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Case Management With Maternal Substance Abusers in Rural Communities: The "WRAP" Experience

Teri L. Nelson, C.C.S.W., A.C.S.W.
Director, Recovery Services
Community Mental Health Center, Inc.
Lawrenceburg, Indiana

Kimberly Brockman, B.S.N., R.N.
Case Management Supervisor
Women's Recovery Alternative Program
Community Mental Health Center, Inc.
Lawrenceburg, Indiana

The intent of this paper is to enhance the body of professional knowledge concerning treatment of maternal substance abusers in rural communities. The paper provides information for those interested in utilizing innovative and creative treatment strategies to address the multiple needs of rural substance-abusing women.

Introduction to the Agency and Community

Founded in April 1966, the Community Mental Health Center, Inc. (CMHC) is a private, nonprofit organization that provides a comprehensive range of services to residents in a five-county area of southeastern Indiana. CMHC is governed by a board of directors who represent a cross-section of the service area population. The primary mission of CMHC is to efficiently provide high-quality services that will enhance and maximize the mental health of the citizens of the service area. The services provided reflect the needs of the service area. Most services are reasonably available to all citizens through satellite offices located in each of the five counties served.

CMHC services are provided in an environment that recognizes and respects the rights of individual consumers. CMHC functions as an integral and competitive part of the delivery network for mental health and health services in the service area. The Center makes a commitment to provide selected services that are consistent with the agency's mission, demonstrated community needs, and the prudent utilization of available resources. Available services through CMHC include the following:

• Inpatient psychiatric hospitalization
• Community support services to seriously mentally ill adults
• Rape crisis services
• Psychiatric/medical services
• Contracted clinical services to youth
• Residential programs for seriously mentally ill and homeless
• A deaf and hard-of-hearing program
• Outpatient services
• An outpatient chemical dependency program

Mental health services are provided by a multidisciplinary staff of 91 that includes psychiatrists, psychologists, social workers, nurses, qualified mental health professionals, residential counselors, and mental health technicians.

Area and Client Demographics

The CMHC service area has characteristically been composed of a population disadvantaged by a lack of industry and economic growth. The five-county region in southeastern Indiana is a 1,498-square-mile section of the State that borders Ohio and Kentucky. The population is approximately 98,000 persons according to the 1990 census data. One of the counties in the region, Ohio County, is the smallest in land mass and population in Indiana. The largest population base is centered in Dearborn County, which has approximately 38,000 residents and, of all the counties, is in closest proximity to Cincinnati, Ohio.

The rate of chemical dependency is slightly higher than the national average because of such factors as the poor economic climate, limited availability of comprehensive treatment services, and the cultural acceptance of alcohol abuse in particular. The per-capita income in the service area is significantly below the State average of $15,830; it ranges from $10,506 in Switzerland County to $14,692 in Ripley County. The number of food stamp recipients increased by 8.7 percent from 1989 to 1990 in Dearborn County, where the largest population base is located. In four of the five counties, Medicaid claims increased by a range of 8.1 percent to 15.2 percent during the same period (1989 to 1990). A review of CMHC's client demographics for the period of 1990 to 1993 indicated at least 90 women with a substance abuse diagnosis who had dependent children; 78 women had annual incomes below $10,000.

The Gap in Services for Chemically Dependent Women

It is within this backdrop of area and client demographics that the Recovery Services Department of CMHC, Inc., specializing in addiction treatment, identified a significant gap in providing services adequate to meet the needs of chemically dependent women. The Recovery Services Department, until implementation of WRAP in September 1993, provided outpatient, intensive outpatient, and early intervention programs with four staff therapists. The main services were provided at CMHC's administrative offices in Lawrenceburg, Indiana, with satellite outpatient offices staffed 1 day per week in three other counties. The frustration in attempting to provide treatment services in a traditional model to chemically dependent women continued to increase. This frustration was fueled by problems inherent in a rural area, including the lack of public transportation, poverty level incomes, and the lack of a comprehensive range of available addiction services within the service area.

It is widely acknowledged that addiction services in a rural area are a challenge in the best of circumstances. In an area that has few available resources and generally is one of the most economically disadvantaged areas of Indiana, there are a wide range of elements that have an adverse impact on the delivery of treatment services. Addressing the special needs of addicted women with dependent children further amplified the challenge facing the Recovery Services Department staff. For a number of years, the clients served were predominantly males who had frequently been court-ordered to attend treatment as a condition of probation. The percentage of women receiving services was, at best, approximately 30 percent.

Although women represented an average of one-third of the total client population, women typically did not remain in treatment beyond the initial three or four sessions. Most often, the initial sessions were crisis-oriented. When the crisis ended, women discontinued treatment only to be seen several months to several years later, once again in crisis, with a more advanced progression of chemical dependency and increasingly regressive functioning in themselves and their families. It was evident that the traditional outpatient model was not effective with maternal substance abusers. However, there were no other known models of treatment for addressing the unique needs of women.

Development of the WRAP

In 1993, the Indiana Family and Social Services Administration, through the Division of Mental Health, announced a request for proposals that would address the specific treatment issues surrounding services to maternal substance abusers. This offered an opportunity to identify possible methodologies that could provide more substantive treatment services to this underserved population. A primary concern in developing the proposal was to identify a treatment approach that would support the ability of women to remain abstinent and enter recovery. This was particularly important given the lack of residential and inpatient services that could accept women and their children. The closest facility for providing such a service is more than 125 miles away. In developing the proposal application, several ancillary factors were considered.

The low income of many families in the area prohibited many women from having access to needed services. Another issue of clinical importance to the Recovery Services Department was the need for a method of intervening with the children in the family. This was seen as vital to the success of any program that would attempt to work with maternal substance abusers. The third issue that was a factor in developing what would become the Women's Recovery Alternative Program (WRAP) was how to improve the self-sufficiency of families.

After 4 months of research and development, the Recovery Services Department of CMHC submitted a proposal to the Division of Mental Health in March 1993. In April 1993, the program was notified of the funding award of $200,000 to support a $379,000 budget. The following section describes the methodology developed in the design of the WRAP program and reviews the program's implementation.

Methodology

The WRAP program is an innovative concept that blends outpatient treatment for chemically dependent women and their children with a community-based case management component. The target population is women with dependent children and pregnant women with a chemical abuse/dependency diagnosis. The program grant supports provision of services to those who are indigent; however, CMHC makes the services available on a sliding-scale fee basis to all women who qualify regardless of income. The goals of the program are to:

• Assist families in obtaining the necessary community services and life skills to enhance abstinence from alcohol and other drugs
• Improve the quality of family life

By reducing barriers to addiction treatment and advocating for the needs of maternal substance abusers, families have greater opportunities for becoming self-sustaining and breaking the intergenerational cycle of chemical dependency and associated family problems.

A case management model was the treatment approach chosen as having the greatest potential for success with addicted women who have dependent children. The model blends outpatient with intensive outpatient treatment from the existing Recovery Services programming. This case management model is adapted from community-based approaches that had been successfully used with other client populations, particularly the seriously mentally ill. The major difference in the case management model used in the WRAP program is that it emphasizes case management with the women and their children through community- and home-based interventions. These interventions are designed to enhance the family's capacity for independence and self-sufficiency after they have completed the program.

Content/Program Design

The WRAP program is built upon three primary components. These are (1) community case management; (2) structured outpatient treatment for women and their children; and (3) family networking to enhance recovery.

Community Case Management

The function of case management is designed to assist women and their children to:

• Access community resources
• Identify employment and educational opportunities
• Ensure access to adequate health and child care services
• Assess and enhance parent-child interaction and functioning by providing home-based services

The program design allows for the most intensive level of service to be home- and community-based, rather than facility-based as in traditional models of addictions treatment. This encourages maximum growth and empowerment of the family by strengthening their ability to have an impact on their own environment. The program is designed to provide an average of 16 hours per month in case management services.

Help in assessing community resources.

The community case management concept focuses on assisting women to access community resources that will enhance their family's capacity for independent functioning. This includes:

• Accessing entitlement programs
• Linkage with employment and education resources
• Maximizing health and child care services
• Accessing adequate housing

The case management reduces barriers to treatment and improves the chance of sustained recovery by linking women with organizations that can provide services and assistance to improve their level of functioning and quality of life.

The importance of this component for the quality of client outcome cannot be underestimated. The linkage of community case management with structured outpatient treatment is an innovative strategy as applied to this population. It is also one that has proved to be successful in the year since the program was implemented. It is a treatment approach that develops natural linkages within communities to promote family growth while addressing the mother's chemical dependency; this is the backbone of program success. Availability of case management in this disadvantaged, rural locale promotes improved chances of successful recovery, enhanced family functioning, and greater access to adequate health care for women and children.

Living support for families.

Another integral part of the program is family living support to offset the basic costs of child care and living necessities. Because many of the clients in the program are below Federal poverty income guidelines, the families are frequently living in impoverished settings without minimally adequate living and housing resources. Family support is based on the costs of child care, housing, and other basic necessities. The family support is closely monitored and is payable only to vendors and not to service recipients as income. A maximum amount is determined based on the family's size and the basic expenses necessary to maintain a minimally adequate standard of living.

Outpatient Chemical Dependency Treatment

The second component is an extended outpatient treatment model based on an average of 6 to 9 hours per week of addiction treatment. Because the service area has no inpatient or residential care available, a structured and intensive approach to treatment is vital to client success. Providing transportation to those families that do not otherwise have the means to access services resolved one significant barrier to treatment in this rural area of Indiana.

The treatment is coordinated through the Recovery Services outpatient program. Utilizing primarily group therapy, the treatment focuses on increasing competency in various life areas to support abstinence and active recovery. These include:

• Improving the relationships with family and children
• Improving parenting
• Addressing women's health issues through education groups and improved access to health care services
• Encouraging emotional well-being
• Choosing healthy partners
• Providing a holistic approach to address physical, psychological, and emotional needs

The initial treatment plan for mothers and children.

After a three-session assessment, each family is presented at weekly Recovery Services Department clinical staff meetings. This multidisciplinary team, which includes a consulting child psychiatrist, offers recommendations for the initial treatment plan. Recommendations are made for both mother and children and may include ancillary services, such as individual and family therapy, psychological testing as indicated, psychiatric evaluation, and interface with schools, welfare departments, and the legal system if warranted.

Intensive outpatient and outpatient groups are frequently the most utilized form of treatment with the WRAP clients. Since the program is designed for a minimum 1-year length of stay in outpatient treatment, it allows the WRAP staff to follow the progress of individual clients as well as families over a longer period than is customary in traditional chemical dependency treatment. This has, we believe, been responsible for the level of success demonstrated by the WRAP program. Another significant factor has been the ability of the outpatient and WRAP staff to coordinate treatment and interface throughout various treatment phases. Both of these clinical components have contributed to the success we have seen to date in the WRAP program.

The children's treatment component.

A children's treatment component parallels the treatment for mothers. Groups were developed for each developmental age of the children participating in the program. These groups utilize diverse age-appropriate approaches, including play therapy and education about the disease of chemical dependency. The emphasis is on:

• Encouraging self-esteem
• Providing opportunities to enhance behavior impulse control
• Developing communication and nurturing relationships between parent and child

A portion of the children's treatment component includes the parent and child working together to improve communication and to develop quality time together. The program works with parents to promote understanding of child development needs and appropriate parenting responses.

Component for pregnant mothers.

Also included is a component for pregnant mothers that focuses on early childhood development and infant care. To date, the WRAP program has had two pregnant women, both of whom remained abstinent and delivered healthy babies. The crucial components in working effectively with pregnant, chemically dependent women have involved providing these women with access to, and an understanding of the importance of, adequate prenatal care as well as support for abstinence. Childbirth education has also been provided by the WRAP Case Management Supervisor for both women.

Networking Among Families

The third component involves assisting families in developing a network and interface among themselves to strengthen the basis of a recovering family community. This is accomplished both formally and informally. The WRAP program offers monthly support meetings and a minimum of four to six "family outings" per year. These formal activities have included an outing to a natural history museum, several trips to local and State parks in the area, swimming, and restaurants.

The purpose is to help families in the development of drug-free recreational and lifestyle skills through interaction in a drug-free environment. It also strengthens the support system among the women and children, who often are isolated because of multiple problems inherent in active addiction. Women and children have begun to learn they are valued and respected, and not judged because of their addictive disease.

Informally, the women and children have learned from one another in the casual interaction that occurs naturally in the process of providing transportation and participating in groups together. This has been a significant help in beginning to eliminate the sense of shame that most addicted women experience. The improved self-concept of the women and children participating in the program is obvious in their interactions with their families, one another, and with program staff.

The WRAP program has also been able to provide age-appropriate activities for the children involved with the program. Some of the activities the children engaged in this year were community library programs, participation in water safety classes, and an educational trip to a local volunteer fire station for preschool-age children to learn about fire safety. As a result of WRAP sponsorship, one adolescent was involved with a summer career camp offered by the Indiana State Police.

Program Staffing

The WRAP program is staffed by one case management supervisor, a position currently filled by a bachelor's-degreed nurse who has professional psychiatric and chemical dependency experience. Three bachelor's-level case managers provide much of the actual case management to families in the community and home. The staff-to-client ratio is kept at a maximum of one case manager to five families. This ratio facilitates the structure and intensity of treatment support necessary to effectively meet the needs and goals of recovery and improved functioning of the families.

The Recovery Services staff, which provides the treatment portion of the program, consists of three master's-level and one bachelor's-level therapists. The entire Recovery Services program, including the WRAP component, is supervised by one master's-level program director, and clerical support is provided by one secretary.

Findings

WRAP began accepting clients in mid-October 1993. Marketing of the program to the five counties served by CMHC resulted in identifying several families who were eligible for the program even before funding had been allocated. The response of the communities to the WRAP component has been quite enthusiastic and supportive. Many of the initial referrals to the program came through the local welfare departments. The relationships previously established between welfare departments and CMHC assisted in the appropriate referral of these families within a brief period after the inception of WRAP.

By the end of the fiscal year in June 1994, the program had served a total of 23 families. This included 23 women and 22 children. In at least three cases, women were working toward reunification with their children, who were wards of the local welfare departments because of the mother's chemical dependency and neglect. In at least two of these cases, the children have been returned to their mothers and continue to participate in WRAP.

In some instances, women were assisted in accessing a women's 60-day residential program that also accepted children. The WRAP staff provided transportation, without which admission would have been nearly impossible for women who have very few resources. After completion of more restrictive treatment, the families were referred back to WRAP, which provided the basis of continuing care through case management and outpatient followup treatment.

All but one family fell 200 percent or more below Federal poverty income guidelines. Most families are receiving AFDC and Medicaid benefits, while some of the women are minimally employed to try and maintain their families. All of the women have been encouraged to make appropriate use of employment and educational resources to increase their ability to be more financially self-sustaining. The case management component of WRAP has been responsible for encouraging women to consider new options in these areas.

Client Demographics

The following information describes the clients who have participated in the WRAP program in the first 9 months of operation. These aggregate data provide an overview of the demographics of the clients served and the type and volume of services provided by the WRAP staff.

Ages of women: Ranges between ages 24 and 40, with a 60 percent concentration between ages 24 and 32.

Ages of children: Ranges from 9 months to 14 years, with a 62 percent concentration between the ages of 5 and 10 years. These data do not include the two babies delivered after June 30, 1994, by two pregnant women in WRAP.

Services provided:

1. Case management—996 hours
2. Group therapy—1,054 hours
3. Individual support/assessment—273 hours
4. Total hours of service delivered—2,323

Of the 22 families served through June 1994, 11 were discharged from the program. Of the 11 discharges, 6 families were successfully discharged, 2 were referred for more intensive residential treatment, and 3 were discharged for repeated program noncompliance.

Client Outcomes

WRAP clients have remained in chemical dependency treatment much longer than those who had previously entered more traditional treatment programs. As a result, they have attained more success in recovery, which we believe is due to the combined case management efforts and structured treatment. The clients have achieved enhanced levels of functioning, both individually and as families. Abstinence rates have improved dramatically for this client population, which again we believe is a direct result of the treatment approach inherent in the program design. By recognizing and attending to the barriers to treatment and active recovery, WRAP has achieved a measure of success with maternal substance abusers.

The financial support of WRAP through the Indiana Division of Mental Health has been supplemented by Medicaid Rehabilitation Option (MRO) revenues for case management services to Medicaid-eligible families. This revenue has been instrumental in the continued viability of WRAP in an economic climate where State and Federal funding is uncertain. We are currently exploring alternate sources of revenue so we can continue this type of case management-based programming.

Conclusions

WRAP has been successful with the limited number of clients who have participated in the program services to date. Success with this limited number of participants lends credence to the belief that creative and diverse strategies can be effective with populations that do not respond to more traditional forms of chemical dependency treatment. The advantages of this program design also speak to the need to enhance the effectiveness of addictions treatment by developing methodologies that unite innovative concepts with the wisdom of traditional settings.

The Importance of Addressing Children's Needs

One of the reasons this design was originally chosen was because of the community support available to enable the recovery of addicted women and their families. What the Midwest region sorely lacks in the currently available continuum of care are treatment programs that accept women and children, particularly in residential care. This is crucial to entering active recovery. It is also a factor in breaking the intergenerational cycle of chemical dependency.

Making available specific programs for women that also attend to the needs of their children is critical in reducing barriers to treatment. Because of the lack of resources for child care, many women do not seek treatment. This is true across the spectrum of treatment modalities.

The Importance of Addressing Basic Needs

Another critical issue is the interface of treatment with other resources, especially health care and entitlement programs. Case management assists women in obtaining these services. Without these coordinated efforts, the remainder of the treatment program is rendered ineffective. When basic, fundamental needs are not being met, addiction recovery is hampered. The benefit of providing the case management service is that the women are empowered by learning to meet these basic needs of themselves and their families. When women can be assured that the basic living needs of their children are being met, recovery becomes a realistic and attainable goal.

Recommendations

The case management approach warrants further study and possible replication in other locations to determine the general effectiveness of this approach in treating maternal substance abusers. While WRAP appears to be effective in reducing barriers to treatment in a rural area where few resources exist, additional research into the combined case management/treatment approach in other locales might provide more evidence as to its efficacy. The success of the WRAP program within the first year does offer some rationale for developing additional programming to meet the needs of this population. It also offers hope about the potential viability of innovative methodologies—hope to treatment professionals and to those women who have struggled with addiction and experienced varied outcomes.

We will develop a retrospective program evaluation of the WRAP component within the next year. We anticipate that part of the research design will incorporate a 2-year followup study of the clients who participated in WRAP. This may provide additional data to demonstrate further the benefits of this treatment approach.

Last Updated 11-7-02