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Theoretical Approaches to AOD Interventions

Substance abuse treatment may be based on one of several traditional approaches (HHS/SAMHSA, 1999; Marlatt & Gordon, 1985):
  • Medical Model, which focuses on the recognition of addiction as a disease, the need for life-long abstinence, and the use of an ongoing recovery program to maintain abstinence;

  • Social Model, which focuses more on the need for long-term abstinence and the need for self-help recovery groups to maintain sobriety;

  • Behavioral Model, which focuses more on diagnosis and treatment of other problems or conditions that can interfere with recovery.

  • Enlightenment Model, which focuses on the individual's responsibility for causing the abuse problems, but assumes the individual cannot be responsible in the self-control sense for resolving it. AA/NA are often cited as examples of approaches based on this model.
Many programs use a combination of some aspects of the various models in order to facilitate the most appropriate treatment for the individual and to give patients options. This is known as the bio/psycho/social approach. Others also include innovative non-traditional models of treatment such as acupuncture and healing practices associated with specific cultural groups.

Conservative Approach to Substance Abuse

The medical model of substance abuse is the most widely accepted in the United States and Canada, though less so throughout the rest of the world. This model describes alcoholism and drug abuse as a progressive disease, possibly leading to death if not treated. It is a disease that the individual cannot self-treat.

Confrontation of Denial Denial is almost always a symptom of the disease. This denial is often a result of abusers not making the connections between the use of substances and the difficulties they may be having at home, at work, in relationships with others, legally, or medically. In order to break through the denial, the person needs to be confronted with the truth.

Forced Treatment
In the medical model, once a person becomes chemically dependent, formal treatment is the appropriate response. For those individuals who do not see the need for treatment, others must get the person to treatment, for their own good. Employers, family members, or other professionals who may be working with the person may be the ones who force the person to get treatment. Treatment is generally done using groups, with some one-on-one therapy. Treatment may be as little as one group a week, up to long-term residential programs.

Abstinence is the only Goal
The medical model is built around the abstinence approach: chemically dependent individuals must be abstinent for the rest of their lives. Since chemical dependency is progressive, any use following a period of abstinence leads to a full relapse, and the disease progresses.

Relapse occurs frequently
Since the disease of chemical dependency is never cured, a large percentage of individuals relapse into further use following treatment (or self-directed efforts to quit). It is often cited by people in the treatment industry that it takes an average of seven treatment episodes before being clean and sober "permanently".

Imposed Consequences for Use
In order to get an unwilling individual to abstinence, it is often required for severe consequences to be imposed. There is the belief that a person must "hit bottom" in order to see the need to quit their use. In extreme situations, hitting bottom may occur through the imposition of a jail sentence, or through having a child or children removed and placed outside the home. These consequences have the added benefit of protecting children and others from the harmful behavior of some substance abusers.

Proponents and Programs
Many well known individuals support the traditional description of substance abuse, and there is credible evidence that it works for many people. Former Drug Czar William Bennett is a strong proponent of the disease model, abstinence and the need for formal treatment in formal treatment settings. Dr. C. Everett Koop, former Surgeon General of the United States, describes and presents the medical model and various methods for treating individuals ( Both have written a great deal about chemical dependency and the need for treatment.

There are also many well-known successful treatment programs based on the Medical model. These four represent different approaches or populations served. The Hazelden Foundation ( has programs in four states and is headquartered in the Minneapolis area. It developed what is known as the Minnesota Model for treatment. Schick Shadel Hospital's unique medical treatment approach incorporates a safe and comfortable detoxification, individualized treatment programs, medical counter-conditioning, individual and group counseling/education, conscious sedation and relaxation therapy ( The Betty Ford Clinic ( is well known for providing treatment services to many rich and famous people from government, entertainment and the business communities. Phoenix House (, is the largest and best-known Therapeutic Community treatment program in the country, providing residential treatment, that provide education, health care, vocational counseling, training and job placement. All of these programs are committed to abstinence and daily attention to recovery, using 12-step support.

The most known program for substance abuse help is Alcoholics Anonymous, followed by Narcotics Anonymous. While they do not work for everyone, these 12-step programs have helped millions of individuals successfully enter and remain in recovery. These programs are designed to provide a sponsor and a supportive environment in which to work on their recovery. They are based on a spiritual approach, giving themselves up to their Higher Power for the help they need.

Limits of the Conservative Approach
The conservative approach generally does not address the impact of the substance abuse on kids, other family members, friends and neighborhoods. Treatment is focused on the individual with the problem, most often not considering the support and help the family needs. The family disruption often caused by substance abuse can lead to childhood and early adulthood difficulties of the children. These difficulties put those children at increased risk to themselves becoming substance abusers, creating a cross-generational cycle.

The conservative approach assumes things are hopeless, particularly with some substances such as crack cocaine or methamphetamine. The medical model of chemical dependency as an incurable disease gives many people a sense of doom about their problem. We know that the formula for enhancing a person's motivation to make difficult behavior changes involves a high sense of self-efficacy, not hopelessness or doom.

The current system has a low rate of success in treatment, as low as under 10% for some populations. Further, it offers a fairly narrow range of services, with few specific approaches tailored to meet different needs of different populations.

A different definition of conservative
If we define the "conservative" approach as one that identifies and uses the best practices and gets the best outcomes, then the family-focused, strengthening approach is the more conservative one.
  • It is built on research-based best practices.

  • It builds in a wide array of treatment options and supports for the individual, the family, and especially for the children.

  • This approach engages the person and family with proven strategies to enhance motivation to change, and to recognize the need to do so.

  • It builds in supervision and follow-up support in the neighborhood for the person and family while treatment is occurring and after it is over.

  • Child safety and substance abuse reduction/elimination are not separate strategies, but are intertwined in the supports and services, so that we do not have to choose one over the other.
Treatment Options and Their Pros and Cons

Substance abuse treatment refers to a broad range of activities or services, including identification of the problem (and engaging the individual in treatment); brief interventions; assessment of substance abuse and related problems including histories of various types of abuse; diagnosis of the problem(s); and treatment planning, including counseling, medical services, psychiatric services, psychological services, social services and follow-up services as needed.

Treatment may occur in various settings, such as: inpatient, hospital-based programs; short- and long-term residential programs; or outpatient programs. Self-help/12-step and other support groups may augment formal treatment. Treatment may also use a combination of therapies, such as pharmacological therapy to treat certain addictions (for example, the use of methadone for heroin addiction or the use of antabuse to treat alcoholism); use of psychological therapy or counseling, education and social learning theories; and non-traditional healing methods such as acupuncture. Treatment may extend over the course of weeks, months, or years, depending on the severity of the problems and the level of needs created by individual's multiple disorders such as alcoholism, other drug addiction, HIV/AIDS, mental illness (especially depression), and serious physical illnesses. The type and intensity of treatment depend on the individual's psychological, physical, and social problems; the stage (or severity) and type of addiction; personality traits; and social skills before the onset of addiction (HHS/SAMHSA, 1999).

Promising Models, Approaches and Steps Forward

From a broad base of research and service delivery experience, there is a common theme: promising family strengthening initiatives should begin a dialogue with professionals and caretakers from many different disciplines, which will lead to innovation in policies, programs, and practices at the local level. Collaborative, coordinated, culturally competent, community based services are more likely to emerge when the professionals and caregivers in a community possess a common base of knowledge about child welfare concerns and AOD problems (Wingfield, 1998). In public hearings around the country in 1999, the Center for Substance Abuse Treatment heard the same themes of coordinating assessments and providing a continuum of care that is family-focused with an array of "wraparound" services and aftercare programs (CSAT, 1999). In these hearings, there was also clear support for providing culturally relevant, gender relevant, and alternative forms of treatment.

A recent report to the United States Congress echoed this same theme in numerous parts of the report (HHS/SAMHSA, 1999). Specifically, the report recommended that prevention and intervention strategies must be:
  • Comprehensive, integrating the contributions of social service, legal, law enforcement, health, mental health and education professionals;

  • Neighborhood-based, strengthening the neighborhood and community by encouraging and supporting local improvement efforts, including self-help programs, that make the environment more supportive of families and children;

  • Child-centered, protecting the safety and personal integrity of children and giving primary attention to their best interests; and

  • Family-focused, strengthening families, supporting and enhancing their functioning, providing intensive services when needed, and removing children when such action is appropriate.
Systems Level

Policy Issues. Policies must be free of punitive aspects and the personal biases of policy makers. The literature is full of tales of the most troubled families being singled out for punitive intervention, while other less troubled families, engaging in identical behaviors, are not. We are primed to see low income and low status families differently than high income and high status families. Populations believed to be the cause of most of the child abuse and substance abuse are targeted for research related to that abuse, while studies of non-abusing parenting are normally done on affluent white families. There becomes a cycle, where the bias leads to surveillance, which leads to detection, which influences research, that influences policy (Colby & Murrell, 1998). This cycle of bias leading to policy must be interrupted.

Policies must support the increase in improving the health of mothers and their children through better assessments and increased treatment and other services. Policies must support the inclusion of fathers, as well. Even though single parenthood is predominantly a female phenomenon, the fathers can still be important for the intervention. Policies must address the effects and impacts of the abuse on the individuals, not singling out and targeting certain drugs themselves. It is not coincidence that the drugs being singled out as the "bad drugs" are often those being used by low-status families. Polices must address the personal beliefs and characteristics of the actual helpers and other providers of service. Team case management can best handle issues of culture, past use, and past family history.

Increase capacity. A review of existing data suggests that, although a high percentage of parents in the welfare and child welfare systems need alcohol- or drug-related treatment, these services are provided to only a fraction of them. Even some biological parents who receive a variety of services are not able to have their children returned to them, due to the relatively short length of the delivery of the services compared to realistic drug treatment time frames (Linares, 1998).

Collaboration and Blending of Services. Different systems need to resolve the separate and conflicting services they deliver to a family or individual. Purposes, goals, philosophies, time frames, staff education, funding steams, values and legal mandates all need review and consistency over the many systems in order for a continuum of services to be effective with families (Azzi-Lessing & Olsen, 1996; Young & Gardner, 1998; Colby & Murrell, 1998). These services should be from a broad spectrum of fields, including: public and private agencies, AOD treatment, mental health, health care, education, housing, vocational and employment, child welfare.

Laura Feig (1998), describes several components that need to be present in a true collaboration across systems. These components require system changes of a large nature.
  • joint system training
  • team staffing
  • joint funding
  • joint goal setting
  • jointly sought treatment milestones and outcomes
  • improved family risk assessments
  • delivery of services as a single package
  • use of a parenting focus to treatment and to child welfare services
  • integrating child development services into treatment
  • provide long-term services
  • do prevention work with the children while the caregiver is in treatment
Diversify treatment. Treatment specific to the needs of women, pregnant women, different cultural groups, and home-based would improve access and appropriateness in matching client needs with treatment options.

Model Level

McMahon and Luther (1998) recommend that we open our minds to new options of meeting the needs of substance abusing parents and their children. They recommend seven structural components to a family-oriented drug abuse treatment program: 1) prenatal intervention, 2) child care services, 3) family therapy, 4) parent intervention (education), 5) child development services, 6) specific interventions for children, and 7) interagency collaboration. Issues of culture, gender, age of the children, parent drug of abuse, and the treatment setting all need to be considered in the actual services to be delivered. A network of agencies, co-located, with multiple points of entry should be part of the design of such a treatment program.

Models That Show Promise

The Opportunity to Succeed (OPTS). This treatment model (Rossman, 1998) was developed in a multi-site demonstration program that helped addicted ex-offenders break the cycle of recidivism and become contributing members of their communities. The program served felons (who were not convicted of rape or murder) who received substance abuse treatment while incarcerated and assisted them in re-establishing their ties to their communities, families and jobs. The core of the program was the close relationship between the participant, the community-based case managers and the parole or probation officer. Local case management ensured that participants received continuing drug treatment, family counseling, medical and mental health care, assistance in finding housing, and employment training; virtually everything they needed to make the transition to community life. The program was operated in St. Louis and Kansas City, Missouri; Tampa, Florida; and West Harlem, New York by a public/private partnership of correctional and social service agencies.

Another successful approach to this population is using contingency management to enhance client motivation (Silverman, 1999; Higgins & Silverman, 1999). Using a combination of positive and negative reinforcements and positive and negative punishments, studies have found that reinforcements are generally more effective in motivating change than punishments. The well-established principles of operant learning are highly applicable to client elimination of drug self-administration. Program elements recommended include: 1) make the program and consequences very clear; 2) use a foolproof system to detect use; 3) aim at relatively brief periods between consequences; 4) use a consequence controlled by the helper; and 5) make the consequences numerous, initially small, and predictable. The study further found that while contingency management can help a person gain a long period of abstinence, it is no better than other interventions in preventing relapse. It does, however, give the person more time in abstinence to develop other relapse prevention strategies. A variety of studies using contingency management have shown significant positive effects in getting and keeping IV drug users in treatment, helping pregnant women stay in treatment at higher rates, having longer periods of abstinence in alcohol and cocaine abusers and those with co-occurring mental health disorders. "A challenge for contingency management practitioners . . . may be to change prevailing concepts of what treatment is, of how it is delivered, and of how one searches for optimal treatments."

CASAWORKS. In January 1999, The National Center on Addiction and Substance Abuse at Columbia University (CASA, 1999) launched CASAWORKS for Families, a three-year demonstration to help drug and alcohol addicted mothers on welfare achieve self sufficiency. CASAWORKS combines in a single concentrated course of treatment and training: drug and alcohol treatment, literacy and job training, parenting and social skills, violence prevention, health care, family services and a gradual move to work. The program is being tested at 11 sites in nine states, including New York and California, and will serve more than 1,100 women and their children. While the effort is too new to show any results, it does blend a wide array of services into a single "service", which addresses many of the difficulties in separate systems working, at times, at cross purposes with each other.

La Bodega de la Familia. This is a program in New York City that includes the addicts' families in the drug treatment process (DOJ, 1998). In response to evidence that substance abusers supported by a caring family are more successful than others in completing treatment, the city opened this program. It uses family case management, with a focus on the whole family and helping friends, not just the addict, building on their strengths. La Bodega identifies the most appropriate treatment and other providers for referral and coordination, and many of the services are provided in the homes and neighborhoods of the participants. They assist the families with access to the Internet, and information about health, housing, mental health, job training, housing and employment services.

CSAT Model Program. The Center For Substance Abuse Treatment has developed a comprehensive treatment model for AOD abusing women and their children. This model, in it's entirety, can be found in Appendix A. In summary, it establishes both program structure and administration, as well as clinical interventions and other services to be provided. It is prepared in a manner to allow for local adaptation.

Sobriety Treatment and Recovery Teams. The Cuyahoga County (Ohio) Department of Child and Family Services operates START, an adaptation of a similar program in Hamilton County, Ohio, called ADAPT. START is an attempt to meld together what is known about addiction services treatment, good child welfare practice and family preservation practice into a model that can work with the special needs of these families. The population targeted for this program is crack cocaine-using women with children in the Child Welfare system. A set of tenets for blended work with these families is included in Appendix B. Unique to this program is the pairing of a Child Welfare Social Worker and an Advocate who is a former substance abuser, and often a parent in the child welfare system. These two share the traditional child welfare roles, with smaller caseloads (15 families maximum) and a great deal of cross training in child welfare, AOD treatment and family preservation. Equally involved are several drug treatment providers, who also receive the cross training. Health and mental health care providers, housing programs, family and friends, and other supports are part of the family team to support the successful outcomes of the unified plan for the mother. (Annie E. Casey Foundation, 1998).

One part of this network of treatment agencies includes the program called Miracle Village. This is a recovery community for addicted women and their children in a public housing environment. After 4 years of operation, 63% of the women who completed initial treatment are sober and living in the area.

Strategies for Family Change. This is a Sacramento County (California) Department of Health and Human Services response to the population of substance abusing child welfare families. Building on an existing substance abuse treatment initiative, SFC conceptualized a network of formal and informal supports surrounding families to keep children safe. Formal and informal supports are located within the neighborhood, where various disciplines are housed together, and work together. Help is available before problems continue to escalate in severity. Two existing neighborhood centers began the effort, with a third being added in 1999. Each center was different, including the array of services existing in the neighborhood. See Appendix C for a description of and picture of the SFC model. (Annie E. Casey Foundation, 1998A).

Maternal Addiction Program. MAP is a combination residential and day treatment program, in Miami, developed to meet the needs of a largely African American, inner city, indigent female population who are pregnant (Calley & Murell, 1998). In this program, the women start in residential treatment for 28 days, and then go into day treatment for a period from 6 to 12 months, depending in needs. The services target drug use with benefits to the mother and children for reaching and maintaining abstinence. They coordinate with child welfare, social services, legal and other community resources, childcare, transportation and parenting programs. A cross-trained multidisciplinary team, with the mother, develops the specifics of a tailored intervention plan.

Prevention. The Center for Substance Abuse Prevention has developed a booklet describing the eight most successful drug abuse prevention programs (CSAP, 1999). Some of these programs are aimed at children and youth, and often based in school settings. Others are community-based, in churches or other community-based organizations, and target families. One is a program targeted to youth in residential placements. The National Institute on Drug Abuse (NIDA, 1997) developed a guide with prevention principles to help in the development of prevention programs that are community-based, school-based or family-based. This same guide describes other successful prevention programs around the country. These two sources provide a wide range of ideas and models for alcohol and drug abuse prevention.

Frontline Practice Level

"Well, I was involved with this guy who had been a heroin addict. He had a 10 year old daughter and she was just wonderful. And they had this huge Husky dog. I would have done anything for them. The guy was gorgeous, and funny, and he stole all my jewelry. All the stuff from my mom. It was awful."

In this section, we will discuss specific approaches, methods and tools, which have been found to improve family functioning and reduce AOD abuse and child abuse.

Client-Worker Relationship. Interview data from mothers in substance abuse rehabilitation who were regaining custody of their children were analyzed to identify social worker and agency characteristics that facilitated their recovery and family reunification (Akin and Gregoire, 1997). Findings were grouped into three categories: 1) the addiction experience, where the worker understood the omnipresent and overwhelming impact of drug use, even when the person really wants to be clean; 2) lack of the usual system shortcomings-changing the paternalistic actions by workers that reinforce parent powerlessness, cynical agency attitudes and unrealistic expectations; and 3) system successes that encouraged addiction knowledge, provided direction, shared power between parent and worker, and built a relationship based on trust and availability. Implications for practice include the importance of developing a supportive and helpful client-worker relationship and that the worker uses the power of the system to help the family, not to coerce it.

Empathy on the part of the interviewer Is a high predictor of positive outcomes in treatment (Fiorentine & Hillhouse, 1999). Accurate empathy has been known for many years to be the most important characteristic of the helper in the helping relationship (Miller, 1992).

Social Support. A body of research and writing describe the importance of social support for women to enter, remain in and follow-up to treatment. One study found that increased social support was significantly associated with increased self-esteem, a key factor in moderating depression and in successful treatment outcomes (Dodge & Potocky, 2000). They recommend that increased social support be a component of treatment and follow-up care.

Blending Disciplines, Integration and Collaboration. Drug problems are not isolated, and they are usually only one of the difficulties the family is struggling with. It is clear that the designation of a "drug problem" as the issue is narrow and superficial. For effective blending of services, it is recommended that we reach well beyond typical enforcement and drug prevention strategies, for example, to proposals for fundamental restructuring of community involvement in prevention and in treatment (Weinstein, et. al., 1991). Many disciplines need to be involved, including social services, public health, mental health, education, housing, law enforcement and the courts (Wallen, 1999).

Providing integrated collaborative services is like going from the traditional two-dimensional to the three-dimensional game of Scrabble. Plans and services can and should be a complex interweaving of individual, family, neighborhood services of prevention and intervention. Like the three-dimensional Scrabble, this blending of another dimension opens up so many new opportunities to address the needs by building on the strengths. Bloom (1998) suggests that we must look at the whole configuration of strengths, supports and resources of the family, the social context, and the neighborhood and community environment as well as the personal, social and environmental difficulties of the individual needing services. Doing so means the challenging of sacred cows, system-specific language, traditions, institutional rigidities and categorical funding.

Parent education, family therapy, and respite care are services that need also to be considered. Family therapy and family-based psychoeducational services are effective strategies to add to traditional AOD treatment (McCreary, et. al., 1998).

Although budgetary constraints for long-term child services are considerable, a larger barrier is that society does not like to think about the long-term management of drug-related child abuse, regardless of the prospects for success. Making commitment to these families means addressing the concomitant real and multiple needs (Besharov, 1996). When services are blended, the societal negative response to drug abuse is reduced by including treatment with an array of other services.

Over the last 10 years, a record number of single-parent families have entered the child welfare system because of the mother's substance abuse. Several elements must be present in order to address this problem (Azzi-Lessing & Olsen, 1996): Services must be comprehensive and well coordinated; staff from all systems must be cross trained in other systems, to be able to understand and make appropriate referrals; practice must be empowerment-based, working toward helping families and also solving environmental issues; helpers must support the development of self-efficacy in families and individuals; policies, procedures and agreements among systems must allow sharing of needed information and methods to solve problems and overcome barriers; there must be a full continuum of services, that are family-centered and home-based for some families; women-centered services must be available, involving the participation of children in the services; and services must be individualized.

Changes in attitudes, knowledge, and skills are required of both the child welfare and the substance abuse treatment worker. These two systems must combine their perspectives to address both the mother's recovery and the child's well-being (Tracey & Farkas, 1994). Many of the interrelationships of the wide variety of service settings (child protection services, primary health care providers, social service settings, legal system, vocational rehabilitation systems and employment settings) encountered by substance abusers were studied by Rose, et. al. (1999). Their analysis identified the same challenges and barriers to the current system of service, and suggest areas for development of nearly identical "best practices".

Case Management. With the effort to collaborate and blend service delivery to families, good case management becomes more than just seeing that the case plan gets written and implemented. Case management, when done in a collaborative and intensive manner, can greatly improve success measures for treatment success and post-treatment maintenance (McLellan, 1999; Greenfield, 1997). With intensive case management, individuals and families receive more, and a wider variety of, services while in treatment than do people without case management. That increase in services can result in improved outcomes following treatment. Use of AOD can be reduced significantly; furthermore, people are more likely to show improvement in employment, family relations, emotional and health functioning, and legal status.

A new title for case management might be "service coordination". This title more accurately reflects the roles and responsibilities of someone in this relationship with a family. Helping the providers coordinate their services, so as to be complimentary and appropriate, is a difficult task. It takes someone who can help bridge the differences among the various systems and phase the services so that they are not all being delivered at the same time.

Community Based Services.

Resnick (1998) outlines many of the elements of community- and neighborhood-based components and services to succeed. First of all, the services should be for the family, not just an individual. They must be comprehensive, and clearly be focused on positive outcomes. Foster care, if needed, should be part of the constellation of neighborhood supports, with the children placed for short term in the neighborhood. The community should focus on increasing the protective factors, decreasing the risk factors, and building child and family resiliency. Families should be fully involved as partners. The effort should be community-wide.

In Baltimore, one program takes treatment to the high-risk neighborhoods in a bus, partnering with churches to use their parking lots. In Rancho Cucamonga, CA, a treatment program partners with the YMCA, where adolescent participants get substance abuse treatment and free access to all the YMCA's facilities (DPRC, 2000). These are two examples of innovative ways communities and treatment programs can work together.

Family Strengthening, Self-Efficacy Building.

"Even now, whenever anyone shows me a bit of affection I immediately deflect it, as I feel they are just getting at my confidence before rejecting me, but I can get close to other people now. I've had difficulties in past years, but as I get older I'm more spiritually enlightened."

Family strengthening refers to efforts that engage the individual and family in the planning and implementation of services, particularly those services which build on existing family strengths and meet their particular needs. In one study, the quantity of services, which matched the clients' belief that the services were relevant to their situation, was a statistically significant predictor of length of stay in treatment; moreover, length of stay in treatment correlates positively with improved treatment outcomes (Dilonardo, 1998). The results may suggest that an additional important pathway to improving treatment outcome is meeting client's perceived needs.

A node-link map is a cognitive-behavioral visual representation and communication technique (Newbern, et. al., 1999). It increases motivation and self-confidence (self-efficacy) to employ behavioral skills cited as outcomes of positive treatment. It also increased the ability of the client to use oral and written communications while in treatment.

Findings suggest that substance abuse treatment is enhanced by service delivery that incorporates clients' perspectives and addresses their interrelated drug abuse problems (Quimby, 1995).

Parenting is often the only role women see as legitimate in their life, and that their children are a stabilizing influence (McMahon & Luther, 1998). Their child abuse or neglect can also lead them to feelings of guilt, shame and failure due to their substance abuse. Programs that work to maintain the parent-child relationship can use this parent role strength to help in raising motivation to address the drug use. The acquisition of the parent role was linked to reduced drinking on the part of women in one study (Crum, et. al., 1998). When the child welfare system places children, it should be for only enough time to get treatment started. Returning the children, with the proper supports and services, can actually help the mother maintain the progress made. Without the proper supports and services, the added stress of the parent role can have a deleterious effect.

Culture and Gender Considerations.

Women in early recovery often experience problems related to parenting, to trauma resulting from physical or sexual abuse, or to mental illness. Recovery will be more likely successful if these other issues, which precipitate or relate to the abuse of alcohol or other drugs, are attended to. Remaining drug free is very difficult if the woman remains in an abusive relationship, if she has no coping skills to deal with her children, if she has no access to counseling, is in unsafe housing, or her and her family's basic needs are not being met. Ongoing counseling, self-help and other supports, and accessibility to other available resources are almost required in order to maintain recovery (HHS/SAMHSA, 1999).

Gender and ethnic congruity between client and interviewer increases client disclosure; however it does not necessarily increase client retention in treatment or treatment outcomes (Fiorentine & Hillhouse, 1999). The helper must also have empathy skills, to help the family members build their sense of hopefulness and ability to succeed with their goals.

Specialized AOD treatment programs have been developed in the recent past for women (Grella,, 1999A). These women-only programs differ from traditional mixed-gender programs in a number of areas: inclusion of children, treatment that is focused on relationships, addressing past trauma from abuse, sexual abuse and domestic violence. Further, since so many of the women have been unemployed, job readiness is often an included service. The process and duration of the treatment itself is more flexible with this population. Many of these programs allow the (young) children to be with the mother, in both outpatient and inpatient programs.

Child welfare practitioners should have several perspectives when attempting to assess and work with families of color they serve. Those perspectives include: competence in ethnically sensitive practice, differences in power, variations in role, and looking at alternative approaches for helping clients who have difficulties with alcohol or drug use (Rooney & Bibus, 1996).

Neighborhood, Self-Help, and Natural Helpers Approaches

"I used to pretend there was nothing wrong. I made sure friends kept out of mom's way and didn't annoy her. I felt it was my responsibility to make it easier. I was very different from my sister-she was more inclined to have confrontations."

Children are not safe enough when we rely solely on the child welfare system to protect them. Funding levels vary from locality to locality, and even with unlimited financial resources, there is no assurance that such reliance would be effective. All stakeholders in the community (e.g. child welfare services, substance abuse treatment, neighborhood associations, religious bodies, community organizations, mental health, domestic violence, criminal and juvenile justice, family members and citizens) are responsible, and necessary, to protect children. While the child welfare system has primary responsibility for the safety and permanency goals of children with abuse and/or neglect or at-risk of, and their families, such efforts even when more efficient, are still attempting to resolve already existing problems. All child and family serving systems, as well as the other stakeholders in the community are needed in order to assure each child is safe, healthy, happy and educated; that each family has improved their well-being.

The self-help movement is well known, well respected, and available in most locations around the country (Riessman & Gartner, 1996). These groups are composed of people who have the same problem or life experience, to support each other, provide information, and enhance skills for coping. They are self-directing, rarely keep membership rosters or information about the group itself, or data. Alcoholics Anonymous, Narcotics Anonymous, Mother's Against Drunk Driving, Parent's Anonymous are four of many hundreds of such groups focused on the individual. There are also community self-help groups, such as neighborhood associations, community development corporations, and community centers. Investment clubs, community lending circles and Time Dollars are examples of what are known as economic self-help groups. The common denominator is that all self-help groups are built on self-improvement through mutual aid-of the individual, the family, the neighborhood or community.

Many people in all of these formal and informal systems recognize that working together and learning from each other would positively impact the safety of children and the well being of their families. With a change in policy and procedures for the many systems, working together in this capacity would not mean the extra time now piled on top of the heavy workloads those systems already have.

Recommendations For AECF Goals and Activities to Address Substance Abuse Issues

Focus on helping family members and neighborhood natural helpers understand the challenges of substance abuse.
  • What they should look for
  • How to identify problem use vs. non-problem use
  • Identify the skills needed to become knowledgeable in identifying abuse
Focus on helping family members and neighborhood natural helpers deal with the challenges of substance abuse.
  • Ways the family members can manage the abuse
  • Ways natural helpers can assist the family members
  • Criteria to consider for when outside help, informal or formal, is needed
  • Identify the skills needed to be able to deal with the abuse
Develop a set of strategies and tools for use by families, natural helpers, community based organizations, faith based organizations, grassroots coalitions and others.
  • Strategies and models to prevent or delay early use of substances by youth
  • Specific skills for assessing the level of use and its consequences
  • Methods to assist the substance user in understanding the need to change
  • Specific strategies that can be used by family members, in their own environment, to reduce or eliminate the substance use
  • Self-help materials that are written specifically for the family and neighborhood helpers
Work with self help and mutual aid programs and models to become the front line of intervention in partnership with families and neighborhood helpers.
  • AA / NA
  • MADD
  • Mad Dads
  • Rational Recovery
  • Women for Sobriety
  • Mutual Assistance Network (Sacramento)
  • START (Cleveland)


This resource guide has attempted to take a current look at the intersection and impact of substance abuse with family strengthening efforts. The literature and research information tells us that the use and abuse of substances is still prevalent in this country, that it still has negative impacts on families, and that the state-of-the-art thinking about how to address that negative impact includes a variety of aspects. No one approach will work.

The first important concept is to view substance abuse, child abuse, and other family difficulties as intertwined. Much of the literature discusses how there is no discernable cause and effect between substance abuse and all those other problems. Child abuse or neglect, and substance abuse, appear more likely to be responses to the persistent effects of poverty, racism, neighborhood deterioration, violence and other on-going risk factors in people's lives.

Substance abuse is very costly, both in terms of dollars, as well as ill effects on individuals and families. Billions of dollars are spent or lost each year due to substance abuse. Many children are placed in alternative care, due to parental substance abuse, and they tend to stay in care longer, with fewer returns to biological parents than children from non-substance abusing families. Single parent families using substances are more likely to have children removed, as do families of color. It is estimated that as many as 80% of the children in alternative care come from substance abusing families.

There are many factors that lead to substance use and abuse. Substance abusing women tend to have a very high incidence of childhood abuse, sexual abuse and family violence. Children who use illicit substances or whose family life exposes them to several risks are much more likely to become substance abusing adults. Children who have lengthy school difficulties tend to have a very high risk for adult substance abuse. Substance abuse in the family may put the children at higher risk for later abuse themselves.

There are many promising models, approaches and steps being taken to better address the impact of substance abuse on family strengthening efforts. From many sources, we learn that promising strategies tend to be comprehensive, neighborhood-based, child-centered and family-focused. These strategies also include tailoring programs and services to the single parent family, and being specific in how to serve women and people of color.

At the systems level, we must remove the punitive aspects of how we work with families, and we must eliminate biases of the systems and staff who work within them. Policies must support family strengthening, particularly those single parent families headed by women. There needs to be more capacity to serve people needing treatment and other kinds of support. Treatment needs to be flexible, to address the unique set of challenges in each family. Most importantly, systems must work collaboratively with other systems, to blend assessments, service planning, service coordination, and support for the families, and to do so with diversity.

We presented brief descriptions of some innovative and promising models of how to work with substance abusing families, using a family strengthening focus. These models cover a wide range of services, target populations, and settings. They are not the only promising models. They represent a growing movement toward collaborative efforts, which tailor the actual services to the family. Over time, additional model efforts will be identified and added as resources to the ones included here.

At the frontline practice level, we presented several approaches and methods that show great promise. Foremost, the literature supported the vital nature of the helper-family relationship as key to family strengthening. Social support, both informal and more structured, is key to on-going success with people whose substance abuse is reduced or eliminated. The blending of many different services, from different systems, into a unified approach that addresses the specific family difficulties is hard to do; however, it must be done. Good service coordination, involving the family and a "case manager", helps dramatically to strengthen the family. The building of self- and family-efficacy is the result of this approach to frontline practice. If a person or a family believes success is possible in what they need to do, they are much more likely to work on it and achieve that success.

*** Taken from Bridging Assets c/o Jill Kinney material

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