9.0 Treatment Approaches and Methods

9.1 Treatment Approaches and Methods: Key Expert Perspectives

Key experts were asked to identify specific substance abuse treatment approaches and methods which result in treatment success. These were discussed in relation to four broad areas.

• treatment approaches and methods to address physical health issues;
• treatment approaches and methods to address emotional health (including mental health) issues;
• treatment approaches and methods to address interpersonal issues (family and peer relationships);
• treatment approaches and methods to address relapse management/prevention.
  

9.1.1 Treatment Approaches to Address Physical Health Issues

Key experts identified seven elements of best practice to address physical health needs.

• A menu of approaches and resources which are based on exploring and addressing the interrelationships between health issues and practices (e.g. exercise as a stress reduction strategy).
  

No single approach is adequate. A variety of services needs to be available.

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Give educational approach (i.e. substance abuse and eating is a triangle - make connections).

• A strong educational component which explores the impact of substances on women's bodies.
  

High degree of education should be done through group and individual work-done with professional and non-professional staff.

• A strong focus on nutritional education, information and support, with opportunities to practice skills.

Have a nutrition counsellor on site, eat in a certain way to help withdrawal symptoms-need good nutrition plan. The residents themselves are involved in food preparations (i.e. budgeting, food temperature and maintaining good eating habit).

• Accessibility (through program referral) to a range of specialists and allied professionals who can address health-specific problems (e.g. nutrition counsellors, health promotion workers, physicians, eating disorder specialists and nurses). For women living with HIV/AIDS or hepatitis, the issue of the interaction between methadone and anti-viral medications for HIV/AIDS should also be addressed.
  

If treatment program does not have on-site staff trained in health issues, you need a good referral network, key is to have a good referral network.

• Availability of on-site medical staff (particularly in residential settings). Key experts stressed the value of having physicians, nurses or nutritional counsellors on program staff. (On-site may not be practical or affordable for most programs. The priority should be on effective linkages with medical/health specialists).
  
  
  

In residential setting have a house physician. Have nursing staff to test, educate, help identify problems.

• Specialized approach to addressing eating disorders using a variety of methods.
  Address eating disorders through lectures, one-to-one counselling and referrals.
  
• Exposure of clients to alternative health therapies. Key experts stressed the value of exposing clients to alternative therapies such as yoga, meditation, massage or acupuncture as ways of supporting exploration of health needs and finding solutions to problems.

9.1.2 Treatment Approaches to Address Personal (Including Mental Health) Issues

Although key experts identified many best practices to address emotional (including mental health) issues, there was consensus on only four approaches. Most of these approaches relate to mild to moderate mental health problems such as mild depression, anxiety and low self-esteem rather than more severe mental health disorders such as schizophrenia and severe depression.

In general, group work was considered to be the optimal method to explore personal issues. Groups provide empowerment opportunities for women, peer support and education. A smaller number of key experts identified one-to-one therapy as an important element of practice, especially to help women prepare for group work or in cases where women prefer one-to-one counselling as an adjunct to group work.

Key experts identified client education as an effective approach to address emotional issues. Education is a powerful tool to explore issues such as:

• the elements of a balanced life;
• patterns of violence (including generational abuse);
• methods of self-care;
• strategies for understanding relapse.
  

In addition, key experts identified the value of teaching life skills to this group. Life skills may include vocational skills, stress management, anxiety-reducing strategies, anger management and goal setting.

In terms of broad approaches, respondents identified a broad multi-dimensional approach to treatment (bio-psycho-social) as being the most effective.

9.1.3 Treatment Approaches and Methods to Address Interpersonal Issues (Peer and Family Relationships)

There was consensus around a number of approaches to address the interpersonal needs of clients. Best practices include:

• The use of the " relational model" as a guiding approach. Treatment should be oriented to understanding and supporting women to build healthy peer and family relationships. An aspect of this approach involves education about what constitutes a health (including a healthy sexual) relationship.
  
• Provision of couples work and/or family therapy. Key experts stressed the importance of providing couples work and family therapy if feasible, appropriate and supportive to clients.
  

Need a place for women and men to go-into their own gender-specific group to explore issues, and then couples counselling.

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Try to get people in her life involved-she comes in with partner and family.

• A focus on practical skill building (life skills, assertiveness, employment and educational skills development).
  

If it comes up within group about how to get back into the workforce, so they'll go with it and put on a workshop and bring in some resource people who will show them how to write résumés, etc.

• A focus on experiential learning. Respondents stressed the importance of providing an opportunity for clients to practice new skills and interactions with others.
  

The person will be different when she goes back without self-destructive behaviour and interaction with the family will be different, so practice is important.

• Teaching of parenting skills. These would include an understanding of children's developmental needs and re-parenting strategies.
• Exploration of family of origin issues. Women need to understand the linkages between their family of origin and how this impacts on parenting. This is particularly important for Aboriginal women where intergenerational issues may need to be addressed.
• Exploration of identity and co-dependency and other identity-related issues such as spirituality.
• Provision of mental health services and resources for children. Children are affected by substance use. Programs should offer services or referral to services so that these impacts can be addressed.
  

9.1.4 Treatment Approaches to Address Relapse Prevention/Management

Key experts identified best practices that support relapse prevention and management. Consensus occurred around general approaches rather than specific techniques. Best practices consist of:

A recognition among staff (addressed through program design) that relapse is likely to occur and can be a positive impetus for exploring client growth and change.
. . . big piece in here (our program) is to normalize it (relapse). We know that women slip (the rate is very high), so number one let them know it will happen-be aware of it and then develop new healthier ways of coping.

A focussed approach to relapse prevention and management . This includes the building of relapse prevention understanding and techniques into treatment from the point of program intake.

Addressing relapse prevention involves helping clients understand:

• that relapse happens for a reason;
• the scenarios that trigger relapse;
• alternative responses to relapse.
  Need to focus on developing skills to manage triggers, develop self-awareness, (i.e. what they are and then what to do to get out of trouble) just being abstinent doesn't give you the skills to deal with relapse.
• The use of a cognitive-behavioural approach to explore relapse triggers and responses.
  

Help clients observe triggers, plan what to do, practice how going to respond-a way to change behaviours.

• Post-treatment support. Respondents also emphasized the importance of a post-treatment support system to address relapse. Post-treatment support comprises three elements:
  - the provision of ongoing post-treatment counselling/support (out-patient counselling);
  - assistance by program staff in developing community connections for clients to support ongoing recovery.

Provide lots of support in early recovery-encourage them to go to AA and get a relationship with sober women.

• assistance in connecting women to life supports such as housing, money, vocational training that will support recovery.

Need to look at the context of their environment (home, money) for relapse prevention, if supports not in place, plans won't work.

• Other relapse prevention/management strategies. Although there was no consensus on the following specific treatment methods to address relapse, several respondents mentioned the value of following:
  - educational methods, seminars to provide information on health issues;
  - use of group work to demonstrate what does or doesn't work;
  - motivational interviewing;
  - one-to-one counselling;
  - " narrative" approach to exploring issues about self;
  - stages of change model.

9.2 Treatment Approaches and Methods:

Literature Review

9.2.1 General Themes

Treatment approaches and methods are discussed broadly in the literature and may include structural approaches, treatment methods, treatment organization or staff characteristics.

Eliany and Rush noted that 50% to 60% of all patients (both male and female) in treatment show improvement, although, " there is no one treatment modality that has emerged as superior to all other approaches. (Eliany and Rush, 1992:79)

A review of several large-scale (U.S.) treatment effectiveness studies concluded that treatment is effective (although dropout is the rule). Successful (drug abuse) treatment includes a range of elements, such as:

• a comprehensive range of services including pharmacological treatment, group and individual counselling and HIV risk reduction education;
• case management;
• a continuum of services;
• provision and integration of continuing social supports.

This study suggested that all these elements " rather than the specific treatment models, determine whether a program will be successful in treating individual clients and affecting the broader, social community problems that exist because of drug abuse." (Office of the U.S. National Drug Control Policy, 1996:18)

In relation to women's treatment, Lightfoot et al. have noted it is difficult to determine the most effective treatment approaches for individual clients:

Deciding whether or not a particular treatment is effective is an extremely complex task. Substance users vary dramatically at the beginning of treatment . . . descriptions of treatment interventions are frequently vague and implementation evaluation is seldom addressed. There is little agreement as to what treatment outcome objectives should include, and what constitutes success in terms of substance abuse treatment is hotly debated. (Lightfoot et al., 1996b:189)

The women's treatment literature identifies several broad approaches which are associated with treatment effectiveness (e.g. multi-component treatment models). Many of these have not yet been empirically demonstrated in the literature.

There are a number of programs throughout the country that are attempting to set up comprehensive treatment models. To date, due to both a lack of funding, as well as the newness of some of these programs, there has been little evaluation of their effectiveness (Finkelstein, 1993:1289 - 1290)

In a review of seven comparative studies of treatment and seven randomized studies, Lightfoot et al. concluded that:

Although these studies are few in number-a common finding appears to be that women do well, compared with men, in treatments that offer training in self-management, develop coping and relapse prevention skills and address personal needs. (Lightfoot et al., 1996b:195 - 196)

9.2.2 Specific Treatment Approaches and Methods Identified in the Literature

This section provides a description of the following treatment approaches commonly associated with effective treatment outcomes and identified in the literature:

a) Multi-component Treatment Model;
b) Gender-sensitive or Gender-specific Treatment;
c) Use of Cognitive-Behavioural Approach;
d) Use of Pharmacologic Agents Where Required (and in cases of women who are pregnant and are injecting drugs);
e) Collaborative and Case Management Approach;
f) Appropriate Client Treatment Matching;
g) Provision of (Practical) Adjunctive Services;
h) Positive, Hopeful and Empathic Staffing;
i) Specialized Staff Training;
j) Empowerment Model;
k) Addressing Sexual Abuse and Other Experiences of Victimization;
l) Addressing Family Issues;
m) Additional Elements of Best Practice.

a) Multi-component Treatment Model

There is a strong consensus in the literature that effective treatment must include a range of direct and indirect treatment services to address a range of client needs (biological, mental health, peer, family and personal). Reed (1987), Zankowski (1987), Finkelstein, (1993), Drabble (1996), Nelson-Zlupko et al. (1996), Swift and Copeland (1996), identified the core service areas which they consider integral to effective treatment. These have been summarized and annotated below (Table 10). Not all these services need to be provided within one program; however, the services need to be made available within a comprehensive and integrated system. Finkelstein (1993) described over 50 components of this comprehensive care system for women, many of which are described below. However, she noted that:

There is little discussion or agreement in the literature as to how such disparate services should be linked into the model. (Hagen et al. as cited in Finkelstein, 1993:1289)

b) Gender-sensitive or Gender-specific Treatment

Substance abuse research has revealed that the impact of substances on women and their treatment needs differ from those of men.

Health problems caused by alcohol/drug misuse have a more rapid onset and become more serious in a shorter period of time.

Women who misuse substances are also more likely to have a history of victimization. Research has also noted that women respond differently than men to treatment settings. Jarvis, in a meta-analysis of 20 outcome studies that distinguish between men and women, concluded that women in treatment tend to act differently in co-ed treatment settings and to minimize their focus on treatment issues.

Females in mixed-sex groups showed less (sic) interactions with other women, a decreased amount of discussion about home and family and less overall interaction. (Jarvis, 1992:1255)

In a study of a co-ed hospital-based treatment program, Zankowski (1987) speculated that the low completion rate among women clients was due to a lack of gender-specific programming. The program was restructured to include the following gender-specific components:

• Speciality seminars for women (to address substance misuse impacts, self-esteem, family relationships, making it " on your own," parenting role conflict, identification of feelings, sexuality, birth control, family communication and vocational planning).
• Assertiveness training in all women's groups.
• Leisure activities programming (to address low female participation, fear of male harassment, exploration of preferences).
• Family intervention counselling.
• Individualized attention to affective disorders most relevant to women.

The inclusion of these elements increased the completion rate of women clients.

Nelson-Zlupko et al. (1996), in a study of treatment experiences of 24 women in recovery, reinforced the importance of women requiring a forum for expression of women's needs and experiences. Eighty percent of her subjects found discussion of women's issues very helpful or helpful; 75% found women-only groups very helpful or helpful. The women, all of whom had received treatment in women-specialized programs as well as traditional programs, preferred the former. Copeland and Hall (1992), in a retrospective study of predictors of treatment dropout of 360 women seeking alcohol/drug treatment, found that certain groups of women were more likely to complete treatment at specialized gender-sensitive treatment services.

Women with a history of sexual abuse in childhood appear to have an increased need for a physically and emotionally safe environment as their trust has been seriously violated in the past. (Copeland and Hall, 1992:809)

For lesbians and women with dependent children, " attendance at a specialist women's service reduced the incidence of dropout" (Copeland and Hall, 1992:833).

In a study of 267 women who had received treatment, Swift and Copeland (1996) found that the women, who had been in women-only treatment positively endorsed women-specific programming. Within the larger sample of all women who had received treatment (N=217), 42% did not have strong feelings about co-ed or women-only treatment. Eighteen percent liked socializing with men; 11% felt mixed programs were more balanced. However, 11% felt unsafe in co-ed programs. Ten percent who had previously dropped out of treatment said they would have stayed longer if there had been fewer male clients.

Dahlgren and Willander (1989) reported that participants in a specialized all-female program were more likely to report abstinence at 12-month and 2-year follow-ups than women in a control group undergoing treatment at a " traditional" mixed-sex treatment centre.

c) Use of Cognitive-Behavioural Approach

Although the cognitive-behavioural approach to treatment was broadly supported by key experts, no specific empirical data assessing the efficacy of this approach, specifically with women, was found. In a review of the treatment outcome effectiveness evaluation literature (related to both men and women), Eliany and Rush noted that: behaviourally oriented treatment approaches for alcohol problems have received the most support from evaluation studies.

In general terms, the evidence confirms one of the expectations drawn from social learning theory that " performance-based" treatment methods are superior to more traditional, " verbally-based" methods such as psychotherapy or education. Behavioural approaches that are generally supported by the literature include family and marital therapy, aversive therapy, contingency management, and broad-spectrum treatment focusing on relaxation training, stress management and a range of skills training (e.g., social skills, problem-solving skills). (Eliany and Rush, 1992:79)

Similarly, in a recent review of the literature (Health Canada, 1999) examining the effectiveness of treatment modalities, good evidence of effect was associated with the following behavioural modalities. Many of these are identified as elements within an " empowerment" approach:

• social skills training;^**
• self-control training;*
• brief motivational counselling;
• behavioural marital therapy;
• community reinforcement approach;
• stress management approach.*
  

* Are elements of the empowerment approach.

d) Use of Pharmacologic Agents Where Required (and in cases of women who are pregnant and inject drugs)

Hagen et al. stated that alcohol/drug treatment providers often show a negative bias toward using psychotropic drugs, although there may be indications for their use in some cases. In a study of impediments to a comprehensive treatment model, she suggests that there are clear advantages to using psychotropic medications:

Psychotropic medications assist in reducing depression while the woman learns to cope with emotions she has previously medicate.... with legal drugs (e.g. alcohol). (Hagan et al. 1994:168)

The literature also identifies methadone maintenance therapy as an important treatment approach for women who are heroin drug users. Methadone assists in the management of withdrawal from heroin, reduces criminal involvement, improves physical and psychological well-being and enables opiate users to focus on social and vocational rehabilitation (Office of the U.S. National Drug Control Policy, 1996).

Svikas et al. (1997), in a study of incentives for pregnant, drug-dependent women, found that methadone-maintained women attended nearly two times more days in treatment than non-methadone-maintained women and stayed in treatment longer. Hagan et al. (1994) noted that methadone may be a useful tool for clients to control cravings and life chaos. Methadone may also ensure better prenatal outcomes (although methadone use during pregnancy requires careful monitoring). Laken et al. (1996), in a non-comparison study, isolated five factors that^. contributed to retention for a group of pregnant women and found that the use of methadone (provided to women addicted to heroin), organized case management and transportation to treatment were three of the factors that contributed most strongly to retention in treatment.

e) Collaborative and Case Management Approach

Laken et al. (1996) identified strong case management as a key element of effective substance abuse treatment for pregnant women. She defined the following components as integral to a strong case management approach.

• staff assessment of client need for health and social services;
• planning and coordination of services;
• monitoring of services to clients (through home visits and calls);
• advocacy on behalf of clients;
• provision of tangible supports to assist access to services (e.g. funding, transportation).
  

f) Appropriate Client Treatment Matching

The literature supports the importance of matching treatment approaches with the needs of people with substance use problems. Mattson and Allen (as cited in Waltman, 1995) concluded that matching of clients' needs to treatment increases the treatment success rate by 10%. Treatment matching appears to work best for people with moderately severe substance use problems.

Waltman considered the following tasks as most important to consider when matching clients to treatment:

• a consideration of the needs of special populations (e.g. needs of women, ethno-cultural groups);
• respect for client-defined choices (self-matching);
• the assessment of the client's need for structure (includes an assessment of client's loci of control, conceptual level and type of alcoholism);
• substance use severity level;
• stage of recovery;
• level of client self-esteem.

g) Provision of (Practical) Adjunctive Services

Milby et al. (1996), in a study of the homeless (primarily using crack cocaine), 20% of whom were women, found that therapy enhanced with specific practical supports was more likely to engage clients in treatment, although long-term retention rates for the groups involved in this study were low.

h) Positive, Hopeful and Empathic Staffing

In a survey of 24 women in recovery, Nelson-Zlupko et al., found that the quality of staff/client interactions was described as the most important factor within substance abuse treatment settings.

The gender, age, race and substance abuse history of the counsellor, while viewed as important characteristics, were collectively perceived as less important than the extent to which the counsellor treated them with dignity, respect and genuine concern. (Nelson-Zlupko et al., 1996:55)

Experiences with good counsellors were perceived by clients as connected to increased use of treatment and even sobriety. In a general study of client dropout from treatment, Allerman, O'Brien and McLellan (as cited in Waltman, 1995) identified three staff characteristics associated with client dropout from treatment:

• hostility/confrontational style;
• lack of empathy;
• low level of expectancy and hope for change.

i) Specialized Staff Training

Staff with specific skills and training may be required to provide treatment to groups with specialized needs. Women with concurrent disorders require such specialized skills. Grella, in a study of women with concurrent psychiatric and substance (drug/alcohol) abuse disorders, found that both substance abuse treatment and mental health staff required specialized skills.

[Treatment] Staff . . . need training on psychiatric assessment and diagnosis, pharmacologic treatment approaches, stages of recovery in mental illness and the effects of trauma. Mental health treatment staff need training in detoxification procedures and effects, assessment of addiction and differences in types of addiction, role of self-help and 12-step programs and stages of recovery from addictions. (Grella, 1996:331)

j) Empowerment Model

Drabble surveyed treatment providers with the objective of identifying the elements of an effective residential recovery program for women with alcohol use problems. She found that the empowerment model was closely associated with positive treatment experiences and outcomes.

Respondents tended to identify the concept of empowerment as critical to the recovering individual as well as important to the philosophical basis and design of programs. (Drabble, 1996:17)

Although broader in focus, Strantz and Welch (1995), in a study of treatment retention among postpartum women, found that a multi-dimensional model which incorporated the philosophy of women's empowerment was most closely associated with treatment retention.

Treatment type was a very strong predictor of treatment retention and outcome. Almost half of the women admitted to the (intensive) program completed treatment; compared to one out of five from the (non-intensive) program. The (intensive) program incorporated a myriad of elements, such as a cognitive-behavioural approach; an empowerment of women philosophy; parenting role models and support; professional/paraprofessional, mostly female staff; and comprehensive support services such as childcare, transportation and medical, social and educational services. (Strantz and Welch, 1995:372)

k) Addressing Sexual Abuse and Other Experiences of Victimization

Research has reported that women requiring treatment are frequently survivors of sexual abuse (rates vary from 34% - 86% depending on the study). Carson, Council and Volk (as cited in Jarvis, 1992), Copeland and Hall, (1992); Russell and Wilsnack (as cited in Drabble, 1996) found that a history of incest was associated with low self-esteem, particularly for women who are alcohol dependent. Young (1990) suggested that there is a strong relationship between incest experiences and substance misuse.

Miller et al. in a study of the interrelationships between experiences of childhood victimization and the development of women's alcohol-related problems, found that two thirds of the women with alcohol use problems had experienced some form of childhood sexual abuse as compared to one fifth or one third of two other samples without alcohol use problems. Nearly half (45%) of the sample, identified as having alcohol-related problems, compared to 13% and 18% of the non-drinking samples, reported severe paternal violence. The rates of childhood victimization were significantly greater for women in treatment with alcohol-related problems when compared to women in mental health treatment without alcohol-related problems.

l) Addressing Family Issues

Drabble (1996) noted that educational sessions and group counselling around partner and parenting issues were considered by clinicians she interviewed as a core treatment component for women with alcohol use problems. However, Swift and Copeland's (1996) study on treatment needs (identified by women themselves) determined only that the provision of child care services would have increased retention in treatment (family counselling was not identified).

Seventy-six percent of 24 women in recovery (Nelson-Zlupko et al., 1996) described family counselling as a helpful component of services. However, other services such as transportation, help obtaining food, housing and clothing and recreational services were rated as helpful by a high percentage of the women clients.

m) Additional Elements of Best Practice

Other approaches, such as harm reduction and the relational model, identified by key experts are not, at this time, addressed in the empirical research, although elements of these models (client choice, importance placed on family and child relationships) have been addressed to some degree in this document.