Substance abuse is a major public health problem that affects millions of people and places enormous financial and social burdens on society. It destroys families, damages the economy, victimizes communities, and places extraordinary demands on the education, criminal justice, and social service systems. To understand the connections between substance abuse problems and the child welfare system, it is important that substance abuse and the medical, social, and economic problems that are associated with the use and misuse of alcohol and other drugs, as well as addiction to these drugs, be clearly understood.
The use of alcohol and other drugs is a multifaceted phenomenon, varying with the individual's level of use and the dysfunction he or she experiences as a result of his or her use. The range includes the following:
The American Society of Addiction Medicine describes drug dependence as having two possible components: 1) psychological dependence and 2) physical dependence. Psychological dependence centers on the user's need of a drug to reach a level of functioning or feeling of well-being. Due to the subjective nature of this term, it is not very useful in making a diagnosis. Physical dependence, however, refers to the issues of physiologic dependence, establishment of tolerance, and evidence of an abstinence syndrome or withdrawal upon cessation of alcohol or other drug use. Tolerance, dependence, and withdrawal develop differently depending on the particular substance (HHS/SAMHSA, 1994).
In order to understand the treatment that is needed for addiction, it is important to emphasize that medical experts today generally consider alcohol and other drug addiction to be a disease that, while treatable, is chronic and relapsing. Because dependency on alcohol and other drugs creates difficulties in one's physical, psychological, social, and economic functioning, treatment must be designed to address all of these areas. Addiction and its related problems can be treated successfully, but no single treatment works for all substances, nor for all substance abusers.
It is important to note that not all persons in recovery for substance abuse relapse. Nearly one-third achieve permanent abstinence from their first attempt at recovery. An additional one-third have brief periods of substance use but eventually achieve long-term abstinence, and one-third have chronic relapses that result in premature death from chemical addiction and related consequences. These statistics are consistent with the life-long recovery rates of any chronic lifestyle-related illness (HHS/SAMHSA, 1996a).
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 for persons with alcohol or other drug problems (Institute of Medicine, 1990).
Substance abuse treatment may be based on one of several traditional approaches: the Medical Model which focuses on the recognition of addiction as a bio/psycho/social disease, the need for life-long abstinence, and the use of an ongoing recovery program to maintain abstinence; the Social Model which focuses more on the need for long-term abstinence and the need for self-help recovery groups to maintain sobriety; and the Behavioral Model which focuses more on diagnosis and treatment of other problems or conditions that can interfere with recovery (HHS/SAMHSA, 1996a). 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. Others also include innovative non-traditional models of treatment such as acupuncture and traditional healing practices associated with specific cultural groups.
Treatment may occur in various settings, such as inpatient, hospital-based programs; short- and long-term residential programs; or outpatient programs; and may be augmented by self-help/12-step and other support groups. 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 burden created by clients' 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 patient'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, 1996a).
The concepts of treatment and recovery are not one and the same. However, treatment is a very important part of the recovery process. When the formal treatment component (s) are completed, whether it be outpatient, inpatient or short- or long-term residential treatment, this is not the end for anyone with an addiction problem, much less for an addicted woman with children. Recovery is a lifelong process that takes place over time and often in specific stages. In addition to abstinence, recovery includes a full return to bio/psycho/social functioning (HHS/SAMHSA, 1996a).
One widely accepted model of recovery, known as the Developmental Model, identifies six stages that addicted individuals must undergo for long-term recovery:
Recovery is very complex, is not exempt from vulnerabilities, and requires a long-term commitment. This important part of the treatment continuum must be taken into account in the design of training programs for providers of substance abuse treatment and those of child welfare services. The complexities of recovery must be understood as well as the compelling need to address the issues of children and addicted parents and other family members. It is often said in the recovery communities that the whole family is in recovery because many changes affecting the entire family system will necessarily occur as the recovering person embarks on this lifelong journey of well being. However, many programs do not include a specific focus on parenting and family dynamics.
With respect to women in particular, additional problems emerge in early recovery, including problems related to parenting, to trauma resulting from physical or sexual abuse, or to mental illness. Together with the model described above, a woman's recovery will only be successful to the extent that the other issues which precipitate or relate to the abuse of alcohol or other drugs are also ameliorated. That is to say, if a woman who is newly drug-free returns to a hostile, abusive environment, to high levels of stress in raising one or more children alone, to unsafe housing and insecurity in the employment arena, and with minimal resources for physical and mental health care and other basic needs, recovery will be difficult. Under such circumstances recovery will require ongoing counseling, attendance in self-help and other support groups and accessibility to other available resources. Child welfare workers must become aware of the implications and critical importance of these factors to overall treatment for women, in particular as they relate to identifying proper services for them and their children.
Relapse is not an isolated event, but rather a process whereby an individual becomes dysfunctional or unable to cope with life in sobriety, and thus can no longer avoid using alcohol or other drugs. This process of becoming dysfunctional may lead to renewed alcohol or other drug use, physical or emotional collapse, or even suicide. The process is marked by predictable and identifiable warning signs that begin long before the return to use or collapse occurs. Progressively increased distress levels in any one of the problem areas physical, psychological or social can lead to physical or emotional collapse, resulting in relapse. These symptoms increase and intensify unless the individual returns to the use of alcohol or other drugs (HHS/SAMHSA, 1996a). One particular warning in early recovery occurs when a recovering person begins to seek out situations involving people who use alcohol or other drugs.
Given that addiction can be a chronic, progressive disorder often characterized by relapse, and given the fact that women who relapse may be in particular need of intensive treatment and continued support, the opportunity to reenter treatment must remain open. Continued relapse may point to a more serious disorder that was not initially diagnosed, such as post traumatic stress syndrome resulting from past sexual or physical abuse or current abuse. In order to address these and other issues in women's lives, such as stress connected with being a single parent, low income, being identified as a maltreating parent, and having few social resources, any or all of which may bring about relapse, separate attention to these issues is needed attention that extends beyond the substance abuse treatment process. In order to prevent relapse, the client may have to continue addressing these issues for years after leaving treatment. Formal relapse prevention components that offer means for early detection of relapse and tools for intervention should be included in every treatment program.
Substance abuse affects and costs the individual, the family, and the community in significant, measurable ways including loss of productivity and unemployability; impairment in physical and mental health; reduced quality of life; increased crime; increased violence; abuse and neglect of children; dependence on non-familial support systems for survival; and expenses for treatment. The physical and mental health and social consequences of alcohol and other drug use by women can seriously affect their lives and those of their families (HHS/SAMHSA, 1997a). Not only are women, especially young women, beginning to close the gap between female and male consumption of alcohol and other drugs, they suffer earlier and more serious consequences. Women become intoxicated and addicted more quickly than men and develop related diseases earlier (National Center on Addiction and Substance Abuse, 1996). As will be described more fully in Chapter 5, children also bear the burden of biological and environmental consequences of parental substance abuse.
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