Project assist: a modified therapeutic community for homeless women living with HIV/AIDS and chemical dependency. (Practice Forum).
THERAPEUTIC COMMUNITY MODEL
Established in the 1950s as a self-help alternative to existing substance abuse treatments, the therapeutic community (TC) model is one of the most common residential treatment modalities. The goal of the TC model is to create a structured, isolated, mutual-help environment in which individuals with substance abuse problems can develop and learn to function as a mature participant through a process of resocialization. Characteristics of the TC model include a focus on the whole person, social and physical isolation, a structured living environment, a system of rewards and punishments, and an emphasis on self-examination (Doweiko, 2001). Studies have found that the TC model is effective in addressing substance abuse for clients who remain in treatment (Melnick & De Leon, 1999). However, the TC model has been criticized for too little attention to women's issues (Brown, Sanchez, Zweben, & Aly, 1996). Project Assist adapted the traditional TC model to the unique needs of chemically dependent, HIV-positive homele ss women by implementing a gender-specific approach to treatment.
It has become generally accepted that the patterns, consequences, and reasons for substance abuse among women are different from those for men (Lex, 1994). Women in treatment for substance abuse report more psychiatric syrnptoms, more depression and anxiety, lower self-esteem, and higher rates of childhood sexual abuse than do men in treatment (Wallen, 1992). Women who' abuse substances also differ from men in patterns of use, psychosocial characteristics, and physiological consequences of their substance abuse. Furthermore, rates of treatment entry, retention, and completion are significantly lower for women than for men, and traditional substance abuse treatment models are less effective for women than for men (Bride, 2001; Nelson-Zlupko, Kauffman, & Dore, 1995).
Gender-specific treatment provides women with an opportunity to concentrate on their own needs and desires away from their traditional concerns of social approval and the welfare of others (Copeland, Hall, Didcott, & Biggs, 1993). The basic requirements of specialized treatment for women are a female therapist, individual counseling, and women-only groups (Cop eland et al.). Other components may include sexual and physical abuse counseling, child care services, family counseling, and vocational training and support (Burman, 1992). Gender-specific programs allow women to discuss issues they would not discuss in mixed-gender settings and display a wider range of behaviors and may prevent the experience of sexual harassment (Hodgins, elGuebaly, & Addington, 1997). Gender-specific programs are more likely to provide services to meet the specific needs of women and may be more attractive and effective (Grella, Polinsky, Hser, & Perry, 1999). Finally, treatment for women should be more supportive and less confront ational, grounded in women's experiences, and focus on empowerment and women's strengths (Finkelstein, Kennedy, Thomas, & Kearns, 1997; Grella et al.; Nelson-Zlupko et al., 1995).
Upon admission, Project Assist residents begin a four-week intensive day treatment phase during which clients attend five, one-hour group sessions Monday through Friday. Group topics include group therapy, spirituality and meditation, stress and anger management, psychoeducation, the 12 steps, social skills, and relationship, family, addiction, employment, and health issues. Residents also attend evening and weekend activities such as community meetings; group therapy; relapse prevention, spirituality, health, and HIV support groups; and individual sessions with their case manager. Residents are required to document attendance at up to six 12-step meetings each week and obtain a 12-step sponsor. Evening and weekend activities, as well as involvement in a 12-step network and meetings are required for the duration of treatment.
An expectation that residents work, either in an approved job outside of the TC or within the TC is a characteristic common to many TCs (Doweiko, 2001). After completion of the intensive day treatment phase, residents are required to obtain and maintain either a paid or volunteer position. However, this requirement is highly individualized according to residents' health status. An employment specialist works with residents on tasks such as conducting a job search, preparing a resume, and developing interview skills as well as issues related to workplace disclosure and the double stigma of being HIV-positive and in recovery from chemical dependency.
HIV Support and Education Services
Project Assist collaborates with a local AIDS services organization to provide HIV support and education services. A process-oriented support group is held weekly, providing residents with time to explore issues related to living with HIV/AIDS. Topics include disclosure to family and friends; adjustment to new medications; stress, its effect on the immune system, and stress management techniques; basic HIV information; grief and fear of death; and stigma associated with HIV. In addition to the support group, a health education group is conducted every other week, providing residents with information about HIV/AIDS and related health issues. Discussion topics include medication side effects, other STDs, high blood pressure, proper hygiene, proper nutrition, safer sex, and the possibility of contracting different strains of HIV. Clients also have the opportunity to discuss HIV/AIDS issues in individual sessions with their case manager or the nurse. Individual sessions often focus on themes related to grief, dea th and dying, and disclosure.
The increasing appearance in TCs of residents who have AIDS or who are seropositive has required programs to collaborate more closely with outside caregiving agencies (Broekaert, Kooyman, & Ottenberg, 1998). To this end, an integral component of Project Assist's professional staff is a full-time registered nurse. The nurse closely monitors residents' health status, provides basic health services and case management, and develops an individualized treatment plan for each client. Perhaps most important because of the finding that links between substance abuse services and medical services have traditionally been limited (Calloway & Morrissey, 1998), the nurse serves as a broker and advocate with other community health services for residents' health care needs. Finally, the nurse facilitates residents' understanding of their health care options and treatment plans, paying particular attention to medication compliance and management of medication side effects.
This article described a substance abuse treatment program for homeless women who abuse substances and are living with HIV/AIDS. A therapeutic community model was modified to meet the unique needs of this population. However, in light of criticism that the traditional TG model fails to attend to women's issues (Brown et al., 1996), the program uses a gender-specific treatment approach. In addition, the treatment program incorporates a variety of HIV support and education services, and provides enhanced health services to address the multiple medical needs of this population. To date, limited treatment options have been available to address the unique issues of women who are homeless, chemically dependent, and HIV-positive. To our knowledge, this is the first description of such a program to appear in the professional literature.
Original manuscript received January 14, 2003
Accepted February 10, 2003
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ABOUT THE AUTHORS
Brian E. Bride, PhD is assistant professor, College of Social Work, University of Tennessee, 193-E Polk Avenue, Nashville, TN 37210; e-mail: email@example.com. Endsley Real, MSW LCSW is program coordinator, Project Assist, St. Jude's Recovery Center, Inc., Atlanta.
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|Author:||Bride, Brian E.; Real, Endsley|
|Publication:||Health and Social Work|
|Date:||May 1, 2003|
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