Editor’s note: This article is the second in what has become a three-part series, based on the responses of readers wanting to know more about holistic assessment and care planning that meets the special needs of women. This article follows “The Role of Hormonal Shifts in Women’s Recovery from Addiction” (Counselor, August 2003), in which the same author presented a new model for women’s treatment. Here, you will benefit from ideas that facilitate application of the treatment model in your daily work.

The differences in how men and women are impacted by addiction and recovery have substantiated the need for women-specific treatment. A woman’s social context, her personal history, and her biochemistry play key roles.

We know, from research and our clinical practice at the Center for Women’s Recovery at Hanley-Hazelden, that more than 70 percent of women suffering from alcohol and other chemical addictions have a history of abuse, often sexual, and they are more successful in primary treatment in a safe, nurturing environment. We also have seen that hormonal shifts throughout women’s life cycles can pose emotional and physical challenges to successful recovery.

By integrating the assessment of hormonal shifts into the Center’s treatment protocol, we have developed engaging care plans that are interactive and more holistic, and that validate women’s life experience and sense of well being as it relates to a hormonal balance or imbalance. This article presents the Center’s holistic hormonal assessment approach, which counselors may tailor for use in their practices. We recommend, that to be interactive, the holistic hormonal shift assessment be self-administered in the form of a worksheet, then reviewed by client and clinician.

Context for a specialized assessment
At Hanley-Hazelden, we have found that the markers involved in hormonal shifts assessment necessarily cover the gamut of a woman’s history: her social and cultural background; medical and medication profile; her sense of self and sexual identity; her menstruation history; her sexual history; and her mental health profile.

The social factors in addiction for women vary across all cultural, racial and socio-economic backgrounds, but they share a common bond: difficulty in yielding to treatment. With a holistic approach to assessment, we are able to better determine barriers to treatment, including dual diagnosis; the denial of addiction by self; the lack of support from family that is so often true for women and the denial or indifference of employers, who often identify absenteeism with a number of excuses. Women tend to internalize addiction, losing a sense of themselves in the process, and they suffer extreme feelings of guilt and shame due to societal stigmas.

During both perimenopause and menopause, mood swings, including sudden, inexplicable depression or feelings of grief; insomnia; hot flashes; loss of libido, forgetfulness and other disruptive symptoms result from the lowly declining levels of estrogen, which influence the way that serotonin and other neurotransmitter pathways affect a sense of well being and sleep patterns.

The emotional and physical upheavals that many women suffer during this time can be significant risk factors in relapse and may accelerate a woman’s current substance or alcohol use. As part of the self-assessment process, our protocol includes a format for daily journaling that specifically tracks cycling, along with the timing of cravings and other emotional and physical symptoms. Many clients are surprised to see that the results are symptomatic of their cycling.

Declining estrogen after a hysterectomy can also result in a virtually premature menopause. If the ovaries are removed in a complete hysterectomy, estrogen is depleted. With the onset of menopausal symptoms, the options of estrogen replacement need to be assessed.
What do we want to know with a holistic hormonal assessment? The assessment records a personal medical and emotional history and charts relevant life events, which are explored further in therapy. Such a history includes a woman’s:

• Knowledge and experience around menstruation. These often form the framework for a woman’s physical and emotional makeup. Perhaps her feelings as an adolescent entering puberty may have been shame-based. Was it a big secret in the household? Was it shameful to sit out during swimming class? Her first traumatic experience may have been when her menses began, if she did not know what to expect. In the case of a woman with no education about menstruation, the first experience of cramping and subsequent bleeding can be traumatic, with reactions such as, “I’m dying,” or “I did something wrong.” This can be especially true of girls who started their menstrual cycles at an earlier than expected age, about 9 or 10 years old.
• First intimate and sexual experiences. These are assessed as they relate to cycling, hetero- and homosexual experience, beliefs, positive or negative feelings about sexuality, and abuse issues.
• History of prescribed, illegal and over-the-counter medications, and the purposes for which they were used. Perhaps a girl experienced cramping that was swiftly medicated by her mother, as her mother’s mother had done for her. American women have a long history of self-medication, starting with addictive opiates, which were widely prescribed for “women’s problems” in the eighteenth and nineteenth centuries. Once laced with cocaine, Coca-Cola® was advertised to women in the late 1900s as “the perfect pick-me-up.” When women are in physical pain, they may rationalize the use of an opiate or other drug.
• History of depression. Prior to puberty, many girls experience sleep disturbances and anxiety, often precursors to clinical depression and other mental disorders. Women experience twice the rate of depression as men (Blehar & Oren, 1997). Depression can worsen the mood swings caused by hormonal shifts. Because mental health issues are significant for women in general, clients present with a high incidence of dual diagnosis.

Assessment focus: Risks of perimenopause, menopause in relapse
Since perimenopause and menopause can usher in a whirlwind of emotions and discomfort that complicates recovery and even contributes to late onset addiction, the Center’s assessment worksheet includes a significant section for women in their late 30s or 40 and older. During perimenopause, women begin to experience changes in their menstrual cycles and may also experience an intensity of PMS symptoms, or hot flashes and night sweats.
Even if hormonal shifts during this time are not the direct cause of discomfort, a woman’s sense of sexual self and even identity may be challenged, especially in a baby boom generation that tends to pursue the appearance and of youth and expects to retain good health.

Outline for developing a holistic assessment approach
The Hanley-Hazelden approach is based on the following outline. Your worksheet may include choices and a yes/no format, and additional space for further explanations and descriptions is suggested.

While this outline covers subjects related to perimenopause and menopause, it is recommended that your assessment include questions to cover a total, or holistic, picture of the client’s medical and personal history, including trauma and abuse issues, medication history, and major grief-inducing events (see the earlier “context” section of this article for ideas).

For a client in perimenopause:

1. Symptoms experienced, age when symptoms started, duration
Offer approximately 15 possible symptoms, such as: weight gain, hot flashes/night sweats, irritability, sexual disinterest.1 It may be useful to ask the client to rate severity of symptoms on a scale of 1-10, 10 being the most severe.

2. Source of knowledge about perimenopause
Ask about where she got her information about this stage of her life. Offer examples, such as friends and doctor, books, television programs, and Web sites.

3. Reactions when perimenopause began
Trace these reactions. Perhaps she didn’t realize what was happening, or thought she was too young. Maybe she was upset, or perhaps she was pleased. We have found a yes/no format useful, with an area for a descriptive explanation.

4. Family history
Ask about a woman’s family history of perimenopause. She may have no knowledge of this history, such as when her mother or sisters began to experience it. Maybe this was not discussed. Or their painful experiences may have made impressions upon her.

5. Managing pain
Did she experience pain and if so, how was this managed/what medications did she take? Ask specific questions about increasing dosages and types of substances taken. Was she given an alcoholic remedy, such as a hot toddy? Did she practice meditation, yoga, breathing techniques?

6. Physical patterns and perceived causes
Ask about changes in menstrual cycle, then ask her to describe any changes in what she did or experienced (eating, stress, or the aging process). This is an area for descriptive explanations.

7. History of depression, trauma, major losses
Ask about when these occurred, what the major losses were, how long did grief last, did depression ensue.

For a client in menopause:
When menses cease completely, the woman has entered menopause, typically occurring as early as mid-40s but more commonly into the 50s. The average age is 51.This is when women are most likely to experience fluctuations of physical discomfort and emotional distress.

This assessment can mirror the assessment for the perimenopausal stage, with a few additions:

8. Sexual behavior
Add a sexual component to the survey for the menopausal phase, to determine sexual desire and activity, if menopause has affected sexual activity, and if she has used chemicals or alcohol before engaging in sex or to feel sexual.

9. HRT
Ask about use and duration of hormone replacement therapy (HRT). It has been shown that women who suffer from chronic depression may experience worse symptoms during major hormonal cycles, and HRT may even exacerbate these.

10. Depression
Ask specifically about depression, when it first occurred as a chronic condition or whether it began with menopause. Depression can also begin during menopause due to a decline in estrogen levels.

Engaging the client in treatment
Our clinical experience and assessments show that changing levels of hormones can stir distressful memories. At the same time, it is precisely when a hormonal shift facilitates remembering that old business can be cleared up if it is appropriately addressed in treatment or in the continuing care plan.

When women resist the use of the holistic assessment worksheet, our protocol is the same as it is when women resist substance abuse treatment in general, and points to the importance of female-specific treatment. We need to practice “carefrontation” here, not confrontation, which amounts to saying, “do what I say.” The idea is to validate the woman’s feelings by affirming that “we hear what you’re saying.” This tends to diffuse resistance. Keep in mind that the dialogue takes time and is based on a relational model of treatment. There is no perfect model to follow, and you will find this is a work in progress.

It is important that women counselors review the assessment worksheet with the woman. A man, no matter how sensitive, cannot convey a sense of relating to this very female and personal experience. While women counselors who have experienced perimenopause or menopause themselves naturally would be empathetic, a younger woman, with training and education about perimenopause and menopause, can be genuinely empathetic with the patient, and can competently review and use a hormonal assessment worksheet. Just as counselors who are not recovering alcoholics can be effective, so can younger women in working with perimenopausal or menopausal assessments.

A holistic self-assessment is the beginning of an interactive process between each client and her clinical team, regardless of her hormonal life stage, and it validates her experience as a woman. For female clients, the knowledge that “normal” hormonal shifts do result in emotional and physical upheavals is in itself reassuring. This assessment becomes the vehicle to engage the woman in her care plan to follow.

Donna Corrente, MS,CAS,CAP, is 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.

Footnote
1 For more information, visit www.menopause-online.
com or www.menopause.org, or read Schwartz, E. (2002). The Hormone Solution. New York: Warner Books, Inc., and , and Northrup, C. (2003). The Wisdom of Menopause. New York: Bantam Books.

Reference
Blehar M.D., & Oren D.A. (1997). Gender differences in depression. Medscape Women’s Health, 2: 3. Revised from: (1995). Women’s increased vulnerability to mood disorders: Integrating psychobiology and epidemiology. Depression, 3: 3-12.

Bibliography
Longnecker, M.P. & Tseng, M. (1998). Alcohol, hormones, and postmenopausal women. Alcohol World: Health & Research, 22, 185-189.
Hutchinson, K.A., & Sachs, J. (1997). What Every Woman Needs to Know About Estrogen. New York, NY: Plume.
Northup, C. (2001). The Wisdom of Menopause. New York, NY: Bantam Books, Inc.
Sichel, D., & Watson Driscoll, J. (2000). Women’s Moods. New York, NY: Harper Collins Publishers, Inc.
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. Revised and updated. New York, N.Y.: Pocket Books.
Teaff, N.L., Wily, K.W., and Hammond, M.G. (1999). Perimenopause - Preparing for the Change, Revised 2nd Edition: A Guide to the Early Stages of Menopause and Beyond. New York, N.Y.: Prima Publishing.
WebMD (Various dates). Menopause (a collection of online articles). Available: http://content.health.msn.com/content/article/9/1680_51675?

This article is published in Counselor,The Magazine for Addiction Professionals, October 2003, v.4, n.5, pp. 32-35.

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