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Project assist: a modified therapeutic community for homeless women living with HIV/AIDS and chemical dependency. (Practice Forum).

Substance abuse among people with HIV may have a negative effect on quality of life, use of health services, adherence to medication regimens, and health outcomes (Bing et al., 2001). Limited treatment options have been available to address the issue of substance abusers with HIV/AIDS (Sargent, Sorensen, Greenberg, Evans, &Acampora, 1999). Furthermore, substance abuse treatment programs for homeless people traditionally have been tailored to men (Wenzel, Koegel, & Gelberg, 1996). Recognizing the paucity of substance abuse treatment options for homeless women living with HIV/AIDS, St. Jude's Recovery Center, a private, nonprofit agency that has provided substance abuse treatment services for more than 35 years in Atlanta, Georgia, developed a program to fill this service gap. Founded in 1996, Project Assist is an eight-bed, modified therapeutic community for chemically dependent homeless women with HIV/AIDS. This article describes the core components of a therapeutic community modified to address the needs of homeless women who are both chemically dependent and living with HIV/AIDS.

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.

GENDER-SPECIFIC 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).

PROJECT ASSIST

Program Structure

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.

Health Services

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.

SUMMARY

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

REFERENCES

Accepted February 10, 2003

Bing, E. G., Burnam, A., Longshore, D., Fleischman, J A., Sherbourne, C. D., London, A. S., Turner, B. J., Eggan, F., Beckman, R., Vitiello, B., Morton, S. C., Orlando, M., Bozzette, S. A., Ortiz-Barron, L., & Shapiro, M. (2001). Psychiatric disorders and drug use among human immuno deficiency virusinfected adults in the United States. Archives of General Psychiatry, 58, 72 1-728.

Bride, B. E. (2001). Single-gender treatment of substance abuse: Effect on treatment retention and completion. Social Work Research, 25,223- 232.

Broekaert, E., Kooyman, M., & Ottenberg, D. J. (1998). The "new" drug-free therapeutic community: Challenging encounter of classic and open therapeutic communities. Journal of Substance Abuse Treatment, 15, 595-597.

Brown, V., Sanchez, S., Zweben, J. E., & Aly, T. (1996). Challenges in moving from a traditional therapeutic community to a women and children's T.C. model. Journal of Psychoactive Drugs, 28, 39-46.

Burman, S. (1992). A model for women's alcohol! drug treatment. Alcoholism Treatment Quarterly, 9, 87-99.

Galloway, M. O., & Morrissey, J. p. (1998). Overcoming service barriers for homeless persons with serious psychiatric disorders. Psychiatric Services, 49,1568-1572.

Copeland, J., Hall, W., Didcott, P., & Biggs, V. (1993). A comparison of a specialist women's alcohol and other drug treatment service with two traditional mixed-sex services: Client characteristics and treatment outcome. Drug and Alcohol Dependence, 32, 81-92.

Doweiko, H. E. (2001). Concepts of chemical dependency (4th ed.). New York: Wadsworth. 168

Finkelstein, N., Kennedy, C., Thomas, K., & Kearns, M. (1997). Gender-specific substance abuse treatment. Alexandria, VA: National Women's Resource Center for the Prevention and Treatment of Alcohol, Tobacco, and Other Drug Abuse and Mental fliness.

Grella, C. E., Polinsky, M. L., Hser, Y., & Perry, S. M. (1999). Characteristics of women-only and mixedgender drug abuse treatment programs. Journal of Substance Abuse Treatment, 17,37-44.

Hodgins, D. C., el-Guebaly, N., & Addington, J. (1997). Treatment of substance abusers: Single or mixed gender programs? Addiction, 92,805-812.

Lax, B. W. (1994). Alcohol and other drug use among women. Alcohol Health and Research World, 18, 212-220.

Melnick, G., & De Leon, G. (1999). Clarifying the nature of therapeutic community treatment: The Survey of Essential Elements Questionnaire (SEEQ). Journal of Substance Abuse Treatment, 16, 307-313.

Nelson-Zlupko, L., Kauffman, E., & Dore, M. M. (1995). Gender differences in drug addiction and treatment: Implications for social work intervention with substance-abusing women. Social Work, 40,45-53.

Sargent, R., Sorensen, J. L., Greenberg, B., Evans, G., & Acampora, A. P. (1999). Residential detoxification for substance abusers with HIV/AIDS:

Walden House Detoxification Program. Journal of Substance Abuse Treatment, 16,87-95.

Wallen, 1. (1992). A comparison of male and female clients in substance abuse treatment. Journal of Substance Abuse Treatment, 9, 243-248.

Wenzel, S. L., Koegel, P., & Gelberg, L. (1996). Access to substance abuse treatment for homeless women of reproductive age. Journal of Psychoactive Drugs, 28, 17-30.

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: bbride@utk.edu. 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
Geographic Code:1USA
Date:May 1, 2003
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