extreme anger
of both the residents and staff
is critical to effectively helping
the woman who experienced the relapse.
Children can become a burden to women in treatment.
(Meta House)
It was necessary for programs to acknowledge and
manage the anger the staff felt toward mothers, as
well as the anger staff felt toward each other,
either for sympathizing with or rejecting these
mothers.
Staff members had to accept the fact that not
everyone wants to be a mother, and not everyone
wants her children in treatment with her. But it’s
tough. (PAR Village)
Culture sometimes heightened staff reactions
when mothers rejected their children. Some
African Americans frowned upon giving up children,
even if it seemed to be in the children’s best
interests, because they believed the larger family
should take responsibility.
Hearing mothers say, "I don’t want to be a parent,
but I should want to be a parent," gets into the
stuff of culture and role. Staff have remarked,
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Critical Issues in Family-Oriented Treatment
"What kind of person is she who doesn’t want her
children? In my culture, you want your children."
Working through those issues means helping the
mother get to the point where she can say and
believe that she doesn’t want her children, instead
of keeping them and then failing them later. (Meta
House)
Parental rejections were dealt with in a number of
ways, including the use of psychotherapy. Since
rejection of parenthood may be a temporary struggle,
programs had to be very careful not to let the
woman make a decision too hastily. These projects
did believe, however, that a woman’s decision
with respect to keeping her children was her own,
and she should be respected and supported no
matter what her decision.
It’s difficult to know just how far to go in the
treatment process when we project a problem that
may occur if and when the mother rejects her
child. When we look at her life and her own rejection,
is she really reliving what happened to her?
It is important to probe this. We’re fortunate; we
have a psychiatrist available. (Watts)
All the grantees agreed that the decision to give
up a child was sometimes in the best interest of
both the mother and the child, even when it
caused a lot of conflict.
The decision about whether to keep a child is the
hardest one that a mother can make. It is the
source of her inner conflict, that she’s doing something
that she feels absolutely inadequate to do,
unwilling to do, has had no support in doing, and
does not want to do. Bringing her to the point
where she can admit that out loud, accept that
feeling, work through it so she can give up her
children and get on with a sober life, and allow
her children to get on with their lives, is indeed a
challenge. Men are able to say, "I don’t want my
children," every day and act on it, but women are
not allowed to do so. (FIT)
The mothers who ultimately decided that they did
not want to keep their children, and made their
children available for adoption, were transferred
by the project to treatment programs for single
women. Sites agreed that it would be useful to
have an assessment instrument that could help
them predict which women would likely recover
from addiction if they kept their children and
which would not.
Occasionally, the reunification of the children with
the mothers was difficult because of the foster parent’s
negative influence on the child. At other
times, major conflicts occurred because CPS sent
a child to be reunited with his or her mother, and
the child did not want to be there.
We’ve had children who wrote to their mother saying,
"Stay out of my life. I don’t want you back.
You ruined my life." But they’re coming in
because foster care wants that mother reunited
with that child. For example, we know we’re
about to get an 8-year-old who is not a happy
camper, and there’s not going to be a joyous
reunion. It’s going to be a constant conflict.
(PAR Village)
Relationships With Family Members
and Spouses/Significant Others
All grantees believed that family involvement in
the lives of clients was very important. Hence, to
reunify and strengthen family units, most of the
projects sponsored activities that involved the
women’s family members and significant others.
Family members [and spouses/partners] can
support the women and children during the treatment
process, encourage them to remain in the
program, provide some respite for the mothers by
inviting resident children to visits outside the facility
on weekends, act as a support network for
women when they reenter the community, and
facilitate family reunification. (IHW)
Treating the whole family is vital because the disease
of addiction encompasses the entire family.
The most potent result of significant other and
family involvement is the support it provides residents
during difficult periods in early recovery.
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Chapter VII
At times, it’s the catalyst to their continued commitment
to treatment and recovery. (Chrysalis)
[Our family component], referred to as
Reunification Planning, is based on the belief that
if women return home to untreated families, they
are not likely to maintain their recovery. (PAR
Village)
Because many of the women in treatment will
return to their parents’ home or to the home of a
significant other, it is important that these individuals
understand the nature of addiction treatment
and the recovery process.
Additionally, once these family members become
aware of the recovery process, they become
invaluable tools to assist the program in retaining
the women in treatment when hurdles arise and
the client is ready to leave against staff advice.
(FIT)
Despite these convictions, few
of the grantees reported that
they were able to involve family
members and
spouses/fathers to the maximum
extent. Although there
were some incentives for them
to become involved in the substance
abuse treatment
process, there were many more
disincentives and obstacles to
this participation.
The major reasons for many relatives and partners
to remain in contact with the women in residential
treatment were to stay in touch with the children
who were living with their mothers and to
facilitate visits with their mother by older children
who were not residing there.
Initially, family members are often alienated from
the substance-abusing mother and refuse to participate
in treatment activities. However, they
very much want to visit the children who reside
at the facility. As time goes on and the mother
demonstrates her sincerity about recovery, family
members typically become more amenable to
active participation in the treatment process.
(FIT)
“[Our family
component] . . . is based
on the belief that if
women return home to
untreated families, they
are not likely to
maintain their recovery.”
(PAR Village)
Most of the grantees found it difficult to get family
members, particularly significant others,
involved in any therapeutic activities, although
they were willing to come for visits, other structured
activities, and meals.
At some sites, many of the relatives lived some distance
from the facility, even in other States, which
limited opportunities for visitation, particularly if
overnight stays at nearby motels were required or
public transportation was not readily available.
Also, many of the women were involved with men
who did not support their recovery; some were in
prison, some were still in the drug culture, and
some broke up with the women when they found
out about their pregnancies or discovered that the
women were no longer interested in a drug-sharing
lifestyle. A substantial majority of the women
entering treatment did not have active or enduring
relationships with male
partners when they were
admitted to the residential
program. Sadly, too many of
the parents, grandparents,
and other relatives of these
mothers were active substance
abusers themselves and the
perpetrators of many of the
abuses they had suffered as
children. Reconciliation was
not always a desirable goal in
families that had multiple,
multigenerational problems.
Nevertheless, all of the grantees offered at least
some services for families. These usually included
three components: family education sessions
about addiction and recovery, structured activities
during special family visiting days, and some clinical
interventions or family counseling. Many of
the sites insisted that family members and interested
friends attend at least a few educational lectures
about addiction and the treatment process
before they were allowed full visitation privileges.
Family therapy with preschool and older children
and their mothers gave all family members an
opportunity to share their concerns and get feelings
into the open in a safe atmosphere for
expressing anger and addressing acting-out
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Critical Issues in Family-Oriented Treatment
behaviors. [We] set up rewards for children who
improved or controlled their problem behaviors
and helped their mothers be supportive. (IHW)
PAR Village conducted a weekly evening group, the
Family and Friends Education Series, which helped
women and their families and friends understand
addiction and the recovery process. The meetings
also helped participants feel included in the
women’s recovery and fostered
better communications among
all parties. Families also could
request special counseling as
needed.
FIT expected family members
and partners who intended to
visit a woman in treatment to
attend an orientation session
shortly after the woman was
admitted and at least four family
educational seminars that helped participants
acknowledge how they had been affected by addiction
and get in touch with their anger. Family
members and friends also were encouraged to participate
in clinically oriented multifamily groups
or conjoint family therapy sessions that met every
other week. Also at this project, the primary therapist
of any woman who was planning to live with
a partner after leaving treatment counseled the
couple biweekly. All relatives, as long as they were
sober, were invited to Family Days, which included
a lecture on some topic of interest as well as
lunch and other refreshments.
At Chrysalis, all family members and significant
others were informed, with the resident’s permission,
about the program’s policies and procedures.
They were required to complete a 3-hour family
education program held on Saturdays and attend
three multifamily therapy sessions before visiting
women at the treatment facility. These sessions
gave family members an opportunity to share their
feelings with each other. This was the first opportunity
for many relatives and partners to share
what it was like living with the addiction of their
loved one. The sessions also helped create a new
awareness for the woman in treatment. According
to this project, involving the family could elevate
. . . involving the family
could elevate the selfesteem
of all family
members and help break
an intergenerational
cycle of addiction.
the self-esteem of all family members and help
break an intergenerational cycle of addiction.
Desert Willow also required relatives and significant
others to attend an orientation session and
several educational meetings to express their personal
concerns before the women in treatment at
the project were allowed to join these sessions.
Watts conducted a family education program and
also held regular conjoint family
therapy sessions that
included nonresident children
age 12 years and older. Some
separate groups were also held
for adolescents. In contrast
to the traditional TC, in which
residents were reluctant to
have families involved, 80 percent
of the women in this program
gave permission for family
members and spouses/partners to be contacted.
GAPP seemed to be one of the most enthusiastic
of all the original grantees about its family involvement
component, which included an array of services
for relatives and partners of women in treatment
during both their residential and aftercare
phases. The Family Support Program provided
education about addiction and individual and multifamily
therapy groups that were facilitated by a
trained addiction and family therapist. The weekly
multifamily group, which alternated with educational
sessions that used videos and discussions,
focused on such topics as prostitution in recovery,
mother-daughter relationships, incest, loneliness,
and adjusting to work. Families encountering specific
difficulties also received individual counseling.
Family literacy and job training services, as
well as case management, were also offered to
women in aftercare services, to their children, and
to other members of their extended families
through the POWER program. This site attributed
much of the success and popularity of its family
program—depicted by clients as very beneficial in
satisfaction surveys—to a very dedicated family
counselor who developed and coordinated the
activities. Although the program was mostly
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Chapter VII
attended by grandparents and older siblings of the
children in the residence, some fathers and current
male friends of the mothers also attended.
FIT also evaluated its family component through
surveys of both the women in treatment and their
family members or friends. Responses indicated
that women appreciated the opportunity to have
relatives and partners directly involved in their
treatment and that family participants were very
interested in learning more about addiction and
recovery issues.
These activities have had a large impact on family
preservation and reunification. There have been
many instances when women who entered treatment
had no contact with their significant others.
They leave treatment having been reunited with
family members as well as their other children not
living with them at the facility. (FIT)
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VIII. Discharge
and Aftercare
A
s residential treatment for women and children
matured, the grantees had to establish
criteria for assessing clients’ readiness for
discharge from the facility and determine what
behaviors or conditions warranted termination
from treatment or transfer to another program.
They also had to decide what services would be
offered as part of continuing care. Initial goals
and expectations often changed as programming
evolved and the grantees became more realistic
about the difficulties of keeping this client population
in treatment or engaging them in postdischarge
services. The projects also devised strategies
to increase women’s willingness to remain in
treatment, particularly during the critical first 30
to 60 days and again at 6 to 9 months following
admission, when many of the mothers seemed to
grow restless. This chapter discusses the criteria
grantees adopted for determining whether clients
successfully completed treatment or graduated,
the rule violations that precipitated treatment termination
or transfer, retention strategies that
were used to decrease dropout rates, aftercare
services that were offered, and major problems
encountered in transitioning women back into
their communities.
Discharge
All of the grantees assigned women who left residential
treatment to one of several discrete discharge
categories: program completers or graduates,
terminations or expulsions for rule violations,
dropouts or withdrawals against staff advice, and
transfers to other, more suitable programs.
Although some sites had somewhat different terms
for these categories, all used the same general
classification system.
Successful Treatment Completion or
Graduation
Grantees considered a number of variables in
determining whether and when women were ready
to leave residential treatment, and each site had
slightly different criteria for success. Some of the
projects additionally distinguished between a satisfactory
discharge—with some staff reservations—
and graduation with full honors, so to speak. At
all sites, clinical teams evaluated the extent to
which clients met discharge criteria. This allowed
a great deal of flexibility and tailoring of decisions
to the special circumstances of each mother and
her children. Most grantees required that women
complete certain tasks as they progressed through
the treatment phases and that they achieve the
majority of goals outlined in their individual treatment
plans.
Our criteria for successful completion now looks
at each woman to see if she’s gotten everything
she can get out of being in treatment. And if she
has, then we’ve been successful.
(PAR Village)
We have phased treatment based on Gorski’s
model, and we have a multidisciplinary [staff
meeting] once a week during which we discuss
the woman’s progress from all different angles,
including input from the woman herself. The
counselor and the woman basically determine
when the woman has met her treatment goals. As
she moves through the latter part of her middle
recovery phase and starts reentering the community,
we look at her needs for education, employment,
housing, and other support. (Chrysalis)
One guideline is to look at the phase of treatment,
and another is to see how the woman is doing in
terms of her general recovery, reentry, substance
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Chapter VIII
abuse, parenting, and involvement with the criminal
justice system. In other words, has she done
everything that needs to be done during treatment?
And then, is she ready financially or economically
to be in the larger community? Does
she have housing, daycare for her kids, and transportation
to her job? (Desert
Willow)
Many of the projects had to
lower their sights—or change
their original expectations—
when establishing criteria for
successful treatment completion.
The women and children
they admitted were so
severely traumatized that
there simply was not sufficient
time in a residential facility to
accomplish all that was needed
to rehabilitate—more
accurately, habilitate—this
population. Although the programs
hoped to connect these women with community
services that would continue after their
discharge, this too was a difficult undertaking,
because appropriate supports, especially adequate
housing and jobs that paid a living wage, were simply
not obtainable in most cases. Sites where a
continuum of community-based substance abuse
treatment modalities were readily available,
including intensive day treatment and outpatient
services, offered the best possibility for continuing
care.
Originally, a woman had to finish about 80 percent
of her treatment plan to be considered a successful
completion. When someone enters [treatment],
you always shoot for the moon. You want
the woman to get all these wonderful things while
she’s in treatment. You start to focus on job training
and education, then realize that she has a 7th
grade education, so your priorities have to shift.
The women are staying sober and they are learning
to read, but they never have enough money,
safe housing, or parenting skills when they leave
us. So we try to connect them to all the long-term
resources needed. Since our organization offers
many different treatment settings, the women may
“When someone
enters [treatment], you
always shoot for the
moon . . . You start to
focus on job training and
education, then realize
that she has a 7th grade
education, so your
priorities have to shift.”
(PAR Village)
leave us and "step down" to a less restrictive program,
like a day treatment modality. We call that
a mutual termination, and our funders like that.
(PAR Village)
Some of the sites even began questioning the
importance of keeping women
in treatment until they graduated
and met program-imposed
criteria for success. Followup
evidence (see Chapter X) suggested
that some treatment
dropouts were actually doing
quite well after their return to
the community.
We’re seeing an 80 percent
sobriety rate after 2 years.
That reinforces [the notion]
that graduation doesn’t always
make the difference; however,
we need to compare those rates
to length of stay. We may have
our own ideas about what’s good for the client,
but the women seem to be doing well, whether
they’ve had a formal graduation or not. (Meta
House)
Frequently Used Criteria for Evaluating
Readiness for Discharge
Although each of the centers established its own
criteria for determining successful treatment
completion, similar accomplishments frequently
were included in a list of considerations.
Exhibit VIII-1, Criteria for Evaluating Readiness
for Discharge, lists these considerations in order
of priority. They include progress in achieving
individual treatment goals; sobriety; demonstration
of appropriate parenting skills; and evidence
that a source of income, employment, housing,
and a support system were in place.
Many of the sites worried about the impact of
managed care restrictions on time in treatment
with respect to what criteria would realistically be
allowed in determining whether a woman was
ready for discharge from the facility as a successful
graduate or treatment completer. It seemed
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Discharge and Aftercare
Exhibit VIII-1. Criteria for Evaluating Readiness for Discharge
1. Substantial progress in achieving individual treatment goals.
2. Sobriety, with evidence that the client knows how to avoid relapse and live a sober life (e.g., have a
sponsor, regularly attend AA or NA meetings in the community).
3. Stabilization or resolution of any serious medical problems or mental illness with appropriate plans
for continuing or reentering treatment, as needed.
4. Demonstration of appropriate parenting skills, including discipline and affection.
5. Evidence that the woman can take responsibility for herself and her children and that the children
will live in a safe environment (including approval from CPS if the woman has an open custody
case) with arrangements for appropriate child care and continuing medical appointments, as necessary.
One program insisted that all women be enrolled in domestic violence prevention groups and
have a referral to a battered woman’s shelter at discharge.
6. Promotion through the program’s treatment phases, at least to a specified level.
7. Evidence of a well-developed support system that may include positive relationships with a spouse/
significant other, family members, and/or friends.
8. Employment or enrollment in a program for adult education, literacy, or vocational training.
9. A legitimate income source, sufficient money saved to meet immediate expenses, a budget, and a
savings plan.
10. Safe, affordable housing.
11. A self-developed exit plan that specifies activities in which the client expects to participate (including
aftercare services provided by the grantee), other arrangements with community-based agencies,
and goals for the future.
12. Evidence that the woman is linked with, or can find, needed family services and negotiate for these
with community agencies and other resources.
unlikely, for example, that managed care providers
would continue to subsidize these women to stay
in a residential setting long
enough to complete long-term
vocational training, to obtain
GED certificates, or even to
demonstrate their capabilities
as parents. Nevertheless, the
grantees were of the opinion
that managed care providers
needed to be aware of the complexity
of interrelated issues
facing these women and the
level of care required to
address and resolve these problems,
thereby reducing the
. . . sites worried about
. . . managed care
restrictions on time in
treatment [and] what
criteria would [be used]
in determining whether
a woman was ready for
discharge from the
facility . . .
likelihood of these women elevating healthcare
costs in the future.
Future funding is a challenge
in terms of managed care.
How long we’ll be able to
make the case for the costeffectiveness
of treatment
completion that includes other
definitions, such as education
and family reunification, is
also a major challenge. We
may be forced to change our
definition in order to continue
to receive funding. (Casa
Rita)
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Chapter VIII
Time in Treatment
As part of the grant application process, all of the
grantees had projected the amount of time women
would need to remain in residential treatment to
complete the program. As already noted in
Chapters I and II, these expected lengths of stay
ranged from 6 to 18 months, although all sites
conceded that the time needed for women to
accomplish their individual treatment goals would
vary. As the projects evolved, and as the reality of
managed care seemed to herald the demise of
long-term residential programs, time in treatment
was less often invoked as a primary criterion for
program completion. Most centers tried to move
away from this structured and fixed
definition of success, although at least two sites
(FIT and GAPP) thought that most clients needed
to stay a minimum of 6 months. Only Flowering
Tree specified that most clients needed a full year
to complete the 12-Step curriculum, although a
few women were discharged after 9 months if they
were accepted by a continuing education program
that was too distant to be attended while living in
the residential treatment program. Over the
course of the grants, several projects (e.g., Desert
Willow, IHW, Chrysalis) scaled back expectations
about the required length of stay as a result of
their own research or of CSAT’s or other funders’
suggestions. (See Appendix B for data on the
length of stay in the different sites.)
Case Examples of Successful Residential Treatment After Varying Lengths of Stay
One complex case involved a 31-year-old woman who brought an infant son into treatment with her, leaving
two other children in the community in a rather loosely formed custody arrangement. She worked diligently
throughout her treatment on regularizing this custody, eventually placing both older sons for adoption with
the family friend with whom they lived. This was a very time-consuming process, as the staff wanted to
make certain she was making her own well-considered decision to relinquish her parental rights over the two
children. Several staff members, as well as the program director, assisted her in all areas of this lengthy
process. She also had a court-appointed counsel and made many court visits, accompanied by at least one
staff member. Additionally, staff supervised her regular visits with the two children who were being given up
for adoption. Transportation and other support were provided by the program during the entire process.
The patient also was enrolled in an anger management class conducted by a cooperating agency to assist her
in working through problems she was experiencing related to the children and her extended family. This
mother eventually entered into an amicable agreement that provided her with full visitation rights. During
her treatment, the mother completed a year-long word processing course at the local community college and
subsequently obtained employment with a social service agency as a receptionist/clerk. After finding appropriate
housing for herself and her infant son, this mother was discharged as having successfully completed
residential treatment. Her son will continue enrollment in the childcare facility, and she will attend a continuing
care group.
Another woman was successfully discharged from the program after being in treatment for just over a year.
While in residence, this mother completed two parenting classes and all of her addiction and family treatment
plans. Because of a disabling medical condition, she could not work. After completing leisure time
counseling, she was discharged to independent housing with her children, who had been in the program
with her. She was referred and admitted to another outpatient program to enhance her understanding of
the importance of structured free time and as a means of relapse prevention. She continued to use the program’s
childcare facility.
A third mother, who had a single child living with her in the residence, successfully completed treatment after
being in the program for just over 7 months. This woman came into treatment with relatively good insight
into her addiction and needed minimal disease education. She needed work in relapse prevention and completed
these treatment plans. She was employed full-time by a local newspaper at discharge and had moved
into independent housing.
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Discharge and Aftercare
There are big disadvantages in equating success
with remaining in treatment for a specified length
of time. If you had a defined 6-month treatment
program, and someone left after 4 months, she
was a "failure" and the State looked at it as such.
We had to move away from defining success in
relation to a period of time and move toward
viewing it as attainment of treatment goals. We
systematically moved away
from a time sequence related to
retention, as opposed to the
attainment of maximum
improvement. That’s been the
biggest challenge in the past
several years, to get the community
and the State to move
away from this notion that success
can be equated with time
in treatment. (FIT)
There is a tendency for nonclinical
people to look at the time in treatment, whereas
clinical people look at progress made [toward
meeting treatment goals]. (Chrysalis)
Hence, most of the grantees had flexible timeframes
for the successful completion of treatment
that reflected the different needs of individual
clients.
It might take 6 months for some women to complete
treatment, 9 months for others, and a year
or so for others, depending on where the person is
when she arrives. (Watts)
Terminations for Cause and Transfers
Decisions about who should be dismissed or terminated
from a project, and for what single or
repeated acts, posed many difficult dilemmas for
staff in these centers. All agreed that acts or
threats of violence to self or others were grounds
for immediate expulsion. However, a single
episode of name-calling or physical fighting
between residents seldom resulted in immediate
discharge; rather, more intensive counseling was
recommended. Similarly, staff hesitated to report
single incidents of mothers’ hitting their children
to CPS without providing other interventions and
trying to balance the mother’s overall progress
“We had to move away
from defining success
in relation to a period
of time and move
toward viewing it as
attainment of treatment
goals.” (FIT)
and attitude toward treatment against the need to
protect her children from harmful violence.
The grantees used various techniques, including
intensive individual counseling, to reprimand
women for violation of house rules and unacceptable
behaviors that jeopardized their continuing
treatment. Several types of negative disincentives
or sanctions discouraged unapproved activities and
usually were applied before
consideration was given to dismissing
a woman from treatment.
Negative behaviors are met
with a loss of privileges (e.g.,
use of the telephone, passes to
leave the facility), restrictions
on interactions with other residents,
learning contracts
(which usually entail writing
about the behavior), or a "stand-up" in a house
meeting. A "stand-up" requires the woman to
speak about her behavior in front of the total community.
Occasionally, when there are numerous
women involved in negative behaviors, the whole
house may lose privileges. (PROTOTYPES)
Negative disincentives include being turned down
for positive rewards such as passes for personal
time offsite or to attend special recreational functions
and sports events, extra telephone privileges,
and overnight/weekend visits with their
families. Behavior that is noncompliant with program
rules may result in negative disincentives or
termination from the program. (PAR Village)
After our program had been in place for about 1
year, we began to admit more women with multiple
treatment experiences and chronic relapse histories.
This led us to implement a new therapeutic
intervention that was very behavioral and cognitive.
We reasoned that the women who were
not following program rules were not being confronted
on these issues in a timely manner, and
they were not receiving behavior modification
strategies relevant to the specific behavior. As a
remedy, the entire staff got together each day at
12:30 p.m. with the previous day’s logs from the
residence in order to determine which clients had
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Chapter VIII
deviated and to confront them immediately. The
staff members of this team query a women who
appears before them with regard to the thought
processes behind her behavior, the consequences
of the behavior, and how the irrational thought
processes might be related to relapse, addiction,
or criminal behavior. Then a consequence is
imposed that speaks specifically to the infraction.
Within a very short time, the behavioral incidents
in the environment substantially decreased, and
the milieu therapists were empowered because
they knew that whatever they wrote in the logs
would be addressed the next day. The women
have affectionately labeled this intervention as the
"After Lunch Bunch." (FIT)
The grantees soon discovered that terminating
women from treatment was very difficult in these
projects, when the negative consequences for their
children were so immediately apparent.
If at all possible, women were transferred to other
suitable treatment projects rather than simply terminated
and sent back to the street or to an abusive
family environment.
Treatment is not viewed as punitive: Clients are
asked to leave only if very disruptive and in rare
instances. (Casa Rita)
Our staff get very attached to the children and
will do almost anything to keep their mothers in
the program. They will go to bat for the moms in
order to keep the children in the residence; they
become desperate if they think the children will
return to the chaos of their previous lives or will
have to go to foster care. (FIT)
The following example depicts some of the difficulties
involved in making decisions to terminate
treatment in a residential facility that admits
mothers with their children.
In traditional programs, the violations of agency
rules about violence, sexual activities, and drug
use, as well as repeated violations of other rules,
may result in discharge. Where children are
involved, there are additional ethical concerns.
What types of rule infractions are severe enough
to warrant the consequence to the children of
being placed in foster care when the mother is
Case Examples of Women Who Were
Terminated From Treatment or Left Against Staff Advice
One terminated client was a 30-year-old mother with two children. This was her second admission to
the program. Although she appeared to be fairly compliant, she was the aggressor in a physical attack
on another patient, and she was enraged and unrepentant. She was immediately terminated from
treatment in the interest of patient safety after less than 30 days at the facility.
A second woman was expelled after being in the residence for a very short time. She had been referred
by the department of corrections. Shortly after admission, this woman reported that she did not want
to have her children with her in treatment and that she did not want to be a mother. Additionally, this
mother showed no interest in making progress; she was acting out in the environment and, despite
interventions by staff, continued this behavior. She was expelled, and her probation officer was notified.
Another woman left treatment without notice. This mother, who was admitted with one small baby,
had been in residence for a few months when she went by bus to a 12-Step meeting with a group of
peers. She apparently decided not to get off the bus at the meeting site and told her peers she had
decided to leave treatment. She abandoned her baby at the residence. The woman’s mother was contacted
and came to pick up the baby. CPS also was notified.
Another woman left against staff advice after being in treatment with her children for 10 months. This
mother with co-occuring disorders found full-time employment, but her work hours did not allow her to
attend group therapy sessions. When she was advised to find a different job that could accommodate
her treatment needs, this woman refused and decided to take her children and leave treatment.
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Discharge and Aftercare
expelled? For example, the Village has historically—with
consideration for individual circumstances—expelled
clients for having sex at the
facility. When this occurred with one of the mothers
at FIT, routine procedures were reexamined.
Should an act by the mother, which could itself be
seen as trivial, result in splitting up siblings and
foster care placement? On the other hand, perceiving
adherence to rules as being unnecessary
for herself and being only for others was part of
this mother’s thinking pattern. If there were no
consequences for her rule violations, would this
encourage similar conduct from others? Would
failure to discharge this woman send a message
to clients in other treatment components in the
Village that it is safe to have
sex with FIT residents? (FIT)
Despite the many attempts to
work with the women on
behalf of their children and to
help them modify unacceptable
behaviors, approximately
17 percent of the women in all
the sites were terminated from
treatment, and another 5.8
percent were transferred to
other programs. Some of
these discharges occurred
when continued CSAT funding
for Year 5 was threatened and
the projects had to scale down,
when sites could not provide appropriate treatment
for serious medical or psychiatric conditions,
or when women persisted in sexual behavior in the
residence or during unapproved absences.
However, most were for some type of aggressive
behavior, such as repeated verbal abuse or fighting.
We have to get rid of [a resident] if others are
afraid of her and lock their doors. We frequently
don’t have anywhere else to transfer a [violent]
woman because this is the most restrictive program
available and not suitable for someone who
should be in jail. (Meta House)
Dropouts
. . . sites instituted special
strategies to discourage
dropouts and help
the women understand
the importance of
remaining in treatment
long enough to achieve
their individual
treatment goals.
Also of concern to all grantees was the high
dropout rate among these women—approximately
38 percent of clients in all the original sites left
treatment against staff advice or simply walked
out. (See Appendix B for site-specific information.)
The projects reported that most of the
women who dropped out of treatment left during
one of two critical time periods: during the first
30 to 60 days or after 6 to 9 months in the residence.
Various reasons why these women did not
remain in treatment were reported by the
grantees.
Chrysalis found that most of the clients who left
treatment in the initial 5 to 6
weeks were not ready to
accept a structured program
or still had cravings for drugs.
FIT similarly reported that
the women who dropped out
in the first 10 days after
admission found the program
structure claustrophobic and
had cravings or were not yet
sober. The staff at Meta
House agreed that women
who left in the first 2 months
were often coerced into treatment,
were hiding out from
someone, or were in need of a
place to stay; they left as soon
as they were confronted with the house rules.
Retention Strategies To Decrease Dropouts
Several sites instituted special strategies to discourage
dropouts and help the women understand
the importance of remaining in treatment long
enough to achieve their individual treatment
goals. Most of the projects assigned newly
admitted women to a special orientation phase in
which they were introduced to program procedures,
given time to become acquainted with
other peers, and released from many routine activities
so they could build relationships with children
from whom they had been separated. A few
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Chapter VIII
sites experimented with additional methods to
improve retention rates.
Desert Willow found that the intensive workshops
conducted at that site not only contributed to
individuals’ improved understanding of their own
problems, but also strengthened peer relationships.
Senior staff also were available at all times
to help and support clients who were experiencing
crises. Further, the enrollment coordinator
screened applicants carefully and asked women
who were admitted to specify the issues they needed
to address and to make commitments about
the length of time they would be willing to stay in
treatment to work on these problems.
At IHW, special team meetings were convened for
individuals whom the staff felt were in danger of
leaving. These women were challenged to explain
why they had enrolled in treatment and to articulate
the reasons why they should remain. Even if
these women stated that the residence was just a
place to stay, staff thought it was a breakthrough
for them to be honest.
Collaborative clinical team interventions, similar
to those designed by the Johnson Institute
to encourage alcoholics to enter treatment,
were conducted at FIT to discourage premature
departures.
[We] hold team meetings to aid retention that
include not only the director and project staff but
carefully selected representatives from other external
resources who have a stake in the outcome,
such as the family, the referral source, and the
CPS unit. Each intervention is planned and
rehearsed by the team members before it is implemented
with the client. The strategy is not to
blame or shame the client and make her defensive,
but to have persons who really care about
this woman point out her real situation, the consequences
that will likely ensue, and the options
she has. [Our] evaluation data from staff interviews,
focus groups of women, linkage interviews,
and client satisfaction surveys all indicate
that this is a valuable tool for increasing retention.
(FIT)
This grantee provided the following case example
of a successful—but less formally planned and
rehearsed—intervention in which the program had
joint custody of the mother’s children.
One of our mothers decided to leave the residence
against staff advice. She took her children to a
local hospital for an appointment and, while she
was there, telephoned her mother—a drug addict
and dealer—to come and pick up the children and
take them home with her. The woman then
returned to the facility and reported to staff that
she had decided to leave treatment and that her
children were already at her mother’s house.
Because our program shared custody of these
children and we knew that the mother’s home
was not a suitable environment for them, we
decided to contact the police and inform them that
this mother had violated a court order by removing
the children from the residential facility prior
to her successful completion of treatment. The
police responded to the facility and were very
cooperative. In the meantime, the client had
taken the children from her mother’s home to her
boyfriend’s house. When the police went to the
client’s mother’s home to pick up the children,
they were not there. However, the client’s mother
agreed to inform her daughter that the police were
looking for her. This woman promptly returned to
the FIT program "voluntarily" with her children—
and she is still in treatment. (FIT)
To prevent the exit of women who had been in
treatment for 6 to 9 months, one project suggested
that these mothers be given more responsibility
for making their own decisions, even if they did
not always seem to make wise choices.
After 6 months in residential treatment, these
women are like teenagers who want more freedom
and who are ready to try their own wings.
The program needs to negotiate more with these
mothers and support them if they slip in gaining
independence. We need to respect their logic and
learning. (FIT)
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Discharge and Aftercare
Case Example of a Readmitted Client
One applicant to the residential facility was a 28-year-old woman who was 9 months pregnant. She
candidly acknowledged that she only wanted to stay until she delivered her baby. She was admitted
despite her attitude in order to limit any further exposure of the fetus to drugs and to determine
whether the woman could be motivated to change. Despite the staff’s persuasive efforts, she only
stayed for 10 days and left before her child was delivered. This admission represented this mother’s second
attempt at treatment at this center in 2 years. She had never, in some eight treatment stays at various
treatment centers, remained for more than 30 days. This same mother asked to be readmitted
again within a few weeks, having delivered her infant. She was accepted because the child was identified
as substance-exposed following the delivery, which led to the involvement of CPS and the court.
Since she was readmitted, the treatment team has focused attention on this woman’s flight behavior
and has managed to retain her, although she is ambivalent about changing and has expressed a desire
to leave and use drugs. It is not very likely that she will be given custody of her newborn child, who is
currently in a shelter, in less than 3 months, if at all. The court has expressed a desire to terminate
parental rights. Our center will, however, continue to advocate for her for as long as she makes
progress in treatment.
Changing Policies Pertaining to Relapse
and Other Issues
Several sites became more lenient about relapse—
a return to some drug or alcohol use—during
treatment, especially in the initial phases of care,
and another reconsidered policies about unapproved
absence from the residence.
The woman may relapse while she’s in treatment
and the staff will work with her, but the goal is to
help her achieve abstinence. (Watts)
With the numerous prior treatment failures that
the women report at intake and the increased
number of relapse episodes during residential
treatment, the project has modified its philosophy
and policies regarding relapse. Women in our
program are not automatically discharged from
the program if they use [alcohol or other drugs]
while in treatment. Instead, the relapse episode is
used as a learning experience. Precipitating factors
to the relapse are examined so any future
relapses might be avoided. Precipitating events
as well as the person’s thoughts and feelings are
extensively reviewed in group sessions as well as
in individual sessions with counseling staff and in
various workshops in which the women engage.
(Desert Willow)
Retention is really linked to the woman’s ability to
"do" the project. When women leave treatment
early, it’s [often] because they’ve relapsed, and
their return becomes a very individualized decision
between them and their counselor. If the
woman is going to be in and out, [repeatedly]
relapsing, the decision will likely be not to retain
her in the project. (Meta House)
We now allow a woman to walk out—to take
treatment breaks. If she returns within
72 hours, we’ll take her back. Sometimes the
women need to leave, to use drugs, and to
get into trouble in order to know that they need to
be with us. When they return, they settle in more
quickly. Five years ago I would have
been opposed to that and rigid about it. If you
leave, you’re gone. We can’t draw the line that
rigidly anymore because it does the women a disservice.
(FIT)
Readmission Policies
As with discharge criteria, programs developed
their own policies with respect to readmitting
women who already had lived in the residence.
Most decisions were apparently made on an
individual basis. Most of the grantees did let
women return to the facility and, often, actively
encouraged this option.
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Chapter VIII
Clients requesting reentry are discussed by the
treatment team and may be granted admission,
depending on the nature of the original discharge,
the length of time since discharge, and motivation.
(PROTOTYPES)
If a client walked out of the treatment center, readmission
was not allowed for approximately 6
months from the discharge date.
(Flowering Tree)
Continuing Care in the Community
All the grantees offered a variety of continuing
services to clients once they were no longer
residents: day or outpatient treatment, case
management, linkages with community agencies
and groups, and other direct supports from the
project.
As part of our continuing care services, we provide
day or outpatient treatment for up to a year,
transitional housing, and indefinite access to an
alumnae group and 12-Step meetings. (PROTO-
TYPES)
Continuing care groups for women completing
treatment at our program are held on an outpatient
basis at three different sites in the community.
Alumnae often return to the program to mentor
women who are still in treatment. Self-help
support groups like AA and NA meetings are also
provided onsite and at various locations throughout
the county. Recently, we networked with
AmeriCorps, a national organization, to provide
mentors for the women during and after treatment.
(PAR Village)
Some of the sites had not developed an aftercare
component, or had envisioned only minimal services,
when the CSAT grant was awarded. Several
sites eventually expanded their aftercare or continuing
care components, although resources to do
so were limited. The only aftercare provided by
one center was contact between former clients
and the evaluation team that conducted followup
interviews. If the evaluators saw that women had
relapsed or were having major problems, they notified
the project staff, who then attempted to follow
up with these women. Another project with
few resources did the best it could.
What we’ve said to the clients is, "Here is the telephone
number. You can call us if you run into a
crisis. But [because of rural transportation challenges
and the fact that many clients lived in other
States], there may be months when we’re not
going to be able to get to you." Plugging them in
with their local services, if they return to a community
where they have AA and support groups,
is important. But sometimes we’re out there beating
the bushes to look for that kind of help.
(Flowering Tree)
After arranging for safe housing for its discharged
women, mandates in New York City required Casa
Rita to refer women who had left treatment to
city-appointed caseworkers, who provided most
aftercare services.
These women, if left on their own, . . . feel isolated,
are often depressed, and are generally living in
unsafe environments. At Casa Rita, all women,
regardless of whether or not they complete the recommended
course of treatment, are given access
to the services of a housing specialist to help them
identify, secure, and move into permanent housing.
Once rehoused, however, the New York City
Human Resources Administration has responsibility
for assessing their aftercare needs and referring
them to an agency that provides these services,
which may or may not be Casa Rita. We still
continue to visit women who terminated treatment
at Casa Rita prior to our recommendation
to make sure that the family receives appropriate
services from its city-appointed worker and also
to help them fill in any gaps in services and try to
reengage them in treatment. (Casa Rita)
Some of the grantees hired case managers to staff
their aftercare components and help women find
employment, gain access to medical care, obtain
housing, or find support in AA meetings or parenting
groups. These case managers sometimes
worked evenings and split-shifts to accommodate
the women’s schedules. In addition, aftercare
counselors conducted individual or group counseling
or referred the women to other outpatient
counseling resources.
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Discharge and Aftercare
[Continuing care] services at our project included
two weekly group meetings for alumnae; home
visits; telephone support; and case management
referrals for housing, employment, medical needs,
individual and family counseling, and self-help
groups. (Desert Willow)
Another director explained why she believed that
aftercare should, at the very least, contain case
management services.
Continuing care needs to be more case management
oriented because some of the same problems
emerge very quickly after treatment if the women
aren’t linked to a workable support system.
Housing, budgeting, employment, relationship
issues, and all the other areas that the program
helped these women with before they left can fall
away very quickly if they get into stressful situations.
(FIT)
Another site stressed the need
to keep mothers connected to
support groups for parents.
Continued parent support, education,
and training are important
components of the aftercare
plan. Mothers feel challenged
when they leave treatment
to live on their own and
must know that help remains
available to them in their first
several months after leaving
the treatment environment.
This need appears to be best
met by connecting mothers to
existing neighborhood-based parent support
groups. (Meta House)
Incentives To Participate in Aftercare
Because not all the women who left treatment,
even if they completed the program, participated
regularly in aftercare services, the sites used various
incentives to keep in touch with them.
Former residents were encouraged by the grantees
to stay connected to the treatment centers after
discharge as well as to form their own healthy
social attachments. The centers realized that
“Mothers feel
challenged when they
leave treatment to live
on their own and must
know that help remains
available to them in
their first several months
after leaving the
treatment environment.”
(Meta House)
some former clients have a difficult time seeking
out new social contacts after treatment and often
are not accustomed to socializing with people outside
the drug culture. These women were encouraged
to call other graduates, if necessary, and
have casual meetings on their own. Some centers
provided meeting space and refreshments for
meetings of peer networks, often run by program
alumnae. Several projects regularly invited alumnae
back to the program.
They participate in the graduations. They run a
peer group. They’re out there working. And that
sends a powerful message to the women in the
residence that says, "To be successful, I need to
work." (IHW)
The major incentive used by sites with licensed
daycare facilities to keep former residents in
touch with the program was to offer free or lowcost
child care to them while
they participated in onsite
aftercare activities or while
they worked. This was important
to both the children and
their mothers, who were
already familiar with the center’s
childcare staff. In one
project, hours at the childcare
center were extended to 24
hours a day to accommodate
women who had to work odd
hours in order to meet the
welfare reform requirements.
Several types of followup services
were provided to women
as they moved into the nonresidential continuing
care component of the program. Upon discharge,
all the mothers continued to use the childcare coop
program while they went to work or engaged
in other productive activities. This arrangement
also ensured that staff had continuing contact
with these women as they dropped off and picked
up their children. Most of these women also
attended weekly meetings of a continuing care
group, and many graduates continued coming to
Saturday family activities. (FIT)
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To streamline its aftercare services, which were
not well used by former residents because of problems
in securing child care, Chrysalis developed a
multidisciplinary team that provided outreach and
home visits to monitor each family’s status and to
connect the mothers and children with needed
services in the community. Despite these efforts,
however, many residents wanted to sever all ties
with this treatment facility and to resume an independent
lifestyle once they were released.
They feel like they have everything they need, and
they want to get out there—to be independent and
support their families. And
having us come back into their
lives, even from a continuing
care standpoint, is not something
they are always open to.
They’ll go to their meetings and
do what they need to do, but
they’re not always open to
being connected with us.
(Chrysalis)
Barriers to Continuing
Success in the
Community
The major barriers impeding
families’ transitions to independence and continuing
success in the community were gaps in accessible
services; little or no safe, affordable housing;
and low-paying jobs that jeopardized the economic
security of the women and children.
Most of the grantees complained that they were
unable to connect graduates of the program to
appropriate community organizations and agencies
that provided mental health services, for the
women and their children, support for trauma survivors,
financial assistance with basic economic
needs, and other necessary ancillary services, such
as child care and transportation supplements.
These services were neither accessible nor affordable
to many of the women.
The major barriers
impeding families’
transitions to
independence and
continuing
success in the community
were gaps in accessible
services; little or no safe,
affordable housing; and
low-paying jobs . . .
Safe and Affordable Housing
Probably the most frustrating task facing many of
the projects was finding appropriate, safe, and
affordable housing for these women and their children
after they left residential care.
The women ask, "Where am I going to be able to
live on $400 a month?" (Watts)
A major challenge for us is finding affordable
housing that is safe and not in the middle of neighborhoods
where there’s a lot of drug use. (Meta
House)
I think that the ones who have
affordable housing, especially
in better neighborhoods or
more supportive environments,
do better in the long
run. (Desert Willow)
When appropriate living
arrangements could not be
found immediately, some projects
delayed a family’s discharge
until a better housing
opportunity emerged. Some
sites were forced to release
women and children to the
street or a shelter so they
could be declared homeless
and have priority eligibility for publicly assisted
housing. When attempts to find adequate housing
failed, women tended to go back to their old
neighborhoods and living arrangements, often in
unsafe environments where drug use was common.
The grantees tried several approaches to securing
housing for their clients. Most encouraged the
women to save money while they were in treatment
and then share low-cost housing with other
graduates. These arrangements provided important
support among familiar peers and made housing
more affordable. Many sites helped women
apply for publicly assisted housing as soon as they
entered treatment because this seemed the only
viable option for families with few financial
resources. However, waiting lists for public housing
and government-supported Section 8 housing
were so long that it could take years in some local-
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Discharge and Aftercare
ities to get into a unit. Moreover, it was often
impossible for women with large families to find
suitable public housing because apartments were
not large enough to accommodate all of their children.
Sometimes women simply left treatment
when they became eligible for public housing and
thought a unit might soon become available.
One mother who had been
referred by a homeless shelter
operated by another substance
abuse treatment agency in the
community left against staff
advice after being in residential
treatment with her three children
for 10 months. She made
arrangements for public housing
as part of her discharge
planning process. Once that
was in place, however, she
returned to the homeless shelter to await notice
that an apartment unit in public housing was
available and did not complete her treatment.
(FIT)
Leasing private housing also posed problems.
Some landlords were reluctant to rent to women
with a history of substance abuse, a poor record
for paying rent on time, or small children.
Housing discrimination based on race or ethnicity
also was encountered. Women usually had to raise
at least enough money to pay for the first and last
month’s rent, a formidable problem.
Some of the sites were able to access special help
with housing. For example, one project worked
with Section 8 representatives to place program
graduates next to each other.
Even though they’re in the middle of chaos in that
environment, they’re close together so they can at
least look out for each other. (Chrysalis)
Another grantee turned to churches and local
landlords in the community for help in obtaining
housing and furniture. One center started a supportive
housing program called a stepdown recovery
house that was located half a block from the
treatment center. This housing was funded
through the city’s housing and community
. . . because of low
literacy rates, many
women would have
difficulty finding and
keeping any jobs at
all, much less ones that
paid a living wage.
development department, and continuing treatment
was financed by the county’s drug and
alcohol program.
The parent agency for Casa Rita in New York,
which serves homeless substance-abusing women
and their children, developed two sober houses
based on the Oxford House model. The women
ran the houses. This site also
used Shelter Plus Care to
secure permanent housing for
women when they were ready
to live on their own. Another
project, which was housed in a
building zoned for apartment
living, rented empty space in
this facility to women who
used these units as transitional
apartments. These women
could receive additional services
for 6 to 12 months while they lived in the transitional
housing.
Employment at Reasonable Wages
Another formidable difficulty encountered by the
projects was finding jobs for the women—or vocational
training that would lead to employment—at
wages that were sufficient to support their families.
Whereas some sites were optimistic about
women’s capabilities for supporting their families
after leaving treatment, others were not so sanguine
and recognized that, because of low literacy
rates, many women would have difficulty finding
and keeping any jobs at all, much less ones that
paid a living wage.
They can work at McDonald’s, go to class a couple
of days a week, and still take care of the
family. We try to teach women from day one in
treatment that, when they graduate from the program,
it’s independent living.
(Desert Willow)
We’ve done some reading and math testing as
part of our grant. Math levels are very, very low.
Even a McDonald’s job would not automatically
be easy. (Casa Rita)
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Chapter VIII
Several sites voiced concerns that both the government
and general public were discarding women
and children who were welfare recipients.
There’s a strong sense that women are unworthy,
particularly women who are poor, who need
assistance of any type, and who are of a different
race than people who occupy positions of power.
(Meta House)
One site was particularly concerned about the negative
impact of welfare reform on women who have
children with disabilities. This situation
presented a particularly difficult problem, because
many of these children needed specialized care
that could not be obtained in the customary
childcare facilities. The same problem existed
for women who had to work night shifts; little
available nighttime child care existed.
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IX. Significant Management
and Policy Issues
I
n developing innovative RWC projects, grantees
had to acquire or renovate facilities, hire and
train staff, enlist referral sources, design
appropriate programming and services, establish
linkages with collaborating agencies, and specify a
host of other policies regarding admission and discharge
criteria as well as rules for the residents.
They also had to work out a management structure
that could respond to the needs of staff and
clients and relate positively to the parent organization,
the wider community, and the political environment
in which the new programs hoped to
thrive. To assist with some of these varied and
daunting tasks, project directors were strongly
encouraged to establish advisory boards of local
citizens and professionals. They were also expected
to keep abreast of dramatic changes in the
financing and control of healthcare services for
poor women and their families and in available
welfare support. As the projects matured,
grantees needed to find and secure replacement
funding for the terminating Federal support.
This chapter summarizes grantees’ struggles and
successes in establishing and using advisory
boards. It recounts adjustments made as the projects
developed their own management structures
and styles and were integrated into parent organizations.
It depicts the major features of two historic
shifts in health care and social policy that
impinged on the futures of these programs: managed
care and welfare reform. Also described are
the grantees’ explorations of future financial support
and accommodations they considered or
implemented to keep these programs operational
with a smaller funding base.
Working With Advisory Boards
Shortly after grant awards were announced, CSAT
recommended to the new grantees that they develop
advisory boards to help gain community acceptance
for their projects, to build strategic alliances
with local professionals and agencies that could
provide many types of programmatic assistance,
and to generate additional resources and financial
support. They also were encouraged to reach out
to media representatives who could help increase
public awareness about the problems and services
needs of the target population of women and children
and the program’s successes in treating
them.
Not all of the projects, however, were equally successful
in establishing active advisory boards. In
fact, only about half of the projects claimed that
these boards had been helpful during the years of
CSAT support. The reasons given for defaults by
some sites included difficulties in getting busy
people from community organizations to coordinate
their schedules sufficiently to meet on a regular
basis, too little project staff time, and some
duplication of roles between this proposed advisory
group and other already-operational boards of
directors and subcommittees at the parent agency.
One site tried to establish an advisory board but
ultimately found it easier to simply use the expertise
and assistance of the individuals who had been
approached to become members for accessing
needed services.
The sites that did put together and use advisory
boards recruited members from key local community
agencies and groups that already served or
had an interest in the target population (e.g., hospitals,
churches, schools, women’s organizations,
businesses, AIDS/HIV networks); State, county,
and city departments of social and family services,
welfare, rehabilitation, or corrections; politicians;
and consumers. One grantee was particularly
enthusiastic about a researcher from the local university
who was very helpful with the program evaluation
and who suggested relevant services, such
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Chapter IX
as play therapy for the children. Several sites
mentioned the contributions of local legislators
and politicians who could cut through red tape to
get things done. A powerful and inspirational
member of a local church helped another site far
beyond her duties on the advisory board. Most of
the active advisory boards were composed of 10 to
25 members, primarily women, and met monthly
to quarterly. It was difficult to keep up attendance
if meetings were scheduled too frequently.
The activities with which the projects most frequently
received help from the
advisory boards were fundraising,
including identifying public
and private sources of
money and advocating for the
grantee with potential
donors/legislators; building
linkages with other resources
or systems and securing such
needed services as transitional
housing or facility permits;
recruiting qualified staff and
volunteers; and collecting
donations of money and goods,
particularly to celebrate
Christmas with the children or
to send older ones to summer
camps.
[The advisory board] is very
important to generate community
support for the program.
It is helpful if the board is very
active, helping staff to do outreach work and to
network with politicians and community leaders.
Ours was very helpful at the end of the grant in
finding new funding and helping us continue services.
(Casa Rita)
The advisory board was very important, especially
in the beginning, in setting up linkages and integrating
us within the wider community. It also
helped solicit goods, services, and monies, and
assisted us in exploring fundraising possibilities
and getting more visibility at the end of the
[CSAT] grant. (Desert Willow)
“Ours was very helpful
at the end of the grant
in finding new funding
and helping us continue
services.” (Casa Rita)
“The advisory board
was very important,
especially in the
beginning, in setting
up linkages and
integrating us within
the wider community.”
(Desert Willow)
The chair of our diverse advisory board is a legislator.
We also have a county commissioner, a representative
from the department of corrections,
people who run local businesses, and others.
Having those connections has really played an
important role. Although our program is in a
major district—the midtown section of our city—I
don’t recall any adverse reactions to the program’s
existence. (GAPP)
The 25 members of our advisory board came
from a variety of community agencies and the
parent organization. The
majority were women, and
about one-half were Caucasian
and one-half African American.
They really helped us in the
beginning of the grant by getting
letters of agreement and
strengthening linkages to agencies
and later by providing
consultation on licensing and
housing and obtaining publicity
by getting involved in community
events. (Chrysalis)
Among the major contributions
of our 14-member, all-female
advisory board were sound
advice, help in strengthening
community linkages—especially
with family court judges,
assistance in recruiting student
volunteers to help with
childcare services, facilitating
rapport with CPS, and gaining access to Section
8 public housing. (FIT)
Developing a Management
Structure
The grantees also had to find ways to integrate
new program components into parent organizations,
not only sharing staff and facilities, but also
determining whether they could use existing financial
and personnel systems or if they had to develop
new ones. Each project director had to work
out a management style that inspired trust among
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Significant Management and Policy Issues
employees in the newly funded residential treatment
component. Project directors also had to
establish positive working relationships with other
personnel and administrators at all levels of the
organization that was the official recipient of the
grant award. This meant understanding organizational
policies and anticipating and resolving any
potentially troublesome relationships with other
preexisting program components. For the most
part, grantees felt positively supported by the parent
organizations and did not have problems in
this domain. A few, however, did "go through
some changes."
We have staff who had been at the agency for a
long time. The CSAT funds allowed for a major
agency expansion, and we added a whole new
project with the children’s services. Designing a
management system that gave staff the support
they needed and allowed for growth and continuity
has been a challenge. (Meta House)
We literally spent the first 3 years of the CSAT
grant dealing with staff and stability, determining
a management and leadership approach, and trying
to find ways to integrate all of this into a parent
agency in a way that made sense. Our biggest
day-to-day challenge during that time was internal
structuring. Now that we are stabilized to a great
extent, we can see where we’re going in the
future. (Chrysalis)
Responding to New Healthcare and
Welfare Regulations
During the 5-year period when the original RWC
grantees were delivering services to substanceabusing
women and their children, significant
changes occurred in the financing of health care
and the conditions for continuing welfare benefits
that inevitably affected the projects. The impacts
of managed care and of welfare reform were topics
of great concern to all grantees, both in day-to-day
operations and in planning for continuing services
and securing future funding support.
Managed Care
Managed care rapidly has become a central issue
in the delivery of physical, mental health, and substance
abuse services to clients in both the private
and public sectors. Yet, very little is known about
the impact of managed care policies on users’
access to treatment, utilization, costs, and outcomes.
In the field of substance abuse treatment,
these uncertainties are compounded by rapid
changes in knowledge about and classification of
disorders, standards of care, diagnosis and treatment
interventions, and accepted roles of professionals
in the treatment process. Efforts to monitor
and assess the quality of substance abuse
treatment services provided through managed
care programs are confounded by the heterogeneity
of managed care programs and the populations
seeking treatment for these disorders.
Managed care programs come in a variety of
shapes and sizes but may be defined loosely by
their use of administrative and financial mechanisms
that are designed to control access to care,
the types and modalities of care delivered, and the
amount and cost of care. To date, most managed
care efforts have seemed to emphasize cost and
resource containment over quality of care,
although the ostensible objectives of managed
care also include monitoring and improving treatment
processes and outcomes.
In most States, administrators of substance abuse
treatment agencies are exploring the feasibility of
some form of managed care to subsidize publicly
funded treatment and prevention services. States
and counties, more and more often, are moving
large numbers of persons with publicly financed
health insurance into mandatory managed care
programs in an effort to control costs and reduce
inefficiencies. Change is being conducted piecemeal.
Some States and counties are contracting
with managed care plans for tightly circumscribed
populations, whereas others are enrolling broadly
defined groups such as Medicaid beneficiaries.
Some jurisdictions allow health plans to assume
full financial risk for all services required by
the public beneficiaries they enroll; others "carve
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Chapter IX
out" certain services to be directly provided in
the public sector or through separately managed
contracts.
Public purchasers of managed care services confront
critical policy issues with little guidance.
Most decisions are being made without the benefit
of information about the characteristics, cost, and
outcomes of alternative managed care options,
especially for the low-income, severely disabled
consumers commonly served in public sector systems.
Despite these uncertainties,
individuals needing
substance abuse treatment are
being enrolled in managed
care plans in all their different
forms throughout the Nation.
For the RWC program, the
implications of these issues
are clear: RWC grantees serve
severely disadvantaged women
who come to treatment with
both acute and chronic physical
and mental health conditions
in addition to substance
abuse problems. This case
severity can negatively affect
comparative performance
measures with other substance abuse treatment
providers and, hence, the ability of residential
treatment providers to compete for managed care
contracts. For example, the cost of health care for
RWC clients during treatment may actually exceed
that prior to treatment, given that many of the
new admissions are diagnosed with previously
undetected acute and chronic conditions. These
considerations and other constraints, including
impending changes in third-party payer coverage,
are already causing some residential treatment
providers to discontinue services. These financing
and reimbursement problems could ultimately
lead to the demise of residential treatment as an
option in the continuum of substance abuse treatment
services.
. . . the cost of health
care for RWC clients
during treatment may
actually exceed that
prior to treatment, given
that many of the new
admissions are
diagnosed with
previously undetected
acute and chronic
conditions.
At the same time that the grantees were attempting
to meet the needs of their clients in this different
environment, they faced additional challenges
from the healthcare system, including new
ways to measure performance; ownership changes
in the umbrella agencies with which they were
affiliated; constraints on public and private sector
coverage for a range of conditions and health services
(e.g., limitations on length of stay); and
requirements to provide data that are difficult for
community-based service delivery providers to
meet.
Many sites looked to Medicaid—for which most of
the women and their children
were eligible—to reimburse
them for services delivered.
This increased their involvement
with both State and
Federal Medicaid regulations.
Actually, Medicaid has not,
heretofore, been a significant
source of funding for alcohol
and drug treatment in many
States, since coverage of these
services is optional under the
program. Reimbursement is
also expressly disallowed for
normally covered Medicaid
services provided to persons
between 22 and 64 years of
age who are residing in socalled
"institutions for mental diseases," defined as
facilities with more than 16 beds that serve individuals
with mental diseases. (Chemical dependence
is included in this category.) Medicaid in
most States also has stringent requirements
regarding the number of hours per day or week
that specified treatment must be provided.
Although these projects tried to adapt to the
changing environment, many expressed fear that
the families they treat would be hurt by the recent
reforms in healthcare financing. Most concluded
that changes in healthcare financing were already
pressuring them to move women through treatment
more quickly. Some projects predicted that
shortened treatment stays for mothers, due to
changes in healthcare financing, with few job skills
and limited housing options could lead to increases
in homelessness, violence, criminal activity, and
family breakup.
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Significant Management and Policy Issues
We’ve increasingly become a Medicaid-funded program.
The Medicaid folks are already asking us
questions, like "Why do you need to do that? It’s
not what everybody else is doing." The impact of
moving to Medicaid reimbursement seems to be
changing the staffing pattern, the recordkeeping,
the management information systems, and the
treatment designs. It’s moving us into a businessoriented
environment rather than a treatment
environment. We’re now seeing our State agency
getting into the business of Medicaid case management.
There’s going to be more pressure to
reduce time in treatment and to control services.
That’s a political effect—a changing attitude that’s
going to have a big impact on our treatment centers.
(Chrysalis)
We all show that treatment works. The longer the
treatment stay, the better the outcomes. But
managed care seems to be moving toward shorter
stays. I think that speaks loudly. If treatment is
to be effective, it can’t be cut short or diluted for
women who need more time. (PROTOTYPES)
Welfare Reform
The Personal Responsibility and Work Opportunity
Reconciliation Act (P.L. 104–193) of 1996 made
dramatic and wide-ranging changes in public assistance
to the poor. Known as “welfare reform,”
this fundamental overhaul of Federal public poverty
policy replaced AFDC with Temporary
Assistance for Needy Families (TANF). It also
changed eligibility requirements for childcare
services, the Food Stamp Program, Supplemental
Security Income (SSI) for children, benefits for
legal immigrants, and the Child Support
Enforcement program. The law, based on the principle
of personal responsibility and self-sufficiency,
seeks to end dependency on public welfare assistance
and benefit programs. Thus, it puts a 5-year
lifetime time limit on, and effectively ends, entitlement
to Federally subsidized public assistance.
This law is being implemented by the States
through block grants from the Federal government.
States must submit plans to the Federal
government for approval. The States do have
broad flexibility in implementing their welfare
reform programs and can request waivers for or
pass legislation opting out of some of the most
stringent and punitive provisions.
Three specific provisions affecting persons with
substance abuse problems and the treatment programs
they enter are (1) prohibitions against persons
with convictions for drug felonies receiving
TANF benefits and food stamps; (2) barring persons
with undefined violations of probation and
parole conditions from eligibility for TANF, food
stamps, SSI, and public housing; and (3) screening
welfare recipients for evidence of illegal drug
use and sanctioning those who test positive. Each
of these provisions not only could have serious
consequences for women and their children who
depend on welfare benefits and food stamps for
basic necessities, but also could reduce available
funding for residential treatment programs that
traditionally use clients’ welfare monies and food
stamps to help offset program costs (Legal Action
Center, 1999).
As already reported, many of the women entering
the RWC projects were referred from courts and
departments of corrections and likely had drug
felony convictions; many were also on probation or
parole and could have violated conditions of these
legal arrangements. However, many States have
opted out of or passed legislation to modify these
particular restrictions or clarify them (Legal
Action Center, 1999).
The expected size of the substance-abusing population
affected by changes in welfare reform policy
is significant, although difficult to measure precisely.
The U.S. Department of Health and Human
Services estimates that, on the basis of the
1991–92 National Household Survey on Drug
Abuse, about 5 percent of the female AFDC population
has significant impairments caused by substance
abuse, and an additional 10.6 percent is
estimated to be somewhat impaired. Others estimate
that substance abusers make up 15.5 to 39.2
percent of the welfare population or that somewhere
between 600,000 and 1 million women in
the AFDC program will require treatment for alcohol
and other drug-related problems (HHS, 1994).
Moreover, the need for substance abuse treatment
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Chapter IX
services is likely to increase as more welfare recipients
are identified as substance abusers with
ongoing treatment and aftercare needs. Again,
treatment slots for all substance abusers are
already in short supply. The oversubscription to
and waiting lists for admission to the original
RWC programs offer evidence that this type of
intensive and long-term residential treatment is in
short supply.
Many officials believe that substance abusers
among the welfare population
may be one of the most difficult-to-employ
groups because
of poor work and interpersonal
skills, low education levels,
lack of previous employment,
homelessness, and histories of
criminal justice involvement.
Nonetheless, substance abuse
treatment has been shown to
be a very useful strategy for
helping recovering women
enter the workforce. Findings
from CSAT’s National
Treatment Improvement
Evaluation Studies show that
employment rates among
women increased from 36 percent
before treatment to 45
percent during the year following
treatment. This change
represents a 25 percent
increase from the baseline for
the group of treated women as
a whole; a larger increase—
from 4 percent at admission to
28 percent at followup—was
observed for a sample of women participating in
the CSAT RWC projects described in this document
(CSAT, 1997).
Because of welfare reform, many of these grantees
changed the way they conducted their treatment
services. Most of them always had a goal of preparing
women to be economically self-sufficient
through education, job skills training, and the
establishment of bank accounts. More emphasis
had to be placed on starting vocational services
. . . the need for
substance abuse
treatment services is
likely to increase as more
welfare recipients are
identified as substance
abusers with ongoing
treatment and aftercare
needs.
. . . substance abuse
treatment has been
shown to be a very
useful strategy for
helping recovering
women enter the
workforce.
earlier in treatment and getting women jobs while
they were still in the program. Another concern
was that the new welfare reform legislation not
only set lifetime time limits on eligibility for welfare
benefits, but also imposed the punitive
restrictions described above with respect to
women with drug felony convictions or violations
of probation or parole conditions.
There are some exclusions in the welfare reform
bill that will impact our clients. Drug felons are
not going to be eligible. We
looked at our data and about
25 percent of our women fall
into that category. Now what
does that mean for the future
of these families? Less than 30
percent of our women have
high school degrees, and most
have never been fully
employed. The reality of trying
to move these women into
recovery and into a job in a
relatively short period of time
is an overwhelming task.
(GAPP)
Although studies of posttreatment
outcomes are optimistic
with respect to improvements
in employment rates among
women treated in the RWC
programs, the followup periods
have generally been
short—a year or less. It is
unclear whether improvements
in employment persist,
although the strong economy
over the past several years, since welfare reform
legislation took effect, has certainly contributed
to unanticipated numbers of women leaving or
never being enrolled on the welfare rolls and
apparently obtaining and keeping jobs. Many
observers, however, are not sanguine about the
longer term impact of moving women, particularly
mothers of small children, too rapidly into the
workforce and having them take low-paying jobs
that do not offer healthcare and sick leave benefits,
paid vacations, retirement plans, and other
148

Significant Management and Policy Issues
benefits expected by middle-class workers.
Moreover, these mothers’ wages are frequently
insufficient to pay for adequate child care or to
cover transportation costs.
Our evaluators found that, 2 years after treatment,
only one-third of the women who had been
in the program had regular, full-time employment,
and few were earning enough money to be the
sole supporters of themselves and their children.
Nearly one in five was still receiving Social
Security Disability benefits at that point. Since
nearly three-fourths of the women followed were
living with one or more minor children, the findings
suggest that the children continue to live in
poverty. (Meta House)
Preparing for the Future
As these sites responded to the challenges of welfare
reform, managed care, and complicated formulas
for securing Medicaid reimbursement for
services, they also had to focus on ways to continue
the residential programs and to provide appropriate
and effective services for the women and
their children after the termination of CSAT support.
This meant both searching for new funding
sources and modifying treatment services to meet
the new expectations of funders. In the new environment
of managed care and welfare reform, this
often meant reducing the anticipated stays for the
women and children in residential components
and integrating job readiness training and employment
into treatment plans at an earlier point in
the treatment process.
One site recognized that treatment outcomes—at
least, the measures used—were often a function of
funders’ expectations, not necessarily of the real
needs of clients.
The emphasis is on the specific outcomes desired
by the funders. If you’re being funded through
jobs programs or welfare reform, then employment
will be the outcome. If you’re getting some
funding through foster care, which will be directly
connected to welfare reform, then your outcomes
will be based on family reunifications or the ability
to keep family together. If you manage to get
any Medicaid money, they have totally different
outcome interests; sometimes, they could be antithetical.
(Meta House)
Part of the adaptation process involved learning
the new systems and making necessary changes in
paperwork. Another important aspect of planning
was considering possible changes in staffing, services,
time in treatment, and even eligibility criteria
for admission to or continuation in the program.
Although the grantees understood the
importance of making plans, they found little time
for this sometimes difficult task.
We’re trying to make staff aware of the changes
required under welfare reform and . . . also let the
women know what’s going on. It’s an ongoing
cycle. (IHW)
In our city, the Department of Homeless Services
is now redefining what it is to be homeless, so
that many people who would ordinarily be
referred to our system are now being turned
away. It hasn’t affected us at this time, but it certainly
has the potential to do so down the road.
Rethinking the future of a program and how you
operate under those conditions is a high priority.
(Casa Rita)
One center held a 2-day meeting with staff to consider
five assumptions that the project called the
"what ifs." For example, what positions would
need to be eliminated if funding was significantly
reduced? The review was done objectively, without
assigning names to positions.
It was difficult. But at least we had the possibilities
before us, which made it a little less difficult.
(PAR Village)
All the grantees took steps over the course of the
projects to look for financing after Federal funding
ended. One set a priority from the inception of
the grant on developing successful strategies for
future sustainability. Another focused on methods
for fundraising other than grant writing, including
capital campaigns. Some established links with
State Medicaid offices and already were being
reimbursed for treatment, whereas some had
approached managed care organizations and were
trying to establish workable contracts. Several
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Chapter IX
grantees discussed the feasibility of setting up
businesses that could help with their own survival
and, at the same time, provide clients with opportunities
to develop work skills and begin earning
and saving money. Other project directors came
to see their roles as advocates with policymakers.
They educated local funding authorities about
their clients, their treatment models, and their
successes. Some went before State legislatures
and managed to get continued funding for their
project included as a line-item in the State budget.
Following a final meeting of
these 11 grantees in May
1997, CSAT surveyed the sites
to ascertain their plans for
continuation. Several of the
projects indicated that they
would be able to provide services
until late 1997 or early
1998, using unexpended, carryover funding from
the CSAT grants. Some expected to operate for
even longer periods, using other supplementary
funding sources. One site planned to augment
CSAT carryover funds with client fees and
Medicaid reimbursements until Medicaid changes
in the State significantly reduced or eliminated
this support. Three projects (FIT, IHW, and PAR
Village) reported existing contracts with managed
care organizations; another project was in the
process of negotiating a contract at the time of
the survey. However, as one grantee pointed out,
the funding was, for the most part, limited to support
for substance abuse treatment and did not
cover many of the comprehensive services seen as
critical for the recovery process. Moreover, funding
through managed care was not sufficient to
sustain a family unit in treatment.
To maintain some modicum of services, most of
the grantees expected to change their programs in
ways that would conserve available monies and
adapt to lower anticipated income levels. Among
the changes planned were cuts in the outcome
All grantees took steps
over the course of the
projects to look for
financing after Federal
funding ended.
evaluations being conducted for CSAT as well as
reductions in the breadth and depth of intake
assessments, the number of women and children
served, and services such as aftercare, fitness
instruction, and staff development. One grantee
substantially reduced the expected length of
stay—from 9 to 12 months down to 30 to 60 days.
As several centers noted, however, even as managed
care seemed to be limiting the choice of
available services and pushing toward shortened
stays, welfare reform was opening new avenues of
support. One site took advantage
of monies
that became available through
welfare reform to create a
family support program that
added case managers and
adult literacy and children’s
education programs to its
aftercare services.
The types of funding that grantees were seeking
(or had obtained) to replace the CSAT grant
monies included the following:
• Grants targeted to homeless women from the
Department of Housing and Urban
Development (HUD)
• State-level TANF (welfare-to-work) programs,
including monies for childcare funds and for
food and other supplies
• Reimbursements from negotiated contracts
with managed care organizations for specified
services, including medical, mental health,
and substance abuse treatment services for
women and medical/developmental or psychological
services for children
• State appropriations that support the criminal
justice and substance abuse treatment
systems
• Grants from private foundations
150

X. Evaluation Designs
and Findings
T
he original 11 CSAT grantees that piloted
the residential treatment programs for
women and children were required, as part of
their grant awards, to have well-developed and
well-funded evaluation plans in place that reflected
the participation of in-house or consulting experts
in the selection of appropriate methodologies.
Further, these site-specific evaluations, which
could account for as much as 15 percent of the
budget, had to be conducted by available professionals
in the field, whether from local universities,
private firms, or the parent agency. To assess
the extent to which each individual
project’s objectives were
met, the evaluations were to
contain both process and outcome
components. They were,
moreover, required to have a
comparison or control group
of matched subjects who
might be composed of eligible
women who applied but were
not admitted to the residential
facilities, who were admitted
but dropped out of treatment
shortly afterward, or who were served in other substance
abuse treatment settings. Baseline data
were to be collected for all clients, and outcome
variables were to be derived from the logic model
that was part of the grant application process.
Finally, these evaluation plans were expected to
specify instruments for collecting appropriate
information, to describe procedures for data collection
and analyses, and to provide assurances
that the clinical staff and evaluators would be integrated
into a unified team.
. . . grantees agreed that
evaluation was much
needed to demonstrate
the positive benefits of
long-term residential
care for . . . women
with multiple serious
treatment needs.
Because many of the grantees were only experienced
in delivering services to the target population
and did not fully understand the intricacies of
conducting program and client evaluations, they
encountered some common difficulties in implementing
and coordinating this mandated project
component. However, the grantees agreed that
evaluation was much needed to demonstrate the
positive benefits of long-term residential care for
these women with multiple serious treatment
needs. Evaluation also could be used to increase
public understanding of the complex nature of
addiction and its potentially negative impact on
the entire family, particularly children.
This chapter describes some
of the issues the grantees confronted
in conducting these
evaluations. It briefly summarizes
the federally supported
data collection system—the
QRS—that was developed for
all CSAT-funded women’s and
children’s programs. It presents
aggregate information
about discharge status and
outcomes following discharge
for clients profiled by this system
and summarizes several treatment outcomes
across the sites. Details on the site-specific evaluation
findings are contained in Appendix B.
Frequently Encountered Issues in
Conducting Program Evaluations
The most common challenges faced by the
grantees in conducting their site evaluations
included melding the evaluators and clinical staff
into a working team, finding appropriate instruments
that were both culturally and gender sensi-
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Chapter X
tive and that addressed family-specific issues,
enlisting a comparison group from which it was
feasible to gather the same information obtained
for clients, collecting accurate data and locating
clients after discharge for followup interviews,
agreeing on how information would be used by the
treatment project, and addressing issues related to
confidentiality and child abuse reporting.
Establishing Relationships Between
Clinical Staff and Evaluators
Although all the grant applications contained evaluation
plans reflecting the participation of knowledgeable
experts in the field, many of the sites
found that staff who actually worked on the project
had not been sufficiently involved in designing
the evaluations. Some of the plans seemed to be
more extraneous than integral
to the assessment of site-specific
goals and objectives.
Sound evaluation plans, the
grantees concluded, should
reflect an understanding of
the project’s treatment model,
goals, and intervention strategies,
as well as anticipated
client characteristics, so that
the design, instrumentation,
and assessment schedules would be appropriate.
The importance of specifying feasible and measurable
project goals, and defining terms such as success
prior to the implementation of the evaluation,
was underscored. Decisions about the evaluation
design and various technical problems were,
however, secondary to addressing and resolving
these issues before the project and the evaluation
began.
Many of the issues related to building cooperative
relationships between treatment and evaluation
staff were similar, regardless of whether the evaluation
activities were contracted out to an institution
(e.g., university, private research firm) or conducted
by employees of the grantee. Generally
speaking, however, fewer problems were encountered
when the evaluation staff were hired by the
same agency. The grantees also recommended
The projects agreed that
standardized instruments
did not adequately
address many issues of
relevance to substanceabusing
women . . .
that the clinical and evaluation teams work
together from the inception of the project, with
initial cross-training in order to understand each
others’ roles and expectations. Ongoing communications
between these two components were also
essential to a coordinated effort.
A related issue pertained to integrating data collection
schedules and procedures into the regular
clinical routines so that assessments seemed natural
and noninvasive. Grantees stressed the importance
of the evaluation team understanding the
clinical approaches used, learning the therapeutic
language, using regularly scheduled activities
(e.g., case review meetings to gather data), and
attending clinical staff meetings on a regular
basis. Reciprocally, clinical staff had responsibilities
for including members of the evaluation team
in their activities and making sure necessary time
was set aside for client assessments.
Further, the grantees
considered it important for
the clinical team to have input
into interpreting the data to
avoid misinterpretations.
You have to understand what
takes place . . . in one instance
the evaluation revealed that a
couple of women complained
that the childcare staff didn’t want to change diapers
. . . so I went back to them and said, "What’s
going on?" And they said, "The women bring the
children in the morning with messy diapers
because they don’t want to change them. And
they get sent back to their apartments to change
the diapers." (IHW)
Several of the grantees also noted the importance
of negotiating data ownership and publication
rights before the evaluation began and deciding
how and when results would be released.
Selecting Appropriate Instruments
The projects agreed that standardized instruments
did not adequately address many issues of relevance
to substance-abusing women and their children,
and none felt completely satisfied that the
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Evaluation Designs and Findings
available instruments were designed to capture
what the interventions were attempting to accomplish.
Standardized assessment instruments were
viewed by many as not being sufficiently sensitive
to gender and cultural issues.
The standard instruments and the ones that have
been tested . . . have really been designed for and
tested on populations of men in treatment. . . .
They’re not sensitive to the issues of women, and
many of the instruments don’t even mention children.
(IHW)
The gender-specific Addiction Severity Index (ASI)
(McLellan, 1980), which
includes a homemaker section,
was thought by several
grantees to be a most useful
assessment tool. Other instruments
designed for women,
however, could be used inappropriately.
For example,
many women were not living
with or providing care for their
children prior to entering
treatment; others had custody of their children
but, because of their substance abuse, were not
their primary caregivers. Under these circumstances,
an instrument such as the Parenting
Stress Index, Third Edition (PSI) (Abidin, 1995)
might not have captured what it was intended to
measure. Most evaluators thought that the available
standardized instruments did not capture the
women’s knowledge—or lack of knowledge—about
their children. Other grantees noted that the current
selection of assessment instruments did not
address the overlap between substance abuse and
psychological symptoms.
The symptomology of drug abuse and mental disorders
overlaps and it’s hard to know . . . where
the symptoms are coming from.
(Meta House)
The need for more appropriate assessment instruments
for children also was noted. Available ones
were thought to measure milestone developmental
changes but missed the more subtle, intermediate
changes that are important in ultimately achieving
Many sites used special
forms and checklists they
developed themselves to
capture special aspects
of treatment or the
women’s characteristics.
developmental targets. Since developmental
stages encompass the child’s growth from birth to
adolescence, several instruments were needed;
specially trained staff who understood child development
also were needed to administer these
assessment tools properly.
A number of issues were raised about the cultural
appropriateness of existing evaluation tools.
Several grantees suggested that the Minnesota
Multiphasic Personality Inventory-2 (MMPI-2)
(Hathaway and McKinley, 1989) was not appropriate
for African Americans, but no replacement for
this widely used instrument was identified. The
cultural relevance of some standardized instruments
for assessing children
was also questioned. More
specifically, the Child Behavior
Checklist (CBCL) (Achenbach
and Edelbrock, 1986) and the
Brigance Early Preschool
Screen (Brigance, 1990)
do not allow a discussion of
cultural issues.
Several grantees commented
that it might have been useful for the separate
projects, or all grantees as a group, to designate a
leadership team to review and critique a number
of instruments and then offer the evaluators a
selection of assessment tools from which to
choose.
With respect to the standardized instruments that
were selected, the site-specific evaluation findings
in Appendix B specify the battery used by each
individual grantee. The ASI for women was the
most popular; eight sites used this assessment
tool. Four projects also used the Beck Depression
Inventory (Beck and Steer, 1987), and another
four chose the Symptom Checklist–90R (SCL-
90R) (Derogatis, 1975). To measure parenting
attitudes and behaviors, three projects used the
PSI, and two others selected the Adult/Adolescent
Parenting Scale-II (Revised) (Bavolek and Keene,
1989). Two sites also used the Circumstances,
Motivation, Readiness, and Suitability Scales
(DeLeon et al., 1994). Many sites used special
forms and checklists they developed themselves to
153

Chapter X
capture special aspects of treatment or the
women’s characteristics.
In addition to assessing baseline indices of functioning
in several areas, including mental health
and parenting behaviors, many of the grantees
tried to measure the mothers’ self-esteem, coping
strategies, family relationships, social support,
and, at two sites, intelligence.
There was less apparent agreement on appropriate
instruments for assessing the children, although
the CBCL, the Hawaii Early Learning Profile
(HELP) (Furuno, 1979), the Kaufman Assessment
Battery for Children (K-ABC) (Kaufman and
Kaufman, 1983), Conners’ Rating Scales
(Conners, 1970), the Denver Developmental
Screening Test Revised (Frankenburg and Dodds,
1978), Bayley Scales of Infant Development (BSID-
II) Second Edition (Bayley, 1993), and the
Brigance Early Preschool Screen were among
those mentioned.
Choosing a Comparison Group
A prominent concern for all of the projects was
finding and working with an appropriate comparison
group. Traditional treatment service providers
that were not part of the parent agency were,
understandably, reluctant to participate without
additional funding and because of complicated
agreements about patient confidentiality.
Additionally, many of the projects reported that it
was difficult to contact women in a comparison
group to conduct followup interviews if they had
not been in close touch with them during treatment
and did not have sufficient information
about their likely whereabouts following discharge.
As a result of these and other difficulties, the
grantees were not very successful in choosing and
working with appropriate comparison groups. Five
sites compared the outcomes for women in residential
treatment with their children to those of
mothers in very similar programs that did not
include children, matching client characteristics
as best they could. The numbers of women in the
samples, however, were very small, ranging
between 37 and 154. Two grantees (Casa Rita and
Chrysalis) did not specify a comparison group at
all, and the three other sites that conducted evaluations
(PAR Village, PROTOTYPES, and GAPP) did
not complete any comparative analyses because
the numbers of clients recruited into the designated
and appropriate comparison groups were
too small or the women’s characteristics were
too disparate.
Collecting Sufficient and Accurate Data
Another difficulty encountered by all evaluators
was collecting the desired data from the clients at
designated time points. In some cases, clinical
staff were very protective of their clients and, if
they did not fully understand the evaluation plan,
limited evaluators access to the women and children.
These clinicians feared that evaluators
might not be sufficiently sensitive, given the
nature of many of the questions asked; might not
understand their professional boundaries; or
might not realize the impact that the assessment
could have on the women. Additionally, given the
women’s lifestyles and drug use, self-reported
information about past behaviors of the mothers
and their children might be inaccurate, particularly
just after intake and before trust was developed
in the staff or program. Clinicians also thought
the evaluators would not get accurate answers if
the women were still experiencing symptoms of
drug withdrawal or were having a bad day for other
reasons. A further complication was that many of
the women did not have the needed literacy to
complete self-administered questionnaires. Lastly,
the mothers also had to be dismissed from clinical
activities and freed from their childcare responsibilities
to take any tests and participate in interviews
with the evaluators. In a busy, already overscheduled
program environment, making and
keeping appointments with evaluators could be
very difficult unless clinical staff agreed that evaluation
was a critical component of the grant.
Collecting postdischarge, followup data was a particularly
difficult task, especially with women who
were homeless, who were in the comparison
group, or who had returned to their former substance-abusing
lifestyle.
I think that the clients who have relapsed are the
most difficult to find . . . it’s always hard to locate
154

Evaluation Designs and Findings
people who have gone back to their addiction.
(IHW)
Other field staff reported that it was also difficult
to follow up with women who were doing well,
because they had little free time to participate in
an interview.
The grantees offered several suggestions, based on
the field experiences, to increase the likelihood of
locating the women and conducting followup
interviews. Of primary importance is hiring the
right person for this work: someone who has adequate
training, who is motivated and persistent,
who is familiar with the neighborhoods where the
women live, and who understands that the task is
challenging and time-consuming. It is also helpful
to obtain necessary information for locating these
women at the beginning of treatment, to update it
frequently, and to get a signed agreement with the
client herself that allows the project to contact
her and allows others to release information about
her whereabouts. Useful information to document
includes the addresses and telephone numbers of
persons known to the client who are not highly
mobile, any odd identifying features of the women,
and locations where clients like to spend time
with friends or acquaintances. Followup staff need
to use numerous sources of information, including
contacts with various systems (e.g., CPS), clinical
staff, informational networks, graduates, and documenting
systems (e.g., traffic tickets). Offering
toll-free collect calls from jails also may increase
followup rates.
Even though all agreed that clients should be paid
for their time to complete the followup interview,
some thought that giving a gift certificate for groceries
was more ethical than giving money, especially
for clients who had relapsed and might use
the money to buy drugs.
Using the Findings
Although there was disagreement among the
grantees about how data and evaluation results
should be shared and used, most of the projects
thought that aggregated evaluation results could
be helpful in program planning and in modifying
clinical strategies to make treatment more effective.
Hence, some feedback mechanism between
clinical and evaluation staff was deemed important.
Evaluation as an action-oriented research process
includes the participation of all staff. (GAPP)
Our evaluator is right onsite, she’s full-time, she
attends staff meetings, she shares information
with us, and she shares interesting trends that she
sees. Thus, if we need to adapt our program
activities to handle that trend, we can do just
that. (PAR Village)
The most helpful information used by most of the
grantees came from variations of brief client
and/or staff satisfaction surveys. Most projects
regularly asked clients’ opinions about numerous
aspects of the project, from the adequacy of the
environment to the appropriateness of staff conduct
and the therapeutic utility of different clinical
components. One site examined differences
between staff and client prognoses for their postdischarge
outcomes. The grantees noted that asking
clients what they thought could be a healthy
exercise and also could yield important feedback
about the project.
We’ll spend a couple of hours or a day going over
the process evaluation and then brainstorming;
okay, parenting classes rated very low, so what
are some other ways that we can teach parenting
information to the women? (Desert Willow)
We use [the client satisfaction survey] to see if
there are ways that we can improve what we’re
doing or if we’re missing out on something that
the women would really like to be receiving in
treatment. (Chrysalis)
Some projects found that examinations of intermediate
outcomes—most commonly, changes
between admission and discharge—provided
enlightening information about the women, the
children, and treatment effects, although major
changes were not always apparent if these mothers
and children were only in residence for 4 to 6
months. Case studies also were mentioned as
offering a more indepth view of the women’s treatment
experience and her corresponding behavior
change. The grantees agreed that it was important
to note and document other small but positive
outcomes and behaviors, such as the number
155

Chapter X
of children born drug-free and improvements in
school attendance and grades for the children who
lived with their mothers at the treatment center.
Addressing Ethical Issues in Data Collection
There were considerable differences among the
projects regarding how data were shared between
the evaluation and clinical teams. At some sites,
no data were exchanged; at others, evaluators
shared aggregated data or specific and sensitive
information they obtained about, for example,
child abuse or suicidal ideation. Some evaluators
thought that giving assessment data to clinical
staff violated confidentiality; others routinely
exchanged data at case reviews with clinical staff.
At sites with close coordination between evaluators
and clinicians, baseline data from standardized
instruments were used as part of the overall
clinical assessment to develop individualized treatment
plans. Grantees recognized the pros and
cons of each approach for sharing information.
One benefit of not sharing information was that
the client might have provided more honest
answers to the evaluators. One benefit of sharing
information was that duplication of data collection
was avoided. Most importantly, projects stressed
that the role of the evaluator had to be made clear
to the clients; the women needed to understand
exactly what information would be shared with the
clinical staff.
Another ethical issue encountered by the grantees
was how evaluators, in followup interviews in the
field, should handle suspicions that a mother was
abusing or neglecting her children or should
respond to other crisis situations involving apparent
mental disorientation or serious illness. Most
projects agreed that the suspicion of child abuse
or neglect was a difficult problem, best dealt with
by the person who observed the situation. If the
staff member or evaluator concluded that the
suspected abuse met reporting requirements,
then a formal report was filed. Proactive
measures, however, also were taken at the project
level while the mother was still in treatment by
telling all women, in advance, that it was the
obligation of any staff member to report child
abuse. Additionally, evaluation staff needed to
understand that the assessment or interview itself
may precipitate emotional distress, which they
should be prepared to handle. Most grantees
thought that providing a former client with
referrals for additional help would be an ethical
response to such a situation. Evaluation staff in
this situation also could try to convince a
discharged client to consider returning to the
program or an aftercare group.
Advantages and Disadvantages of Site-
Specific Evaluations
At the time when these RWC projects were funded,
few evaluations had addressed the efficacy and
effectiveness of substance abuse treatment programs
that allowed women to bring their children
with them into a residential facility. Originally, a
national cross-site evaluation was planned to study
and compare these projects, and participation in
this process was a condition of the grant award.
However, when responsibility for administering the
projects was turned over to CSAT, funds to support
this plan were not available. Although this was a
setback in many ways to coordinating the development
of the projects, there were compensating
advantages to not conducting this cross-site
assessment. Each grantee independently developed
its own evaluation component, selecting an
evaluation design (e.g., goals to measure, comparison
group, analytic plan), methods (e.g., data collection
procedures and points, instruments), and
content (e.g., variables to be included that were
specific to the theoretical model). It was hoped
that this flexibility would allow for later appraisal
of which designs, instruments, and data collection
procedures were most suitable for studying this
client population. It also was hoped that it would
shed light on the relative value of
different content domains as they relate to substance-abusing
women and their children.
There were also drawbacks to using independently
developed evaluation plans at each site. Without
comparable designs, methods, and definitions of
variables, no cross-site comparisons were possible.
In fact, differences in methodologies and instru-
156

Evaluation Designs and Findings
mentation—rather than in treatment strategies—
may be responsible, at least partially, for observed
differences between the sites in clients’ treatment
outcomes. Most of the grantees collected information
on similar variables, such as types of substances
abused by the mothers, their criminal history
and current involvement, child custody
arrangements, education level or work experience,
and psychological functioning. However, differences
in how these terms were defined, and omission
of some information by several projects, made
it almost impossible to compare any but the most
basic demographic characteristics of clients across
sites. Further, data from the separate sites could
not be collapsed or combined to increase sample
sizes sufficiently so that tests for significant differences
could be performed to assess the impact of
relatively rare variables (e.g., HIV status, Asian
ethnicity).
At the conclusion of CSAT funding for these projects,
almost all grantees indicated that participation
in a national cross-site evaluation would have
been worthwhile. Benefits of such an evaluation
might have been a larger sample size for data
analyses, the capability to examine regional differences
and other variables that typically have a
small response size, and more oversight and training
to resolve problems frequently encountered in
conducting evaluations.
During FY 1996, CSAT did fund and implement a
cross-site evaluation of women and children’s
grant programs that were funded between 1993
and 1995. This evaluation regularly analyzed the
effects of such variables as length of stay and different
client characteristics on discharge status
and treatment outcomes.
The Quarterly Reporting System
At startup, all grantees were required to submit
quarterly narratives to designated Government
Project Officers specifying their progress in implementing
the projects and describing the status of
clients who were admitted. Aggregate data were
collected in the initial quarterly reports that could
be used only for simple descriptions of the separate
sites. No outcome data were obtained, and
no cross-tabulations could be provided. By early
1994, it became evident that more uniform data
were needed to answer inquiries about these projects
from Congress, the U.S. Department of
Health and Human Services, and CSAT, as well as
from the grantees themselves. Hence, the technical
assistance contractor for these grants, Policy
Research Incorporated (PRI), was charged by CSAT
with developing a new grantee reporting process
(i.e., the QRS) that would “ensure that the data
and information that are provided by grantees support
their own treatment and management decisionmaking
processes, those of CSAT and the
Branch, and those of the public and private sector
in general.”
To identify the types of information actually used
in decisionmaking, PRI began examining the types
of inquiries made about these projects by various
sources, as well as earlier quarterly reports submitted
by the grantees and the types of variables
and outcome indicators the sites were already
tracking in their evaluations.
All stakeholders in this revised system concluded
that the most appropriate design for the
quantitative component of the quarterly reports
was a client-centered reporting system that did
not place an undue burden on grantees, most of
whom had to respond to reporting requirements
from multiple funding sources and oversight
agencies. Every effort was made to protect client
confidentiality in the system design and to
balance the need for improved data and
information with the sensitivity of some of the
information requested. The quantitative quarterly
reports, which were divided into client and child
subsections, were supplemented by a narrative section
and a recounting of financial expenditures.
The data collected pertained to characteristics of
the clients and children at intake; referral sources;
services provided during treatment; the
circumstances of discharge and referrals made;
and the health, social, and drug use status of
clients after discharge. All information of a sensitive
nature (e.g., relating to sexual or physical
157

Chapter X
abuse, gender preference, HIV/AIDS status) was
aggregated in the reports.
Data on discharge status and improvements
between admission and followup (described in the
next two sections) were obtained from the QRS.
This system was implemented in April 1995,
almost 3 years after the 11 grantee projects
began. The period covered runs through the end
of September 1997, the official end date for these
5-year grants. A family could be included in the
QRS database if it was actively receiving RWC program
services during April 1995. The limitations
of this system pertain to the inclusion of selfreported
information for many items, a restricted
number of followup records due to difficulties in
locating former clients, the shortened timeframe
that does not cover all 5 years that these projects
were supported by CSAT, the inclusion of data
from only 10 of the original 11 RWC sites, and the
absence of some variables of interest to the individual
grantees. However, differences between the
numbers of clients included in the QRS and the
aggregated totals of clients served by all of the
grantees together are not very large. Specifically,
the admission profiles from the QRS are based on
1,168 women; the grantees reported baseline
information on an aggregated total of 1,627
women—a difference of fewer than 500 women.
Followup data are available for 335 women from
the QRS and for a total of 569 clients served by all
of the RWC grantees—a difference of 234 women.
Hence, the QRS findings may be seen as generally
reflective of the grantees’ aggregated evaluation
results.
Discharge Status (From the QRS Data)
• N = 915 mothers discharged by September
30, 1997.
• More than one-third (35.2 percent) of these
women successfully completed treatment by
meeting the individualized treatment success
or graduation criteria established by the separate
grantees.
• Another 5.8 percent were transferred to a
more suitable treatment program, making a
total of 41 percent with hopeful outcomes
(35.2 percent who successfully completed
treatment plus 5.8 percent who were transferred).
• Nearly two in five (38 percent) of the women
dropped out or left treatment against medical
advice.
• Seventeen percent left involuntarily or were
terminated for cause.
• No discharge status was indicated for 2 percent
of clients.
• The average number of days in treatment for
all women was 141 (about 20 weeks or 5
months). The median number of days in
treatment (50th percentile) was 103 (about
15 weeks or nearly 4 months).
Comparison of Clients’ Status at Admission
and After Discharge (From the QRS Data)
In followup interviews conducted from 1 to 18
months after discharge from treatment, clients
were asked about certain behaviors and experiences
that had also been assessed at admission.
The status of all women in these RWC projects for
whom followup data were available showed
improvement with respect to their drug use,
involvement with the criminal justice system,
and employment status over their self-reported
assessment of these variables at admission, irrespective
of their length of stay. Women who completed
treatment displayed even more positive
changes between admission and followup on these
three measures of successful outcome than did
those who dropped out or were terminated.
Summary of Site-Specific Evaluation
Findings
The final evaluation reports submitted by the
grantees, for the most part, fell short of expectations;
not all the objectives set forth in the original
plans were accomplished. The evaluators did
profile major characteristics at intake of the
women and children served; however, not all of the
projects aggregated admission data for all the
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Evaluation Designs and Findings
women enrolled, and descriptive information pertaining
to the children’s characteristics and problems
was sparse. None of the projects presented
data to document anecdotally noted trends toward
admitting clients with increasingly more serious
problems. For the most part, the evaluators’ difficulties
in tracking and interviewing clients after
discharge resulted in small, sometimes biased,
samples. Despite the emphasis on comparison
groups, only 5 of the 11 sites were able to compile
data on a sufficient number of women in these
groups for analysis, and one comparison, according
to the evaluators involved, was marginal, consisting
only of trend lines. Because the evaluations
at each project were separately and independently
designed, it is difficult to compare outcomes
across the sites in a meaningful way. As
already noted, projects were encouraged to select
assessment instruments that measured the different
goals each was trying to achieve and that
reflected different perspectives on women’s and
children’s problems. Followup points also differed
among the sites.
Despite these shortcomings, however, the evaluation
findings document many achievements of the
grantees and inspire some hopefulness about the
overall positive impact of these projects on the
women and children served. As already noted, several
sites used the results of regularly scheduled
client and staff satisfaction surveys to monitor the
perceived utility and relevance of project components
and to make indicated changes in programming,
staffing, and the project environment.
Three sites provided useful data showing improvements
among the women during treatment. PAR
Village reported on general improvements in selfesteem,
academic standing, parenting attitudes
and behaviors, and enrollment in school or a vocational
training program while in treatment. PRO-
TOTYPES documented significant decreases in several
measures of psychopathology and distress—to
levels that were within normal ranges—among
women who, on average, remained in treatment
for nearly a year. At Watts, all women in three
comparison groups, including mothers with children
in the residential facility who completed
treatment, reduced their levels
of problem severity in six of the seven areas
measured by the ASI, increased their self-esteem,
and decreased their symptoms of depression and
other psychiatric disorders between admission and
discharge.
Table X-1 compares outcomes for women who were
treated at 10 of the sites and for all of the women
included in the QRS. Notably, a little over onethird
(35 percent) of all women profiled by the
QRS completed residential treatment, although
the percentages at individual sites vary from 29
percent at Watts and FIT to a remarkable 65 percent
at Casa Rita. For most projects, the percentage
of women successfully completing the project
ranged between 35 and 40 percent. Interestingly,
Casa Rita, which admitted only homeless women
with their children, explained its success rate as
possibly indicating that the project represented "a
last hope for mothers who had exhausted all their
housing and treatment options
and were also disillusioned with male intimates"
(i.e., their partners and fathers who had a history
of substance abuse). These women, in the vernacular
of AA, had truly "hit bottom" and were without
other resources. Casa Rita represented both a
last chance and a new beginning.
Residential treatment, however, appears to have
improved the overall functioning of many women
on a number of dimensions, whether or not they
stayed long enough to graduate. Outcomes
appear to be positive whether the data were analyzed
with dropouts and treatment completers
together or were examined for only those who successfully
finished the program. Women from all of
the sites who were interviewed at followup periods
of 3 to 24 months apparently decreased their use
of drugs and alcohol from levels acknowledged at
admission. All eight of the projects that examined
employment status also found that these women
were more likely to be working when interviewed
after discharge than at intake. The four sites that
monitored women’s involvement with the criminal
justice system also found improvements over the
same time periods. Seven projects found similar
amelioration of psychological symptoms between
admission and followup. Six of seven projects that
studied custody arrangements found increases in
159

Chapter X
Table X-1. Summary of Treatment Outcomes for 10 Center for Substance Abuse Treatment,
Residential Women and Children’s Grantees
CSAT/
RWC
Grantee
Total
Clients
Served
Baseline
Data
Followup
Data
Followup
Period
Casa Rita 96 65 35 and 40 6.5 and 18
mos.
AOD
Use
Employment
Status
Criminality
Psychological
Status
Parent
Stress
Level
Child
Custody
ALOS for
All Clients
NR NR NR NR 48% =
>1 yr.
ALOS for
Completers
Percent
Completing
NR 65%
Chrysalis 197 101 27 6 mos. NR NR NR 127 days 331 days 36%
Desert 111 102 67 6 mos. NR NR 273 days 477 days 41%
Willow
FIT 147 118 77 12 mos. NR 149 days 343 days 29%
GAPP 142 132 30 3 mos. NR NR NR NR 181 days 46%
IHW 115 115 81 6 to 24
mos.
Meta
House
PAR
Village
PROTO-
TYPES
NR 137 days NR 40%
estimate
170 101 33 24 mos. NR NR 270 days 38%
279 127 62 6 mos. 144 days 319 days 33%*
765 702 124 6 mos. NR 161 days NR NR
Watts 64 64 14 6 mos. NR NR NR NR NR 267 days 29%
QRS data 1168 1168 335 1 to 18
mos.
NR NR NR 141 days NR 35%
n = 912
Key:
= Improvement from baseline to followup; = No improvement from baseline to followup; NR = Not reported.
* PAR Village reported that 33 percent of clients completed treatment successfully and another 17 percent were referred or transferred for additional
treatment after completing treatment. However, transfers at other programs were not included in the percentages cited as successful.
the numbers of mothers reunited with and supporting
children following treatment, and three of
the four sites that looked at parenting stress levels
discovered that mothers were more comfortable
with their responsibilities by the time they had
been on their own in the community for some
time.
Women from IHW who were followed for periods of
6 to 24 months also showed significant improvements
on other dimensions, including self-esteem,
family relationships, friendships with supportive
adults, and educational levels. They were much
less likely to be living with substance-abusing partners
or to be victims of domestic abuse at followup.
The evaluators at Meta House who tracked
women for 24 months after discharge reported
similar findings and commented that "a majority
of the mothers who live with their children are
functioning at remarkably high levels—behaving
responsibly . . . and are providing a completely
drug-free family environment." Conflicts with family
members and others also had decreased significantly
over baseline levels.
Improvements in postdischarge functioning were
even more pronounced among women who completed
the treatment programs when compared to
women who dropped out. At Chrysalis, outcomes
for graduates of the program were significantly
improved with respect to alcohol use, family conflict,
and parenting stress in comparison to those
who left treatment before completion. Women
who successfully finished treatment at FIT were
significantly more likely than those who dropped
out to be working 10 to 12 months after discharge,
particularly if they continued to participate
in aftercare services. Although the sample
sizes were very small, women who completed any
of the three comparison programs at Watts apparently
improved much more than those who
dropped out, especially with respect to psychological
functioning. Bonding with a staff member
appeared to have a significant impact on remaining
in
treatment at PROTOTYPES. The median time in
treatment for women who felt close to someone
on the staff was more than 9 months, but it was
less than 6 months for those who did not develop
this sense of trust.
With respect to average lengths of stay (ALOS),
the data suggest large—three- to fourfold—differ-
160

Evaluation Designs and Findings
ences between the time spent in treatment by
those who completed the program and those who
dropped out or left against staff advice. At Desert
Willow, for example, graduates of the program
remained in treatment for an average of nearly 16
months, compared to only 4 months for dropouts.
This difference was 11.4 months, compared to a
little over 2 months, at FIT; 10.5 months, compared
to nearly 3 months, at PAR Village; 9
months, compared to almost 3 months, at Watts;
and 6 months, compared to not quite 2 months,
at GAPP. Although there are wide differences
among the sites in the amount of time women
needed to complete the program—ranging from
almost 16 months to only 6 months—the more
dramatic finding is the similar time-in-treatment
disparities between completers
and dropouts.
Mothers who spent
6 months or more in
the residential facility
at PROTOTYPES were
functioning better at
followup with respect
to life skills,
employment, and
meeting basic needs
than those who left
treatment before
6 months.
Three of the grantees examined
differences in treatment
outcomes for women who
remained in treatment a minimum
of 3 to 6 months and
those who left earlier. At
Desert Willow, women who
stayed in treatment for more
than 3 months, compared to
those who left treatment earlier,
were significantly more
likely to be employed and less
likely to have committed
crimes or to be using drugs
when followed up at 6 and 12
months after discharge.
Remaining in treatment for
more than 3 months at this program also was
associated with decreases in psychopathology at
followup. A comparison of women who remained
in treatment for 6 months or more at FIT with
those who left earlier also found that length of
stay was significantly associated with later abstinence;
in fact, women who stayed in treatment at
FIT for 6 months or more were nearly 10 times
more likely to be drug-free at followup than those
who dropped out before 6 months. Mothers who
spent 6 months or more in the residential facility
at PROTOTYPES were functioning better at followup
with respect to life skills, employment, and
meeting basic needs than those who left treatment
before 6 months. These longer staying
women at PROTOTYPES were also less likely than
those who stayed in treatment for a shorter time
to have been arrested or to have been homeless in
the interval between discharge and followup.
However, findings with regard to differences in
postdischarge outcomes between women who had
children living with them in the residence and
comparison women who did not bring children
with them to treatment were more complicated.
At Desert Willow, the women who had children living
with them were only slightly more likely to
complete treatment than those without children
in the residential facility (41
and 33 percent, respectively).
Whether or not women had
children living with them
while in treatment at Desert
Willow, however, did not seem
to affect their functioning at 3
months after discharge in any
consistent manner with
respect to such variables as
employment, criminality, or
psychopathology.
At Meta House, mothers who
had children in residence with
them were also more likely
than counterparts without
children in treatment to graduate
(38 percent compared to
26 percent), but there was no
difference in the ALOS between mothers with and
without children in the treatment program who
graduated. Women completing treatment at Meta
House who had children with them stayed an average
of 9 months; graduates who did not have their
children with them remained in treatment for an
average of 9.3 months.
By contrast, women who had their children with
them at FIT completed the program at nearly the
same rate as comparison women who did not have
their children in residence. However, graduates of
FIT who had their children with them were more
161

Chapter X
likely than counterparts in the comparison program
to be drug-free and employed at followup.
Comparisons by IHW evaluators of women with
and without children in residence found that both
groups were equally likely to
remain in treatment for at
least 3 months and that both
groups showed significant and
persisting, but similar,
improvements in functioning
on a number of dimensions.
In sum, having children with
them in the residence was no
guarantee, by itself, that
women would remain in treatment
longer, graduate, or
function better at followup.
Other factors were probably
more influential with respect
to these measures of successful
treatment (e.g., stipulation
to treatment by the referral
source, support from family
members and partners who
were not drug-involved, "readiness"
for treatment, the availability
of safe and alternative
child care, employment skills, less traumatic histories).
Outcomes for the children who lived with their
mothers in the residential facilities also were
encouraging. At Desert Willow and at Chrysalis,
young children with developmental delays showed
improvements between baseline assessments and
6- to 15-month postdischarge followups in gross
and fine motor coordination and language skills.
The school-age children at Chrysalis had significantly
improved their prosocial behavior at the 6-
month posttreatment assessment, and children
who attended public schools while living with their
mothers at FIT improved their grades impressively.
Only 40 percent of these children had passing
grades at admission, but all were passing all courses
after a single semester with their mothers at
FIT.
The women who
participated [in an RWC
program] . . . were likely
to have decreased their
use of substances and
criminal behavior and to
have improved their
status with respect
to employment,
psychological symptoms,
parenting behaviors and
attitudes, and reunification
with children at
followup points.
Although not all of the grantees were able to
implement the evaluation plans initially envisioned,
the findings from the analyses conducted
do confirm the importance of residential treatment
programs for improving the post treatment
functioning of mothers who
had very traumatic histories
and multiple problems at
admission. The women who
participated, whether or not
they completed treatment,
were likely to have decreased
their use of substances and
criminal behavior and to have
improved their status with
respect to employment, psychological
symptoms, parenting
behaviors and attitudes,
and reunification with children
at followup points.
These improvements and others
were more dramatic for
women who successfully completed
treatment than for
those who dropped out.
Length of stay was strongly
associated with improved functioning
for up to 2 years after discharge. Even
remaining in treatment for more than 3 to 6
months positively affected these women’s postdischarge
functioning. Dramatic differences in ALOS
between those who graduated from these projects
and those who dropped out suggest that many
women without much apparent interest or investment
in treatment do leave very early—within a
few days or weeks of admission. It is unclear from
the comparisons made whether having children in
residence increases mothers’ likelihood of remaining
in treatment longer, graduating, or doing better
in the community following the residential
stay. However, the improvements in motor skills
and language abilities shown among toddlers with
diagnosed developmental delays at admission and
in the academic performance levels and behaviors
of school-age children reinforce the positive
impact that these projects had on the women’s offspring.
162

XI. Conclusions
and Epilogue
T
his final chapter summarizes the achievements
of the original 11 RWC grantees,
including project directors’ perspectives on
the most essential elements of these innovative
efforts; reflects on some remaining issues that
need more attention; and reports on the projects’
struggles and successes in obtaining funding to
continue operating, with some changes in the
numbers of families served, the expected length of
stay, and programming.
Achievements of the Grantees
The RWC projects were designed to address the
multiple needs of substance-abusing women and
their young children by delivering comprehensive,
onsite services in a residential environment and
also by connecting these women to a variety of
other community-based service delivery systems.
These projects not only improved the lives of many
of the women and children they served, but also
contributed new knowledge to the field of substance
abuse treatment about the complex deficits
and correlated disorders of this population and the
types of gender-appropriate and culturally sensitive
services that could ameliorate them. The grantees
made many contributions to the clients they treated—and
to clients served by later versions of these
projects—by identifying, intervening, and at least
partially stabilizing many longstanding health and
social problems that previously had been overlooked
and not diagnosed by other public and private
sector agencies.
Collective Accomplishments
Over the course of their 5-year project periods, the
original 11 RWC grantees made important strides
in conceptual and practical approaches to delivering
comprehensive treatment services for substance-abusing
women and also to intervening in
the lives of their infants and young children, helping
them to overcome developmental delays, academic
deficiencies, and emotional or behavioral
problems. These projects fulfilled all or most of
the tasks mandated by their grant awards and also
surmounted many unanticipated challenges, particularly
in reconciling differences between
women- versus children-focused staff and programming
components. Among the major achievements
of these grantees are the following:
• The original RWC grantees all succeeded in
reaching the target population of severely
troubled and disadvantaged substance-abusing
women and their young children and attracting
them into residential treatment. The
women who were served manifested all the
correlates of substance abuse previously identified
in the literature or reported by other
programs, including co-occurring medical
problems and mental illness; polydrug abuse;
horrific histories, as children and adults, of
physical violence and sexual abuse, including
incest and rape; criminal records or involvement
with the criminal justice system; dysfunctional
families and relationships with abusive,
substance-abusing partners; poverty;
homelessness; membership in minority
racial/ethnic groups; illiteracy or low levels of
education; unemployment and few job skills;
and pending or threatened child custody
cases. The children who lived with their
mothers in the treatment centers had developmental
delays in motor and language skills,
poor academic records, and predictable emotional
and behavioral problems as a result of
their own neglect or abuse. More women
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Chapter XI
needing this type of treatment were identified
and referred for admission than the projects
could serve; many had to be referred elsewhere
or placed on waiting lists. Most of the
women were referred not only from other substance
abuse providers and the criminal justice
system, but from new contacts with agencies
that had not traditionally encouraged
these women to enter treatment; these
included child and family services or welfare
offices, child protective agencies, hospitals,
and prenatal or perinatal clinics.
• These 11 centers made important strides in
developing treatment philosophies and protocols
that incorporated research-based or fieldtested
elements of TCs, case management
coordination of care, group dynamics, and 12-
Step approaches to rehabilitating women.
Importantly, these disparate elements also
were melded with an understanding of child
development and ageappropriate
interventions
that encouraged the maturation
of children, culminating
in innovative, cutting-edge
family-oriented
treatment that also
responded to the specific
needs of culturally diverse
populations.
These 11 centers made
important strides in
developing treatment
philosophies and protocols
that incorporated
research-based or fieldtested
elements of TCs,
case management coordination
of care, group
dynamics, and 12-Step
approaches to rehabilitating
women.
• These grantees secured
and renovated appropriate
physical structures in
which to locate their
unique services, ensuring
that the sites were adequately
equipped to provide
comprehensive services
to adult women and
their newborns and young children. In most
cases, this required a significant investment of
time and effort to address concerns of the
communities in which the facilities were
located, to make certain the structures met
local fire and safety codes, to obtain necessary
furniture and other equipment, and to negotiate
with relevant public agencies and acquire
special licensure and certification requirements
not common to other substance abuse
treatment programs (e.g., approvals for
onsite, therapeutic child care). These
grantees made decisions about whether dormitory-
or apartment-style living quarters
were most suitable for the women and children
served, and they also envisioned how the
physical sites could be used as part of the
rehabilitation process to improve the women’s
life and household management skills. Many
of the projects were creative in using all of
their employees, including maintenance workers,
to help the women learn how to fix toilets
or make other repairs, in addition to shopping,
cleaning, cooking, budgeting, and establishing
mealtime and bedtime routines for the
children.
• Significant contributions to the field were
made by these centers in developing and
improving the capacity of staff members to
provide comprehensive health
and social services, in addition
to substance abuse treatment,
to women who are living with
their young children in a residential
facility. The grantees
also experimented with a variety
of staffing patterns, integrating
trained professionals
in child development, nursing,
medicine, psychology, and
case management with certified
substance abuse counselors
and employees who
were recovering from substance
abuse or mental illness.
They tried to match staff characteristics
with respect to
race, ethnicity, and gender
with those of the clients
served. All of the sites opted to hire a majority
of women, but some thought men had a
particular role in helping the women overcome
negative experiences with, and attitudes
toward, men. At least two sites concluded
that gender and race/ethnicity were less
important than caring and supportive attitudes
among staff in helping these women
recover. All the sites offered extensive in-
164

Conclusions and Epilogue
house and offsite training opportunities, as
well as supervision, to staff members to
improve job-related competencies and to meet
programmatic needs. Most importantly, the
grantees worked to build a coordinated team
of employees who could agree on, and work
together for, the best
interests of the whole family,
not the women and
children separately. Staff
openly examined and discussed
very difficult
issues, including how children
ought to be disciplined;
what violations of
program rules required
immediate expulsion of a
woman, even though it
might result in foster care
placements of her children;
and whether family
reunification was always the most desirable
outcome. Staff from the children- and
women-focused components came to grips
with and had to resolve problems not traditionally
encountered in this field. With their
training and experience, these employees constitute
a new pool of staff
who can provide helpful
insights. They should
have many opportunities
in this innovative programming
arena and for
transferring knowledge
across sites.
• The RWC grantees developed
and tried many
approaches to meeting
the myriad needs of this
population of women in
treatment. They had to
resolve many scheduling
challenges, including finding enough time for
all the activities they expected to offer the
women and their children. While most sites
preferred to have onsite services, they also
attempted to reintegrate the women back
into their neighborhoods and connect them
with ongoing community-based services.
. . . the grantees worked
to build a coordinated
team of employees
who could agree on,
and work together for,
the best interests of the
whole family, not
the women and children
separately.
While most sites
preferred to have onsite
services, they also
attempted to reintegrate
the women back into
their neighborhoods and
connect them with
ongoing communitybased
services.
Since they were mandated to provide as-needed
physical and mental health assessments
and treatment for both the women and children,
the projects had to develop innovative
ways to schedule appointments and accompany
clients on visits to doctors and therapists,
as well as to other benefit specialists,
probation and parole
officers, lawyers, and child welfare
caseworkers. The projects
were very creative in finding
local experts or consultants
who were willing to provide
onsite therapy or instruction
on a variety of topics. Many
relied on case managers to
identify and establish productive
relationships with
resources such as vocational
training and employment
agencies; adult education and
literacy programs; medical specialists; mental
health centers; AA, NA, and other 12-Step
groups in the community; support services for
persons diagnosed with HIV infection or AIDS;
public housing authorities and other
resources for safe, affordable housing; public
schools; and public benefit
programs. The grantees were
also creative in garnering
additional financial support
and donations of goods and
services from churches, local
businesses, politicians, and
other private sector community
groups.
• These centers were ingenious
in developing many of
their own services by
selecting and blending
materials and approaches
for relevant curricula from
previously published programs
or articles, videos, and the imaginative
resourcefulness of their own staff. Among the
more innovative programmatic elements that
the sites developed were healthcare curricula
to improve women’s understanding of their
own anatomies, nutritional needs, sexuality,
165

Chapter XI
and risk for certain diseases and conditions,
as well as how to care for ill children; recreational
activities and physical exercises to
expose them to low-cost, drug-free forms of
entertainment, improve their health and fitness,
and reduce stress; and life skills programs
to teach and provide hands-on guidance
regarding household management,
assertiveness in accessing services in the community,
and establishing other daily routines.
Critical to the delivery of family-focused treatment
and the management of potential
relapse triggers were the core services piloted
by the grantees. These services affected the
interrelated, often painful
issues of inadequate parenting
practices, traumatic
experiences with sexual
abuse and violence, and
abusive, destructive relationships
with significant
others/sexual partners
and family members.
These problems often
were addressed through
traditional individual,
group, and family counseling
by program staff and
by referral to knowledgeable therapists.
However, the sites also devised innovative curricula
and protocols for hands-on guidance
and modeling that did not seem, for the most
part, to have been formally documented,
reviewed, and disseminated.
• The grantees additionally designed and implemented
a wide array of age-appropriate services
targeted to meet the early developmental
needs of the infants and young children in
treatment, including remediating any diagnosed
delays. The therapeutic childcare services,
many of which can be replicated in other
settings, were primarily provided onsite under
the supervision of professionally credentialed
teachers or child development specialists or
through such well-evaluated programs as Head
Start. In view of society’s increased understanding
of the critical importance of early
childhood development, the knowledge gained
through the RWC projects about service needs
. . . RWC grantees succeeded
in improving the functioning
of the mothers
and children served, both
during treatment and at
followup points of 3 to 24
months after discharge.
for at-risk children, and the extent of the children’s
problems, made a contribution to the
field of substance abuse and more broadly in
health and social services. Older, school-age
children who lived in the residences were
enrolled in local public schools and improved
their very prevalent academic deficiencies
through afterschool tutoring programs, consultations
by program staff with their teachers,
and involvement of their mothers in the
schools and in coaching efforts. The emotional
and behavioral problems of all the children,
but particularly the older ones, were assessed
through observations and testing. They were
addressed by helping mothers
express affection, play with
and read to their children, and
provide structure instead of
harsh discipline. The children
also were encouraged to interact
with each other in constructive
ways while they were
involved in recreational and
other educational activities
that also promoted their intellectual
growth through exposure
to a wider world. Some
children with continuing
behavioral problems were referred to therapists
for special counseling. All of the sites
provided some educational, recreational, and
counseling services for older children who did
not live in the residential facilities with their
siblings.
• Most of the RWC grantees successfully
secured funding from a variety of sources
elaborated in this chapter to sustain operations
after the CSAT grant expired.
• All of the grantees worked independently with
site-specific evaluators and a federally supported
technical assistance contractor to collect
data and other information pertaining to
clients and the project. These data were analyzed
and used for individual treatment planning;
program management; modifications in
operations and programming; and documentation
of client profiles, in-treatment improvements,
and postdischarge outcomes that
166

Conclusions and Epilogue
could justify funding solicitations and contracts
with managed care organizations.
• Findings from the evaluations conducted at
each site confirmed that these RWC grantees
succeeded in improving the functioning of the
mothers and children served, both during
treatment and at followup points of 3 to 24
months after discharge. The projects were
most successful in their primary assignment—
substantially and significantly decreasing
mothers’ use of alcohol and other drugs, particularly
crack cocaine, from levels reported
at admission. They generally made positive
impacts on the women’s likelihood of employment,
reunification with children and families,
parenting skills, and comfort with parenting
responsibilities, while decreasing their criminality
and psychological distress. During
treatment, all of the women and children
received healthcare services they would not
likely have obtained otherwise. These included
comprehensive physical examinations, HIV
counseling and testing, prenatal and obstetrical
care, pediatric supervision, and up-to-date
immunizations for the children, as well as regular
monitoring and treatment of other medical
conditions. The grantees also demonstrated
that women who completed treatment
or stayed in treatment for more than 6
months showed more improvement on a
number of measures than did counterparts
who dropped out early without completing
treatment.
Perspectives of the Project Directors
Two years after the official end of CSAT support
for the original RWC projects, 10 former project
directors or administrators were asked what they
thought were the most essential services and critical
program factors that helped this population of
troubled women remain in treatment and function
better after discharge. The answers varied, but
the following program features were stressed as
most important:
• Therapeutic relationships that women developed
with caring and supportive counselors
and other staff who believed in these clients’
capabilities for positive change, who accepted
them nonjudgmentally where they were, and
who modeled appropriate behaviors.
• Integrated services for the women and their
children that were delivered onsite so that
project staff were always directly aware of
what was going on with each individual person—as
well as the family unit—rather than
relying on reports from many uncoordinated
experts who provided offsite care.
• Family-oriented treatment teams composed of
staff members from many backgrounds and
disciplines who struggled to confront and
understand the multiple, interrelated problems
these women faced; learned to talk
about and be comfortable with many sensitive
and difficult issues (e.g., sexual abuse, domestic
violence, child neglect); and established
positive connections among themselves and
with the residents.
• Variable lengths of stay and individualized
treatment plans that helped the women focus
on resolving their problems and improving
their skills, not simply on the time they spent
in the treatment center. This flexible
approach allowed clients to examine their own
problems and deficits at the most suitable
points in treatment for them, rather than
exposing all women or children as a group to
phase-determined services.
• Intensive, several-day workshops that
addressed the sensitive and critical issues of
these women and helped them to open up and
express feelings; interact meaningfully with
other peers and staff in a trusting environment
away from their children; view the issues
from a number of perspectives; and make
commitments to themselves and others to
change, ask forgiveness, heal, and plan or
practice new behaviors. The intensity of this
approach and the group process that was facilitated
by professional experts elicited more
positive responses than those garnered
through more traditional individual and group
counseling and therapy.
• Stipulations to treatment—as a condition of
criminal justice involvement or pending child
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Chapter XI
custody cases—that seemed to help many
women both enter and remain in treatment.
• Client-specific interventions—convened and
conducted by staff, referral source representatives,
and other concerned family members
and friends—that helped women in residential
treatment recognize the realities of what they
would lose if they did not complete treatment.
• A safe, structured, and supportive environment
that allowed these women sufficient
time to ponder and practice, at a crisis point
in their lives, healthy changes they could
make and sustain to benefit not only themselves,
but their children and families.
Some Remaining, Unresolved
Issues
Despite their accomplishments, however, the
grantees neither resolved all the challenges they
faced nor found workable solutions to many ongoing
problems. Several of the most troublesome
issues deserve further attention by similar programs
and also by Federal, State, and community
agencies with special and overlapping interests in
the target population. Among these are the following:
• The RWC grantees, for
many reasons, did not
admit all the children of
the mothers in treatment.
Restrictions on ages and
numbers of children who
could live with their mothers
limited the population
of children in residential
care mostly to youngsters
under 5 years and to only
a few of a mother’s
youngest offspring. As a
result, many of the
hypothesized reasons for
mothers to enter and
remain in these projects—as opposed to those
that did not allow children—were not as relevant.
It did not become clear how much of a
difference having children in residence made
A safe, structured, and
supportive environment
that allowed these
women sufficient time to
ponder and practice . . .
healthy changes they
could make and sustain
to benefit not only
themselves, but their
children and families.
on mothers’ remaining in treatment and
improving their own lives, although the services
provided did positively affect their children.
More attention needs to be given to ways to
screen for women who do and do not benefit
from having a few of their younger children
with them in treatment. Methods for ascertaining
the best time for admitting these children—immediately
at intake or only after the
women have been stabilized and are committed
to staying—also should be examined.
• The rates of early dropout from most of the
projects were very high, although they were
not out of line with similar ones in other residential
settings. Nevertheless, more attention
needs to be given to the correlates of leaving
early, often within a few days or weeks of
admission. Initial indications that dropout
rates were influenced by women’s multiple
serious problems, described as levels of burden
by PROTOTYPES, were not definitively demonstrated.
Indeed, completion rates at one site
suggested that homelessness and previous
treatment failures may have inspired mothers
to take this treatment opportunity more seriously.
Although some sites provided more
intensive and supportive programming during
initial orientation periods to help retain
women in treatment, more
needs to be learned about the
characteristics of these early
dropouts who, anecdotally,
had multiple problems, resented
program structure, and
retained connections with dysfunctional,
drug-using families
and partners. The impact of
mandated treatment participation
by the CJS, CPS, and
TANF agencies on treatment
retention for this population
also needs further elucidation.
Admitting and assessing so
many mothers who leave early
is not a prudent use of limited
resources; it is possible that better screening
tools, different admission criteria, or probationary
programming could improve retention
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Conclusions and Epilogue
rates for these mothers or winnow them into
a more appropriate therapeutic milieu.
• All the grantees adopted and justified flexible
approaches for estimating the amount of time
needed for individual
women to complete treatment.
However, managed
care contracts and other
funding sources are pressuring
treatment programs
to shorten lengths
of stay considerably.
Adoption laws that limit
the length of time mothers
can be in treatment or
have children in foster
care placements before
the State can terminate parental rights also
pressure mothers with pending custody cases
to move through treatment more quickly. All
women need enough time in treatment to
achieve sobriety and make substantial
progress toward meeting other important
treatment goals. It is not clear, however,
whether some usual or maximum length of
treatment can be set, with exceptions made
for women with different circumstances.
More attention needs to be given to stepdown
arrangements used by some of the sites to
transfer women to less intensive and less costly
treatment modalities for aftercare services
following residential care. Greater effort also
needs to be directed at placing working mothers
in nearby transitional housing, where they
can continue to receive some program supports
and keep children in familiar daycare
facilities for extended hours.
All women need enough
time in treatment to
achieve sobriety and
make substantial
progress toward meeting
other important
treatment goals.
• Funding sources place competing demands on
the priorities that should be given—and time
committed—to intervening with and ameliorating
selected problems manifested by these
women. "Work first" strategies in the welfare
reform laws mandate an early focus on vocational
training and employment, child welfare
insists that mothers immediately improve
their parenting skills through education and
hands-on guidance, and Medicaid requires a
certain number of hours in therapy. The literature
on this population suggests that past
and current experiences of sexual abuse and
domestic violence remain potent relapse triggers
unless confronted and resolved through
therapeutic interventions.
More attention—at local,
State, and national levels—
needs to be given to collaborations
among the many separate
agencies that refer
women to these programs.
These stakeholder agencies
(e.g., child-serving organizations;
violence prevention
groups; public housing agencies;
departments of corrections,
welfare, and mental
health; other substance abuse
treatment providers) need to prioritize the
demands they make on these service recipients
and enter into joint funding ventures.
• Most of the grantees were successful in securing
needed community-based services for the
women and their children—most notably,
medical care, education, and vocational services.
Several sites, however, noted long waiting
lists and other difficulties in accessing
mental health care, dental services, and
affordable housing for the women. More
attention needs to be given to securing these
critical services for this population though
cooperative arrangements and more direct
advocacy with legislators and other funding
sources.
• The original RWC grantees independently
designed numerous curricula and conducted
training for the women that incorporated a
variety of approaches, including didactic lectures,
experiential guidance, and group discussions.
Among the topics most frequently
addressed in these training packages were
women’s health, parenting practices, relationships,
anger and violence, and grief and loss.
More attention needs to be given to collecting
and analyzing these materials to determine
the content covered, the appropriateness of
the reading level and vocabulary used, and the
suitability of the approaches for the target
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Chapter XI
population. Also unknown, for the most part,
is whether these curricula improved participants’
knowledge, attitudes, and behaviors.
There seemed to be little time for these analyses
in the midst of all the other activities
undertaken by the grantees. It does not
appear that the curricula developed by these
grantees were widely shared, and few sites
reported using the same already-published
materials. Hence, groups of experts at the
local, State, and national level might be
involved in reviewing these training packages,
advising about other available research or
peer-reviewed findings that should be included,
and recommending an array of appropriate
curricula from which programs could choose.
A similar review process also would be useful
for recommending a core battery of standardized
assessment instruments and other supplemental
checklists and questionnaires that
have yielded useful data for profiling this population
and intervening with their problems.
Epilogue: Continuing Operations
How have the grantees fared with respect to consolidating
funding and continuing program operations?
Only one of the projects has closed completely,
and one was barely holding on when contacted
in 1999. Two others had officially closed,
with similar programs serving much the same population
opening or functioning at the same sites.
The residential projects of the other seven
grantees were continuing; some with reduced services
and staffing, others with an even stronger and
expanded overall effort.
• GAPP shut down its facility on May 30, 1999.
The project had managed until that time to
secure enough funding from the State legislature
and the county to pay for 6 months of
residential treatment (the original length of
stay) for 10—not 24—families. However,
when a new governor cut State support, there
were insufficient monies to remain operational,
even at the reduced level. Before that
decision, GAPP had dropped the onsite physician
and had relied more on offsite resources
and agencies to provide services. This was not
working out well, because too much time was
consumed by coordinating appointments and
providing transportation for the women and
children. Further, and more discouragingly,
some women were simply not ready to participate
in offsite services. Because they were in
the community too soon and were tempted to
go back to using drugs, they left treatment
early. Programs need to have most services
onsite, particularly in the early phases of
treatment, even if they are delivered by staff
from other agencies.
• Flowering Tree was just managing to survive
when contacted in late June 1999. The Tribal
Council had supplemented carryover funds
from CSAT to that point. The project hoped
to continue operations through September so
that current residents could meet court
requirements to have 6 months of treatment
if they were to retain custody of children.
• Despite extensive efforts and appeals for funding,
Desert Willow shut down its residential
women’s facility at the end of June 1998,
although services were provided to several
families through November 1998. The facility
is now on the market. However, Amity, Inc.,
the original grant recipient and parent agency
for Desert Willow, has started a similar program
for 12 to 15 families with funding from
the Department of Economic Security. The
budget is smaller, and more emphasis will be
placed on vocational services. The site is
across the street from the old Desert Willow
facility, and the length of stay is still anticipated
to average 1 year.
• Watts also was forced to close its residential
facility for women and children at the new
Lynwood facility. This site has been taken
over by a project that is funded by city, county,
and State monies and that focuses on
reducing domestic violence among substanceabusing
women and their children up to 12
years old. The length of stay can last up to 16
months, and transitional housing is provided.
Meanwhile, a program similar to the CSAT initiative
for substance-abusing women and their
children up to 5 years is operating at the
Watts, Inc., facility, House of Uhuru. This
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Conclusions and Epilogue
effort anticipates an ALOS of 9 months and
also operates a comprehensive child development
center that is open until 6:00 p.m., as
well as a Head Start program.
• Meta House has patched together financial
support from a variety of sources, including
TANF, State monies for county child welfare
cases, small grants from the United Way and
HUD (for homeless women), State substance
abuse block grant funding, and some reimbursements
from HMOs that refer women to
treatment. Funding—not the assessed needs
of the clients—now drives the program and
determines treatment goals. The director is
able to put together 6 to 7 months of residential
treatment for the women and their children
if she is very creative. At this point,
HMOs usually pay for only 7 days of treatment,
child welfare reimburses another 90
days of care, and central intake funds still
another 90 days. In order to add 30 to 60
days of residential services to these approved
treatment plans, the director must use
monies from special grants that do not have
slots attached.
• The residential project at Chrysalis is also
continuing. This site obtained approval for
Medicaid reimbursement for medically monitored
women’s treatment and therapeutic
child care. These funds make up 70 percent
of the operating budget. TANF monies are
used to contract with the Pee Dee Community
Action Agency to teach assertiveness and various
preemployment skills, such as how to
search for jobs, write resumes, or interview for
a job. TANF monies also pay for the women’s
transportation and clothing in which to interview.
The Department of Social Services supplements
this funding with per diem room
fees for its clients.
• IHW, the only provider in Philadelphia offering
residential treatment for substance-abusing
women and their children, continues to operate,
albeit with major changes in funding, a
somewhat shortened length of stay, and slightly
downsized services. The budget is composed
primarily of reimbursements through a
managed healthcare contract; the Department
of Human Services fills gaps in per diem costs
for 15 children. Time in treatment has been
shortened to a maximum of
12 months, with an average of 5 months in
the therapeutic community and 5 months in
the independent living phases of residential
care, followed by outpatient continuing
care services.
• FIT is continuing to operate its residential
program for 40 families—doubled from the
CSAT level of 20 families. The length of stay
is expected to average 4 to 6 months, but
women can remain in the residence until they
have maximized their development. The program
now has its own onsite Head Start program;
more emphasis is placed on employment,
using job coaches who are on staff;
home visits are made for women in continuing
care; and admission criteria incorporate the
American Society of Addiction Medicine standards.
The site is one of three former CSAT
grantees among 20 model programs described
by the Legal Action Center as exemplary projects
for moving substance-abusing women
from welfare to work. This effort is funded by
a blending of monies from the State substance
abuse block grant funds, TANF, and the
State Department of Children and Families.
• The residential component of PROTOTYPES’
Women’s Center is also operational and is
able to accommodate up to 178 women and
children. The multifaceted onsite work training
programs that enroll women in one of five
12-week tracks (i.e., retailing, word processing,
culinary arts, child care, receptionist/
office work) also are cited by the Legal Action
Center as an exemplary model for moving
women from welfare to work. Funding comes
from the State block grant, TANF, Medicaid,
the criminal justice system, other State and
local appropriations, and the Ryan White
Comprehensive AIDS Resources Emergency
(CARE) Act.
• PAR Village, the third of the CSAT grantees
selected as a model for moving substanceabusing
women from welfare to work, also
continues operations. The director was successful
in lobbying the State legislature for
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Chapter XI
$1 million to replace CSAT support. Smaller
amounts of monies also come from Medicaid,
Department of Corrections, and a HUD grant
for homeless women. Total funding is reduced
somewhat from the CSAT grant, and the program
notes that vigilance will be necessary to
ensure that the current line item in the State
budget for the Department of Children and
Families remains committed to PAR Village.
Although staffing has been reduced somewhat
(the program has no dedicated director or
nurse), the families are still expected to stay
in residential treatment for 9 to 14 months.
The program has also added an onsite Head
Start component.
• Casa Rita has managed to both expand and
strengthen its nonpunitive and supportive program
for homeless, substance-abusing women
and their children. CSAT awarded the site a
Targeted Capacity Expansion grant
to add 45 slots for women in the immediate
community. The program also uses welfare
reform monies, taking advantage of a New
York City regulation requiring substanceabusing
women on public assistance to enroll
and participate in a residential treatment
program as a condition for continuing TANF
benefits. The length of stay now averages 9
instead of 12 months, and there are more
intensive rehabilitation and vocational services
are available. An employment agency in
the Bronx delivers onsite educational and
vocational training, and the program has
been selected by the National Center on
Addiction and Substance Abuse as a demonstration
site for employment training and
placement services. The hours of available
child care for working mothers also have
been expanded, and there are more counselors
for the women.
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Appendix A:
Summary Profiles
of the 11 Grantees
T
his appendix contains summary profiles for each of the 11 original RWC grantees.
Each separate profile provides identifying information about the grant location and
contact persons as well as synopses of the target population, project goals, facility,
staffing patterns, treatment services, community linkages and contractual services, and
evaluation design.
The grantees are listed in alphabetical order by the CSAT-funded project component.
Contact information is current as of April 23, 1998.
Women In Need (WIN), Inc.
Government Project Officer: Linda White Young, (301) 443-8802; Grant #5 HD8 TIO0388-05
Funding Began: 1992
Grantee:
Contact Person:
Address:
Women In Need, Inc.
Dr. Ophelia Smith
115 W. 31st Street
New York, NY 10001
Telephone: (212) 695-4758
Fax: (212) 736-1649
Project:
Director:
Address:
Casa Rita, New York, NY
Ms. Nancy Sarah
292 E. 151st Street
Bronx, NY 10451
Telephone: (718) 402-0066
Fax: (718) 402-5052
Evaluator:
Dr. Linda Glickman
Telephone: (718) 402-0066
Fax: (718) 402-5052
Project Description
I. Target Population
The target population at Casa Rita consists of homeless, substance-abusing women and their
children. The majority of the clients are women of color averaging 30 years of age, with
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Appendix A
10th grade educations, and between two and three children. The primary drug of choice for
this population is crack cocaine.
II. Project Goals
Goal 1: To decrease the incidence and prevalence of drug and alcohol use among
homeless women.
Goal 2: To enhance the healthy development of the children of female clients.
Goal 3: To create a holistic program that is relevant to the racial, cultural, and
economic characteristics of the population served.
Goal 4: To design and implement a holistic system of prevention and family treatment
that integrates each family member’s physical, social, psychological, and
spiritual needs.
Goal 5: To decrease posttreatment relapse and help improve social and psychological
functioning.
III. Project Facility
Casa Rita is housed in a two-story building that provides 16 bedrooms, 8 bathrooms, a
kitchen, dining room, television room, and laundry area. A second building holds administrative
offices.
IV. Staffing
Casa Rita staff positions include a program director, a program supervisor, a treatment supervisor,
three addiction counselors, an aftercare counselor, two family therapists, a
recreation/volunteer coordinator, an acupuncturist, a pediatric social worker, a head teacher,
childcare workers, a facility manager, an education/vocational coordinator, residential aides, a
cook, an administrative assistant, and an office manager.
V. Treatment Services
The CEW Residence at Casa Rita is WIN’s award-winning Residential Substance Abuse
Treatment Program, which used local expertise to convert a school into a residence designed
to meet the needs of homeless women with children. This residence at Casa Rita received its
name from the Cosmetic Executive Women Foundation whose financial commitment enabled
WIN to renovate the structure and build a backyard playground. Casa Rita follows an empowerment
model of treatment with services that build on clients’ strengths, promote the development
of independent living skills, and facilitate the maintenance of a substance-free existence.
Originally developed in 1985 as a transitional shelter, Casa Rita added treatment services in
1991 to meet the needs of homeless women experiencing drug and alcohol problems. The
treatment facility provides a safe, sober atmosphere to support women recovering from substance
abuse while enabling these women to keep their children with them. Casa Rita was the
first
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Summary Profiles of the 11 Grantees
such residence to recognize women’s need to have their children with them, a crucial factor
in initial entry into treatment as well as long-term successful recovery. The staff at Casa Rita
provides comprehensive family-based treatment that is responsive to the multiplicity of needs
presented by homeless women and has proven to be successful in engaging women with addiction
problems and facilitating their long-term recovery as well as improving their physical,
psychological, educational, and employment status.
Specifically, the program consists of a weekly schedule of 12 substance abuse treatment
groups, educational/vocational training and computer literacy workshops, comprehensive family
assessment and treatment, acupuncture, health education and HIV/AIDS prevention/ education
groups, relapse prevention groups, nutrition and menu-planning workshops, recreational
activities, and childcare services. The Casa Rita staff includes a program director, a program
supervisor, three addiction counselors, two family therapists, a pediatric social worker,
an educational/vocational specialist, an acupuncturist, and a consulting psychiatrist, all of
whom are specifically trained and qualified to administer quality services within Casa Rita’s
holistic philosophy. Casa Rita treatment components for children include child care, ageappropriate
recreation, and educational activities.
VI. Community Linkages/Contractual Services
Casa Rita has collaborative agreements with a number of community agencies for the provision
of a broad range of clinical and supportive services. These agencies include local health
centers and hospitals, Narco Freedom V-18 Health Center, the New York City Board of
Education, Philip Michael Day Care, and United Families of the South Bronx.
VII. Evaluation
Casa Rita is conducting process and outcome evaluations that use repeated measures and a
quasi-experimental design. The goals of the process evaluation are to describe patient use of
services, length of stay in treatment, program completion, drug testing results, and reason for
discharge. The process evaluation is based on qualitative data. Periodic staff and client interviews
are conducted. The interviews explore service delivery experiences, client priorities and
needs, and changes and effects of the environment on the project—from clients’ perceptions
of housing policy to the principal investigator’s understanding of the city’s political concerns
as they affect the project, homelessness, and alcohol services. A comparison group is drawn
from a Women In Need outpatient alcohol and drug center and a control group from a nonspecialized
shelter. At both sites, initial data collection and assessment procedures are identical
to those that are standard at Casa Rita. At the end of the project, matching will be done
with key variables, including substance use, age, and any other variables identified as likely to
be related to treatment outcome. Standard inferential statistics are used to identify and
assess the significance of differences between groups in terms of outcome (retention in treatment,
urine test results, reason for discharge) and between the control group and the two
treatment groups in terms of substance use and major areas of life functioning. Statistical
analysis also focuses on the identification of predictors of measures of sobriety. Detailed
records are kept on clients’ use of treatment services; length of stay; in treatment; urine test
results; circumstances of discharge; and, at 6-month intervals, updates on much of the data
collected at intake. These 6-month followups continue for 18 months.
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Appendix A
Circle Park Associates
Government Project Officer: Jane Ruiz, (301) 443-8802; Grant #5 HD8 T100385-05
Funding Began: 1992
Grantee: Circle Park Associates
Contact Person: Mr. Charles Young
Address: P.O. Box 4509
City: Florence, SC 29502
Telephone: (803) 665-9349
Fax: (803) 667-1615
Project:
Director:
Address:
Telephone: (803) 673-0660
Fax: (803) 679-5666
Evaluator:
Mr. Tony Cellucci
Telephone: (803) 656-9349
Fax: (803) 667-1615
Project Description
Chrysalis Center, Florence, SC
Ms. Shirley Williams, Interim Project Director
2385 Pamlico Highway
Florence, SC 29505
I. Target Population
The target population for the Chrysalis Center is women with children and pregnant women
who have severe substance abuse problems and have experienced previous treatment failure,
homelessness, unsupportive or dangerous home environments, low income, and involvement
with the legal system. These women have educations less than the ninth grade, a history of
domestic violence, and/or impaired access to treatment because of dependent children. A
condition of program participation is that the woman’s children, up to age 10, reside at the
center with her. Many of the women are polydrug users whose primary substances of abuse
are cocaine and alcohol. The women range in age from 20 to 45 years old, although 50 percent
of the women are between 25 and 30 years old.
II. Project Goals
Goal 1: To decrease drug and alcohol use and improve the psychosocial functioning of
women in treatment along multiple dimensions.
Goal 2: To increase developmentally appropriate functioning of the children of women
residents.
Goal 3: To increase the capacity of women residents to function effectively as parents.
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Summary Profiles of the 11 Grantees
Goal 4:
To maximize the ability of the Chrysalis Center to function as a successful
intervention program for women whose severe and persistent substance abuse
problems have complicated effective family functioning.
III. Project Facility
Housed in a renovated nursing home, the Chrysalis Center is situated a half mile beyond the
Florence city limits, directly across the street from an elementary school. The facility has 16
one- and two-room units, with bathrooms that are shared by two families. Clients also enjoy
the use of a large dining room, a renovated kitchen, a laundry area, a medical examination
room, an infant room, and three adult lounges. Children are provided with an infant room, a
fully functioning child development center, a children’s lounge, and a large sandbox.
Administrative facilities include offices, group rooms, and a reception area.
IV. Staffing
Chrysalis Center’s 29 staff positions include a project director, administrative assistants, a
women’s services coordinator, a nursing coordinator, a director of food services, an afterschool
coordinator, an outreach specialist, counselors/case managers, nurses, an activities
counselor, teachers, teacher’s assistants, a life skills specialist, a maintenance coordinator, a
continuing care counselor, and a resident care specialist.
V. Treatment Services
Chrysalis Center treatment components for women include outreach and identification, comprehensive
preventive and well health care, dental services, parenting education, money management,
vocational/educational skills, home management, time management, relapse prevention,
group therapy, continuing care, jobs skills development and placement, case management,
safer sex courses, and spirituality workshops. Chrysalis Center treatment components
for children include comprehensive preventive and well health care, developmental assessments
and treatment services, therapeutic daycare, play therapy, mother/child play areas,
case management, afterschool services, and recreational services.
VI. Community Linkages/Contractual Services
Chrysalis Center has collaborative agreements with a number of community agencies and
providers for a broad range of clinical and supportive services. These include evaluation personnel,
two physicians, a licensed social worker, a variety of maintenance services, the
Department of Social Services, the Vocational Rehabilitation Department, County Alcohol and
Other Drug Commissions, BabyNet, Carolina’s Hospital System Child I Development Center,
Poyner Adult Education Center, the Literacy Council, Pee Dee Coalition Against Domestic
Violence and Sexual Abuse, and the Department of Health.
VII. Evaluation
Chrysalis Center is conducting a process and outcome evaluation through the collaborative
efforts of an onsite evaluation specialist, Chrysalis staff, Francis Marion University, and Circle
Park Associates. The goals of the process evaluation are to describe the characteristics of
clients, staff, and services and to identify whether the program operates according to the
177

Appendix A
plans. Outcome evaluation goals focus on three questions: (1) Does participation in the
treatment program decrease drug and alcohol use and improve the psychosocial functioning,
parenting skills, and family functioning of women? (2) Does participation in the program
increase the developmentally appropriate functioning of the children? (3) Is the program
meeting the needs of the community and the women it serves?
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Summary Profiles of the 11 Grantees
National Development and Research Institute (NDRI)
Government Project Officer: Melissa Rael, (301) 443-8002; Grant #5 HD8 T110339-05
Funding Began: 1992
Grantee:
Contact Person:
Address:
Telephone: (520) 749-7122
Fax: (520) 749-7192
Project:
Director:
Address:
National Development and Research Institute
Ms. Robin McGrath
10755 E. Tanque Verde
P.O. Box 30340
Tucson, AZ 85751
Desert Willow, Tucson, AZ
Ms. Robin McGrath
10755 E. Tanque Verde
Tucson, AZ 85751
Telephone: (520) 749-7122
Fax: (520) 749-7192
Evaluator:
Dr. Sally Stevens
Telephone: (520) 749-7156
Fax: (520) 749-7155
Project Description
I. Target Population
The target population for Desert Willow consists of low-income women, most of whom use
cocaine and alcohol as drugs of choice, many of whom are homeless, and approximately half of
whom were referred by the criminal justice system. The average age of the women in treatment
is 28 years.
II. Project Goals
Goal 1: To provide long-term intensive TC treatment to pregnant and postpartum
women with severe substance abuse problems and to their children.
Goal 2: To provide gender-specific treatment to pregnant and postpartum women with
severe substance abuse problems and to their children.
Goal 3: To successfully document program outcome through well-designed research and
evaluation strategies.
III. Project Facility
Desert Willow is housed on a 20-acre ranch on the far east side of Tucson, Arizona. The facility
is conducive to the therapeutic process, providing ample space for a children’s playground,
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Appendix A
sports activities, and large dining and living areas. Culturally relevant areas on the facility
include a Native American sweat lodge and an outdoor pavilion.
IV. Staffing
Desert Willow staff is composed of both professional and experienced trained personnel, many
of whom are themselves in recovery. Positions include counselors, developmental specialists,
a family services coordinator, a quality assurance coordinator, a nurse, a family therapist, an
outdoor program coordinator, and others.
V. Treatment Services
Desert Willow treatment components for women include a comprehensive curriculum to
address gender-specific issues such as rape; incest; traditional female roles; anger and violence,
both as victim and perpetrator; grief and loss; family dynamics; parenting skills; medical
services; vocational and continuing care services; and substance abuse treatment. Desert
Willow’s approach in conducting these curriculum sessions is through an intensive workshop
format. The intensive workshop is a minimum of 18 hours in length and up to 7 days and
consists of a variety of interactive modules such as video feedback, role-playing, drill questions,
didactic sequences, and group sessions. Desert Willow treatment components for children
include complete medical and developmental assessment, referrals for severe or special
needs, developmentally appropriate activities, children’s groups, mother and child groups, and
parent-child interaction workshops.
VI. Community Linkages/Contractual Services
Desert Willow has collaborative agreements with 40 community agencies for the provision of a
broad range of clinical and supportive services. These services include child care, medical
care, outreach, legal assistance, housing assistance, vocational training, child development,
continuing care, and mental health services.
VII. Evaluation
During the 5 years of the grant, Desert Willow was conducting process and outcome evaluations.
The process evaluation is designed to elucidate the program components and establish
which components are most effective in facilitating positive behavioral change. The methodologies
include record review of all community linkages and services received by the women
and children and a quarterly process evaluation using focus groups of staff and clients to further
understand the process of treatment, identify areas for improvement, and identify new
client needs. Quantitative data on the efficacy of the program components are collected from
both staff and clients prior to the focus group. The outcome evaluation is extensive and ongoing.
Outcome data are collected at 6, 12, and 24 months after discharge from the program.
Client interviews take place in private individual sessions with the evaluation staff. Numerous
instruments that address both behavioral and psychological functioning are administered.
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Summary Profiles of the 11 Grantees
The Village South, Inc.
Government Project Officer: Linda White Young, (301) 443-8802; Grant #5 RD8 T100389-05
Funding Began: 1992
Grantee:
Contact Person:
Address:
The Village South, Inc.
Mr. Matthew Gissen
3180 Biscayne Boulevard
Miami, FL 33137
Telephone: (305) 573-3784
Fax: (305) 576-1348
Project:
Director:
Address:
Telephone: (305) 573-3784
Fax: (305) 576-1348
Evaluator:
Dr. Lisa R. Metsch
Telephone: (305) 243-3470
Fax: (305) 243-4612
Project Description
Families in Transition (FIT), Miami, FL
Dr. Michael Miller
3180 Biscayne Boulevard
Miami, FL 33137
I. Target Population
The target population for the Families in Transition program consists of pregnant and postpartum
substance-abusing women and their children. As many as five children may accompany
each mother who is accepted into the program. The primary drug of choice for this population
is crack cocaine (75.7 percent).
II. Project Goals
Goal 1: To reduce the incidence and prevalence of alcohol and other drug abuse among
substance-abusing women.
Goal 2: To increase the percentage of women who complete comprehensive treatment.
Goal 3: To develop and refine discharge criteria.
Goal 4: To decrease the relapse rate among women who have completed treatment.
Goal 5: To increase the standard of living among recovering women with children.
Goal 6: To increase the ability of the substance abuse, health, and social service
systems to provide effective services through integrated case management,
thereby improving client treatment.
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Appendix A
Goal 7:
Goal 8:
To promote maternal/infant bonding and parenting skills.
To provide primary health, prenatal, and postnatal care.
III. Project Facility
Located in downtown Miami, Florida, Families in Transition is on a campus that provides
apartment living for participating families. Additional facilities are separate childcare quarters,
office space, treatment rooms, vocational and education training rooms, recreational
facilities, and medical and food service departments.
IV. Staffing
Families in Transition staff positions include a principal investigator, a project director, an
administrative coordinator, case managers, a vocational specialist, therapists, a milieu coordinator,
a family coordinator, a pediatric nurse, a pediatrician, a developmental psychologist, a
childcare director, childcare aides, a driver, a housekeeper, maintenance personnel, a secretary,
a cook, and a recreational specialist.
V. Treatment Services
Families in Transition is a family-centered habilitation effort with equal focus on maternal substance
abuse, infant/child well-being, and mother-child interaction, the component in which
changes are seen to foster and support changes in the others. Individual, group, family, and
couples substance abuse services are designed to encourage engagement in treatment, motivation
for change, and understanding and skills to accomplish and maintain change in recovery.
Motivational enhancement counseling, cognitive therapy, and behavioral management are
some of the tools used to accomplish this. Healthy choices, such as living without violence,
are encouraged through assertiveness and anger management training, and healthy relationships
are promoted through consciousness raising and sexuality groups. Recreational therapy,
remedial education, and life skills are also important. A major emphasis is placed on parenting
and parenting skills development, accomplished through both class work and in vivo
coaching at the Village’s licensed childcare center. Learning and empowerment in parenting
create a sense of accomplishment and efficacy that encourages the hard work of developing a
non-drug-abusing lifestyle. Remedial education and vocational counseling and coaching
include interview skills, resume building, education regarding the values and expectations of
the workplace, budgeting, and money management. Medical care and case management are
also critical services.
Families in Transition components for infants and children include primary and specialty
health care. Academic support, including tutoring, coaching, parental involvement, and program
and school collaboration, is used to enhance attendance and academic performance, fostering
rapid and significant progress in the performance of elementary school children. Other
services include day- and afterschool care, developmental assessment, recreation, and play
therapy when appropriate. Daycare focuses on delivery of developmentally appropriate stimulation
in an enriched environment to rectify developmental delays and encourage
normal development. Efforts of childcare and clinical staff are coordinated and integrated
toward the goal of family habilitation.
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Summary Profiles of the 11 Grantees
VI. Community Linkages/Contractual Services
Families in Transition has collaborative agreements with a number of community agencies for
the provision of a broad range of clinical and supportive services. Programs within the
University of Miami/Jackson Memorial Medical Center include the Department of Medicine
(general medical care), Comprehensive Drug Research Center (evaluation), Linda Ray
Interventions (child care, parenting skills training, consultation), the Department of
Pediatrics (medical care, development assessments, outreach, case management and referral),
the Department of Obstetrics and Gynecology, the Department of Family Medicine (pediatric
primary and adult medical care), New Horizons Community Mental Health Center (mental
health services), Health Crisis Network, and Body Positive (HIV education, counseling and
case management). In addition, services are provided by Dade County Public Schools (child
and adult education), the Department of Vocational Rehabilitation (vocational assessments,
counseling, and education), and the Miami Coalition (job placement).
VII. Evaluation
The conceptual approach to the Families in Transition program is a systemic interventions
model coupled with a harm-reduction treatment approach. Outcome methodologies include
the repeated analysis of data from standardized instruments, the analysis of functional behaviors
(e.g., work status, sobriety, custody) over time, and the comparison of the Families in
Transition program with a comparison group. The comparison group consists of clients
matched on several salient characteristics who receive residential treatment from the Village,
Inc., in the same location, with the only difference being that those in the comparison group
are not allowed to have their children physically with them during the intensive residential
phase of treatment. Process methodologies include record reviews, interviews with clients
both while they are in treatment and after discharge, focus groups with clients and staff, case
studies, client satisfaction surveys, participant observation of program services, and a comparison
of how the program has been implemented as compared to the proposed model for the
project.
183

Appendix A
Oglala Sioux Tribe
Government Project Officer: Dorothy Lewis, (301) 443-8802; Grant #5 HD8 T100381-05
Funding Began: 1992
Grantee: Oglala Sioux Tribe
Contact Person: Ms. Squeak Herman
Address: P.O. Box 1992
Pine Ridge, SD 57770
Telephone: (605) 867-5904
Fax: (605) 867-1216
Project:
The Flowering Tree Project, Pine Ridge, SD
Director:
Ms. Squeak Herman
Address: P.O. Box 1992
Pine Ridge, SD 57770
Telephone: (605) 867-5904
Fax: (605) 867-1216
Evaluator:
Dr. Richard Nankevel
Telephone: (605) 867-5904
Fax: (605) 867-1216
Project Description
I. Target Population
The target population for The Flowering Tree Project consists of low-income, young, substance-abusing
Oglala Sioux (Lakota) women and their children. Most women are involved in
the criminal justice system, have a range of health problems, and are at risk of losing their
children as a result of their substance abuse. Although most of the women are polydrug
abusers, alcohol is the drug of choice in this treatment population.
II. Project Goals
Goal 1: To decrease the incidence and prevalence of drug and alcohol use among
substance-abusing Lakota women.
Goal 2: To enhance the healthy development of the children of substance-abusing
Lakota women.
Goal 3: To provide a holistic, culturally specific treatment program that empowers
Lakota women to lead productive lives that encompass the four sacred
directions of the self (spiritual, emotional, mental, and physical).
Goal 4: To establish an aftercare treatment component for substance-abusing Lakota
women and their children.
184

Summary Profiles of the 11 Grantees
III. Project Facility
The Flowering Tree Project is located in a facility within the boundaries of the Pine Ridge
Indian Reservation. Bathrooms and room partitions have been added, heating and air conditioning
systems were installed, and ceilings and floors have been repaired.
IV. Staffing
The Flowering Tree Project staff positions include a project director, counselors, counselor
trainees, a life skills trainer, houseparents, and a part-time social worker.
V. Treatment Services
The treatment components for women include culturally specific drug treatment, comprehensive
health services, counseling and support groups, life skills classes, nutrition classes, physical
fitness classes, and parenting classes. The mothers who enter Flowering Tree have feelings
of guilt, shame, and an inability to bond with their children. The project developed parenting
and interacting practices for the mothers and children. The philosophy was to provide a holistic,
culturally based treatment program that would empower Lakota women to live a healthy,
productive life, following in the footsteps of their ancestors. This lifestyle encompasses the
nurturing of the four sacred directions of the self: spiritual, emotional, mental, and physical.
This philosophy was implemented throughout treatment, including the four values of respect,
humility, generosity, and fortitude and that children are wakan (sacred). The treatment components
for children include comprehensive medical services, counseling and support groups,
daycare, Parent Child Center services, Head Start, and aftercare. In reviewing admissions over
the 5-year period, at least 50 percent of the children were diagnosed with fetal alcohol syndrome,
fetal alcohol effects, or attention-deficit disorder, and 90 percent had been sexually
abused.
VI. Community Linkages/Contractual Services
The Flowering Tree Project has collaborative agreements with a number of community agencies
for the provision of a broad range of clinical and supportive services. These agencies
include the Holistic Healing Center (nursing and addiction services), Oglala Sioux Tribal
Court, the Oglala Nation Tiospaye Resource and Advocacy Center, Oglala Lakota College, and
the Northern Plains American Indian Chemical Dependency Association. Other services are
provided by a physician and a client development specialist. Other agencies provide specific
parenting information on how Native Americans discipline their children.
VII. Evaluation
During the grant, The Flowering Tree Project was conducting process and outcome evaluations.
The evaluation compares women in treatment with those American Indian women who
refuse treatment, those who drop out, and those who are in treatment in other geographic
regions. The goals of the process evaluation are to describe the characteristics of clients,
staff, and services; to identify program strengths and weaknesses; and to assess the degree to
which the program operates according to the original plan or modifications to that plan. The
outcome evaluation assesses the effectiveness of the treatment program for the women and
children separately and together in a family constellation.
185

Appendix A
Georgia Department of Children and Youth Services
Government Project Officer: Dorothy Lewis, (301) 443-8802; Grant #5 HD8 T100382-05
Funding Began: 1992
Grantee:
Contact Person:
Address:
Telephone: (404) 657-2414
Fax: (404) 657-2473
Project:
Director:
Address:
Georgia Department of Children and Youth Services
Ms. Iris Smith, Deputy Commissioner of Programs
2 Peachtree Street N.E., 5th Floor
Atlanta, GA 30303
Georgia Addiction, Pregnancy, and Parenting (GAPP) Project
Family Enrichment Center, Atlanta, GA
Ms. Lorna Fairweather
1010 West Peachtree Street
Atlanta, GA 30309
Telephone: (404) 894-1382
Fax: (404) 657-1827
Evaluator:
Ms. Iris Smith
Telephone: (404) 657-2414
Fax: (404) 657-2473
Project Description
I. Target Population
The target population for the GAPP Family Enrichment Center consists primarily of African
American, low-income, substance-abusing pregnant and/or parenting women and their children,
most of whom (74 percent) report polydrug abuse with cocaine/crack as the drug of
choice (72 percent).
II. Project Goals
Goal 1: To implement a comprehensive residential drug treatment model program for
addicted women with children.
Goal 2: To increase posttreatment abstinence rates and reduce relapse in substanceabusing,
parenting women.
Goal 3: To empower substance-abusing, parenting women to become more involved in
their own and their children’s healthcare, social, and emotional needs.
Goal 4: To reduce the severity of impairment in children of substance-abusing women
through educational enrichment and provision of supportive services.
Goal 5: To conduct a comprehensive evaluation study to determine the effectiveness of
the treatment program in meeting its stated goals.
186

Summary Profiles of the 11 Grantees
III. Project Facility
The GAPP Family Enrichment Center provides 20 adult women and 36 child beds; the child
beds are suitable for toddlers and children up to age 10. A therapeutic nursery, a medical
services unit, a fully equipped kitchen, and all treatment rooms are provided onsite.
IV. Staffing
The GAPP Family Enrichment Center staff positions include a clinical director, a children’s
program director, case managers, counselor assistants, a registered nurse, houseparents, an
education coordinator, consulting physicians, a psychologist, a food service worker, a principal
investigator, an administrative coordinator, a database coordinator, and research interviewers.
V. Treatment Services
The GAPP Family Enrichment Center is a comprehensive, family-focused residential facility
that serves addicted pregnant and/or parenting women and their children. The GAPP Family
Enrichment Center treatment components for women include primary substance abuse treatment,
comprehensive psychological assessments, onsite primary health care, and structured
aftercare services. Psychological services include counseling on issues such as relapse prevention,
anger management, history of suicidal ideation and attempt(s), harsh parental disciplining
practices, and behavioral management. The treatment program also provides stress prevention
training and eye movement desensitization reprocessing therapy. Through implementation
of the Home-Based Medical Record and Pediatric Passport, women are encouraged to
advocate for their own health care and that of their children.
The GAPP Family Enrichment Center treatment components for children include comprehensive
developmental assessments, onsite primary health care, therapeutic preschool, and an
after-school program. Developmental histories and the Vineland Adaptive Behavior Scales
(useful in corroborating developmental delays) are completed on all admitted children. The
Developmental Profile II, an instrument that is useful in delineating developmental delays, is
also used. In addition, educational enrichment services are provided to preschool-age children,
and a psychologist provides individual therapy on conflict resolution, self-concept, and
self-esteem.
VI. Community Linkages/Contractual Services
The GAPP Family Enrichment Center has collaborative agreements with a number of community
agencies for the provision of a broad range of clinical and supportive services. These
agencies include Grady Memorial Hospital (prenatal, postnatal, and general medical care);
Outreach, Inc. (HIV/AIDS education); Fox Recovery Center (detoxification services); the
Fulton County Health Department (staff health training); Southside Health Center; Atlanta
Project; the Department of Family and Children’s Services; the Fulton County Alcohol and
Drug Treatment Center; Morehouse Medical School; the Atlanta Bureau of Cultural Affairs;
Project Leap Forward; the Office of Adult Literacy; Atlanta Enterprise Center; Initiative For
Affordable Housing Dekalb, Inc.; and others.
VII. Evaluation
187

Appendix A
The GAPP Family Enrichment Center is conducting process and outcome evaluations. The
process evaluation examines program implementation using both quantitative and qualitative
data. The database compiles basic demographic information on clients referred to the program,
including age, ethnic group, marital status, number of children and custody status, current
drug use, prior treatment history, referral source, and case disposition. These data allow
project staff to identify changes or patterns in client referrals over the life of the project and
track those clients who must be referred to other programs when this program is at capacity.
The process evaluation also uses information obtained through focus group interviews, which
elicit information on client and staff perceptions of the goals and objectives of the program.
Focus groups occur at 30 days, 6 months, and during aftercare with clients, family members
of clients, and staff. The outcome evaluation uses a quasi-experimental design with three nonequivalent
comparison groups selected from program dropouts, clients on the waiting list, and
a matched cohort of women who are admitted to any of the metropolitan Atlanta alcohol and
other drug treatment programs. The experimental sample consists of women who are admitted
and complete the GAPP Family Enrichment Center treatment process.
188

Summary Profiles of the 11 Grantees
Philadelphia Health Management Corporation (PHMC)
Government Project Officer: Karen Urbany, (301) 443-8802; Grant #5 HD8 T100390-05
Funding Began: 1992
Grantee:
Contact Person:
Address:
Telephone: (215) 985-2500
Fax: (215) 985-2550
Project:
Director:
Address:
Telephone: (215) 871-0300
Fax: (215) 477-0244
Philadelphia Health Management Corporation
Ms. Leslie Hurtig
260 South Broad Street
Philadelphia, PA 19102
Interim House West, Philadelphia, PA
Ms. Laurie Corbin
4150-52 Parkside Avenue
Philadelphia, PA 19104
Evaluator:
Dr. Kathleen Coughey
Telephone: (215) 985-2557
Fax: (215) 985-2550
Project Description
I. Target Population
The target population for Interim House West consists of predominantly urban low-income
African American polydrug-addicted women between 18 and 60 years of age and their
children up to 12 years of age. The primary drug of choice for this population is crack
cocaine. Most residents are recipients of public assistance, over 25 percent have co-occuring
disorders, 25 percent have had involvement with the criminal justice system, most are
survivors of physical or sexual abuse, and 75 percent have sexually transmitted diseases.
II. Project Goals
Goal 1: To decrease substance use among addicted women and to reduce relapse rates
among recovering women.
Goal 2: To foster the growth of healthy, strong, successful children.
Goal 3: To prevent substance abuse in children of addicted mothers.
III. Project Facility
Facing Fairmount Park, a newly renovated Victorian mansion and a nearby three-story house
serve as facilities for the project. The mansion houses the TC residence, the preschool
189

Appendix A
program, the family apartments, and administrative offices. The three-story house provides
staff offices and is the residence for families in the TC phase.
IV. Staffing
Interim House West staff positions include a project director, a treatment coordinator, a coordinator
of children’s services, adult therapists, case managers, teachers, assistant teachers, an
adult education instructor, family therapists, a child psychologist, and a registered nurse.
All staff are trained in the areas of addiction and recovery issues, early childhood development,
and domestic violence issues. Ninety percent of the staff are female; the client to staff
ratio is 11:1.
V. Treatment Services
Interim House West treatment components for women include educational assessments and
remediation, vocational skills training, individual therapy, family counseling, couples counseling,
random drug testing, group therapy, employment readiness services, housing assistance,
and financial management assistance.
Interim House West treatment components for children include educational assessments and
placement, developmental and behavioral assessments, individual therapy, clinical preschool
and afterschool programs, nursing care as needed, prevention programs, and recreational
activities.
VI. Community Linkages/Contractual Services
Interim House West has collaborative agreements with a number of community agencies for
the provision of a broad range of clinical and supportive services. These agencies include
Jewish Employment and Vocational Services; the Philadelphia Child Guidance Center;
Spectrum Health Services, Inc.; the Parkside Historic Preservation Corporation; and an independent
fitness instructor.
VII. Evaluation
The evaluation includes both process and outcome evaluations. The process evaluation serves
two purposes: to facilitate future replication of the project by providing documentation of the
project’s implementation and to contribute valuable information on the analysis of project outcomes.
The goals of the outcome evaluation are to assess the effectiveness of the treatment
program, collect data to assess program outcomes, and provide data for the national evaluation.
The evaluation is based on a quasi-experimental design. Data collected at Interim House
West are compared with data collected at Interim House, a 30-day residential program for
women that does not include children. Women in the experimental group who remain in treatment
for 3 months but do not complete 12 months of treatment are compared to women who
complete 12 to 18 months of treatment. Clients are interviewed within 2 weeks of admission
and every 6 months for a period of 24 months. Two instruments are used: the Fifth Edition of
the Addiction Severity Index and an interview instrument. Other standard instruments include
the Rosenberg Self-Esteem Scale; the Depression Scale from the Health and Daily Living Form;
the Social Support Network Inventory; the Adult-Adolescent Parent Scale; and the
Circumstance, Motivation, Suitability and Readiness Scale. Annual satisfaction
190

Summary Profiles of the 11 Grantees
surveys are conducted through interviews with all the clients. Results of these surveys are
shared with the program administration for program improvement. Occasional focus groups
are held with the clients to gather qualitative data about the programs. Admissions and discharges
are monitored, and analyses of retention rates and all other data are conducted.
191

Appendix A
Our Home Foundation, Inc.
Government Project Officer: Karen Urbany, (301) 443-8802; Grant #5 HD8 T100386-05
Funding Began: 1992
Grantee:
Contact Person:
Address:
Our Home Foundation, Inc.
Dr. Francine Feinberg
1200 East Capitol Drive
Milwaukee, WI 53211
Telephone: (414) 962-1200
Fax: (414) 962-2305
Project:
Director:
Address:
Telephone: (414) 962-1200
Fax: (414) 962-2305
Evaluator:
Planning Council
Telephone: (414) 224-0404
Fax: (414) 224-0243
Meta House: Project MetaMorphosis, Milwaukee, WI
Dr. Francine Feinberg
1200 East Capitol Drive
Milwaukee, WI 53211
Project Description
I. Target Population
The target population for Meta House: Project MetaMorphosis consists primarily of substanceabusing
women of color (75 percent) and their children who are less than 10 years of age. Most
of the women have co-occuring disorders (60 percent), with cocaine as their drug of choice.
II. Project Goals
Goal 1: To provide for substance-abusing women and their children a variety of
services and opportunities that will reduce their incidence of substance abuse.
Goal 2: To increase the capacity of substance-abusing women to become self-sufficient,
productive members of society.
Goal 3: To reduce the incidence and severity of impairment in children affected by
maternal substance abuse.
III. Project Facility
With three separate facilities, the combined capacity of Meta House is 42 adult beds, 18 child
beds, and a childcare center that can service and accommodate 32 children.
192

Summary Profiles of the 11 Grantees
IV. Staffing
Meta House staff positions include substance abuse counselors, substance abuse counselor
aides, a facilities coordinator, daycare staff, a child services administrator, live-in house managers,
a director of clinical programs, an education counselor, and a child abuse prevention
services coordinator.
V. Treatment Services
Meta House treatment components for women include individual counseling, group counseling,
nutritional counseling, parenting classes, basic skills education, substance abuse education,
specialized treatment for victims of sexual and physical abuse, recreation activities, support
groups, vocational and educational counseling, and aftercare services. Meta House treatment
components for children include developmental assessments, medical care, and recreational
activities.
VI. Community Linkages/Contractual Services
Meta House has collaborative agreements with a number of community agencies for the provision
of a broad range of clinical and supportive services. These agencies include Sinai
Samaritan Hospital, Children’s Hospital, the Wisconsin School of Professional Psychology,
Milwaukee Health Consultants, Milwaukee Public Schools, Birth to Three Program, Meta
Munchkins, and the Milwaukee Council on Alcoholism and Drug Dependence.
VII. Evaluation
Meta House is conducting process, outcome, and formative evaluations to look at the problems
with which the women entered treatment, their experience and progress in treatment,
and data from posttreatment followup. The process evaluation focuses on the women’s experience
in treatment and the components of treatment that different women experience. It
addresses the dimensions of treatment that relate to success, whether having their children in
treatment affects women’s success after treatment, and the relationships between dimensions
of treatment and success and the level of functioning of the women at the time of entry into
treatment.
The outcome evaluation focuses on the mothers’ ability to raise their children as drug-free,
symptom-free, self-sufficient, law-abiding members of the community. These outcomes are
measured through intensive interviews and standardized measures at 6-month intervals,
following each woman for a period of 2 years from her entry into treatment. This evaluation
explores how these outcomes are related to the length of time in treatment, the minimum
amount of time treatment is needed for success, and whether this minimum amount of
treatment time depends on the level of functioning of the woman at the time of entry
into treatment.
The formative evaluation considers what aspects of the program are most valued by clients
and how these program components could be offered in related but less restrictive programs,
such as day treatment or outpatient treatment.
193

Appendix A
Operation Parental Awareness and Responsibility (PAR), Inc.
Government Project Officer: Linda White Young, (301) 443-8802; Grant #5 HD8 TIO0384-05
Funding Began: 1992
Grantee: Operation Parental Awareness and Responsibility, Inc.
Contact Person: Ms. Shirley Coletti
Address: 10901-C Roosevelt Boulevard, Suite 1000
St. Petersburg, FL 33716
Telephone: (813) 570-5080
Fax: (813) 570-5083
Project:
Director:
Address:
Telephone: (813) 524-4400
Fax: (813) 524-4452
PAR Village, St. Petersburg, FL
Ms. Carol Renard
13800 66th Street North
Largo, FL 33771
Evaluator:
Mr. Richard Newel
Telephone: (813) 538-7244, ext. 262
Fax: (813) 524-4452
Project Description
I. Target Population
The target population for PAR Village consists of substance-abusing pregnant and postpartum
women and their children, most of whom have been referred through social services or the
criminal justice system. The primary drug of choice for this population is crack cocaine.
II. Project Goals
Goal 1: To provide a continuum of substance abuse recovery and related services to
substance-abusing women and their children.
Goal 2: To decrease the incidence and prevalence of substance abuse among female
program participants.
Goal 3: To enhance the healthy development of the children of substance-abusing
mothers.
III. Project Facility
PAR Village occupies 14 houses located on 9 acres of land in Pinellas County, Florida. The
houses serve as residences for the women and their children and also provide space for a therapeutic,
developmental daycare center.
194

Summary Profiles of the 11 Grantees
IV. Staffing
PAR Village staff positions include a program director, a clinical supervisor, a women’s
resource specialist, a vocational counselor, an admissions coordinator, an administrative assistant,
primary counselors, a case manager, a pediatric nurse, a director of children’s services, a
child services coordinator, childhood specialists, and a parenting educator/counselor.
V. Treatment Services
PAR Village treatment components for women include substance abuse education, substance
abuse treatment, vocational and employment training, parenting classes, individual living
skills, sexual abuse counseling, relapse prevention education, educational testing and planning,
GED preparation, healthcare education classes, and aftercare services. PAR Village
treatment components for children include therapeutic child care and development assessments
and related therapies.
VI. Community Linkages/Contractual Services
PAR Village has collaborative agreements with a number of community agencies for the provision
of a broad range of clinical and supportive services. These agencies include the
Department of Vocational Rehabilitation, Abilities of Clearwater, Job Services of Florida,
Lashley and Associates (speech and language services for children), and contracts with individual
practitioners for child developmental therapies and adult sexual abuse counseling.
VII. Evaluation
PAR Village is conducting an evaluation that compares the outcomes of substance-abusing
women and their children to those of similar women and children who do not enter PAR
Village for treatment. Women in the demonstration and comparison groups are compared
on substance abuse treatment outcome measures and on measures directly related to the
gender-specific components of the treatment program. In its fourth year, PAR Village will
make comparisons with a population that has participated in day treatment as well as those
only completing a 5- to 7-day detoxification program.
The data collection method is based on face-to-face interviews, supplemented with other data.
Process methodologies include evaluation of treatment sessions using class test results, client
progress notes, and subjective measures such as client satisfaction surveys. Outcome methodologies
include review of client aftercare plans and verification of outcome variable information
(e.g., hair analysis, court record searches, and employment verification).
195

Appendix A
PROTOTYPES
Government Project Officer: Maggie Wilmore, (301) 443-8802; Grant #5 HD8 T100387-05
Funding Began: 1992
Grantee: PROTOTYPES
Contact Person: Dr. Vivian Brown
Address: 5601 West Slauson Avenue, #200
Culver City, CA 90230
Telephone: (310) 641-7795
Fax: (310) 649-4347
Project:
Director:
Address:
Telephone: (909) 624-1233
Fax: (909) 621-5999
PROTOTYPES Women’s Center, Pomona, CA
Ms. Carol Notley
845 East Arrow Highway
Pomona, CA 91767
Evaluator:
Dr. Lisa Melchoir/Dr. George Huba
Telephone: (310) 216-1051
Fax: (310) 670-7735
Project Description
I. Target Population
The target population for PROTOTYPES consists of substance-abusing and alcohol-dependent
women of color and their children. The primary drugs of choice include cocaine, alcohol,
and heroin.
II. Project Goals
Goal 1: To design an individual, case-managed continuum of services linked to a
women’s residential center for substance-abusing women and their children.
Goal 2: To increase the accessibility of substance-abusing women to a broad spectrum
of mental health, social, educational, vocational services, and leisure time
activities by providing services within an overall continuum of services and a
therapeutic treatment community.
Goal 3: To improve the overall health of women in addiction treatment through the
provision of primary health care, health education, and drug abuse prevention
services.
Goal 4: To reduce the incidence of illicit substance abuse among program participants
through recovery programs and drug testing.
196

Summary Profiles of the 11 Grantees
Goal 5:
Goal 6:
To enable recovering women and their resident and nonresident children to
successfully reenter society.
To document the progress of the program and its characteristics through
careful process and outcome evaluations.
III. Project Facility
PROTOTYPES is located on 3.8 acres in a former Christian school facility. The large church
structure is used for spiritual activities, marathon meetings, and conferences. Residents are
housed in two-story buildings not visible to the public and have living room spaces, a central
laundry, and a dining room/kitchen that is equipped for 200 persons. Children have a large
play area and house located in the center of the quad, a therapeutic nursery, and a childcare
center.
IV. Staffing
PROTOTYPES staff positions include an executive director, a program director, a clinical
director, a part-time psychiatrist, a part-time nurse practitioner, case managers, counselors, a
vocational training coordinator, a parenting center specialist, a child aide, an administrative
assistant, a grandparent coordinator, an afterschool tutor, an evaluation coordinator, and others.
The staff consists of degreed and nondegreed persons. Staff members in recovery must
have been drug-free for at least 2 years.
V. Treatment Services
PROTOTYPES treatment components for women include individual, group, and family therapy;
women’s survivors group; parenting training; health education; prenatal education; vocational
training and rehabilitation; recreational activities; 12-Step groups; job-readiness group;
psychological diagnosis and counseling; wellness clinic and primary health care; community
reentry and aftercare planning; drug testing; and personal behavior management training.
Prototypes treatment components for children include family therapy, therapeutic nurse child
care, Mommy and Me group, and aftercare planning.
VI. Community Linkages/Contractual Services
PROTOTYPES has collaborative agreements with a number of community agencies for the
provision of a broad range of clinical and supportive services. These agencies include Los
Angeles County/USC Medical Center; Pomona Valley Hospital Medical Center; the San
Bernardino Public Health Department; Los Angeles County Social Services; the California
Department of Rehabilitation; Martin Luther King, Jr., General Hospital; Royal Comprehensive
Health Center; Tri-City Mental Health Center; Pomona Adult School; Pomona Public Library;
and the Southill Presbyterian Church/Women, Infants and Children Program.
VII. Evaluation
The evaluation plan for PROTOTYPES is integrally linked with the treatment experience at the
center. All evaluation data are entered and analyzed in a database system designed and maintained
by the measurement group. Data cover a variety of domains, including the woman’s
197

Appendix A
background characteristics, her history of substance abuse, prior experience with substance
abuse, social support network, behaviors that put her at risk for HIV, health problems and
mental illness, criminal justice system involvement, educational background, and information
about her family, including her children. These evaluation domains are intended to capture
the complexity of the PROTOTYPES project, which focuses on each woman’s individual treatment
needs.
Evaluation data are collected in multiple ways and at various points during treatment. The
longer a woman remains in treatment, the greater the intensity of the information collected.
For example, data collected at intake are still somewhat limited because clients may not be
completely detoxified, may be experiencing withdrawal, or may not have established relationships
with program staff. After several weeks, when the client has had sufficient opportunity
to adjust to her new environment, more detailed and sensitive assessments are obtained. Not
only are withdrawal symptoms gone by this point, but the client usually has established relationships
with staff. Throughout the program, services are recorded at the time of use.
A number of data sources are used for the evaluation, including standardized and customized
assessments, client interviews, staff ratings, and chart reviews.
An important element is having an onsite evaluation assistant who collects data from the
women and children and who also makes this information available to program staff on a regular
basis. The onsite evaluation assistant is viewed by clients as "another counselor" and by
clinical staff as a "helper." She also helps ensure that evaluation data are used to improve
individual treatment plans.
198

Summary Profiles of the 11 Grantees
Watts Health Foundation, Inc.
Government Project Officer: Melissa Rael, (301) 443-8802; Grant #5 HD8 T100391-05
Funding Began: 1992
Grantee:
Contact Person:
Address:
Telephone: (310) 608-0408
Fax: (310) 631-8774
Project:
Director:
Address:
Telephone: (310) 608-0408
Fax: (310) 631-8774
Watts Health Foundation, Inc. (WHF)
Arlene Everett
3598 Martin Luther King Jr. Boulevard
Lynwood, CA 90262
WHF/Women and Children’s Residential Program,
Lynwood, CA
Arlene Everett
3598 Martin Luther King Jr. Boulevard
Lynwood, CA 90262
Evaluator:
Mr. Robert Nishimoto
Telephone: (310) 608-0408
Fax: (310) 631-8774
Project Description
I. Target Population
The target population for Watts Health Foundation consists of inner-city, pregnant, postpartum,
and substance-abusing women and their children, many of whom live below the poverty
level. Approximately half of the women have drug-related child custody cases and/or direct
involvement with the Department of Children’s Services and the Los Angeles Superior
Court/Dependency Division. Many women report polydrug abuse, with crack cocaine as the
primary drug of choice.
II. Project Goals
Goal 1: To provide comprehensive residential substance abuse treatment services for
women, their children, and their families.
Goal 2: To develop an assessment/triage team at the Los Angeles Superior Court and
the Children’s Dependency Court to provide comprehensive healthcare
services to substance-abusing women, their children, and their families.
Goal 3: To provide comprehensive case management services to court-referred,
substance-abusing women, their children, and their families.
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Appendix A
III. Project Facility
Located in a remodeled and redecorated California ranch-style convalescent building with four
large patios, the facility can accommodate 50 women and 40 children. Group rooms, staff
and administrative offices, lounges for women and for children, a modern kitchen, and a therapeutic
nursery are provided on site.
IV. Staffing
Watts Health Foundation staff positions include a project director, a program coordinator, a
licensed and certified social worker/court liaison, a physician, a nurse coordinator, a supervising
counselor, a senior counselor, a case manager, counselor I, a licensed vocational nurse, a
driver, a cook, a child development specialist, and an assistant health educator.
V. Treatment Services
Watts Health Foundation treatment components for women include individual, group, and
family counseling; parenting classes; drug education; employment referrals; psychoeducational
assessments and interventions; and limited outreach and followup. Watts Health
Foundation treatment components for children include family counseling, play therapy, and a
therapeutic nursery program.
VI. Community Linkages/Contractual Services
Watts Health Foundation has collaborative agreements with a number of community agencies
for provision of a broad range of clinical and supportive services. These agencies include the
Compton Job Service Employment Development Department; the City of Lynwood; the Los
Angeles County Private Industry Council; the Lynwood Chamber of Commerce; the Lynwood
Unified School District; the Department of Public Social Services; Equipoise, Inc.; Hub Cities
Consortium; Watts Health Foundation’s Women and Children’s Center; and the Office of
Supervisor Yvonne Braithwaite Burke.
VII. Evaluation
During the 5 years of the grant, Watts Health Foundation was conducting a process and
outcome evaluation that assesses the efficacy of long-term comprehensive substance abuse
treatment for women and their children. A traditional treatment modality for women is used
as a comparison group to the Women and Children’s Residential Center Program. The ASI
assessment is being used at treatment entry, followed by interviews at discharge and at
followup points.
200

Appendix B:
Site-Specific
Evaluation Findings
T
he available evaluation findings for the projects are reported in this appendix. The sites
are given in alphabetical order. Each individual report contains information—to the
extent available—about the total number of women and children served by the grantee,
the evaluation design and instruments used, the percentages of clients classified in different
discharge categories and the average length of stay for each group, changes in clients’ status
from admission to discharge, and outcomes at designated followup points. Several sites conducted
other analyses, which also are summarized. Also see Chapter III for site-specific depictions
of client characteristics at admission.
Casa Rita: New York, New York
Between October 1992 and November 1997, Casa Rita served a total of 96 women. A sample
of 65 of these women was included in the evaluation: 16 of the remaining women had not yet
completed treatment by the cutoff point of March 1997; 7 others did not provide informed
consent; and data were not available for an additional 8 women.
Evaluation Design
Three instruments were administered at baseline: the Addiction Severity Index (McLellan,
1980), modified to reflect the experience of homeless women, the Beck Depression Inventory
(Beck and Steer, 1987), and a Women In Need intake form. Urine tests were conducted 2 to
4 days a week on a randomly selected sample of clients during residential treatment.
Followup questionnaires were administered by trained interviewers at approximately 6.5
months following discharge to 35 clients (53.8 percent of baseline sample), using an abbreviated
form of the ASI and the Beck Depression Inventory. Observational data on posttreatment
sobriety for 40 clients (60 percent of baseline sample) were collected over an interval of
18 months following discharge using information from aftercare or residential counselors,
interviewers, and unsolicited reports from other clients. This indirect method was used
because of clients’ unwillingness to acknowledge a relapse—probably out of concern about the
potential for loss of child custody or eligibility for safe housing. Relapse was defined as an
independent verification by two independent sources. The key outcome measures examined
were program completion, posttreatment sobriety, and changes in social and psychological
functioning. Qualitative data also were obtained through interviews with clients and staff in
the residence and by observations at staff and resident meetings.
Retention and Discharge Status
Approximately half (48 percent) of the women stayed in the program for more than 1 year. Of
the 65 women in the evaluation sample, 64.6 percent (n = 42) completed treatment and
201

Appendix B
moved into permanent housing. Women who graduated from residential treatment were
homeless before entering residential treatment for significantly longer periods than noncompleters
(155 versus 74 weeks, p = .02), were significantly more likely to have had more than
two previous treatment episodes (81 versus 19 percent, p = .08), and significantly more likely
to have a partner or father with a history of substance abuse (76 versus 24 percent, p = .04;
56 versus 44 percent, p = .09, respectively), as determined from t-tests and chi-square tests
exploring the association of selected variables with program completion. These findings may
indicate that women who complete treatment have exhausted all their housing and treatment
options and are also disillusioned with male intimates (partner and father) who are substance
abusers. For this group, Casa Rita may have represented a last hope. In fact, client interviews
revealed that, for many, this program was a last chance—and a new beginning. Other women
expressed the view that they had few options left and that this residence provided a safe haven
where counselors believed in them and served as positive role models. The majority of women
also reported that having children in treatment with them was a major factor contributing to
their recovery, although they also were concerned about not having all of their teenage children
in residence.
Outcomes
Followup data collected from independent, indirect sources indicated that 22 (55 percent) of
the 40 women interviewed 18 months after discharge had not relapsed. The only baseline
variable significantly associated with this sobriety was the number of children: The women
who did relapse had fewer children (1.7 versus
2.8, p = .07). The evaluators speculate that "having
to care for more children, even one more
child, greatly increases the responsibility of
women raising children alone . . . and the effort
to keep a somewhat larger family together [may
help] women with more children remain sober."
. . . women who lapse
during treatment can,
with counseling, support,
and understanding, go on
to complete the program
and remain sober.
Interestingly, having one or more positive urine
tests during treatment was not related to program
completion or to posttreatment sobriety.
Apparently, women who lapse during treatment can, with counseling, support, and understanding,
go on to complete the program and remain sober.
The 35 women who had ASIs at both admission and followup had formed significantly more
close friends (1.1 at baseline versus 3.9 at followup, p = .05) and also had significantly fewer
child custody cases at followup (down from 56.7 percent at baseline to 16.7 percent at followup,
p = .05). None of these clients reported either physical or sexual abuse at followup,
and 80 percent of these women (n = 28) remained in permanent housing. However, this
small group of clients for whom two ASI scores were available did not reflect a random sample
of women who entered Casa Rita.
202

Site-Specific Evaluation Findings
Chrysalis Center: Florence, South Carolina
Beginning with the first admissions in October 1993, the Chrysalis Center served a total of
197 women and 280 children over the course of the 5-year CSAT grant.
Evaluation Design
The original goal of the Chrysalis evaluation was to answer basic questions about the utility of
the program for residents, their children, and the community, using measures from the ASI,
the PSI (Abidin, 1995), several locally developed instruments, the Brigance Early Preschool
Screen (Brigance, 1990), and the CBCL (Achenbach and Edelbrock, 1986). In early 1997, the
initial evaluation team from the Medical University of South Carolina was replaced, because of
financial considerations, by a team from Francis Marion University. At that time, the SCL-90R
(Derogatis, 1975) was added to the evaluation instruments, and some of the locally developed
measures were dropped. Most of the data used in the analyses were collected at baseline and
at 6 and 12 months postdischarge.
Retention and Discharge Status
The discharge status for 190 women who had been treated before the grant ended was as follows:
Graduated with staff approval (n = 65) or reservation (n = 3) 36%
Left against staff advice (n = 70) or without staff knowledge (n = 5) 39%
Left at staff request (n = 30) 16%
Transferred to another program (n = 17) 9%
During FY 1995, the average length of stay for women at Chrysalis was 127 days, with graduates
staying an average of 331 days and nongraduates staying less than 100 days. According
to the counselors, the major reason for leaving the program prematurely was the women’s difficulty
with rules and regulations (53 percent). From the perspective of the clients, the most
commonly cited reason for leaving prematurely was interpersonal conflict with other clients
(10 percent).
During the last years of the grant, the program purposely shortened the expected length of
residential stay to 6 months to accommodate the needs of the clients served and to comply
with changes in the approval process by the South Carolina Department of Alcohol and Other
Drug Abuse Services for Medicaid reimbursements for the women and children.
Outcomes
At 6 months after discharge, Chrysalis Center clients (n = 27) showed significant improvements
on several subscales of the ASI. For graduates, outcomes significantly improved for
employment (p

Appendix B
those of noncompleters. By the 12-month followup, graduates showed significant improvements
over baseline in the parent domain (≤.04), in the child domain (≤.004), and in the
total score (≤.023). By 6 months after discharge, treatment completers also reported significantly
less family conflict than did those who
dropped out (p

Site-Specific Evaluation Findings
Desert Willow: Tucson, Arizona
As of November 1997, 111 women had been enrolled in the Desert Willow project: 102 stayed
long enough for baseline data to be obtained. A total of 130 children were served in the residential
program. Baseline data were obtained for 54 of the 61 women in a comparison group
of clients without children in treatment.
Evaluation Design
As part of a process evaluation, the evaluation staff administered a questionnaire and facilitated
focus groups each quarter with program staff and participants. The results were presented
and discussed with all respondents, and suggestions for program changes based on the data
were solicited. Women enrolled at Desert Willow were assessed at intake, during treatment,
and at specified points following discharge, using a variety of instruments, including the ASI
(with addendum); the Circumstances, Motivation, Readiness, and Suitability Scales (DeLeon
et al., 1994); the Beck Depression Inventory; the Michigan Alcohol Screening Test (Selzer,
1971); Family Environment Scale (Moos, 1974); the PSI; the SCL-90R; and the Tennessee
Self-Concept Scale (Fitts, 1964). Followup activities, which continued through April 1998,
focused on obtaining data at 6, 12, and 24 months after discharge. In addition to process and
outcome evaluations, the staff produced several descriptive studies on issues such as violence
and partner abuse, HIV knowledge and behavior, grief and loss, and risks of alcohol use and
abuse in this population.
Client Satisfaction With Program Components
The program components consistently found to be most helpful to clients in the recovery
process were the workshops, rated highly by over 80 percent of women, in comparison with
one-on-one counseling sessions, which were similarly ranked by only 40 percent of respondents.
Among program changes that stemmed from process evaluation findings were the
addition to the curriculum of more workshops on violence, the development of a more structured
curriculum and schedule, more emphasis on healthy relationships and peer affirmation,
more focus on assessment of vocational skills, increased activities for children, and enhancement
of program supports for the transition from residence to the community.
Retention and Discharge Status (N = 111)
ALOS for all 111 CSAT admissions
ALOS for RWC treatment completers
ALOS for RWC noncompleters
273 days (9.1 months)
477 days (15.9 months)
117 days (3.9 months)
RWC graduates participating in aftercare 34%
Successful treatment completion for 111 RWC women (n = 45) 41%
Successful treatment completion for 61 women without children 33%
in treatment (n = 20)
205

Appendix B
Outcomes for Women
Assessments at 6 months after discharge for 67 of the women with children who were admitted
to Desert Willow (66 percent of both dropouts and treatment completers) showed
improvements in many areas. Although only 29 percent reported having been employed during
the year prior to treatment and 3 percent reported being enrolled in school at admission,
56 percent were employed and 33 percent were enrolled in school at the 6-month assessment.
At baseline, 38 percent reported having been incarcerated in the previous 30 days, compared
to 19 percent who acknowledged being in jail/prison during the 6-month followup period.
The percentage who reported using selected drugs in the 30 days before baseline and before
the 6-month followup interviews also decreased significantly. At baseline, 29 percent reported
having used marijuana, compared to 11 percent at followup; 11 percent used heroin at baseline,
compared to 5 percent at followup (p = .04); 36 percent used cocaine/crack at baseline,
compared to 13 percent at followup (p = .01); and 13 percent used amphetamines at baseline,
compared to 5 percent at followup (p = .02). At admission, the mean number of friends
the women reported was 3.1, compared to 5.4 by 6 months after treatment. With regard to
child custody, only 52 percent of the women had their children living with them at baseline,
compared to 82 percent at the 6-month followup.
Although confounded with the length of stay, outcome data at 6 months after discharge also
suggested that women who participated in the intensive workshops (n = 40) were more successful
on a number of parameters than women who did not participate in the intensive workshops
while in treatment at Desert Willow (n = 19). The women who attended the workshops
averaged 11.4 months in treatment, whereas those who did not participate in them stayed an
average of only 2.4 months. With respect to outcomes, 65 percent of the women who attended
the workshops were employed 6 months after discharge, compared to 11 percent of those
who did not participate in the workshops; 85 percent of the workshop participants had children
living with them at the 6-month followup, compared to 63 percent of their counterparts
who did not attend the workshops; 54 percent of the women who frequented the workshops
participated in continuance services, in contrast to only 28 percent of their peers who did not
go to the workshops; 53 percent of the workshop graduates were not using drugs or alcohol at
followup, compared to 32 percent of the nonparticipants who were sober at 6 months postdischarge;
and only 15 percent of the workshop participants had been in jail in the 6-month
interval since leaving treatment, compared to 28 percent of their counterparts who did not
participate in the workshops.
Improvements for Children
Data on the children living with their mothers at Desert Willow also demonstrated improvements.
At the initial testing, 70 percent of the children were newborn to 3 years old. Of the
29 children who had a baseline and fifth test (15 months after baseline), 24 percent evidenced
language delays at baseline, compared to only 7 percent at the fifth test; 7 percent
had gross motor delays at baseline, compared to 3 percent at the fifth test; and 14 percent
had fine motor delays at baseline, compared to only 3 percent 15 months later.
206

Site-Specific Evaluation Findings
Time-in-Treatment Effects on Outcomes
An examination of time-in-treatment effects on postdischarge outcomes for the first
81 enrollees at Desert Willow showed that women who remained in treatment for more
than 3 months were significantly more likely to be employed and less likely to commit crimes
or use drugs at 6 and 12 months after treatment than those who dropped out of treatment
before 3 months. Remaining in treatment also was associated with decreases in psychopathology,
particularly depression. In general, these improvements for women who remained in
treatment for more than 3 months were similar for both the women who had their children
with them in residential care and for the comparison
group of women who did not have
their children with them. Whether or not the
women had their children with them in treatment
did not seem to affect the results in any
consistent manner.
Violence and Partner Abuse
Desert Willow evaluation staff collected data
on violence involvement from 98 women in
treatment at the baseline interview. Results
from the study indicated that many of the
women were both the victims and perpetrators
of violence. More specifically, 78 percent
reported being a victim of violence from their
sex partner, while 58 percent reported perpetrating
violence against their sex partner. A
large majority of these women (71 percent)
reported being assaulted at least once in their
lifetime, with the average age of first assault
being 11.5 years. Also, 65 percent of the
women reported having been raped at least
. . . women who remained in
treatment for more than
3 months were significantly
more likely to be employed
and less likely to commit
crimes or use drugs at 6 and
12 months after treatment
than those who dropped out
of treatment before 3
months. Remaining in
treatment also was
associated with decreases in
psychopathology,
particularly depression.
once; for nearly half of these women (48.4 percent), the rape was their first sexual experience,
and the average age at the initial rape was 13 years.
With respect to perpetration of violence, 28.6 percent of these women acknowledged directing
violence (mostly verbal abuse) at their mothers; 20 percent reported carrying out some
type of violence against their fathers; nearly half (49 percent) admitted perpetrating some
form of violence against siblings; and 21.4 percent committed some form of violence (about
half of which was verbal abuse) against their children. Most of this acknowledged violence
occurred on numerous occasions.
207

Appendix B
. . . 65 percent of the
women reported having
been raped at least once; for
nearly half of these women
(48.4 percent), the rape was
their first sexual experience,
and the average age at the
initial rape was 13 years.
To learn more about violence among sexual partners, the evaluation staff administered two
sets of questionnaires to 18 women residents in the spring of 1996 that asked separately
about being a perpetrator or a victim of violence.
The data confirmed that women more
frequently were victims of sexual or physical
abuse than perpetrators with male sexual
partners. The women were much more likely
to have a jealous partner who did not want
them to have friends or to work outside the
home. Women, in turn, were more verbally
abusive, belittling and screaming at their
male partners. They also threw dangerous
objects more often and bit and scratched the
men but, nevertheless, experienced more serious
physical injuries from the male partners.
In discussions, the women agreed that men
tried to keep them dependent—financially, emotionally, and socially—and that their frustrations
about this lack of power often erupted into explosive arguments and physical fights.
208

Site-Specific Evaluation Findings
Families in Transition: Miami, Florida
As of October 1997, 147 women and 237 children had enrolled in the Village South’s Families
in Transition (FIT) program. A total of 118 women and 203 children who completed the program
by May 1996 were included in the evaluation study. A total of 37 women were enrolled
in the comparison program of women without their children in residence from June 1993
through 1995, when intake slowed because the referral source began giving qualified women
the option of residential care at FIT. The research design initially had required that women
from this referral agency be treated in the comparison residential program.
Evaluation Design
Standardized assessments, including the ASI, the PSI, the SCL-90, and the Beck Depression
Inventory, were administered at intake, at 6 months, and at discharge. Other information was
collected from intake questionnaires and treatment data. The ASI and PSI were administered
again, with consent, at intervals of 3, 6, 12, and 18 months after discharge by a trained
female outreach worker. Comparisons were made with women in a comparable residential
program who did not have their children with them during treatment.
Retention and Discharge Status
ALOS for all women
ALOS for treatment completers
149 days (range from 1 to
498 days) (4.9 months)
343 days (11.4 months)
ALOS for noncompleters 67 days (p = .0001)
(2.2 months)
Completion rate at FIT (n = 35 of 126 discharges over the 29%
course of the program)
Completion rate at comparison program (n = 10 of 37 enrollees) 27%
The evaluators found that women in treatment
with their children at FIT completed the program
at nearly the same rate as comparison women who
did not have their children in residence. They also
found that the length of stay was significantly
associated with later abstinence: As the length of
stay increased, drug use at followup decreased.
Whereas 84 percent of women who stayed at FIT
for less than 6 months were using drugs at followup,
only 16 percent of those who stayed for 6
months or more were using drugs at followup.
Hence, women who stayed in treatment at FIT for
more than 6 months were nearly 10 times more likely to be drug-free at followup than those
who left before 6 months. The median length of stay for women who were drug-free at fol-
. . . women who stayed in
treatment at FIT for more
than 6 months were
nearly 10 times more
likely to be drug-free at
followup than those who
left before 6 months.
209

Appendix B
lowup was 185 days (a bit over 6 months), compared to 50 days (1.6 months) for those who
were using drugs at followup.
Improvements During Treatment
Over 60 percent of the women who enrolled in FIT completed one of two parenting classes
offered. As a result of this education and other experiential interventions, these women
improved their parenting skills between admission and discharge as measured by the PSI.
They significantly decreased their perception that the parental role was restricting their
freedom and self-identity and also increased their attachment to their children. Whereas only
6 percent of women were employed at admission, 57 percent of the graduates were working at
discharge. Women who entered treatment with mild clinical depression also decreased their
symptoms, as measured by the Beck Depression Inventory, to nonclinical levels by the time of
discharge.
Outcomes
Of the 35 FIT graduates, followup data were available for 24 (70.5 percent followup rate).
Of the 10 comparison program graduates, followup data were available for 8 (80 percent
followup rate).
Graduates of the FIT program were more likely to be drug-free at followup than counterparts
in the comparison program who did not have children with them. Successful treatment at FIT
substantially improved employment rates at both discharge and followup over those at intake,
and employment rates for FIT graduates were also better than those of the comparison group
of women without children in the residence who completed treatment.
FIT graduates had many more months of employment after discharge than noncompleting
counterparts. Additionally, FIT graduates were much more likely to have custody of their children
at followup than at admission. Women in treatment at FIT also improved their psychological
functioning while in the residence.
FIT graduates drug-free at latest followup (n = 19) 79.1%
Comparison program graduates drug-free at latest followup (n = 5) 62.5%
FIT residents employed at admission 5.7%
FIT graduates employed or in school at discharge 57.1%
FIT graduates employed or in school at most recent followup 41.7%
Comparison program graduates employed or in school at
latest followup 12.5%
Average time worked since discharge for FIT graduates
Average time worked since leaving FIT for women who
did not complete treatment
FIT graduates with reduced reliance on welfare at latest followup 66.6%
402 days (13.4 months)
111 days (3.7 months)
210

Site-Specific Evaluation Findings
FIT residents with custody of children at admission 33%
FIT graduates with custody of children at followup 75%
Scores on the Beck Depression Inventory for women enrolled in FIT decreased from an
average of 12.43 at admission—indicating mild depression—to nonclinical levels at discharge.
Similar decreases between admission and discharge also were found on several scales of the
SCL-90, including those for interpersonal sensitivity, obsessive-compulsive behavior, somatization,
and psychoticism.
Data indicated that children living with their mothers also demonstrated improvements. In a
cross-sectional study of 15 school-aged children attending public schools, only 40 percent had
passing grades at treatment entry, compared to 100 percent who were passing all courses
after one semester at FIT.
Women’s Employment Following Treatment for Substance Abuse
A special study on moving substance abusing women from welfare to work (Metsch et al.,
1999) focused on the barriers and supports that 100 women who were treated in the FIT project
experienced in obtaining and maintaining employment. All of the low-income respondents
were welfare-eligible at admission to FIT (i.e., receiving AFDC, food stamps, and/or Medicaid
benefits) and had been discharged for 10 to 12
months at the time of followup interviews conducted
between February and July 1997.
Most of the women were not working at the time
of the special followup interview for this study:
Only 20 percent were employed, 26 percent were
looking for a job, and over half (54 percent)
were not searching for work. Almost all of those
who were not working (91.3 percent) reported at
least one barrier to finding or holding a job. The
most commonly cited barriers were lack of child
care (21 percent), involvement in illegal activities
or incarceration (20 percent), the perception
that jobs were not available (16 percent),
inadequate job skills and tools (9 percent), and
other commitments and responsibilities (9 percent).
Although three in five (60 percent) said
they had received some training for job interviewing,
only a third (33 percent) had a resume.
Women who had remained
in treatment for a year or
longer also were more
likely to be working at
followup than those
who left earlier (64 versus
16 percent) . . .
The women who had
participated in an
aftercare program
following discharge also
were more likely to be
employed (67 versus 14
percent . . .)
Bivariate analyses indicated several factors that
were associated with working. FIT program completers
were more likely to be working at the
time of the interview than noncompleters (37 versus 13 percent, p = .006). Women who had
remained in treatment for a year or longer also were more likely to be working at followup
than those who left earlier (64 versus 16 percent, p = .006). Women who had a resume and
who had participated in training for job interviewing were more likely than counterparts without
this level of professionalism to be working (36 versus 12 percent, p = .004; 30 versus 5
211

Appendix B
percent, p = .002, respectively). High school graduates also were significantly more likely to
be working than those without this minimal level of education (30 versus 9 percent, p =
.007). The women who had participated in an aftercare program following discharge also
were more likely to be employed (67 versus 14 percent, p = .00149). Additionally, a multivariate
analysis showed that a high school education, participation in the aftercare program,
and treatment duration of more than a year were independently related to work status at followup.
The evaluators concluded that long-term treatment for drug abuse, with appropriate
aftercare, can be a valuable tool in moving a selected group of women from the welfare rolls
to gainful employment.
212

Site-Specific Evaluation Findings
Georgia Addiction, Pregnancy, and Parenting Project
Family Enrichment Center: Atlanta, Georgia
Over the course of the 5-year CSAT grant, the GAPP project served 142 women.
Evaluation Design
Three nonequivalent comparison groups were proposed: wait-listed clients, program dropouts,
and women admitted to other treatment facilities during the same period who met criteria for
admission to the GAPP Family Enrichment Center. Interviews were to be conducted at intake;
at 30 days after admission (after stabilization); at discharge; and at 3, 6, 9, and 12 months
following discharge. The data to be collected relied primarily on the ASI, the SCL-90R, and
assorted other checklists and symptom scales for assessing health knowledge, traumatic history,
posttraumatic stress syndrome, and parenting interest and knowledge.
Retention and Discharge Status
Of the 142 women enrolled, 129 had left the program by September 30, 1997, with the following
discharge status and average lengths of stay in the program:
Completed treatment 46%
Dropped out or were terminated 54%
Completed first 30 days of orientation 85%
ALOS for program completers
ALOS for noncompleters
181 days (6.0 months)
55 days (1.8 months)
Outcomes
Outcomes at 3 months after treatment for the first 30 women who completed the followup
assessment showed improvements in multiple areas. Clients reported being less troubled by
family relationships (p

Appendix B
The psychological status of women residents
at GAPP was assessed repeatedly during and
following treatment. Analyses of data from
the SCL-90R at 30 days after admission indicated
a significant decrease in scores from
baseline on subscales for obsessive-compulsive
disorder (≤.02), phobia (≤.04), and the
total positive symptoms distress index
(≤.02). At the 6-month postdischarge followup,
there were decreases in the subscale
for depression (≤.05) and in the global
symptoms index (≤.007). By 9 months after
discharge, psychiatric symptoms appeared to
stabilize, with no significant changes noted.
At this time, the clients interviewed appeared
better able to concentrate and respond to
questions (≤.0l). These clients also believed
that they were no longer in need of psychiatric
treatment (≤.001).
When the characteristics of
women who dropped out of
treatment were compared
with those of residents who
completed treatment, the
dropouts were more likely
than completers to have a
history of physical, sexual,
and/or emotional abuse;
relationship problems; and
previous episodes of
depression or anxiety and to
have had psychiatric
medication prescribed.
214

Site-Specific Evaluation Findings
Interim House West: Philadelphia, Pennsylvania
Between May 1993 and the end of December 1997, 115 women enrolled at the CSAT-funded
long-term residential program, Interim House West. During the same period, an additional
154 women enrolled at Interim House, a similar but much shorter 6-month residential program
for women that does not include children. The IH residents, who were similar on many
baseline indices, served as a comparison group for the IHW clients.
Evaluation Design
Data were collected at baseline and at 6, 12, 18, and 24 months following intake, using
four instruments:
• An initial composite instrument that included several standardized scales from the
Rosenberg Self-Esteem Measure (Rosenberg, 1965); the Social Support Network Inventory
(Flaherty et al., 1983); the Adult-Adolescent Parenting Inventory (Bavolek and Keene
1999); and the Circumstances, Motivation, Readiness, and Suitability Scales
• The ASI
• A followup composite instrument that used the same scales administered at admission,
with the exception of the Circumstances, Motivation, Readiness and Suitability Scales
• A special form for record review.
The analyses focused on comparing these two types of residential treatment with respect to
clients’ retention in the program and their improvements during and following treatment, as
well as determining the costs of providing drug treatment for women with children.
Differences in Client Characteristics
Although many indices were similar, significant differences were noted between the two comparison
groups of women at baseline. Compared to IH women, the IHW women were more
likely to have preschool children, less likely to have just one child, and more likely to have
used drugs during a pregnancy. In addition, IHW women reported more severe family problems,
higher self-esteem, fewer indications of depression, and fewer years of substance use
than did IH women. Also, the IHW residents were more likely to mention children or family as
a reason for entering treatment. Several of these differences had important implications for
the outcome findings.
Retention in Treatment
The analysis of retention data indicated that women in treatment with their children were
likely to stay in treatment as long as women in treatment without children. The average
length of stay at IHW during the period of the evaluation was 137 days (4.5 months). There
were no significant differences in the lengths of stay at the two facilities during the first 3
months—the maximum time authorized by most funding sources for women to remain in residential
care. The ALOS at IHW for the initial 14 weeks of treatment was 93 days, compared
to 104 days at IH. Retention at the two facilities was nearly identical for the first 3 weeks,
during which time approximately 20 percent of clients left treatment. By 14 weeks, about 45
percent of the women at IHW had left treatment, compared to less than 40 percent at IH.
215

Appendix B
The data also suggested that women at IHW who dropped out of treatment before 2 months
tended to have less severe legal problems and were less likely to have been formally mandated
to treatment than those who stayed longer.
Outcomes
A total of 81 women in IHW completed both baseline and at least some followup interviews;
the number of counterparts from IH numbered 55. The analyses of pre- and posttreatment
data were based on these four overlapping
groups of women who had one or more followup
assessments. The evaluators found that
the sociodemographic characteristics of the
women who were followed and those lost to
attrition were very similar in most respects.
However, the women who could not be found
were less likely than those interviewed to have
preschool-age children and more likely to have
reported a substance abuser in their social network
at admission.
Their drug and alcohol
severity—as well as their
self-esteem—scores were
significantly improved, and
all women . . . were
significantly less likely to
have indications of
depression.
Comparisons of pre- and posttreatment data
demonstrated significant improvements among
women in both programs that were maintained
over a 2-year period. At all followup points, the
severity of the women’s problems, compared to
total ASI scores at baseline, was significantly
reduced. Their drug and alcohol severity—as
well as their self-esteem—scores were significantly
improved, and all women (except those
from IH who were interviewed at 24 months)
were significantly less likely to have indications
of depression. At nearly all four followup
points, the women’s psychiatric scores on the
ASI showed significant improvement over baseline.
Additionally, the women in both programs
were significantly less likely to report that they
lived with a drug or alcohol user, less likely to
report that their children were part of their support network, and more likely to report that
adults—spouses/partners at IHW and parents/siblings/friends at IH—were part of their support
network at all followup points.
Posttreatment employment
was increased dramatically,
compared to baseline.
Twenty-seven percent of
IHW women and 40 percent
of IH women were
employed, compared to
baseline levels of 3.5 and
2.6 percent, respectively.
At IHW, where ASI family/social indices were initially higher than those at IH, there was significant
improvement in family relations and increased family interactions. The IHW women also
reported increased confidence in their sobriety at followup periods and significantly decreased
legal problems. Of those interviewed at followup, 42 percent of IHW women and 51 percent
of IH women had taken posttreatment educational courses, passed a section of the GED, or
obtained their GED. Posttreatment employment was increased dramatically, compared to
baseline. Twenty-seven percent of IHW women and 40 percent of IH women were employed,
compared to baseline levels of 3.5 and 2.6 percent, respectively. The evaluators noted that
216

Site-Specific Evaluation Findings
differences in followup employment rates between women treated at IHW and IH might be
related to differences in child status; IHW women were more likely to have preschool children
and to have more than one child, compared to IH women.
At baseline, nearly all of the women reported that they
had been the victims of domestic abuse at the hands
of their partners, and over half had experienced family
abuse. There was a significant and sharp decline in
domestic abuse in the followup periods, compared with
the baseline experiences. However, parenting attitudes
and behaviors, as measured by the Adult-Adolescent
Parenting Index, remained remarkably unchanged for
both groups of women. Additionally,
15 percent of IHW women and 6 percent of IH women
were reunited at followup points with children whom
they did not have living with them prior to treatment. This did not include children reunited
with IHW mothers during treatment.
Women’s Personal Perspectives
Comments made during focus group discussions and satisfaction surveys suggested that, for
addicted women, concerns about children are a compelling motivation for entering drug
treatment, and the option of having their children with them in the residential facility was the
only reason some women enrolled. More importantly, if addicted women can take children
with them to treatment, they are likely to enter drug treatment at an earlier stage in their
addiction than if that option is not available.
However, having children in treatment also posed difficulties for the women. Coping with
their own recovery issues, as well as parenting, was described as a hardship by some IHW
women. In the same vein, many IH women expressed relief that they were able to address
their addiction without their children. Yet, the more children IH women had, the more likely
they were to drop out of treatment. This suggests the complex nature of providing drug treatment
for parenting women and the obstacles faced by addicted women seeking treatment.
It appears that women may enter and remain in treatment for the children who are in the program
with them, but they may leave treatment because of concerns about their children outside
of the program.
Another interesting finding was that the women’s satisfaction with treatment was not significantly
related to retention but, rather, to satisfaction with their therapist who played a crucial
role in drug treatment.
Cost Allocations and Savings Attributed to Treatment
There was a significant
and sharp decline in
domestic abuse in the
followup periods,
compared with the
baseline experiences.
Nearly half (46 percent) of the 1996 IHW budget was allocated to intake and treatment,
whereas 23 percent was for specific children’s services. Health care accounted for 8 percent
of the budget, and 11 percent was for case management. The remaining 12 percent of the
costs were for adult education, life skills, recreation, and aftercare.
Comparisons of the costs of IHW services with similar services or service options outside of
IHW suggested cost savings while the women were in treatment and the potential for long-
217

Appendix B
term savings after treatment. The benefits of having comprehensive drug treatment programs
for women that include children are not only in costs savings, but include saving women and
children from additional years of living with addiction and the negative consequences of drug
use to society. Moreover, comprehensive drug treatment for women begins to prepare them
for gainful employment and coping with the dual roles of parenting and employment and/or
getting an education.
The benefits of having comprehensive drug
treatment programs for women that include
children are not only in costs savings, but
include saving women and children from
additional years of living with addiction and
the negative consequences of drug use to
society. Moreover, comprehensive drug
treatment for women begins to prepare them
for gainful employment and coping with the
dual roles of parenting and employment
and/or getting an education.
218

Site-Specific Evaluation Findings
Meta House: Milwaukee, Wisconsin
Between April 1, 1993, and June 30, 1995, a total of 170 pregnant or parenting women was
admitted to Meta House (Project MetaMorphosis). Assessment information was collected on
101 of these women who stayed in treatment for at least 4 weeks. The data for this group
provided a demographic profile of the population being treated during a time when the program
was relatively stable and the referral system was constant.
Evaluation Design
Selected items of the ASI thought to be most relevant to women’s functioning were administered
to Meta House mothers who completed at least three admission interviews and again at
6-month intervals after discharge over a 2-year followup period. The evaluation focused on
depicting the needs of women with substance abuse
problems, their experiences during treatment, and outcomes
at 24 months after discharge. From an initial
cohort of 48 early enrollees, 33 (69 percent) completed
followup interviews at 24 months after discharge.
Retention and Discharge Status
Data were available for a total of 107 mothers discharged
from Meta House programs during the period
from October 1, 1994, through March 31, 1996.
Although the numbers of women in each category were
not specified, the following comparisons were made
between discharge categories of mothers who had their
children in residence with them and those who did not.
Mothers with children in residence were more likely to
Mothers with children
in residence were
more likely to
complete treatment
and less likely to leave
against advice than
their counterparts
whose children were
not with them.
complete treatment and less likely to leave against advice than their counterparts whose children
were not with them. In addition, there was no difference in the length of stay for mothers
with or without children who graduated from the program—270 days (9 months) and 279
days (9.3 months), respectively.
Discharge Status for Mothers With and Without Children in Residence
Discharge Status Mothers With Children Mothers Without Children
Completed Treatment 38% 26%
Left Against Medical Advice 34% 41%
Involuntary Termination 25% 26%
Transferred 3% 7%
219

Appendix B
The planned length of stay at Meta House was determined individually, on the basis of a
client’s needs. The range for graduates was 127 days (4.23 months) to 478 days (15.9
months). Most of the women who left treatment against medical advice dropped out in less
than 3 months. An analysis of 161 women in treatment between April 1, 1993, and June 30,
1995, found, cumulatively, that 59 percent of enrollees were discharged by the end of the fifth
month—21 percent left in the initial 30 days, another 15 percent left during the second
month, and 11 percent left during the third month. The remaining 41 percent of women
stayed in treatment for 6 months or longer.
Outcomes
An analysis was conducted for 33 of 48 women in the first cohort of 101 mothers who were
interviewed at the 24-month followup. Data were compared for the 30 days prior to treatment
entry and the 30 days prior to the 24 month followup. Significant reductions in drug
use were evident in terms of the number of days of cocaine use (p = .03), the use of alcohol
to intoxication (p = .02), and the use of more than one drug per day (p = .04). There was
also a significant decrease in both the number of days that women experienced any psychological
symptoms (p = .001) and the number of different psychological symptoms experienced (p
= .013). Days of work for pay significantly
increased (p = .009) from an average of 4.2 days
prior to treatment to an average of 8.7 days at
the 2-year point. Moreover, days of illegal activity
decreased correspondingly, although not significantly
(p = .08). Additionally, family conflict significantly
decreased (p = .014) from an average
of 9.4 days before treatment to an average of 3.8
days at 2 years, and days of conflict with non–family
members also significantly decreased (p =
.017) from an average of 7.8 days to an average of
2.7 days.
. . . 2 years after entering
treatment, a majority of
the mothers who lived
with their children were
functioning at remarkably
high levels, behaving
responsibly with respect
to illegal activities and
drug or alcohol use . . .
and providing a
completely drug-free
family environment . . .
The evaluators concluded that, 2 years after
entering treatment, a majority of the mothers
who lived with their children were functioning at
remarkably high levels, behaving responsibly with
respect to illegal activities and drug or alcohol
use (70 percent) and providing a completely drugfree
family environment (56 percent). Their posttreatment
psychological functioning was somewhat less optimistic, with three in five of these
women (61 percent) continuing to experience significant or severe psychological symptoms.
The area in which these women appeared to be least successful was economic self-sufficiency.
Only a third of the women had full-time regular employment at the 24-month followup point,
and very few were earning enough money to be the sole supporters of themselves and their
children. Nearly one in five (18 percent) was still receiving social security disability benefits
at this point. Since 73 percent of the women were living with one or more of their children,
the findings suggest that their children continued to live in poverty.
220

Site-Specific Evaluation Findings
PAR Village: St. Petersburg, Florida
During the CSAT grant period, from October 1992 through September 1997, PAR Village
served a total of 279 women and 208 children, with program utilization remaining between 90
and 100 percent throughout the period.
Evaluation Design
The original evaluation plan, involving researchers at the University of South Florida, focused
on five major domains associated with the goals of residential treatment. With experience,
the major instruments selected for assessing the women and children—at baseline and at
3, 6, and 12 months during treatment, and at 6 and 12 months after discharge—were the
Kaufman Brief Intelligence Test (Kaufman and Kaufman, 1990) and the Kaufman Assessment
Battery for Children (Kaufman and Kaufman, 1983), the Culture-Free Self-Esteem Inventory-II
(Battle, 1992), the Adult-Adolescent Parenting Inventory, the Millon Clinical Multiaxial
Inventory (Millon, 1987), the Hawaii Early Learning Profile (Furuno, 1979), and the Bayley
Scales of Infant Development (Bayley, 1983), as well as other locally developed measures.
After several changes in the evaluation design, substitutions among the evaluators, and a decision
to move the evaluation component onsite at PAR Village, the final plan called for outcome
comparisons of the CSAT sample with three other groups: non-CSAT-funded women in
residential treatment who did not have children with them; an equivalent group of women in
intensive, outpatient day treatment; and substance-abusing women who received 3 days of
detoxification without followup. The differences among these groups with respect to interviews
completed and characteristics, however, were too great for meaningful statistical comparisons.
Hence, the evaluation has, thus far, been limited to descriptive analyses of the data
collected for the CSAT-funded component for women and their children.
Retention and Program Completion (N = 127)
ALOS for all women
ALOS for successful completions
ALOS for discharges against medical advice
ALOS for terminations
ALOS for transfers to another program
143.8 days (range from 1 to 926 days)
(4.8 months)
318.5 days (10.6 months)
88.2 days (2.9 months)
126.3 days (4.2 months)
96.9 days (3.2 months)
Successful treatment completion (n = 41) 32.8%
Left against medical advice (n = 46) 36.8%
Terminated for noncompliance (n = 16) 12.8%
Transferred or referred after treatment (n = 21) 16.8%
Still in treatment or not reported (n = 2) 1.6%
Other (n = 1) 0.8%
221

Appendix B
Improvements During Treatment
The women participating in the CSAT-funded project improved their self-esteem, academic
standing, and parenting attitudes and behaviors while in treatment. A total of 22 women
completed the Culture-Free Self-Esteem Inventory-II at baseline and 3 months after
treatment entry. The scores for general self-esteem rose from a mean of 7.69 at baseline
(lower half of the intermediate range) to 9.46 (upper half of the intermediate range) after
3 months of participation in therapeutic sessions addressing this problem. Correspondingly,
the percentage of women assessed in the low to very low range with respect to personal
self-esteem decreased from 73 percent at admission to 58 percent after 3 months. As a result
of participation in a remedial skills basic curriculum, women who scored below the 8th grade
level of academic performance at admission increased their grade level rating by two grades
within a 4-month period. During the last 2 years of the CSAT grant, when more emphasis was
placed on obtaining vocational skills, the percentage of women assessed at 6 months who
were enrolled in vocational training or other schooling increased from 30 percent to almost
50 percent.
Comparisons of pre- and posttest mean scores for parenting classes required for the
CSAT-sponsored women showed improvements in meeting the child’s basic needs
(60.9 versus 96.4), modifying behavior (58.4 versus 89.4), and building the child’s self-esteem
(36.6 versus 92.4).
Outcomes
Outcome data obtained at 6 months after discharge for 62 women showed positive results
in terms of drug use, employment, criminality, child custody, parenting attitudes, and
psychopathology. At the 6-month followup, the drug-free
status of women residents had increased from zero at
entry to 64.5 percent; gainful employment rose from
5 percent at admission to 38.7 percent; arrest-free status
improved from 12.6 percent at enrollment to 87.1 percent;
and custody of children increased from 40.2 percent
at program admission to 67.7 percent. Additionally, there
was a dramatic decrease in the percentage of women
assessed with serious borderline personality disorders
between baseline (40.5 percent) and 6 months after discharge
(10.8 percent), as indicated on the Millon Clinical
Multiaxial Inventory. Mean baseline scores on several
domains of the Adult-Adolescent Parenting Inventory fell
in the low range (i.e., inappropriate expectations, lack of
empathy, parent-child role reversal), although the mean
score for belief in corporal punishment reflected an average
range. At 6 months after discharge, there were slight improvements in the mean scores
. . . there was a
dramatic decrease in
the percentage of
women assessed with
serious borderline
personality disorders
between baseline . . .
and 6 months after
discharge . . .
for inappropriate expectations, role reversal, and belief in corporal punishment, but almost no
change in the mean score for lack of empathy.
222

Site-Specific Evaluation Findings
PROTOTYPES Women’s Center: Pomona, California
Between October 1992 and September 30, 1997, 765 clients were enrolled in the residential
treatment program at PROTOTYPES Women’s Center. Between December 1992 and July
1997, intake information was recorded for 244 children. Of these, 166 (68 percent) resided
with their mothers for part or all of their treatment duration, 56 came for 60-day visits, and
7 visited for shorter periods. Information about the type of participation was not available for
17 children.
Evaluation Design
During residential treatment, women were assessed at specified points with various programspecific
forms. These included an Initial Interview Form, Health Questionnaire, Urinalysis
Report, Tuberculosis Report, Natural History Interview, Social Support Measure, Supplemental
Client Interview, Client Satisfaction Assessment, and Team Rating Form. About 6 weeks after
admission—when the women no longer had withdrawal symptoms,
had formed some relationships with clinical staff, and were adjusted to the new environment—
they also were administered the Center for Epidemiological Studies Depression
Scale (CES-D) (Radloff, 1977), the Basic Personality Inventory (Jackson, 1989), and the Luria-
Nebraska Neuropsychological Battery: Children’s Revision (Golden, 1987). Short or long versions
of the CES-D also were administered again at monthly intervals throughout residential
care. Children who resided with their mothers were evaluated with a child intake form and
the Developmental Profile II (Revised Edition) (Alpern and Shearer, 1980). Children over 3
years old also were assessed with the Conners’ Rating Scales (Conners, 1970). Finally, mothers
who participated in the Mommy and Me parenting groups were critiqued with the Mother-
Child Relationship Rating Scales (Crawley and Spiker, 1982). All women who left the residential
facility were assessed at 6-month intervals following discharge.
Analyses of the data depicted the demographic and psychosocial characteristics of the
women and their children in the residential program, the effects of specified variables on
women’s retention (survival) in the residential component, changes in functioning among
the women during treatment, staff ratings of client progress and prognoses, and 6-month
postdischarge outcome comparisons for women with short (less than 181 days) and long
(more than 180 days) stays. Although the original design called for comparisons of women in
residential treatment with those admitted to outpatient care and other facilities, these analyses
were not conducted.
Retention
Survival curves were calculated for 702 women to determine the probability of retention
and the correlates of remaining in treatment. About 68 percent of admissions were likely
to remain in the program after 30 days, but the cumulative probability of survival dropped
to 54 percent of enrollees by 60 days. The average retention time was 161 days (a little
over 5 months), with a range of 1 day to about 18 months, and the median was 95 days
(about 3 months).
Cox regression analyses showed that race was not related to retention in residential care, but
a history of cocaine abuse was significantly associated with earlier departure from treatment
(p = .05). Women with a history of cocaine abuse typically stayed in the residence several
223

Appendix B
weeks less than those who primarily abused other substances. Among 261 women who
received psychological testing, higher initial levels of thought disorder or depression were
associated with decreased length of stay (p

Site-Specific Evaluation Findings
ing fun with her children). Graphs of the staff exit ratings at the time clients left treatment
showed that women who remained in treatment longer had significantly better prognoses on
all indicators than those who left earlier (p

Appendix B
Watts Health Foundation: Lynwood, California
A total of 64 women were enrolled in the Watts Health Foundation Experimental Women and
Children’s Residential Program during the 22-month period from its beginning in August
1995 to the end of May 1997, when recruitment of new subjects ceased. Another 62 women
had been admitted to the Transitional Program—the more traditional therapeutic community
model of residential care for women and children that operated for approximately
3 years from the beginning of the CSAT grant in October 1992, until the new facility was
opened and a new curriculum was implemented. In addition, 62 women who were enrolled
in a coed, but male-oriented facility, operated by the Foundation served as the original
comparison group.
Evaluation Design
The evaluation compared the three groups of women with respect to characteristics at admission,
retention and discharge status, client satisfaction with the program components,
improvements from treatment entry to discharge, and posttreatment outcomes at 3 and
6 months. The evaluators collected data from the ASI, the Beck Depression Inventory, the
Index of Self-Esteem (Hudson, 1974), the Nowicki-Strickland Locus of Control Scale (Nowicki
and Strickland, 1971), the Brief Symptom Inventory (Derogatis and Spencer, 1975), and the
Coping Strategies Inventory (Tobin, 1984).
Differences in Client Characteristics
Only two significant differences were found among the three comparison groups with respect
to demographic characteristics: Women in the Transitional Program were older than those in
the other two groups by a few years (p = .00), and more women in the Transitional Program
identified themselves as being married or in a common-law relationship (p = .03). In terms
of other characteristics, women in the experimental group had significantly less severe composite
ASI drug scores than did women in the other two comparison groups (p

Site-Specific Evaluation Findings
ALOS for terminations
21 days (0.7 months)
Less than one-third of the women in each of the comparison groups completed treatment,
although women in the experimental group were somewhat more likely to drop out of treatment
than those in the other two groups. Women in the Transitional Program were more likely
to be terminated for cause (5%) than counterparts in the other two groups (2% each).
Length-of-stay data indicated that women who dropped out against medical advice in all three
groups usually left within 3 to 4 months, whereas women who were transferred to another
program usually did so at 4 to 6 months. Program completers in all the groups remained in
treatment between 9 1 ⁄2 and 10 1 ⁄2 months.
Improvements During Treatment
Women in the experimental program who successfully completed treatment (n = 11) significantly
improved their levels of problem severity in six of the seven life areas measured by the
ASI between intake and discharge. Similar improvements were shown among
graduates of the other two comparison programs. Additionally, the women who completed
any of the three treatment programs showed statistically
significant improvement from admission to discharge
in their levels of depression and in their self-esteem. At
discharge, mean scores for depression were well within
the normal range, down from low to moderate levels at
the intake assessment. Statistically significant improvement
in psychiatric symptomatology also was shown at
discharge by treatment completers in the experimental
group on six of the nine Basic Personality Inventory subscales.
Clients’ Satisfaction With the Program
Components
Over 80 percent of the treatment completers at the
experimental program (n = 12) rated five of eight program
components as very helpful. In order of perceived
helpfulness, these included individual counseling, selfhelp
groups, educational groups, parent education, and women’s support groups. The components
receiving lower ratings on helpfulness were recreation, family counseling, and group
counseling. Not surprisingly, dropouts from the program were not nearly so positive in rating
any of the treatment components, although nearly 83 percent of those who left against medical
advice (n = 17) reported that individual counseling had helped a great deal.
Outcomes
Women . . . who
successfully completed
treatment . . .
significantly improved
their levels of problem
severity in six of the
seven life areas
measured by the ASI
between intake and
discharge.
Because followup data only were collected at entry, discharge, and 3 and 6 months following
discharge for a total of 75 program completers and dropouts in all three groups, no statistical
tests were conducted. However, trend lines were drawn for four outcome measures: the ASI
Drug Severity Index, the ASI Social/Family Composite Index, the Beck Depression Inventory,
and the Index of Self-Esteem. The most substantial improvements in all these functional
areas—for clients from all three programs—appeared to occur between treatment entry and
227

Appendix B
discharge, with a slight elevation (or worsening) at 3 months after discharge and a leveling off
or slight improvement again by 6 months after treatment. Except for improvements in the
severity of drug problems, program dropouts did not improve as much between entry and
discharge as treatment completers—in any of the programs. These differences between
treatment completers and dropouts were most pronounced with respect to improvements in
psychological functioning, as indicated on the Beck Depression Inventory and the Index of
Self-Esteem.
228

Appendix C:
Selected Publications
and Presentations by
Residential Women
and Children’s Grant
Evaluators and Staff
Brown, V.B.; Huba, G.J.; and Melchoir, L.A. Level of burden: Women with more than one
co-occurring disorder. Journal of Psychoactive Drugs 27(6):339–346, 1995.
Brown, V.B.; Sanchez, S.; Zweben, J.E.; and Aly, T. Challenges in moving from a traditional
therapeutic community to a women and children’s TC model. Journal of Psychoactive
Drugs 28(1):39–46, 1996.
Center for Substance Abuse Treatment. Practical Aproaches in the Treatment of Women Who
Abuse Alcohol and Other Drugs. Department of Health and Human Services, Public
Health Service. ISBN 0-16-045254-6. Washington, DC: U.S. Gov. Print. Off., 1994.
Coletti, S.D.; Hamilton, N.L.; and Donaldson, P.L. PAR Village: Long-term treatment for women
and their children: Process evaluation and research findings. Operation PAR, Inc. In:
Service Outcomes for Drug- and HIV-Affected Families. AIA Monograph. Berkely, CA:
National Abandoned Infants Assistance Resource Center, 1996, pp. 104–118.
Coletti, S.D.; Schinka, J.A.; Hughes, P.H.; Hamilton, N.L.; Renard, C.G.; Sicilian, D.M.;
Urmann, C.F.; and Neri, R.L. PAR Village for chemically dependent women: Philosophy
and program elements. Journal of Substance Abuse Treatment 12(4):289–296, 1995.
Glider, P.; Hughes, P.; Mullen, R.; Coletti, S.; Sechrest, L.; Neri, R.; Renner, B.; and Sicilian, D.
Two therapeutic communities for substance-abusing women and their children.
In: Rahdert, E.R., ed., Treatment for Drug-Exposed Women and Their Children:
Advances in Research Methodology. NIDA Research Monograph 165. NIH Pub. No. 96-
3632. Rockville, MD: National Institute on Drug Abuse, 1996, pp. 32–51.
Hughes, P.H.; Coletti, S.D.; Neri, R.L.; Urmann, C.F.; Stahl, S.; Sicilian, D.M.; and Anthony,
J.C. Retaining cocaine-abusing women in a therapeutic community: The effect of a
child live-in program. American Journal of Public Health 85(8 Pt. 1):1149–1152, 1995.
Lapine, L., and Larson, L. “Outcomes of Successful Treatment for Women: Early Returns from
the Meta House Women and Children’s Study.” Prepared for the Planning Council for
Health and Human Services, Milwaukee, WI, May 1997.
Lapine, L.; Larson, L.; and Feinberg, F. “Secret Gardens: Rediscovering and Sowing Resiliency
in Families Affected by AODA Use.” Presented at the International Evaluation
Conference, Vancouver, Canada, November 1–5, 1995.
Metsch, L.R.; McCoy, C.B.; Miller, M.; McAnnay, H.; and Pereyra, M. Moving substance-abusing
women from welfare to work. Journal of Public Health Policy 20(1):36–55, 1999.
229

Appendix C
Metsch, L.R.; Rivers, J.E.; Miller, M.; Bohs, R.; McCoy, C.V.; Morrow, C.J.; Bandstra, E.S.;
Jackson, V.; and Gissen, M. Implementation of a family-centered treatment program
for substance-abusing women and their children: Barriers and resolutions. Journal of
Psychoactive Drugs 27(1):73–83, 1995.
Murphy, B.; Stevens, S.J.; McGrath, R.; Wexler, H.K.; and Reardon, D. Women and violence: A
different look. Drugs & Society 13(1/2):131–144, 1998.
Stevens, S.J., and Arbiter, N. A therapeutic community for substance-abusing pregnant women
and women with children: Process and outcome. Journal of Psychoactive Drugs
27(1):49–56, 1995.
Stevens, S.J.; Arbiter, N.; and McGrath, R. Women and children: Therapeutic community
substance abuse treatment and outcome findings. In: DeLeon, G., ed. Community
as Method: Modified Therapeutic Communities for Special Populations in Special
Settings. Westport, CT: Praeger Press, 1997, pp. 129–141.
Stevens, S.J., and Bogart, J.G. Reducing HIV risk behaviors of drug-involved women: Social,
economic, medical, and legal constraints. In: Elwood, W.N., ed., Power in the Blood: A
Handbook on AIDS, Politics, and Communication. Mahwah, NJ: Lawrence Erlbaum
Associates, 1999, pp. 107–120.
Stevens, S.J.; Estrada, A.L.; Glider, P.J.; and McGrath, R. Ethnic and cultural differences in
drug-using women in- and out-of-treatment. Drugs & Society 13(1/2):81–96, 1998.
Wexler, H.K.; Cuadrado, M.; and Stevens, S.J. Residential treatment for women: Behavioral
and psychological outcomes. Drugs & Society 13(1/2):213–234, 1998.
230

Appendix D:
Participants in the
Development of
This Document
Discussion Facilitators at the Final Grantee Meeting, May 1996
Karen Allen
Associate Professor, School of Nursing
University of Maryland
Margaret Cramer
Staff Practice Psychologist
Eric Lindermann Mental Health Center, Inc.
Susan Galbraith
Independent Contractor
Policy Research Inc.
Susan Gallego
Independent Consultant
Policy Research Incorporated
Juana Mora
Professor, Chicano Studies Department
California State University, Northridge
Paula Roth
Independent Contractor
Policy Research Incorporated
Participants at the Final Grantee Meeting, May 1996
Denise Auclair
Clinical Director
Desert Willow/National Development and
Research Center
Cristina Brown
Coordinator of Children’s Services
Interim House West/Philadelphia Health
Management Corporation
Vivian Brown
Principal Investigator
PROTOTYPES/Women’s Center/Moms and Kids
Drug Treatment Project
Shawna Campbell
Continuance Coordinator
Desert Willow/National Development and
Research Center
Barbara Carey
Project Director
The Village, Families in Transition/Village
South, Inc.
Shirley Coletti
Principal Investigator
Parental Awareness and Responsibility
Village/Operation PAR, Inc.
Laurie A. Corbin
Project Director
Interim House West/Philadelphia Health
Management Corporation
Kathleen Coughy
Project Evaluator
Interim House West/Philadelphia Health
Management Corporation
231

Appendix D
Debbie Dahl
Clinical Director
Parental Awareness and Responsibility
Village/Operation PAR, Inc.
James DeVance
Treatment Coordinator
Watts Comprehensive Residential Drug
Prevention and Treatment Program/Watts
Health Foundation
Pamela Donaldson
Nurse
Parental Awareness and Responsibility
Village/Operation PAR, Inc.
Sharon Dorr
Vice President, Client Services
Casa Rita/Women In Need
Romaine Edwards
Clinical Director
Watts Comprehensive Residential Drug
Prevention and Treatment Program/Watts
Health Foundation
Arlene Everett
Project Director
Watts Comprehensive Residential Drug
Prevention and Treatment Program/Watts
Health Foundation
Francine Feinberg
Project Director
Meta House (Project MetaMorphosis)/Our Home
Foundation, Inc.
Maryann Fraser
Executive Vice President
PROTOTYPES/Women’s Center/Moms and Kids
Drug Treatment Project
Amy Freidlander
Principal Investigator
Interim House West/Philadelphia Health
Management Corporation
Matthew Gissen
Executive Director
The Village, Families in Transition/Village
South, Inc.
Linda Glickman
Program Evaluator
Casa Rita/Women In Need
Nancy Hamilton
Vice President
Parental Awareness and Responsibility
Village/Operation PAR, Inc.
Sandra Hendricks
Clinical Director
Meta House (Project MetaMorphosis)/Our Home
Foundation, Inc.
Squeak Linda Herman
Project Director
The Flowering Tree Project/Our Home
Foundation, Inc.
George Huba
Program Evaluator
PROTOTYPES/Women’s Center/Moms and Kids
Drug Treatment Project
Valera Jackson
Executive Vice President
The Village, Families in Transition/Village
South, Inc.
Kathryn Keifer
Children’s Services Coordinator
Meta House (Project MetaMorphosis)/Our Home
Foundation, Inc.
Louise Lapine
Program Evaluator
Meta House (Project MetaMorphosis)/Our Home
Foundation, Inc.
Robin McGrath
Project Director
Desert Willow/National Development and
Research Institute
232

Participants in the Development of Document
Michael Miller
Principal Investigator
The Village, Families in Transition/Village
South, Inc.
Richard Nankivel
Program Evaluator
The Flowering Tree Project/Oglala
Sioux Tribe
Robert Nishimoto
Program Evaluator
Watts Comprehensive Residential Drug
Prevention and Treatment Program/Watts
Health Foundation
Paul Pittman
Program Evaluator
Chrysalis Center/Circle Park Associates
Carol G. Renard
Project Director
Parental Awareness and Responsibility
Village/Operation PAR, Inc.
Linda Robinson
Project Director
GAPP Family Enrichment Center/Georgia
Addiction, Pregnancy, and Parenting Project
Beverly Rollins
Program Evaluator
GAPP Family Enrichment Center/Georgia
Addiction, Pregnancy, and Parenting Project
Chris Sanderson
Children’s Services Coordinator
Chrysalis Center/Circle Park Associates
Iris E. Smith
Executive Director
GAPP Family Enrichment Center/Georgia
Addiction, Pregnancy, and Parenting Project
Ophelia Smith
Principal Investigator
Casa Rita/Women In Need
Sally Stevens
Project Evaluator
Desert Willow/National Development and
Research Institute (NDRI)
Cathy Urmam
Program Evaluator
Parental Awareness and Responsibility (PAR)
Village/Operation PAR, Inc.
Lucille Windom
Project Director
Chrysalis Center/Circle Park Associates
Charles L. Young
Principal Investigator
Chrysalis Center/Circle Park Associates
233

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240

Glossary of Acronyms
Acronym
Definition
AA
Alcoholics Anonymous
ADAMHA Alcohol, Drug Abuse, and Mental Health Administration
ADHD Attention Deficit Hyperactivity Disorder
AFDC Aid to Families with Dependent Children
AIDS Acquired Immune Deficiency Syndrome
ALOS Average Length of Stay
AOD Alcohol and Other Drugs
ASI
Addiction Severity Index
BSID-IIBayley Scales of Infant Development, Second Edition
CA
Cocaine Anonymous
CARE Comprehensive AIDS Resources Emergency
CBCL Child Behavior Checklist
CDA Child Development Associates
CES-D Center for Epidemiological Studies Depression Scale
CJS Criminal Justice System
COSA Children of Substance Abusers
CPR Cardiopulmonary Resuscitation
CPS Child Protective Services
CSAP Center for Substance Abuse Prevention
CSAT Center for Substance Abuse Treatment
DDD Department of Developmental Disabilities
DHEC Department of Health and Environmental Control
DSS Department of Social Services
DVR Department of Vocational Rehabilitation
EDP Educational Development Plans
EMDR Eye Movement Desensitization Reprocessing
EPSDT Early and Periodic Screening, Diagnosis and Treatment
241

Glossary of Acronyms
Acronym
FAS
FDC
FIT
FY
GAPP
GED
HELP
HHS
HIV
HMO
HUD
IH
IHS
IHW
IQ
K-ABC
LS
MMPI-
NA
NDRI
NIAAA
NIDA
NIJ
NIMBY
PAR
P.L.
POWER
PPW
PRI
PSI
PTA
QRS
Definition
Fetal Alcohol Syndrome
Florida Department of Corrections
Families in Transition
Fiscal Year
Georgia Addiction, Pregnancy, and Parenting
General Equivalency Diploma
Hawaii Early Learning Profile
U.S. Department of Health and Human Services
Human Immunodeficiency Virus
Health Maintenance Organization
Department of Housing and Urban Development
Interim House
Indian Health Service
Interim House West
Intelligence Quotient
Kaufman Assessment Battery for Children
Long-Stay Group
Minnesota Multiphasic Personality Inventory-
Narcotics Anonymous
National Development and Research Institute
National Institute on Alcohol Abuse and Alcoholism
National Institute on Drug Abuse
National Institute of Justice
Not in My Back Yard
Parental Awareness and Responsibility
Public Law
Professional Opportunities for Women Entering Recovery
Pregnant and Postpartum Women
Policy Research Incorporated
Parenting Stress Index
Parent-Teacher Association
Quarterly Reporting System
242

Glossary of Acronyms
Acronym
RFA
RSVP
RWC
SAMHSA
SCL-90R
SIDS
SS
SSI
STD
STEP
TANF
TB
TC
TIP
WAGES
WIC
WIN
YMCA
Definition
Request for Applications
Reserve Senior Volunteer Program
Residential Women and Children’s (CSAT program)
Substance Abuse and Mental Health Services Administration
Symptom Checklist–90R
Sudden Infant Death Syndrome
Short-Stay Group
Supplemental Security Income
Sexually Transmitted Disease
Systematic Training for Effective Parenting
Temporary Assistance for Needy Families
Tuberculosis
Therapeutic Community
Treatment Improvement Protocol (CSAT publication series)
Work and Gain Economic Self-sufficiency
Women, Infants and Children (Federal food program)
Women In Need
Young Men's Christian Association
243

DHHS Publication No. (SMA) 01-3529
Substance Abuse and Mental Health Services Administration
Printed 2001