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Project Wings! Inpatient Services for Mothers And Their Children

Mary Sullivan, M.A., CDS III
Director, Focus Unit/Project Wings
St. Mary's Regional Health Center
Detroit Lakes, Minnesota

Abstract Project Wings, St. Mary's Regional Health Center, in the heart of the lake country in Minnesota, has been in operation since 1994. Project Wings serves chemically dependent pregnant women and women and their children in a primary chemical dependency treatment center. The women and children reside in the Wings house and receive a core chemical dependency treatment program through the Focus Unit. Programming is also offered at the Wings house when the women return home in the evening. The program provides parenting, sex abuse groups, family therapy, life skills, children's support and therapy groups, and education and career/employment counseling when appropriate. The usual length of treatment is 6 weeks. Three-quarters of the clients are American Indian, and the program is culturally sensitive to their needs. The program subscribes to the 12-Step model of recovery; the needs of the individual are considered paramount. Project Wings offers Minnesota's only program providing inpatient services to both women and their children.

St. Mary's Regional Health Center, a member of the Benedictine Health System, is a hospital located in the heart of the Lake Country in Detroit Lakes, Minnesota. In a rural community of approximately 7,000, this facility serves a tri-county area with a total population of approximately 30,000.

The Focus Unit has been a part of St. Mary's since 1987. This unit was developed in response to a community coalition whose mission was to provide treatment services to alcoholics and their families. Focus Unit provides inpatient, outpatient, and day treatment as well as education and intervention services at no cost to individuals.

In October 1994, St. Mary's Regional Health Center was awarded a grant through the State of Minnesota. This grant was for the purpose of opening a specific chemical dependency treatment program for women who are pregnant and/or mothers of minor children. This program continues to be the only Minnesota program providing inpatient services to both women and their children.

Purpose

The purpose of Project Wings is quite simple: We want women who are also mothers to experience the same quality of treatment available to others. This was not happening in our area, and in fact was not happening in any part of the State. Women who are mothers often do not have access to inpatient treatment settings, even when that is the level of care indicated—the children take priority in their lives. Our experience was that even when the mother could find appropriate care for her children, she was unable to focus completely on her recovery. All too often, the caretaker of those children continued to look to the mother for instruction and emotional assistance. Frequently, the mother would receive a telephone call to come home for the daily crises that children of alcoholics are so adept at manufacturing.

It is our philosophy that men and women do have major differences in the ways in which they receive, interpret, and process input. When these differences are acknowledged, it is seen that different approaches are required in providing chemical dependency treatment to men and women.

In addition, children who grow up in an environment where one or more parent is addicted often become addicted themselves, both through genetic and environmental influences. It is our intent to minimize the detrimental effects of this, as we provide child care for mothers during treatment hours.

It is our mission to provide quality inpatient—and outpatient—chemical dependency treatment for families, to keep families together through prevention, education, and therapeutic interventions, and to allow mothers to get the help they need without needing to choose between themselves and their parenting needs. We subscribe to the 12-step model of recovery, believing that the needs of the individual are paramount.

Program Description

The methods we use for our program are not generic methods that can be used for each client. Rather, each client gets what we call client-specific strategies for achieving positive outcomes and increasing potential for recovery.

We work closely with our referral sources to get as clear a picture as possible of the family situation, the mother's motivation for treatment, and past history of chemical use. We require school records and immunization records for the children and past treatment history records for the mothers. If the mother is pregnant or has given birth within the past 7 days, we require medical records and a referral from her medical doctor to a local physician. In addition, we request that the referral source make every effort to locate funding for daycare; our funding sources for treatment do not include expenses incurred for children's services. Thus those services (for food and beds, etc.) are provided at no extra charge; daycare services are charged for through the referring counties.

Wings clients live with their children in a house located adjacent to the hospital. Each family has a room of its own; we have four bedrooms with space for a total of four mothers and up to nine children. The clients awaken each morning with their children, getting themselves and the children dressed and ready for the day. This includes 20 minutes of exercise for all residents, and time for house chores and preparing breakfast for their children. When they have completed these tasks, the mothers leave the children at Wings Daycare while they go to the Focus Unit for the "core" chemical dependency programming. They remain at the Focus Unit throughout the day, working with our chemical dependency counselors.

When the mother is finished with her day at Focus Unit, she returns to the Wings house. During the school year, this is also the time when she will walk to the local school (where all the children at Wings are enrolled while they are here) to escort her child home. The mothers and children spend time in structured interactions and play activities between school and supper; supper is provided through the hospital food services. Family therapy, parenting, life skills, and play therapy are a part of the weekly schedule. Step parenting (Adlerian-based), assertive parenting, and process parenting are combined for a philosophical approach that our staff both models and teaches. We use a planned video/workbook program to teach basic life skills, as well as teaching budgeting, nutrition and menu planning, housekeeping, etc.

The methods that we use in working with these clients are commonly accepted in the chemical dependency field, education and group therapy being primary methods. We also include recreation therapy, art therapy, experiential writing, and play therapies. Relaxation, self-esteem, 10th Step, and day review, as well as Big Book study are an everyday part of the program schedule for all clients. In addition, a women's group and an abuse group are provided for women in the program. Our family component includes 1 day a week for those people who have close relationships with our clients. This may include parents, grandparents, a spouse, children, or a minister. The client makes the determination of who in their life would provide the most support for making necessary changes, and whom they wish to invite to this family program.

Our staff are able to see the changes in the family members and the positive impact to the family structure in the 6 weeks that the family is in our Wings program. Our "core" chemical dependency program is geared for those 6 weeks, with each week being a self-contained module. We have set up our program in this way in order to allow us to provide continuity of care. There are basics in education, lifestyle, and group therapy for clients who need only a short time for stabilization; at the same time, those clients who are here for the full 6 weeks are able to build on those basics in an inpatient setting.

Common therapeutic approaches include our rational emotive therapy group series on Saturdays. Adlerian, Gestalt, and other appropriate philosophical methods are utilized in all of our programs. During the time

in which clients are here, our program uses standardized methods of

providing recovery treatment. Those methods are built around:

1. Bio/psycho/social assessment and summary
2. A problem list
3. Treatment plan
4. Group therapy and therapy assignments
5. Education, including lectures and films
6. Discharge planning
7. Aftercare

The bio/psycho/social assessment is a three- to four-page document that contains a medical assessment done by the nurse (an R.N.), a psychological evaluation done by the consulting psychologist (who holds a Ph.D.), and a spiritual assessment done by our consulting clergy. In addition, this document contains the presenting problem or problems, family history, social history, legal history, education, and work history. A history of chemical use and treatments are included. We also ask what the client's daily pattern of living, including recreational activities, has been prior to coming into treatment.

With this information, we develop a short-term treatment plan for the client's first several days. This includes attendance at Alcoholics Anonymous (AA), orientation to the Unit, and attendance at all treatment unit activities. A master problem list is also formulated. This document itemizes current issues in the client's life that may impede recovery. These issues may include items such as family relationships, being charged with driving under the influence (DUI), grief, and a lack of appropriate housing.

The master treatment plan addresses specific methods of working on those problems and includes dates and times the client is expected to complete each assignment. The client's case is presented to the multidisciplinary staff team weekly; history and current conditions as well as progress in the program are discussed. Input from the team is noted in the chart.

Clients are expected to work on barriers to recovery in our group therapy sessions. Methods utilized by staff are Gestalt, Adlerian, rational emotive therapy, experiential therapy, and play therapy. Self-disclosure is expected from each client; each client's comfort level and ability to follow through with this is respected and handled individually. There are several types of group therapies throughout the week; some focus on specific topics such as anger and study of the Steps.

Our education series consists of two lectures daily. The schedule is designed so that each client who is here for 5 days will be provided basic education in family, relapse prevention, spirituality, denial, and the disease concept, as well as in recreation and medical effects of substance abuse. It is our philosophy that a lack of education regarding the basics of addiction can be a leading factor in relapse.

Discharge planning for each client begins as soon as that client comes in. Wings clients often are admitted from referral sources with suggestions for discharge plans such as locating a halfway house that will take women with children, or attending an aftercare program in their location. Areas identified on the problem list that were not addressed or not completed on the treatment plan are also addressed. Discharge planning includes support for the children and for the woman in her role as mother. All women who reside within our area attend Aftercare at our facility, and the children continue to attend the Children's Group here as well on a weekly basis.

Aftercare at our facility includes one education session and one group therapy session per week. Additional sessions are available if indicated in the discharge plan. An example of this would be if the discharge plan included anger work, grief work, or domestic abuse issues. We would then assign the women to these groups, or make connections with local providers for psychological followup or domestic abuse followup.

Meeting Population Needs

Extensive research underpins the program. The research was done as part of the work required to obtain a State grant, showing the need for such a program. Additional research was done to ensure that the program design and development would meet the needs of the targeted population. A basic approach to program design was provided through the Women's Alcoholism Program of CASPAR (Finkelstein 1993). This treatment guide for caregivers provided us with education for all staff and was the basis for several of our lectures and groups, including the medical effects of substance abuse on women, family work with the families of our Wings clients, and Women's Group topics. We also utilized the Resource Manual: Model Treatment Program for Chemically Dependent Women published by the State of Minnesota (Teel 1989). From this we based several of our treatment planning approaches on issues such as boundaries, victimization, sexuality, and mental health planning.

As our Wings population is approximately 75 percent Native American, our program needs to reflect cultural differences while enhancing pride in heritage for that population. We have incorporated as many of the recommendations as possible from the American Indian Women's Chemical Health Project (Hawkins et al. 1993). Examples of these are our emphasis on spirituality and chemically free recreational activities for the family. Each woman (and many of the children) make one dreamcatcher while they are here. In addition, a local American Indian Center hosts a women's AA group that all of the women attend and report great benefit from.

Our nursing staff provides women of childbearing years information regarding fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE), and our local physicians work with those women who are pregnant or who have just given birth. We have had women with infants as young as 48 hours old, and women who were 8 months pregnant when they completed our program.

An outside speaker comes in weekly to discuss topics such as birth control, domestic abuse, and budgeting. This program enables us to provide extensive amounts of information utilizing local specialists in these areas, thus making maximum use of our resources while promoting community involvement.

Relationships With Others

Women who are involved in relationships with a significant other are encouraged to work on those relationships while admitted to our program. We believe that when these relationships exist, women will continue with these relationships; recovery needs to occur within that context. We can provide assertiveness, boundary, and self-esteem work, and can point out some trouble spots as well as options for resolution if we accept these clients where they are, rather than attempt to move them toward where we think they should be. We utilize a family assessment, with a treatment plan for the family. This assists our staff in providing a cohesive approach to working with this family whether they are on the Focus Unit floor or at the Wings house. We have had several occasions when supervised visits or restraining orders were required to preserve safety; this necessitated a unified approach from staff as well as assisting the woman while she worked through some boundary and self-esteem issues.

Our program continually changes and evolves; new information is added through workshops and staff professional and personal growth. Things that worked well with some groups do not work at all with others, and modifications are required. Through this process the Wings program has become flexible in its ability to provide a great deal of individual attention, while maintaining a structure that provides clients a safe, nurturing environment in which to make fundamental changes.

Barriers/Problems Encountered and Solutions

One of the first problem areas we encountered after we received our grant funding was the overwhelming amount of red tape required for the licensure process. Since this program was the first of its kind in our State, it seemed that no one agency or person was able to provide us with clear and concise information on rules and regulations for licenses or even what licenses were required. Although a halfway house for women and children had opened up several years prior to our program, and those licenses had been obtained, many of the State employees who had assisted with that process were no longer with that department. We were finally licensed after 9 months and after a great many hours. Zoning was not a problem because the house was located in an area between the hospital and the nursing home and had been zoned commercial already.

Programming problems that emerged after opening centered around provision of care to the children while mothers were present, provision of care to children whose mothers came to our program intoxicated, and formulation of policies to deal with supervision of mothers who were providing care. The changes made to the program as a result of these problems have implications for other agencies. One policy we now have is that if children and mother have been separated through foster care, etc., reunification is an inappropriate and disruptive event for our program. Women need to have been the primary caregivers of the children prior to admission for at least 6 weeks. In addition, women who present for admission and are intoxicated must be admitted to the Focus Unit for detoxification. Local social services are involved to provide care for the children, as our licenses do not cover such contingencies.

Several of the staff members who have been in the chemical dependency treatment field for some time were skeptical about our program and took a "wait and see" attitude. This presented neither a barrier nor a problem; our Wings staff simply saw this as a challenge to prove the basic "rightness" of such a program.

Community response to our program has been overwhelmingly positive; we have received donations in the form of both items and dollars. Marketing has presented no problems. When referral sources heard of this program, they began to refer to it. We have sent out two newsletters and have received referrals from counties in all parts of the State, as well as from several other States. The program has met our census expectations as well.

Findings

Our findings are showing that the women who complete our program report a marked increase in the quality of life. While not all of the women completing the program maintain abstinence, they do improve their parenting skills, life skills, and their relationships with their children.

Children have tended to improve in the school setting and to exhibit more self-confidence when leaving our program. Because we do work with both the mother and the child, the long-term implications of a program such as this are enormous. We provide prevention techniques, problem solving, emotional resource building, and self-esteem to both mother and child. Additional research would need to be funded on a long-term basis in order to ascertain the impact on these future generations.

We have found that 6 weeks in the program is usually necessary for the women, as they are required to perform so much more than in a regular program. We have also found that having this 6 weeks is one of the components of our success.

Our program participates in the Minnesota Treatment Accountability Program, which is an evaluative vehicle. We are currently awaiting the first results of this program to provide us with correlative material as well as numerical numbers regarding client success after 6 months of completion of our Wings program.

Our Focus Unit is a 10-bed facility and Wings adds another 4 beds. Our previous census had been an average of 2.5 daily; currently it averages 7.5. For safety reasons, we were required to hire more staff due to the location of the new facility (Wings is staffed round the clock). Additionally, one program therapist position was required to ensure that program elements were provided at the Wings house. With the additional staff, we have been able to provide programming that is gender specific, age specific, and culturally specific, within a program whose numbers are very small.

Recommendations

It is our belief that this program is an example of how specific programming can be provided to special populations in rural America, utilizing the resources of a small treatment program to maximum benefit. Project Wings proves that women and children benefit greatly from keeping the family intact, through providing programming that recognizes the role of women within the context of their lives and that builds on their existing strengths while providing structure, modeling, nurturing, and a safe place to experience the first stages of recovery from chemical dependency. We recommend that programs such as ours be available for each chemically dependent woman who is pregnant and/or has children.

We recommend that agencies contemplating beginning such programs contact existing ones. This research is basic to making the decision to go ahead, as barriers do exist and are formidable, although certainly not prohibitive.

We also recommend that funding for such programs be made available. Currently, our funding is in jeopardy at the Federal level. While our program will struggle if no other changes to funding and current allocations to counties for chemically dependent populations changes, we will survive. However, we are currently unable to serve the large numbers of women who are in need of a program such as ours, are willing to make the changes, and are ready now. Our waiting list sometimes is over 8 weeks long.

We believe our program reflects the growing need to make maximum use of resources, especially in rural settings where programs are small and specific populations are generally not treated with population-specific programs. We also believe there needs to be a recognition from government agencies that such populations do exist, that programs need to address them, and that regulatory bodies should make efforts to assist these efforts.

References

In addition to the resources named here, Project Wings benefited from the expertise and experiences shared by Jessili Moen, Journey Home, St. Cloud, Minnesota, and Pamela Young, Grants Coordinator, Minnesota Department of Human Services.

Center for Substance Abuse Treatment. Improving Treatment for Drug Exposed Infants. Treatment Improvement Protocol (TIP) Series, No. 5. DHHS Pub. No. (SMA) 93-2011. Rockville, MD: Center for Substance Abuse Treatment, 1993.

Finkelstein, N.; Duncan, S.A.; Derman, L.; and Smeltz, J. Getting Sober, Getting Well: A Treatment Guide for Caregivers. The Women's Program of CASPAR, 1993.

Hawkins, N.; Day, S.; and Suagee, M. American Indian Women's Chemical Health Project. St. Paul: American Indian Section, Chemical Dependency Division, Department of Human Services, State of Minnesota, 1993.

McCollum, E.E.; Trepper, T.S.; Nelson, T.S.; Wetchler, J.L.; and Lewis, R.A. Systemic Couples Therapy for Substance Abusing Women. Purdue Research Foundation, 1993.

Teel, L., ed. Resource Manual. Model Treatment Program for Chemically Dependent Women. 2d ed. St. Paul: State of Minnesota, Department of Human Services Chemical Dependency Division, 1989.

Last Updated 11-7-02