Editor’s note: This article is the last in a three-part series by Ms. Corrente focusing on holistic women’s treatment. This final piece follows “The Role of Hormonal Shifts in Women’s Recovery from Addiction” (Counselor, August 2003) and “Holistic Hormonal Assessment in Women’s Addiction Treatment” (Counselor, October 2003). We welcome your thoughts, comments, opinions, and questions about the series at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

We know that many women experience menstrual cycling and major hormonal/reproductive events as an emotional “roller coaster” ride, sometimes careening through twists and turns, catapulted through space with a sense of total anticipation, only to find that when they stop they feel either sick or exhilarated! As we have seen in clinical practice, the impact of hormonal shifts on women in recovery from chemical dependency is significant.

To gauge the significance of this cycling, we have developed a Holistic Hormonal Shift Assessment, now in use at the Hanley-Hazelden Center for Women’s Recovery in West Palm Beach, Florida. This assessment covers a woman’s history from adolescence through midlife, and identifies a pattern of hormonal shifts relative to substance abuse and a sense of well-being or lack of well-being (Corrente, 2003a, 2003b). The assessment helps to develop a continuing care plan that addresses menstrual cyclical patterns within the picture of addiction recovery.

This article focuses on continuing care planning for women recovering from chemical dependency, incorporating this assessment. Care planning is the basis of treatment and needs to include identifying the client’s problems, goals and objectives for resolution of those problems, and a means to achieve resolution. As with all care planning, this is done with the client.

An awareness of menstrual cyclical patterns that women can identify through personal assessments and holistic education is critical for women in achieving an ongoing care plan for recovery. Clients can achieve this awareness through education (physical, emotional, social, and spiritual) and in relapse prevention planning, through nutrition, exercise, meditation, therapy/treatment, women’s 12-Step meetings, and connection to the 12-Step process, especially Step 4, when self examination can lead to self discovery and understanding of past events.

For the client, continuing care planning is like learning how to ride the roller coaster without getting sick or dizzy. It starts with “awareness” and a commitment to the process. This is true not only for the client but also for the counselor. For women, it’s easy to forget to take an inventory of where they are in their menstrual cycles. Women tend to put that part of themselves aside as it is simply the fabric of their lives. However, one of the keys to the road to recovery is discipline and structure.

Effective care planning
Learning how to develop care plans is a significant component of core competencies for counselors. The process of how to develop a treatment/care plan is described in both Addiction Counseling Competen-cies: The Knowledge, Skills and Attitudes of Professional Practice (SAMHSA-CSAT, 1998) and The Chemical Dependence Treatment Planner (Perkinson & Jongsma,1997):

The process of developing a treatment plan involves a logical series of steps that build on one another. The foundation of any effective treatment plan is the data gathered in thorough biopsychosocial assessment.... Assessment data may be gathered from a social history, physical exam, clinical interview, psychological testing, or contact with a patient’s significant others. The integration of the data by the clinician or the multidisciplinary treatment team members is critical for understanding the patient. (Perkinson & Jongsma,1997, p. 4)

A standard approach for care planning may be: identifying problems with an “as evidenced by” section, setting long-term and short-term goals/objectives, and establishing methods to measure the achievement of these goals. As in all care planning, this needs to be individualized.

Developing a care plan
In determining a focus for care planning for our clients, we first review the holistic hormonal assessment (Corrente, 2003b) with a multidisciplinary team. At minimum, your multidisciplinary treatment team should include medical and mental health professionals, a chemical dependency counselor/professional, a wellness specialist, and a spiritual mentor. A multidisciplinary team supports the holistic approach and helps to validate and clarify hormonal shift continuing care planning. While including the professional team is important, it is critical to remember to include your client in this planning, i.e., good communication is essential.

When developing the care plan, the client’s own description of her problems around hormonal shifts, goals/objectives, and methods for continuing recovery will be important. Using the following examples as a guide, know that your interactions with clients will bring your own insight and assessment skills to bear in the care planning around hormonal shifting. This is not a comprehensive list, and of course, all care planning is meant to be individualized to meet the needs of the client.

Problem
The following are examples of problem statements you might include in your care plan:

___ I started using alcohol/drugs shortly after my first period.
___ I notice that since becoming perimenopausal, I use more tranquilizers to help with the intensity of my anxiety.
___ I sedate perimenopausal moodiness and irritability with alcohol and/or drugs.
___ Since becoming permenopausal, I find that I get into intense arguments with people I care about and then feel bad later.
___ My period is a trigger for me to abuse drugs or use alcohol.
___ When I first got my period, I felt traumatized and used alcohol/drugs to deal with those feelings.
___ Since becoming perimenopausal, I tire easily — so I use stimulants to help me keep going.
___ I use alcohol and drugs during my menstrual cycle for relief of feelings.
___ I eat sweets/dairy products/salty foods during my menstrual cycle for relief of feelings, which leads to using/drinking.
___ I engage in sex during my menstrual cycle for relief of feelings, which leads to using/drinking.
___ During my menstrual cycle, I relapsed with alcohol and /or drugs despite 12-Step program efforts.
___ During my menstrual cycle, I have a poor self-image so, I isolate, feel angry, ugly and/or bloated and/or uncomfortable.
___ I experience intense cravings for alcohol just before my period.
___ I experience intense cravings for cocaine just before my period.
___ I experience intense cravings for opiates or pain killers just before my period.
___ I am emotionally exhausted and can’t maintain my relationship anymore.
___ I just found out that I’m perimenopausal/menopausal and don’t know what to do.
___ My husband/significant other hates my moodiness and constant PMS so I drink/abuse drugs to take the edge off of our marriage/relationship.
___ I hate uncontrollable gaining of weight and being perimenopausal/
menopausal.
As evidenced by
___ I have refused to discuss or act on the fact that I am perimenopausal other than to increase my use of chemicals.
___ Acting irritable and moody doesn’t feel good, so I use more alcohol and/or drugs than I intended in order to ease the discomfort.
___ Since becoming perimenopausal, I’m constantly tired and can’t get anything done at work or the house without the use of alcohol and/or cocaine/amphetamines.
___ I’ve missed work because I haven’t had cocaine/amphetamines to help me get through the day.
___ I drink during the day, at home, just to get chores/housework done.
___ Even though alcohol helps me to get work done, I usually end up passing out from drinking too much.
___ I get angry easily and act out by yelling and screaming at my family and friends for no apparent reason.
___ I get so depressed that I drink all day in the hopes that I’ll eventually feel better.
___ I often put myself down and look to drugs to help me feel better about myself.
Goals
The following are examples of goals and objectives to use in a care plan:
___ I will continually identify a relationship between my mood swings and my cravings for drugs and/or alcohol relative to my premenstrual time.
___ I will alleviate my hormonal shift symptoms by following the treatment team’s continuing care plan.
___ I will stabilize my mood swings and cravings relative to my menstrual hormonal shifts by following my relapse-prevention continuing care plan.
___ As I move through my recovery process, I will continue to recognize my menstrual hormonal shifts in relationship to my relapse prevention plans.
___ I will consistently use healthy coping skills to deal with my perimenopausal/
menopausal symptoms.
___ I will learn about the menopause process and how it may affect my recovery.
___ I will learn to consistently use healthy coping skills to deal with my perimenopausal symptoms.
___ I will work on ways to increase my self-esteem despite my perimenopausal symptoms.
Objectives
___ I will follow the recommendations of the treatment team regarding my continuing care plans and relapse prevention.
___ I will develop a Step 1 approach to my menstrual issues.
___ I will begin looking at the patterns of my hormonal shifts relative to my substance abuse, my sense of well-being, and my relationships.
___ I will identify the onset of my period before I physically experience it.
___ I will develop and practice daily healthy, holistic coping strategies regarding my menstrual hormonal shifts while I’m in treatment.
___ I will develop and practice daily coping skills to deal with my menstrual mood swings and cravings.
___ I will use the process of Steps 1, 2, and 3 of my recovery program to help me understand and work through the connection of my hormonal shifts and my alcohol/drug abuse.
___ I will create a daily relapse prevention plan relative to my hormonal shift patterns.
___ I will develop a holistic approach to my menstrual hormonal shifts including a balanced nutritional and exercise plan.

Methods
The following are examples of methods to achieving goals/objectives:

___ Prior to leaving treatment I will get a list of all the Women’s AA/NA/CA meetings in my home area and incorporate them into my continuing care plan.
___ I will add to my Step 1 approach a focus on the unmanageability of my life due to my menstrual issues.
___ I will participate in at least two healthy, positive leisure activities with my peers as a way to learn to keep from
isolating during my PMS.
___ I will read a pamphlet on PMS and alcoholism provided by my counselor, and will incorporate this information into my continuing care plan.
___ I will keep a daily focus journal of my moods/feelings and what triggers them.
___ I will identify self-soothing techniques to manage my moods, feelings, and cravings, recording at least one per day in my focus journal. I will process this with my counselor.
___ I will keep a monthly calendar of my menstrual cycle identifying: beginning of flow, actual flow, and cessation of flow. I will identify, on the calendar, those days that I am experiencing intense cravings and will discuss coping strategies with my group and/or my counselor.
___ I will prepare a brief history of how I see my PMS relating to my drug or alcohol use. I will present this to my counselor and/or group.
___ I will write a letter to my menstrual cycle, identifying the frustrations I have experienced and my need to have healthier coping strategies, other than alcohol/drugs, to deal with it.
___ I will ask my peers to help me make a list of 10 different things I can do to help manage my premenstrual/perimenopausal hormonal shifts in a more healthy way than by using alcohol or drugs.
___ I will ask my peers to help me make a list of 10 things I can do to engage in healthier behavior during my hormonal shifts. I will act on at least two of these while I am in treatment and I will share this with my counselor and/or my group.
___ I will do a collage identifying the most intense times during my menstrual cycle and I will present this to my counselor and/or group, highlighting the following:

• The relationship with my alcohol/drug use history.
• The impact on my relationships: self, family, intimate relationships, work.

___ I will begin looking at the patterns of my hormonal shifts relative to my substance abuse, my sense of well-being, my relationships. I will do this using a Fourth Step process.

Focus on the process
It is essential to remember that the purpose for continuing care planning is to help the client stay focused on developing an on-going, positive change process for sustained recovery. The concepts here are simple to understand but can be difficult to put into practice. As women treatment professionals, we can relate to the need to outline healthy habits, which are needed in recovery. However, the challenge lies in practicing the new habits and in really integrating these into our daily lives. It is also important to consistently review care plans with your clients and to keep in mind that this review must keep a positive focus. It is always about “process,” which by definition implies movement.

The recovery process is like a roller coaster ride in several ways: for some, deciding to take the ride comes with much rumination as to what the results of the ride might be. By following the flow of the ride, rather than resisting, the woman will have a more satisfying experience; and once there is a commitment to participate in it, the quality of the ride will depend on how it is approached. Knowing the path of the roller coaster gives the client an advantage in how to prepare for the ride. A good holistic continuing care plan, using the 12 Steps of recovery, will help clients to approach their ride with greater knowledge now and through their recovery process. Our clients need to know and understand that the recovery process is an ongoing change process, as are all aspects of our lives. Most important to remember is that, like the roller coaster, life can be difficult, not impossible and, sometimes you have fun!

Gender of the counselor
Given the high percentage of trauma/abuse victims, with men generally identified as the perpetrators, we recommend that those clients in primary treatment work only with female counselors. This is not to imply that we question male counselor competencies; however, it supports the need for women who also suffer with trauma issues to feel safe.

At Hanley-Hazelden we choose to treat women concurrently — i.e., we treat the mental health issues relative to trauma/abuse during their chemical dependency primary residential treatment. Therefore, providing women with female counselors in this milieu is more productive. The issue is one of vulnerability and providing an environment of safety for women.

Unfortunately this is not always available, and can be frustrating for men who want to help women. As an example of this, we do not have male counselors participating in the program in our phase 1 for women, but we do incorporate male clinicians during our phase 2 of primary residential treatment. It should also be noted that this is relative to the primary counselor only and not necessarily relative to other multidisciplinary team members.

Motivation and outcomes
A holistic and multidisciplinary treatment team approach helps to keep the team and the woman focused on her treatment care plan. Women stay motivated through a variety of ways (for information on motivational strategies, see pages 32-38). Family, significant others, and employers can exert the most pressure for women to stay in treatment. This type of leverage is fairly traditional. However, clinical interventions such as “carefrontational” approaches, which are the acknowledgement of feelings while helping to identify and change negative behaviors, can also be productive. The “carefrontational” approach supports the relational model of treatment for women, developed by Dr. Stephanie Covington and based on a model by the Stone Center at Wellesley Collge.

Butler Center for Research at the Hazelden Foundation indicates that men and women who have a longer length of stay in treatment, and complete treatment inclusive of aftercare planning, have better recovery outcomes. We are still in the process of gathering outcome data relative to our hormonal shift assessments. Initial responses from patients have been positive. A comment heard most often is that incorporating hormonal shifts is like adding a missing piece to the puzzle.

Donna Corrente, MS, CAS, CAP, is the director of the Hanley-Hazelden Center for Women’s Recovery in West Palm Beach, FL. For more information about the center, call 800-444-7008 or 561-841-1000.

References
Corrente, D. (2003a). The role of hormonal shifts in women’s recovery. Counselor Magazine 4(4): 22-25.
Corrente, D. (2003b). Holistic hormonal assessment in women’s addiction treatment. Counselor Magazine 4(5): 32-35.
Galanter, M. & Kleber, Herbert D. (Eds). (1999). The textbook of substance abuse treatment (second edition). Washington, DC: American Psychiatric Press.
Perkinson, R. R., & Jongsma, A. E. (1997). The chemical dependence treatment planner. New York, NY: John Wiley & Sons, Inc.
SAMHSA-CSAT. (1998). Technical Assistance Publication No. 21 (TAP 21) “Addiction Counseling Competencies: The Knowledge’s, Skills, and Attitudes of Professional Practice.” Available: http://treatment.org/Taps/tap21/
TAP21Toc.html
Schwartz, E. (2002). The hormone solution: Naturally alleviate symptoms of hormone imbalance from adolescence through menopause. New York, NY: Warner Books, Inc.
Sheehy, G. (1998). The silent passage: Menopause. New York, NY: Simon & Schuster Adult Publishing.
Sichel, D. & Watson Driscoll, J. (1999). Women’s moods. New York, NY: Harper Collins Publishers, Inc.
Teaff, N. L., & Wiley, K. W. (1999). Perimenopause —Preparing for the change: A guide to the early stages of menopause and beyond. Roseville, CA: Prima Publishing, Div of Random House, Inc.
Warga, C. (1999). Menopause and the mind. New York, NY: Simon & Schuster, Inc.

This article is published in Counselor,The Magazine for Addiction Professionals, December 2003, v.4, n.6, pp. 44-49.

No one has commented on this article.

Please keep your comments brief and on topic, and remember that this is not a discussion thread.
Name :
Comment(s) :

J! Reactions 1.09.00 • Professional Site License
Copyright © 2006 S. A. DeCaro

---