Executive Summary: Overview 
Women’s Law Project 
RESPONDING TO THE NEEDS OF 
PREGNANT AND PARENTING WOMEN 
WITH SUBSTANCE USE DISORDERS IN PHILADELPHIA 
Executive Summary 
Overview 
Substance use disorders and exposure to violence are prevalent, if not endemic, in the 
lives of women who are served by the social and health systems in Philadelphia. A large 
body of evidence-based information about the complex and co-morbid conditions 
resulting from physical and sexual assault of women and girls now exists. The research 
is overwhelming in concluding that exposure to violence is the primary precursor to 
dysfunctional behavior in women, including substance abuse. The problem of substance 
abuse in women cannot be addressed without understanding and addressing the 
consequences of violence and exposure to trauma. 

The Women’s Law Project (WLP) entered into a contract with Community Behavioral 
Health (CBH) to develop recommendations to address gaps in services for pregnant and 
parenting women suffering from substance abuse disorders. Our initial understanding of 
these service gaps emerged from the Working Group on Chemically Dependent women. 
To further our understanding of the problems and potential solutions to service delivery, 
we convened a steering committee composed of leaders in women’s issues in the 
mental health, physical health, and legal and advocacy communities and then we read 
and we listened. We listened to approximately 93 consumers and over 70 providers 
from approximately 50 agencies through structured roundtables, interviews and 
discussion groups; we reviewed current public policies; and we reviewed over 700 
academic articles to glean the most current understanding of the problems of these 
vulnerable mothers and children, their treatment options, and implications for best 
practices. The findings from this extensive review of the literature were echoed in each 
focus group with both vulnerable mothers and the professionals who serve them: 
poverty, domestic violence, sexual assault and substance abuse are recurrent and 
concurrent themes. 

Our tasks were to make recommendations on reaching women who need substance 
abuse treatment, particularly those who are pregnant, and to identify the unmet needs of 
those in treatment. Clearly, with our findings so inextricably linked to violence and 
untreated physical, sexual and emotional trauma our recommendations are more 
expansive than initially anticipated. The needs articulated by the vulnerable mothers, 
the frustrations reported by the providers, and the exhaustive review of the literature all 
underscore the interconnectedness of violence-induced trauma and behavioral 
problems. They point to an urgency with which these connections must be actively 
addressed to achieve productive treatment outcomes. 

We found that the problems encountered by this population are systemic and rooted in a 
lack of public policy that addresses the needs of vulnerable women, and therefore, of 
their children. The city’s health and social services predominantly serve pregnant and 
parenting women and their children. Yet women have only received peripheral attention 
in the public policy arena because their needs are addressed primarily in the context of 
their parenting or pregnancy. Their other needs are neither acknowledged nor served. 
Attempting to serve children by improving parenting skills or pregnancy outcomes 
without understanding or addressing the concomitant problems of the mothers is 
shortsighted and ineffective. There is no locus in government that identifies, serves, or 
coordinates the needs of the vulnerable women who are in the city’s public health and 
social services system. Current attempts by city government to move away from a 
fragmented and single-problem focused system will fail if the needs of mothers in this 
system are not acknowledged and addressed. 

Yet, in spite of the inadequacies in the systems that serve these women, we found 
extraordinary motivation and resilience on the part of seriously traumatized and addicted 
women. We also found compassion, sensitivity and a sincere desire to help on the part 
of many providers who are working with them. The desire of many women to heal - 
usually for the sake of their children - has led some to conquer seemingly 
insurmountable problems. In the face of crushing poverty, inadequate welfare benefits, 
unfit housing, and crime-ridden neighborhoods, many women have vanquished their 
own demons of abuse and addiction, usually with the help of a competent provider, and 
learned to live productive, healthy lives. 

Philadelphia has many positive initiatives in place and has recognized that there are 
populations that require extensive, inter-agency coordinated services. In fact, 
Philadelphia has emerged as a national leader in both research and practice for issues 
affecting substance exposed families. There is a clear recognition on the part of policy 
makers of the need for a coordinated, integrated system of care. Philadelphia has the 
knowledge and resources necessary to launch a new initiative for these vulnerable 
mothers. As a steward of a major urban human service delivery system, Philadelphia 
has the responsibility to intervene in the endemic problems of addiction, poverty, 
violence and trauma. The city must now make the commitment to address the needs of 
this challenging, stigmatized, and marginalized population. Our recommendations are 
focused on filling the service gaps and, when implemented, will substantially move 
Philadelphia forward in achieving the integrated, coordinated system of care that the city 
aspires to deliver and that these women deserve. 


Summary of Findings and Recommendations 

Finding 1 
Philadelphia’s health and human service delivery system does not address the 
specific needs of women, does not integrate the linkage of trauma, violence, and 
substance abuse in service delivery, lacks cross-system training, and fails to fully 
comprehend the long term needs of families affected by trauma, violence and 
substance abuse. 

Substance abuse, violence and trauma are inextricably linked and are endemic in the 
lives of women in Philadelphia’s health, social service, and criminal justice systems. 
Untreated trauma leads to behavioral health problems. It is essential to address 
exposure to violence in order to effectively treat women’s substance use disorders. 
Substance abusing mothers have long term problems; for many, their addictions and 
victimization started when they were abused children. Addictions take years to evolve 
and years to solve. 

Philadelphia has no unified system specifically for women. Pregnant and parenting 
women with behavioral health problems must access multiple, uncoordinated, and 
inadequate services. Separate services are offered with multiple short-term relationships 
with caseworkers and providers of services. An extensive and expensive patchwork of 
services exists that are only intermittently successful. 

Poorly integrated systems turn women into systems nomads. Without a coherent 
framework for developing successful and consistent treatment programs or intervention 
strategies, mixed and ineffective services are provided. Cross-systems training about 
mandates, philosophies, services, and limitations is essential. Information about legal 
proceedings is critical for consumers and caseworkers since addicted women are 
enmeshed in numerous legal proceedings, with consequences that can be life altering. 
Recommendations 

.. Create a system of care for women in Philadelphia with a locus in city 
government to develop and coordinate services for adult women. 
.. Adopt a trauma-informed system of intervention. 
.. Develop a policy of a multi-year commitment to families affected by trauma 
and addiction. 
.. Create a coordinated response to domestic violence. 
.. Create a training institute to develop and coordinate cross-systems training 
and appropriate resource material. 

Finding 2 
Addicted women have histories of abuse and deprivation, are socially isolated, 
and are exhausted and grieving. 

Today’s addicted mothers grew up in households where they experienced child abuse 
and/or neglect, an absence of parental care-giving, parental substance abuse, domestic 
violence, and community violence. They are socially isolated and have difficulty forming 
trusting relationships. For many addicted women, the only social activity they engage in 
revolves around drug use. 

Recommendation 
.. Develop community-based services or centers for women that have recreational 
and social activities as well as information and referral to health and social 
services. 

Finding 3 
Appropriate consumer education material about addiction and trauma does 
not exist. 

Pregnant and parenting women with behavioral health problems do not understand how 
the violence they have endured has affected their behavior and drug and alcohol use. 
Most of their counselors, caseworkers and the public at large do not understand the 
relationship between violence and trauma. 

Recommendations 
.. Develop a communication strategy to increase public understanding of trauma 
and addiction. 
.. Develop consumer information on trauma and addiction. 

Finding 4 
Most pregnant substance abusing women do not receive substance abuse 
treatment. 

Research has established that pregnancy is one of the most effective windows of 
opportunity to engage women in substance abuse treatment. However, communication 
between health care providers and the behavioral health system is lacking. Further, 
social workers are no longer employed in obstetric and delivery room sites. 

Recommendations 
.. Set up regular meetings among health care stakeholders. 
.. Reinstate social workers in prenatal and delivery settings. 


Finding 5 
Case workers and home visitors who provide services to children lack appropriate 
tools, training, and professional development to address violence and addiction. 
Caseworkers and home visitors are faced with challenging situations involving addiction 
and domestic violence for which they are poorly prepared to handle. In addition, 
caseworkers lack good consumer educational material regarding parenting, trauma, and 
addiction. Bias and stereotypes among caseworkers and counselors continue to exist 
requiring professional development and education. 

Recommendations 
.. Provide a trauma informed checklist for home visitors. 
.. Develop a “team network” for home visitors. 
.. Provide trauma-informed parenting education programs. 
.. Expand mobile therapy options. 
.. Provide accurate training about parenting issues and child’s behavioral issues for 
workers. 
.. Create materials for consumers that help them understand their child’s behavior. 

Finding 6 
Women need gender-specific, trauma informed substance abuse treatment. 

The research overwhelmingly concludes that women need gender-specific, traumainformed 
treatment. Philadelphia’s women-centered residential treatment programs 
provide more intensive intervention for adult women living with their children than any 
other system of care. 

Recommendations 
.. Assure that all substance abuse treatment programs serving women understand 
gender and trauma, and provide gender-specific, trauma-informed treatment for 
all women seeking treatment. 
.. Create a consortium of women’s treatment programs. 

Finding 7 
Children whose mothers are in treatment have not received adequate intervention. 
The needs of children whose mothers are in substance abuse treatment have been 
ineffectively subsumed into the adult system. Intergenerational transmission of violence, 
substance abuse, and other disorders are common. These children suffer from 
numerous debilitating factors and have significant needs. The children’s presence in a 
residential treatment system, where they are safe and provided for, affords an 
extraordinary window of opportunity for creative and positive intervention. Those 
children not living with their mothers also have a complex web of needs for services. 
DHS is providing funding to enhance services to children in both residential and 
outpatient programs 

Recommendations 
.. DHS should to continue supporting this important interagency initiative. 

Finding 8 
Residential treatment programs do not have the resources to address women’s 
health care needs or to provide appropriate “aftercare” to prevent relapse. 

Women who suffer from substance abuse disorders are often in poor health. They need 
primary care to treat their health care concerns, particularly their reproductive health 
care needs, and trauma-informed treatment to address their emotional needs. They 
need “aftercare” after completion of residential treatment program to prevent relapse. In 
addition to the women in treatment, staff at treatment centers often suffer from 
secondary trauma and need assistance in the form of professional development to 
understand their own reactions to working with trauma survivors. 

Recommendations 
.. Help secure funding so that the Nursing Consortium can provide on-site health 
care and health education. 
.. Create “aftercare” specialists at each program who will be a troubleshooters for 
women leaving treatment. 
.. Provide systems-wide training in trauma so providers and consumers can fully 
understand the behavioral impact and self-medication that flows from the 
traumatic injuries of sexual and physical abuse. 

Finding 9 
Lack of childcare and transportation are serious barriers to obtaining outpatient 
treatment. 

Many addicted women are consumed with exhaustion and grief and cannot overcome 
barriers to accessing outpatient treatment without extensive assistance. The barriers to 
treatment include transportation and childcare. Mobile therapy can be an important 
alternative for women who cannot manage traveling to outpatient treatment. 

Recommendations 
.. Provide actual transportation to outpatient programs through funding for vans or 
other van services and funding for taxi vouchers. 
.. Implement the intensive case management model that mental health and MPP 
(Maximizing Participation Project) use, which includes transporting clients to 
appointments. 
.. Provide babysitters at home for women who are exhausted and unable to travel 
to treatment or set up on-site child care at treatment centers. 
.. Provide more behavioral health mobile therapy options for mothers who cannot 
physically get to treatment. 

Finding 10 
The mental health problems of pregnant and postpartum women and children are 
not appropriately addressed by the behavioral health system. 

There are no residential treatment programs for severely mentally ill pregnant and 
postpartum women and their children, and the mental health system is not well trained in 
trauma-informed treatment. In addition, the mental health system has not developed 
gender specific programs the way the substance abuse treatment field has. Group 
therapy opportunities are an effective way to reach addicted women. 

Recommendations 
.. Open a residential program, preferably associated with a psychiatric facility, for 
severely mentally ill pregnant and postpartum women and their children. 
.. Assure that mental health providers are properly trained in trauma-informed 
treatment 
.. Create group therapy opportunities for women. 
______________________________________________________________________ 
APPOINT A TASK FORCE TO MONITOR THE IMPLEMENTATION OF THE 
RECOMMENDATIONS OF THIS REPORT. 




RESPONDING TO THE NEEDS OF 
PREGNANT AND PARENTING WOMEN WITH 
SUBSTANCE USE DISORDERS IN PHILADELPHIA 
Report to Community Behavioral Health 

Section 1 
Background 
In 1997, the Women’s Law Project (WLP) organized The Working Group on Chemically 
Dependent Women to develop an advocacy initiative to improve services and public 
policy for pregnant and parenting women in Philadelphia who suffer from substance use 
disorders. The Working Group is a highly collaborative effort bringing together substance 
abuse treatment providers, health care providers, maternal and children’s advocates and 
outreach workers, the public interest legal community and government officials. Women 
in treatment and recovery from substance abuse disorders (“consumers”) also attend the 
Working Group. The Working Group reviewed existing services in Philadelphia for 
chemically dependent women in order to establish an advocacy agenda. The Working 
Group created a “continuum of care” flow chart looking at prevention, outreach, transition 
to treatment, treatment and recovery. Specific gaps in services were identified and 
presented to Community Behavioral Health (CBH). In 2001 CBH contracted with the 
WLP for the purpose of making recommendations to fill the service gaps identified in the 
areas of: 

• Outreach to pregnant women who are using drugs and alcohol to enable 
them to access necessary physical and behavioral health care to improve 
their health and the health of their pregnancies. 
• Engaging mothers whose children are in the child protective services 
and mental health systems because of their mother’s addiction so that 
the dual goals of healing and family preservation can be achieved by: (a) 
identifying services that can be provided by the child protective system; (b) 
improving communication and collaboration between child protective 
services, family court, the behavioral health system, and various users of 
these systems; and (c) developing a proposed curriculum and/or pilot 
programs for child protective services and mental health workers. 
• Documenting the unmet needs of women in treatment and developing 
recommendations to address those needs, with a focus on access to, and 
integration of, mental health services, child care, housing, and civil legal 
services to pregnant and parenting women in substance abuse treatment 
program.

Methodology 
To fully understand the challenges, interrelated issues, and pressing policy concerns 
that affect services to chemically addicted women and their children, the WLP employed 
many different methods of gathering information. We spoke with approximately 93 
consumers and over 70 providers from approximately 50 agencies. The WLP held seven 
focus groups with 73 consumers, including women in residential treatment, outpatient 
treatment, women in need of treatment, and women in the dependency legal system. 
Focus groups and meetings with providers were held, including obstetricians, 
pediatricians and certified midwife practitioners, perinatal social workers; Community 
Legal Services staff, CODAAP Women’s Treatment providers, WATCH, and staff from 
the DHS Substance Abusing Mothers Project. Health care professionals were 
interviewed including physicians, social workers, a nutritionist, and a nurse coordinator. 
A Roundtable was held with outreach workers from six organizations. In addition, we 
consulted with David Fair of the Department of Human Services, with legal services 
organizations, treatment providers, domestic violence and sexual assault programs, and 
home visitors from the Maternity Care Coalition. At the core of the effort were the 
Working Group meetings, with five meetings of the large Working Group, attended by a 
total of 340 people. There were 10 meetings of the Steering Committee. 
In addition to gathering information from the people intimately involved with the service 
delivery system, we conducted an extensive review of the professional literature, 
including over 700 articles that focused on the interrelatedness of substance abuse with 
trauma and violence. The full literature review is attached as a separate document, The 
PVS Disaster: Poverty, Violence and Substance Abuse in the Lives of Women and 
Children. Highlights of the literature review are contained in Appendix 2. We also 
researched and updated the WLP’s Resource Guide for Substance Abuse Programs for 
Pregnant and Parenting Women, which is also attached as a separate document. 
Finally, Dr. Sandra Bloom developed a trauma-informed parenting training curriculum 
(Appendix 3). 


Section 3 
Scope of the Problem: 
Women, Their Children, Violence, Poverty and 
Substance Abuse 

Violence, Poverty and Substance Abuse Nationally: It is estimated that at least 
460,000 families on welfare are affected by addiction – about 1.2 million parents and 
children. Most of adults have less than a high school education and have difficulty 
finding lasting employment. Up to 40% have learning disabilities. Between 20% - 30% 
are currently involved in a physically or psychologically abusive relationship and 
between 50% -70% of mothers on welfare have been in an abusive relationship at some 
point in their lives. Substance abuse causes or exacerbates 7 out of 10 cases of child 
abuse and neglect. According to the National Crime Victimization Survey, the lower the 
annual household income, the higher the rate of intimate partner violence. Among 
females ages16-19, rates of intimate partner violence for households receiving $7,500 or 
less were at least twice those of females in the same age category but at higher income 
levels. For females ages 2 - 24 in the lowest income category, intimate victimization 
rates were at least 20% higher than those in households with a larger income (Rennison 
2001). Women are exposed to high levels of violent attacks in childhood and as adults: 
52% of women have been physically assaulted, 18% have been raped, 8% have been 
stalked, and 22% have been battered by an intimate partner (Tjaden and Thoennes 
2000). 

Childhood Exposure to Violence: Understanding the connections among violence, 
substance abuse, and stress are particularly important for child well being. Within a 
sample of inner city Philadelphia children 75% had heard gunshots, 60% had seen drug 
deals, 18% had seen a dead body outside, and 10% had seen a shooting or stabbing in 
the home (Hurt, Malmud et al. 2001) In 1997, 22,688 children were reported abused or 
neglected in Pennsylvania (CWLA 2000). In 1998, 108,494 children were arrested in 
Pennsylvania. Exposure to violence in all its forms has been strongly associated with an 
array of psychological, medical, social, and school problems that children endure. 
Exposure to violence in adolescence is as potentially damaging as violent victimization 
in childhood. As a longitudinal study has shown “[v]iolent victimization during 
adolescence appears to be a risk fact or for – and a cause of – most of the adult 
problem outcomes measured: violent crime victimization, domestic violence perpetration 
and victimization, violent and property crime perpetration, and problem drug use,” 
(Menard 2002). 

Substance Abuse Among Pregnant and Parenting Women in Philadelphia: The 
scope of the problem of substance abuse disorders among pregnant and parenting 
women in Philadelphia is significant. The Department of Human Services has reported 
that 80% of foster care placements involve some level of parental substance abuse. 
The Department of Public Health and the Philadelphia Perinatal Society performed two 
prevalence studies showing that 17% of all births (5,000 babies) were born cocaineexposed. 
The result of these studies is an alarming indication of the volume of untreated 
chemically addicted mothers. 
 
Violence Against Women in Philadelphia: Violence against women is equally 
alarming. In 2000 alone in Philadelphia there were 1,021 reported rapes. At least 
45,000 women are battered in the city every year. Over 13,000 petitions for protection 
from abuse are filed in Philadelphia Family Court. Twenty percent of the emergency 
room visits by women in the city are the result of domestic violence, and 75% of these 
women will have additional injuries requiring treatment within the year (WAA 1996; DPIC 
2002). 

Emergence of Women-Centered Treatment Programs in Philadelphia: The City of 
Philadelphia Behavioral Health System has responded to the needs of pregnant and 
parenting women suffering from substance use disorders by supporting specialized 
women-centered drug treatment programs. These programs include six residential 
treatment facilities where mothers can live with their children, one residential program for 
women and children where the mothers are suffering from co-occurring substance use 
disorders and mental health problems, four residential programs for women alone and 
ten intensive outpatient programs. Several of the residential programs began as federal 
demonstration projects with a research component. When funding for the demonstration 
was exhausted, the city’s behavioral health system drew from a variety of public funding 
streams to keep these programs running. 

The residential treatment facilities allow women to remain for varying amounts of time, 
ranging from three to twelve months. The programs serve approximately 160 women. 
Residential programs that permit children serve approximately 200-240 children at any 
given time. Women may bring two children into treatment if they are under the age of 11 
and living with the mother. Most of the children are under school age. These programs 
provide intensive treatment services for their adult clients along with a variety of other 
case management and life skill services. Residential treatment programs are reserved 
for the most seriously addicted and women must be assessed for admission in 
accordance with the Pennsylvania Client Placement Criteria (PCPC). 

The women-centered outpatient programs usually provide three sessions, three times a 
week for women. This includes both therapeutic treatment for the substance use 
disorder and other supports to assist in recovery. Referral for intensive outpatient 
services usually suggests serious addiction problems. Some of these women should be 
in residential treatment facilities, but due to logistics or other circumstances instead 
attend intensive outpatient services. A recent housing initiative has been developed for 
people in outpatient programs who have no safe or secure place to live and whose 
success in outpatient services would be compromised because of their precarious living 
situation. Supervision and social supports are provided on a twenty-four hour, seven day 
a week basis. Four recovery houses are for women only. One recovery house serves 
women with children. 


Section 4 
Findings and Recommendations 
During our intense year of study we found multiple, interrelated issues about the service 
delivery system and approaches to treating addicted women and their children. 
Although our recommendations follow each set of findings, it is important to note that the 
recommendations are interrelated, and usually apply to more than one finding. 
Embedded in our findings section are quotes from consumers and providers. These 
quotes are drawn from notes of comments made in focus groups and minutes from 
larger working groups, and have been edited for clarity and brevity. 

Finding 1 
Philadelphia’s health and human service delivery system does not address the 
specific needs of women, does not integrate the linkage of trauma, violence, and 
substance abuse in service delivery, lacks cross-system training, and fails to fully 
comprehend the long term needs of families affected by trauma, violence and 
substance abuse. 

Substance abuse, violence and trauma are inextricably linked. 
Substance use disorders and exposure to violence are endemic in the lives of 
women in Philadelphia’s health, social service and criminal justice systems: A 
large body of evidence-based information about the complex and co-morbid conditions 
resulting from exposure to violence now exists. The 
research and anecdotal reports about women who are in 
various social and health systems in Philadelphia -- 
homeless shelters, the criminal justice system, prisons, 
child abuse and neglect proceedings, domestic violence 
shelters and services, substance abuse and mental health treatment, maternal and 
children’s health services, and emergency medical services – indicate that violence and 
substance use disorders are prevalent, if not endemic, in their lives. The research 
overwhelmingly in concludes that exposure to violence is the primary precursor to all of 
the other dysfunctional behavior, including substance use. (See Bloom, S. L. The PVS 
Disaster, attached). Despite this, none of our interlinked systems fully understand the 
complex ways in which exposure to violence impacts on the development, cognition, 
emotional responses, or behavior of those affected. As a result, there is no integrated 
system to work with adult women on the myriad of problems that flow from the trauma of 
experiencing violence and the resulting self-destructive or dysfunctional behavior. 
Domestic violence is widespread: Although domestic violence and sexual assaults are 
notoriously underreported, the police and court data for Philadelphia nevertheless 
document the prevalence of domestic violence. Case workers and outreach workers who 
enter families’ homes identify frequent incidents of domestic violence, but have little 
knowledge about resources that can help. There is an extraordinary lack of knowledge, 
on the part of health and social service providers about the role of the police, the district 
attorney, and the courts in dealing with domestic violence. There is no office in 
government to deal with the full impact of domestic violence: to assess needs, to 
evaluate services and to coordinate and integrate efforts. 

Untreated trauma leads to behavioral problems: As research and practice have 
demonstrated, treating the symptom without treating the underlying trauma is ineffective. 
Substance abuse is frequently a symptom of trauma and many behavioral health 
problems emerge from un-treated trauma. Self-medication, through the anesthetic 
effects of drugs is an attempt to manage the pain and overwhelming fears associated 
with trauma. Trauma-based models 
exist which are effective in treating both 
the underlying problem and the 
behavioral symptoms it produces. 
Woman after woman told stories of 
untreated trauma and loss, and related 
that they used drugs to try and take 
away the pain. 

Philadelphia has poorly integrated systems for women with addictions 
Fragmentation creates systems nomads: Most of these vulnerable mothers are 
interacting with various systems of care. Some are “systems nomads” who move from 
system to system, without any coordinating efforts. For example, a woman might be in a 
domestic violence shelter and move to a homeless shelter, go to prison and then enroll 
in a substance abuse treatment program. While she is moving from system to system, 
her children are also system nomads and may be in 
Child Protective Services, different school systems, and 
different health clinics. Although presenting problems 
may be targeted and addressed by each separate 
system, the underlying issues of violence, poverty and 
trauma are never fully addressed or resolved. 

Philadelphia has no coherent framework for developing successful and consistent 
treatment programs or intervention strategies, resulting in mixed and ineffective 
messages being sent to vulnerable women: A clear problem emerges for clients in 
the system as a result of these unspoken conflicts between the models: there is no 
common language, no common assumptions, no common goals, and no clearly 
articulated practice-based models that have emerged within the Philadelphia system. 
The opportunity to utilize trauma-based theory to treat addiction, provide consistent 
training across the Philadelphia system, and ensure coordination of mission and staff 
support will be a vital link in improving the functioning and success of Philadelphia’s 
health and human service system. 

Philadelphia has no unified system for women: As we interviewed women and 
treatment providers, it became clear that there is no organized or coordinated system of 
care for adult women. Women receive services primarily because they are the 
caretakers of children or are pregnant. Their other needs are rarely addressed. The 
system that exists is fragmented. There is a lack of ease of access to services, multiple 

entry points, and a variation in treatment depending on where and under what 
circumstance treatment is provided. When women get compartmentalized in one 
problem, they don’t get seen as a whole person. Although it makes sense for the system 
to try to specialize and isolate a problem for effective treatment, the multi-dimensional 
aspect of gender, trauma, and addiction bely this simple approach. 

Pregnant and parenting women with behavioral problems are especially 
vulnerable and must access multiple uncoordinated services: Due to the variety of 
problems this population faces, many separate services will be offered, with multiple 
short-term relationships with caseworkers and providers of services. There is a lack of a 
continuum of care that can build upon a successfully negotiated relationship between the 
vulnerable mother and health and social services. There is a lack of communication 
among different agencies about their mission, services and limitations. There is also a 
lack of alignment of goals and philosophies of treatment that creates an extensive and 
expensive patchwork of services that is only intermittently successful. This is a costly 
and inefficient use of services, satisfying neither the women’s need for a stable, longterm 
relationship and coordination of services, nor the need to serve these women in the 
most efficient manner possible. 

Substance abusing mothers have long term problems 
Today’s addicted mothers were yesterday’s abused children: Researchers and 
practitioners are consistent in reporting histories of physical and sexual abuse in 
childhood and ongoing violence in the lives of 
women suffering from behavioral health problems. 
They grew up in households where they 
experienced violence and addiction with childhoods 
that were chaotic and disorganized. Their children 
are at extremely high risk for repeating the pattern 
as they move into adulthood. 

Addictions take years to evolve and years to solve: It is critical to understand that 
there are no quick fixes to effectively address the lifetime of abuse and resulting trauma 
that so many addicted women face and that effective 
intervention takes time. Research has shown, for 
example, that it takes seven attempts for a battered 
woman to leave her abuser and that it takes three to four 
times or more for substance abuse treatment to “take.” It 
is of particular importance as insurers and funders are 
developing outcome measures to recognize that a longterm 
continuum of intervention is necessary for effective work with these families. 
Indeed, it may be necessary to rethink the entire concept 
of relapse in addressing the treatment requirements of 
complex cases involving addiction in women who suffer 
from PTSD and other psychiatric and social problems. 
The corollary may mean redefining success as women 
move along the continuum of care. 

Women who are addicted are involved with multiple legal systems. They often 
have no or inadequate legal representation. The outcome of these proceedings 
may be life altering. It is imperative that consumers and their caseworkers 
understand these proceedings. 

Substance use disorders often bring women into Dependency proceedings in 
Family Court because their children have been determined to be at-risk for 
placement and/or are receiving services in their 
home: The passage of the Adoption and Safe 
Families Act has dramatically accelerated the 
process to terminate parental rights. Termination of 
parental rights has caused significant grief, even 
when voluntarily done, and is considered a major 
relapse trigger. 

Mothers are also in the Domestic Relations branch of Family Court: In some cases 
women have voluntarily relinquished custody to relatives; in other cases relatives have 
petitioned and been awarded custody. This is often done to avoid involvement with DHS. 
The legal basis for custody determinations is the “best interest of the child.” Custody 
proceedings, unlike dependency (child abuse and 
neglect) proceedings, do not call for family 
reunification and do not have family service plans 
associated with them. Mothers seeking to keep 
their children out of the child protective services 
system often mistakenly believe that they can 
regain custody when they achieve sobriety. The 
“best interest standard” provides a considerable 
amount of discretion on the part of the judge hearing the case, and more often than not, 
custody will not be disturbed in cases like this, although visitation should be permitted. 
Also, unlike dependency proceedings, there is no entitlement to legal counsel in these 
cases, and there is a paucity of public interest lawyers available to represent mothers in 
custody proceedings. Mothers in recovery are surprised and heartbroken when they 
cannot regain custody of their children. It is important for service providers to understand 
these systems. 

Addicted mothers are involved with Protection from Abuse Proceedings in the 
Domestic Relations Branch of Family Court: Violence is rampant in the lives of 
women suffering from addiction. Their 
ability to negotiate the legal system needed 
to protect them from violence is 
compromised by their addiction. Even when 
women have entered residential treatment, 
they might need help. While there, they and 
their children are most likely in a physically 
safe place. However, even if the daily 
threat of violence recedes, their need for 
protection from abuse will continue when 
they leave treatment. Women who have been in residential treatment for several 
months and seek to obtain a Protection from Abuse Order (PFA) can face practical 
barriers from judges who are reluctant to issue such orders in the absence of a recent 
act or threat. A PFA can provide numerous remedies, including limiting the abusers 
proximity to the victim. Although not necessary in all cases, a safety assessment should 
be performed to determine whether a PFA is needed. Violation of a PFA is a crime and 
it can invoke immediate police intervention. Without such an order, women are not 
protected until additional abuse has occurred. Our legal survey indicated that very few 
women in the residential programs had PFA’s, which, in the face of the violence that has 
usually been a part of their lives before treatment, could pose very serious problems 
after treatment. Domestic violence can be lethal. 

Addicted women have consumer-related legal issues: Consumers who attend the 
large Working Group meetings have repeatedly mentioned consumer related legal 
problems that cause virtually insurmountable 
barriers to transitioning to recovery. Our survey of 
the residential treatment programs to ascertain 
the types of legal needs of their clients showed 
more than 60% of their client base have debt and 
credit problems, which prevents them from 
getting housing and utilities. 

Local and national statistics show an exponential increase in the numbers of 
women involved in criminal justice proceedings: The vast majority of this increase is 
due to drug related activity, which ranges 
from drug sales to prostitution and shoplifting. 
Many of the women in the focus groups 
mentioned prostituting themselves in order to 
obtain drugs. Even after prison terms are 
served, the women continue to be under the 
supervision of probation and parole. Many of 
these women have outstanding bench 
warrants and unpaid fines, which can lead to re-arrest. 

Women with criminal drug convictions are adversely affected by numerous civil 
laws and welfare restrictions: For example, TANF contains a lifetime ban on 
individuals with drug-related felony convictions for conduct after August 1996. This ban 
includes automatic ineligibility for cash assistance or food stamps. Federal laws make it 
difficult for persons with drug convictions to get public housing or federal financial 
assistance for higher education. Individuals with drug and other criminal convictions are 
barred from employment in certain occupations. These policies make recovery from 
addiction and other mental health problems profoundly more difficult, and serve as 
obstacles to overall social improvement. 

Philadelphia has a lack of cross-systems training and information on services 
available: There are so many treatment providers that interact with families affected by 
addiction that the lack of cross-systems information becomes a major barrier to providing 
efficient and effective services. Providers in each system need to understand the legal 
mandates of the different entities, the mission of the organizations, the limits of their 
services and the relationship with the rest of the treatment providers. Cross training 
among Behavioral Health, Child Welfare, Homeless and Housing, Recreation and 
Prisons and the legal systems and services is crucial for the provision of integrated 
services. 

Recommendations 
.. Create a system of care for women in Philadelphia with a locus in city 
government to develop and coordinate services for adult women: This office 
should inventory and integrate existing services, coordinate the creation of new 
services where gaps exist, and coordinate implementation of the recommendations 
from this report. 

.. Adopt a trauma-informed system of intervention: Trauma informed treatment 
will address the problem of substance abuse and related social dysfunction 
throughout the city’s health and human services system and provider network. 
.. Develop a policy of a multi-year commitment to families in the substance 
abuse treatment system: Multiple interventions are the norm and do not 
represent client or system failure, but are a fact of treating trauma and addiction. 
It is therefore cost effective and programmatically practical to anticipate multiple 
returns to treatment. 

.. Create a coordinated response to domestic violence: The City of 
Philadelphia should follow the model of several other cities, e. g., Chicago and 
Boston, and create a coordinated response to domestic violence by creating a 
Task Force composed of key officials from the Philadelphia Police Department, 
Philadelphia District Attorney’s Office, Family Court, Health and Human Services, 
Recreation, and provider agencies and advocates. 

.. Create a training institute, using a model such as BHTEN, to develop and 
coordinate cross-systems training and appropriate resource material: 
Include in contracts with providers a schedule of training and give appropriate 
professional education credits. The training should be trauma-informed and 
culturally competent. The institute should provide training that includes: (a) 
Systems capabilities: the legal mandates, mission, treatment philosophy, 
organizational structure, and service delivery of its provider organizations, (b) 
Legal procedures and processes that flow from legal mandates, and legal 
services that are available to assist families in these proceedings and, (c) 
Professional development on current research and best practices 

Finding 2 
Addicted women have histories of abuse and deprivation, are socially isolated, 
and are exhausted and grieving. 

Today’s addicted mothers grew up in households where they experienced child 
abuse and/or neglect, an absence of parental care-giving, parental substance 
abuse, domestic violence and community violence: Their childhoods were chaotic 
and disorganized. They are single mothers with their first pregnancy occurring in their 
teens. They are not healthy and have numerous untreated physical ailments. Their 
reproductive health needs are particularly unaddressed. Their education was interrupted, 
frequently by pregnancy, and they have limited job skills. They are socially isolated, 
without social supports. They have few opportunities for social or recreational activities 
that are not drug-involved, and they are very unhappy. Once they are in a system of 
care, they are besieged by caseworkers and conflicting mandates. They are also 
enmeshed in numerous legal proceedings. They believe they have caused irreparable 
harm to their children, from drug use during pregnancy and through poor childrearing. 
They are exhausted and grieving. The service delivery systems they are in do not 
understand their needs. The women do not understand the cause of their behavioral 
health problems. 

For many addicted women, the only social activity they engage in revolves around 
drug use: Their traumatic histories interfere with their ability to build relationships and 
their addiction destroys the few relationships they might have. Women in our focus 
groups complained about needing “something to do.” At virtually every small group 
discussion in the Working Group, providers and consumers alike talked about the need 
for community based drop-in women’s centers that would have social and recreational 
activities and also information and referrals to health and social services. Congreso’s 
“sewing circle” was cited as a model for engaging Latina women in domestic violence 
services. Another example of a social activity is the creation several years ago of a 
basketball team by one of the women’s residential drug treatment programs. 

Recommendation 
.. Develop community-based women’s centers: Providing structure and support 
for isolated women in a community context will facilitate empowerment and 
access to services, and reduce the isolation of addicted women in the 
community. Explore ways to use existing community centers to develop or 
expand social and recreational activities for women, and for women with their 
children. These centers can help transition women to needed health and human 
services and also provide activities to help sustain sobriety for those who are in 
recovery. Investigate places where women currently congregate, e.g. 
Laundromats, grocery stores, and manicurists, to see if services could be colocated 
there. Use the model of the Momobile, to communicate the existence of 
social and recreational activities, as well as social and health services at these 
types of locations. 

Finding 3 
Appropriate consumer education materials about addiction and trauma do not 
exist. 

There is a lack of information to help addicted women understand their own 
connection between trauma and addiction: Our focus group findings illustrate 
consumer frustration over not understanding their own addictive behavior and how to 
frame their recovery efforts. We need to develop quality, easy to understand consumer 
education material to help consumers understand addiction and empower them to take 
charge of their recovery process. Very little consumer information and education exists 
about the relationship between trauma and substance abuse in women. In order for 
women to “take back their lives” it is critical for them to understand what has gone on in 
their lives. At this juncture all they know is stigma, shame, and blame. Given their 
histories of pain, abuse, and deprivation, it is grossly unfair to keep information from 
them that explains their behavior and offers them tools and hope that they can live 
without pain and fear. Communicating that message, however, is extremely complex, 
since it also requires undoing the massive public perception of moral failure associated 
with addiction. Developing these materials is beyond the scope of health and social 
service workers, and communications and marketing professionals are needed to assist. 

Recommendations 
.. Develop a communication strategy to increase understanding of trauma 
and addiction: We recommend that Estelle Richman, Managing Director of 
Philadelphia, contact Oprah Winfrey and request that she use her production 
company, Harpo Productions, to develop a communications strategy to help 
women understand addiction, trauma, and healing and “why they do the things 
they do." Oprah Winfrey is perhaps the most influential woman in America today 
and her ability to communicate with vast numbers of people, primarily women, is 
unparalleled in popular culture. One of her most enduring contributions has been 
her openness about her childhood sexual abuse and the behavioral impact it had 
on her, including eating disorders and obesity. She not only understands the 
connections between behavior and trauma, but she and her production company 
know how to communicate difficult subject matter effectively. We believe that she 
would take seriously a request from a person of Estelle Richman’s position, 
stature and reputation. 
.. 
Develop consumer information on addiction and violence that is trauma 
informed: Consumers need the structure of hearing a consistent message from 
the provider community about addiction, and the way to view themselves in the 
context of recovery. Misinformation and mixed-messages dilute the impact of the 
treatment for consumers. Home visitors, case managers, treatment providers, 
lawyers and other workers who work with families affected by addiction can 
distribute the material. 

Finding 4 
Most pregnant substance abusing women do not receive substance abuse 
treatment. 

Research has established that pregnancy is one of the most effective windows of 
opportunity to engage women in substance abuse treatment: Significant public 
health efforts have increased the numbers of pregnant 
women getting appropriate prenatal care. Frequently those 
who receive no, or inadequate, prenatal care are afflicted 
with substance abuse disorders. Assuming that the 
prevalence studies that have been conducted are 
accurate, it is clear that most pregnant substance using 
women receive prenatal care, but do not receive substance 
abuse treatment. It is critically important therefore to 
provide maximum efforts to reach pregnant women who are in the public health system 
who suffer from substance abuse disorders in order to assist them in getting appropriate 
treatment. Unfortunately, communication between the behavioral health system and the 
medical obstetric community is practically non-existent. 

Philadelphia lacks a connection between health care providers and the behavioral 
health system: In a focus group with more than twenty health care providers – 
obstetrician/gynecologists, pediatricians and certified nurse midwives – it became 
apparent that little to no connection exists between them and 
the behavioral health system. “What is CBH?” was a 
question raised by a physician who had the interest in 
working to improve maternal and infant care among those 
affected by substance abuse. Physician led initiatives have 
been shown to influence public opinion, particularly on 
controversial subjects such as needle exchange. Our medical community has the 
expertise to provide this leadership, however, a structure is needed for this leadership to 
come forward. Convening physicians, nurses, and social workers from OB/GYN and the 
emergency departments around these issues will provide an educated, visible and 
powerful coalition. City government can convene meetings of the Department Chairs of 
OB/GYN, Emergency Medicine, Pediatrics, the Philadelphia Perinatal Society, the 
Nursing Consortium, the Pennsylvania Medical Society to develop a community dialogue 
about the needs of women. 

Perinatal social workers are no longer employed in obstetrics and delivery room 
sites: Social workers are no longer employed in obstetrics departments in hospitals. 
Hospital based social workers were a vital link in identifying women who needed 
treatment and then facilitating the entry into treatment. Reports from the physicians and 
perinatal social workers indicated that social workers who identified and referred women 
with addiction-related problems were critical components of appropriate obstetric and 
pediatric care. Most hospital social workers now are primarily involved with discharge 
planning. Nurse care coordinators have played a role in filling this gap, but they do not 
have the training or referral network that social workers have, and they have other 
responsibilities. The trend of hospitals to eliminate and/or reduce social work coverage 
in in-patient and out-patient settings has created a serious gap in the referral network. 
Lack of coverage in out-patient clinics and delivery units in hospitals has created 
enormous gaps in referring pregnant and postpartum women to needed services, and 
has dramatically reduced the system’s effectiveness in reaching those in need. 

Recommendations 
.. Set up regular meetings among health care stakeholders: Regular meetings 
with representatives from the behavioral health system the hospital department 
chairs of OB/GYN and Pediatrics, The Philadelphia Perinatal Society, the 
Nursing Consortium, the Public Health Commissioner, and doctors and nurses 
from healthcare centers should take place. 

.. Reinstate social workers in prenatal and delivery settings: If hospitals are 
unable to pay for this service, consideration should be given to having HMOs, 
including CBH, pay for it. 

Finding 5: 
Case workers and home visitors who provide services to children lack the 
appropriate tools, training, and professional development to address violence and 
addiction. 

Caseworkers and home visitors are faced with challenging situations which they 
are poorly prepared to handle: Home visitors, case workers, and nurses in our focus 
groups, Working Groups meetings, and provider meetings have acknowledged that they 
are identifying addiction and domestic violence in the homes they visit. Yet, they also 
admit to having trouble negotiating the difficult line between maintaining a relationship 
with the mother and discussing her addiction and the abuse she has experienced. Most 
of the workers are in the homes to assist children and do not have a mandate, much less 
a background, in providing support for adult women. Those who are successful in 
bridging these sensitive and delicate issues, and helping mothers to find help, do so 
primarily because of their own personal ability to relate to the woman. Virtually all of the 
professionals in the field echoed the participants in our Roundtable Discussion on 
Outreach who indicated that relationship-building was the most important step in getting 
women to access any service. However, most of our informants stated that they felt ill 
equipped to deal with addiction and domestic violence. The complexities of traumainduced 
violence and related addictions require more sophisticated training to enhance 
existing skills. 

Caseworkers lack good trauma-informed parenting information they can provide 
for mothers: Many mothers in the DHS system are encouraged or mandated to attend 
parenting classes. Findings from our focus group suggest that parenting issues were the 
most compelling issues that brought women to treatment. Over half of the respondents 
said that some aspect of parenting issues brought them 
into treatment. For some, this was DHS or SCOH 
involvement and the potential or actual loss of custody of 
their children. For others, it was observing the impact that 
their drug use had on their children, and wanting a better life for their children than they 
could provide while using. Parenting education is a very powerful tool; however, parents 
need to understand how their trauma affects their parenting. During the course of this 
contract period, Dr. Sandra Bloom developed a trauma informed parenting curriculum, 
which her team conducted as part of a DHS contract with Interim House; this contract 
has been renewed by DHS. 

The caseworkers in all systems need professional development and education: 
Educating workers in the many service entities is difficult and challenging. Each worker 
has his or her own personal and professional experience mixed with differing levels of 
education and value-based beliefs and prejudices. But when the information that 
maternal-health, addictions, and other case workers have is wrong, and the message 
that vulnerable mothers receive is inconsistent, it is difficult 
for the mothers to figure out which course to take. For 
example, many educational and training programs have 
been offered that provide accurate medical and scientific 
findings debunking the media created myth of the “crack 
baby”, which held that children exposed in utero to crack suffered irreparable physical 
and developmental damage. This misinformation remains widespread in society and 
among the many workers working with families affected by substance abuse. It 
continues to stigmatize both mothers and children and perpetuates the notion that 
children born “crack exposed” are a biological underclass. The result is that the mothers 
are totally devastated because they believe they have ruined their children and as a 
result they avoid needed services. 

Philadelphia needs a treatment philosophy that supports self-esteem, a sense of 
safety and security: Workers talked about addicted women needing to “hit bottom” 
before they can accept and benefit from treatment. Yet trauma theory has clearly shown 
that receptivity to treatment has to do with the ability to feel safe and secure, and that 
self-esteem must be supported and enhanced if treatment will be effective. Skepticism 
about the effectiveness of substance abuse treatment is 
rampant in services other than the substance abuse treatment 
system. Stigma, blame and moral failure continue to fuel the 
public perception of addiction, including the perception of 
many providers who work with families affected by drugs and 
alcohol. Unlike other chronic afflictions like diabetes or 
hypertension, when relapse occurs in an addicted person it is 
all too frequently considered a “failure in treatment.” 

Recommendations 
.. Provide a trauma informed checklist for home visitors: Home visitors need a 
structured way to approach addressing addiction and domestic violence needs. 
A clear protocol of areas to address, services for referral, and steps for follow-up 
will provide a consistent message for consumers. 
.. Develop a “team network” for home visitors: Models exist that put the home 
visitor in the context of a full inter-disciplinary treatment team, thus expanding 
their ability to respond to the complex situations encountered. 
.. Provide trauma-informed parenting education programs: (see model 
curriculum at Appendix 3). 
.. Expand mobile therapy options: Providing more mental health mobile therapy 
options, as well as expanding mobile therapy to include substance abuse 
treatment, will improve accessibility of services for vulnerable mothers. 
.. Provide accurate training about parenting issues and children’s behavioral 
health issues for workers: Through the Training Institute recommended above, 
workers should receive thorough training about parenting issues and children’s 
behavioral health. 
.. Create materials for consumers that help them understand their children’s 
behavior: Through development of the consumer materials recommended 
above, consumers will receive information that helps them to understand 
children’s behavior and their parenting role. 

Finding 6 
Women need gender-specific, trauma informed substance abuse treatment 
The research is overwhelming in concluding that women need gender-specific, 
trauma-informed treatment: The U. S Department of Health and Human Services drug 
and alcohol treatment and prevention programs (SAMSHA and CSAT) have long 
concluded that women-centered treatment is crucial to positive outcomes and is now 
emphasizing that this treatment must be trauma-informed as well. Co-ed treatment or 
treatment that does not understand gender or trauma is not effective for the vast majority 
of women who suffer from substance abuse disorders. In fact many report that their 
experience in co-ed treatment programs worsened their problems as men in the 
programs criticized them for their poor parenting. In addition, women report having 
difficulty coping with the sexual behaviors that are more commonplace in co-ed 
programs. 

Philadelphia’s women-centered residential treatment programs provide the most 
intensive intervention that adult women living with their children receive than from 
any other system of care: These families are in healing environments, under clinical 
supervision, for six to nine months. In these programs, not only is the hierarchy of need 
– food, clothing and shelter – provided, so is clinical treatment for trauma and addiction, 
as well as parenting and life skills training. No other services present such a unique and 
extraordinary opportunity to intervene in the cycle of addiction, abuse, neglect, and 
violence that are prevalent in the lives of these families. As such, the programs should 
be viewed not only as drug and alcohol programs, but programs that have the potential 
to decrease crime and homelessness, reduce and prevent child abuse and neglect, 
improve physical and reproductive health care, assist in improving education and job 
readiness, and reduce poverty. The need for these services exceeds the current 
capacity. 

Recommendations: 
.. Assure that all substance abuse treatment programs serving women understand 
gender and trauma and provide gender-specific, trauma-informed 
treatment for all women seeking treatment. 
.. Create a consortium of women’s treatment programs: A consortium will 
enhance professional development about “best practices” and coordinate 
services, such as housing and legal assistance. The city can also assist in 
securing grant and federal funding to research their practice methods and to 
follow families involved with the women’s treatment system for an extended 
period of time. 

Finding 7 
Children whose mothers are in treatment have not received adequate intervention. 
Children’s needs have been ineffectively subsumed into the adult system: 
Treatment personnel from all of the treatment programs stated that the children of the 
women in the treatment system are in need of a wide range of services that are currently 
not offered. These services include therapeutic interventions for the children, motherchild 
healing and bonding interventions, play activities, and childcare. To be effective, 
the needs of children must be woven into the fabric of treatment for their mothers. 
Intergenerational transmission of violence, substance abuse, and other disorders 
is common: Parental substance abuse is a leading cause of child abuse and neglect, 
as was clearly demonstrated in our review of the literature, The PVS Disaster. Addicted 
mothers frequently have had histories of abuse and 
neglect themselves and did not receive adequate 
parenting, which in turn has compromised their caregiving 
ability. Intergenerational transmission of 
violence, substance abuse and other disorders are 
commonplace in this vulnerable population. 

Children of addicted women suffer from numerous debilitating factors: The 
mothers are likely to be victims of domestic violence and sexual abuse, which their 
children witness and/or are also victimized by - either of which is traumatic. Addiction 
leads to chaos and disorganization, and homelessness and hunger, leaving children 
insecure, frightened and hurt. These children often suffer from significant attachment 
disorders. Many of them wind up in the child protective services or mental health system; 
many are removed from their mother’s care. 

Children living in residential treatment are safe which provides an extraordinary 
window of opportunity for creative and positive intervention: Children who are living 
with their mothers in residential treatment facilities are physically safe; their primary 
health and physical needs are being met. Program personnel from these programs have 
called for the creation of specific intervention/treatment services for children to address 
the crises that many of these children have experienced. Since the children are safe and 
cared for, this time is an extraordinary window of opportunity for creative and positive 
intervention efforts. 

Many children of mothers in treatment are not living with their mothers: Many 
mothers have children that are not living with them in the women and children’s 
residential facilities, because they are older than 11, there are too many children, or the 
children are already in foster care. These children likely have additional issues of feeling 
abandoned or unwanted. These problems also exist for the children whose mothers are 
in the women-only residential programs. Because these children are with other family 
members or in foster care, resources are needed to provide services to them and to 
engage their caretakers in this process. 

DHS has committed funding to enhance services to children in women’s 
residential and outpatient programs: During this contract period, contact was made 
with David Fair, from the Department of Human Services, to advocate for use of child 
abuse prevention funds to enhance the services to children in both residential and 
outpatient women’s centered programs. Mr. Fair met with providers and had contract 
staff participate in two Working Group focus groups with women in treatment, to 
ascertain how and if DHS could intervene. The psychological needs of children were 
paramount in these discussions, along with the physical health care needs of both 
women and children, and a range of aftercare needs from relapse intervention to 
housing. As a result, DHS will provide a professional to each program who is charged 
specifically with assessing and serving children. Dr. David Dan, former CBH children’s 
mental health director, is supervising this project for DHS. 

Recommendation 
.. DHS needs to continue this important inter-agency initiative: The 
coordination of efforts between DHS and the behavioral health system reduces 
fragmentation in service delivery. This linkage between child protective services 
and behavioral health has potential to improve system integration and 
cooperation by expanding the knowledge and practice base. Many social 
services outside of substance abuse services do not understand the treatment 
field or believe that treatment is effective or that appropriate intervention can 
occur. Similarly, the substance abuse treatment field has not been effective in 
providing competent services to children whose mothers are being treated. Their 
combined efforts in this project should prove to be very meaningful. 

Finding 8 
Residential treatment programs do not have the resources to address women’s 
health care needs or provide appropriate “aftercare” to prevent relapse. 
Women who suffer from substance abuse disorders are often in poor health: Their 
disorganized or chaotic lifestyle does not lead to good physical health. Their health 
issues can range from poor nutrition to hypertension, diabetes, liver disease, and major 
reproductive health care issues, including untreated sexually transmitted diseases, 
HIV/AIDS, pregnancy with no prenatal care, and unwanted pregnancies. Reproductive 
health care issues involve many challenges, particularly because so many women have 
significant histories of sexual abuse. Gynecological examinations, contraception, 
childbirth and abortion, STD’s, HIV/AIDS pose not only physical health care issues, but 
also psychological. A gynecological examination for a woman with a history of sexual 
abuse can be traumatic, even for those who have borne children. Sensitive intervention 
and a supportive environment are necessary for the provision of such care. Education 
about healthy and pleasurable sexuality and sexual orientation also needs to be 
introduced in this setting. Children’s health care needs similarly have been neglected, 
including routine health care checks and immunizations. In the residential setting, where 
there are approximately 20 adult women and 24 – 36 children, organizing their health 
care needs takes a considerable amount of time, particularly in the early phases of 
treatment, which necessarily intrudes upon treatment time. 

Addicted women need trauma-informed treatment: Increasingly women-centered 
substance abuse treatment providers are recognizing that trauma is the underlying 
problem and addiction (or self-medication) is the symptom. BHTEN has done a 
significant amount of training for the behavioral health system in the last several years. 
and has invited leading experts in the country to provide trauma training: Dr. Sandra 
Bloom, Dr. Maxine Harris, Dr. Carol Warsaw, and Dr. Karen Saakvitne. One series of 
programs involved developing TREM (Trauma, Recovery, Empowerment), a workshop 
for clients in residential treatment. The series of exercises are designed to help women 
recognize the behavior that has led to addiction and ways to recover from it. Program 
staff report significant satisfaction from the clients in TREM groups. Trauma-informed 
treatment is not only therapeutic for the clients, but is also necessary for organizational 
culture and practice needed for treating traumatized individuals. 

Staff at treatment centers often suffer from secondary trauma and need assistance 
in the form of professional development to understand their own reactions 
to working with trauma survivors: Staff who work daily with traumatized women often 
suffer secondary trauma, and need trauma-informed professional development to 
develop their insights into their own reactions, ensuring that they can continue to 
maintain a safe supportive environment for the women they are treating. 
The problems that women encounter after leaving intensive residential treatment 
can become triggers for relapse: Women frequently encounter problems after 
leaving the structured living environments of residential treatment even though case 
management around housing, education and 
employment takes place while women are in treatment 
to prepare families for living more independently. Upon 
leaving residential treatment, the women “step down” 
to less intensive treatment in another treatment program. The problems that are 
encountered after leaving intensive residential treatment – including domestic violence, 
intense poverty and lack of safe, stable housing - can be relapse triggers. Unless the 
woman herself contacts the residential program in which she had lived and improved for 
six to nine months, information about her relapse is not known to that program, and the 
program therefore has no ability to intervene. Since relationships are so difficult for 
women with these histories to develop and maintain, when relapse occurs it makes 
sense to reconnect them to the people and place where they encountered success. The 
human and financial investment that has been made in residential treatment should not 
be forfeited by bureaucratic rules and protocols. 

Recommendations 
.. Help secure funding so that the Nursing Consortium can provide on-site 
health care and health education: We have approached the Nursing 
Consortium. Nurses and midwives are the most appropriate health care providers 
for this population, and have histories of providing care in residential facilities 
such as homeless shelters. In addition, mapping indicated that the existing 
nursing centers are located in proximity with the residential programs. At this 
time, the nursing programs are not “federally qualified health centers” (FQHC) 
and have reimbursement rates that are too low to provide the services of a 
FQHC. Two approaches to the problem are underway: 
(1) The Nursing Consortium has prepared a foundation proposal to provide 
onsite care and education at the residential treatment centers and ongoing 
connection to centers upon graduation. With the current enhancement of 
services underway, we think we can convince a foundation to fund these 
services, provided a sustainability plan can be developed. 
(2) Sustainability will include plans to have the nursing centers become eligible 
to be FQHCs. We have learned that nursing centers can currently qualify 
for FQHC if they collaborate with local community health centers. A 
suggestion has been made to develop a pilot program in which two nursing 
centers, two residential treatment programs, and two community health 
centers would collaborate to provide these services. With such a plan, a 
foundation would be more likely to support the plan. Support from city 
administration would be critical to obtain such funding. Another initiative 
involves The Family Planning Council, which is independently considering 
ways to provide more reproductive health care and education to these 
programs through direct service or through enhanced referral for outpatient 
programs. They currently provide some services to several drug treatment 
programs and have had significant experience in working with vulnerable 
women. 

.. Create an “aftercare” specialist who will be a troubleshooter for women: 
This position would be designed to be a bridge for the consumer back to the 
place of greatest safety and success. The aftercare specialist will also potentially 
be able to develop an alumni group that can eventually be used as mentors for 
recovery and hopefully develop leadership for more public advocacy. This 
position would not however, be designed to be a case manager or supplant 
existing case management services nor interfere with current “step down” 
treatment. 

.. Need for systems-wide training in trauma is necessary so providers and 
consumers can fully understand the behavioral impact and self-medication 
that flows from the traumatic injuries of sexual and physical abuse: The 
staff in the network of women’s treatment services should have comprehensive 
training to help them understand the interaction of violence-induced trauma and 
substance abuse and the impact of working with traumatized women and 
children on the organization. 

Finding 9 
Lack of childcare and transportation are serious barriers to obtaining outpatient 
treatment. 
Addicted women are consumed with exhaustion and grief and cannot overcome 
barriers to treatment without extensive assistance: The mothers in our focus groups 
spoke of being beyond tired. They exhibited inexorable 
grief and loss, and while desperate for a different life for 
themselves and their children, they described being unable 
to complete the most basic of tasks due to exhaustion 
undoubtedly caused by depression. Trying to take advantage of services of a 
fragmented delivery system was impossible. 
The barriers of transportation and child care: The city’s women-centered, genderspecific 
outpatient programs present a different set of challenges for enhancement of 
services. While the women and children have the same psycho-social, health care, and 
housing needs of those in residential treatment, these programs face additional needs 
that may serve as barriers: transportation and child care. Virtually all of the research 
literature indicates that these two issues pose the most significant barriers to treatment 
for pregnant and parenting women. Reports have in-dicated that attendance is sporadic 
at outpatient programs. Transportation and child care go hand-in-hand. Even if programs 
had child care facilities, the consumer might still have transportation problems. If other 
child care arrangements are possible, transportation can remain problematic. We 
learned during meetings with providers that during the last SEPTA strike, programs had 
to hire vans to bring clients to treatment, and experienced their highest attendance 
record. The sheer exhaustion that the women displayed during our focus groups 
suggests that use of public transportation to get to treatment may be more than some 
can handle, particularly when they are also under stress from not using drugs. Bringing 
children along with them does not necessarily contribute to the motivation to attend 
treatment. Their grief and sense of loss further dissipates energy required to make 
positive change. 

Need for mobile therapy as alternative to outpatient care: It is clear that some 
women may need treatment in their homes. Community Legal Services reports some 
very good results with mobile therapists. 

Recommendations 
.. Provide actual transportation to outpatient programs through 
• Funding for vans or other van services 
• Funding for taxi vouchers 
• Implement the ICM (Intensive Case Management) model that mental 
health and MPP (Maximizing Participation Project) use which includes 
transporting clients to appointments.
 
.. Provide babysitters at home or set up on-site child care at treatment 
centers: Provide babysitters at home for woman who are exhausted and unable 
to travel to treatment or set up on-site child care, preferably therapeutic child 
care, at treatment centers. 

.. Provide more behavioral health mobile therapy options for mothers who 
cannot physically get to treatment. 

Finding 10 
The mental health problems of pregnant and postpartum women and their 
children are not appropriately addressed by the behavioral health system. 
The current mental health system does not adequately respond to the needs of 
traumatized women: The mental health system 
has not developed gender-specific programs the 
way the substance abuse treatment field has. 
Substance abuse and mental health are 
frequently co-occurring. There is only one small 
residential program for women and children 
specializing in co-occurring disorders. 
Philadelphia does not have a residential program 
for pregnant and postpartum women with a 
primary diagnosis of severe mental health 
disorder. Some substance abuse residential 
treatment programs will not admit women on 
psychotropic medication. Pregnant and parenting 
women who have a primary diagnosis of mental 
illness have been inappropriately placed in 
substance abuse treatment programs. Meetings 
with women’s treatment providers have indicated 
that the lack of appropriate care for mentally ill 
pregnant women has resulted in tragic 
consequences. 
The mental health system is not well trained in trauma-informed treatment: The 
system is not as well informed about trauma as the women’s substance abuse treatment 
system. 
The mental health system has not developed gender-specific programs the way 
the substance abuse treatment field has. 
Group therapy opportunities are an effective way to reach addicted women: There 
are few, if any, outpatient programs that provide group therapy, which is an effective 
intervention for women. 

Recommendations 
.. Open a residential program, preferably associated with a psychiatric 
facility, for severely mentally ill pregnant and postpartum women and their 
children: Friends Hospital and Belmont have facilities that could accommodate 
this at a cost of $1 million dollars in renovation. 
.. Assure that mental health providers are properly trained in the field and 
practice of trauma. 
.. Create group therapy opportunities for women. 
______________________________________________________________________ 
APPOINT A TASK FORCE TO MONITOR THE IMPLEMENTATION OF THE 
RECOMMENDATIONS OF THIS REPORT. 



Conclusion 
We found that the problems encountered by pregnant and parenting women with 
substance use disorders are systemic and rooted in a lack of public policy that 
addresses the needs of vulnerable women, and therefore, of their children. Although 
pregnant and parenting women receive services in the city’s health and social service 
delivery system, they have only received peripheral attention in the public policy arena 
because their needs are addressed primarily in the context of their parenting or 
pregnancy. Their other needs are neither acknowledged nor served. Attempting to serve 
children by improving parenting skills or pregnancy outcomes without understanding or 
addressing the concomitant problems of the mother is shortsighted and ineffective. 
There is no locus in government that identifies, serves, or coordinates the needs of the 
vulnerable women who are in the city’s public health and social services system. 
Current attempts by city government to move away from a fragmented and singleproblem 
focused system will fail if the needs of mothers in this system are not 
acknowledged and addressed. 

Yet, in spite of the inadequacies in the systems that serve these women, we found 
extraordinary motivation and resilience on the part of seriously traumatized and addicted 
women. We also found compassion, sensitivity and a sincere desire to help on the part 
of many providers who are working with the women. The desire of many women to heal 
- usually for the sake of their children - has led some to conquer seemingly 
insurmountable problems. In the face of crushing poverty, inadequate welfare benefits, 
unfit housing, and crime-ridden neighborhoods, many women have vanquished their 
own demons of abuse and addiction, usually with the help of a competent provider, and 
learned to live productive, healthy lives. 

Philadelphia has many positive initiatives in place and has recognized that there are 
populations that require extensive, inter-agency coordinated services. In fact, 
Philadelphia has emerged as a national leader in both research and practice for issues 
affecting substance exposed families. There is a clear recognition on the part of policy 
makers of the need for a coordinated, integrated system of care. Philadelphia has the 
knowledge and resources necessary to launch a new initiative for these vulnerable 
mothers. As the steward of a major urban human service delivery system, Philadelphia 
has the responsibility to intervene in the endemic problems of addiction, poverty, 
violence, and trauma. The city must now make the commitment to address the needs of 
this challenging, stigmatized, and marginalized population. Our recommendations are 
focused on filling the service gaps, and when implemented will substantially move 
Philadelphia forward in achieving the integrated, coordinated system of care that the city 
aspires to deliver and that these women deserve. 

Appendix 1 
List of Findings and Recommendations 

Finding 1 
Philadelphia’s health and human service delivery system does not address the 
specific needs of women, does not integrate the linkage of trauma, violence, and 
substance abuse in service delivery, lacks cross-system training, and fails to fully 
comprehend the long term needs of families affected by trauma, violence and 
substance abuse. 

Recommendations 
.. Create a system of care for women in Philadelphia with a locus in city 
government to develop and coordinate services for adult women. This 
office should inventory and integrate existing services, coordinate the creation of 
new services where gaps exist, and coordinate implementation of the 
recommendations from this report. 
.. Adopt a trauma-informed system of intervention. Trauma informed treatment 
will address the problem of substance abuse and related social dysfunction 
throughout the city’s health and human services system and provider network. 
.. Develop a policy of a multi-year commitment to families in the substance 
abuse treatment system. Multiple interventions are the norm and do not 
represent client or system failure. It is a fact of treating trauma and addiction. It 
is therefore cost effective and programmatically practical to anticipate multiple 
returns to treatment. 
.. Create a coordinated response to Domestic Violence: The City of 
Philadelphia should follow the model of several other cities, e. g., Chicago and 
Boston, and create a coordinated response on domestic violence, by creating a 
Task Force composed of key officials from the Philadelphia Police Department, 
Philadelphia District Attorney’s Office, Family Court, Health and Human Services, 
Recreation, and provider agencies and advocates 
.. Create a training institute, using a model such as BHTEN, to develop and 
coordinate cross-systems training and appropriate resource material. 
Include in contracts with Providers a schedule of training and give appropriate 
professional education credits. The training should be trauma-informed and 
culturally competent. The institute should provide training that includes: (a) 
Systems capabilities: the legal mandates, mission, treatment philosophy, 
organizational structure, and service delivery of its provider organizations (b) 
Legal procedures and processes that flow from legal mandates, and legal 
services that are available to assist families in these proceedings. (c) 
Professional development on current research and best practices 


Finding 2 
Addicted women have histories of abuse and deprivation, are socially isolated, 
exhausted and grieving. 

Recommendation 
.. Develop community-based women’s centers: Providing structure and support 
for isolated women in a community context will facilitate empowerment and 
access to services, and reduce the isolation of addicted women in the 
community. Explore ways to use existing community centers to develop or 
expand social and recreational activities for women, and for women with their 
children. These centers can help transition women to needed health and human 
services, and also provide activities to help sustain sobriety for those who are in 
recovery. Investigates places where women currently congregate, e.g. 
Laundromats, grocery stores, manicurists, to see if services could be co-located 
there, or use the model of the Momobile, to communicate the existence of social 
and recreational activities, as well as social and health services at these types of 
locations. 

Finding 3 
Appropriate consumer education material about addiction and trauma does not 
exist. 

Recommendations 
.. Develop a communication strategy to increase understanding of trauma 
and addiction: We recommend that Estelle Richman, Managing Director of 
Philadelphia, contact Oprah Winfrey and request that she use her production 
company, Harpo Productions, to develop a communications strategy to help 
women understand addiction, trauma, and healing and “ why they do the things 
they do." Oprah Winfrey is perhaps the most influential woman in America today; 
and her ability to communicate with vast numbers of people, primarily women, is 
unparalleled in popular culture. One of her most enduring contributions has been 
her openness about her childhood sexual abuse and the behavioral impact it had 
on her, including eating disorders and obesity. She not only understands the 
connections between behavior and trauma, but she and her production company 
know how to communicate difficult subject matter effectively. We believe that she 
would take seriously a request from a person of Estelle Richman’s position, 
stature and reputation. 
.. 
Develop consumer information on addiction and violence that is trauma 
informed. Consumers need the structure of hearing a consistent message from 
the provider community about trauma and addiction, and the way to view 
themselves in the context of recovery. Misinformation and mixed-messages 
dilutes the impact of the treatment for consumers. Home visitors, case managers, 
treatment providers, lawyers and other workers who work with families affected 
by addiction can distribute the material. 


Finding 4 
Most pregnant substance abusing women do not receive substance abuse 
treatment. 

Recommendations 
.. Set up regular meetings among health care stakeholders. Regular meetings 
with representatives from the behavioral health system and with the hospital 
department chairs of OB/GYN, and Pediatrics, The Philadelphia Perinatal 
Society, public health commissioner, doctors from healthcare centers should take 
place. 
.. Reinstate social workers in prenatal and delivery settings. If hospitals are 
unable to pay for this service, consideration should be given to having HMO’s, 
including CBH pay for it. 

Finding 5: 
Case workers and home visitors who provide services to children lack appropriate 
tools, training and professional development to address violence and addiction. 
Recommendations 
.. Provide a trauma informed checklist for home visitors. Home visitors need a 
structured way to approach addressing addiction and domestic violence needs. 
A clear protocol of areas to address, services for referral and steps for follow-up 
will provide a consistent message for consumers 
.. Develop “team network” for home visitors: Models exist that put the home 
visitor in the context of a full inter-disciplinary treatment team, thus expanding 
their ability to respond to the complex situations encountered 
.. Provide trauma-informed parenting education programs (see model 
curriculum at Appendix 3) 
.. Expand mobile therapy options: Providing more mental health mobile therapy 
options as well as expanding mobile therapy to include substance abuse 
treatment will improve accessibility of services for vulnerable mothers. 
.. Provide accurate training about parenting issues and children’s behavioral 
issues for workers: Through the Training Institute recommended above, 
workers should receive thorough training about parenting issues and children’s 
behavioral health. 
.. Create materials for consumers that help them understand their children’s 
behavior: Through developing consumer materials recommended above, 
consumers will receive information that helps them to understand children 
behavior and their parenting role. 

Finding 6 
Women need gender-specific, trauma informed substance abuse treatment. The 
women’s-centered treatment programs in Philadelphia provide the most intensive 
intervention for adult women in the entire health and human service delivery 
system. 

Recommendations: 
.. Assure that all substance abuse treatment programs serving women 
understand gender and trauma and provide gender-specific, traumainformed 
treatment for all women seeking treatment. 
.. Create a consortium of women’s treatment programs: A consortium will 
enhance professional development about “best practices” and coordinate 
services, such as housing and legal assistance. The city can also assist in 
securing grant and federal funding to research their practice methods and to 
follow families involved with the drug treatment system for an extended period of 
time. 
.. Create more women’s-centered behavioral health treatment programs. 

Finding 7 
Children whose mothers are in treatment have not received adequate intervention. 

Recommendation 
.. DHS needs to continue its important inter-agency initiative. The 
coordination of efforts between DHS and the behavioral health system reduces 
fragmentation in service delivery. This linkage between child protective services 
and behavioral health has potential to improve system integration and 
cooperation, by expanding the knowledge and practice base. Many social 
services outside of substance abuse services do not understand the treatment 
field or believe that treatment is effective or that appropriate intervention can 
occur. Similarly, the substance abuse treatment field has not been effective in 
providing competent services to children whose mothers are being treated. Their 
combined efforts in this project should prove to be very meaningful. 

Finding 8 
Residential treatment programs do not have the resources to address women’s 
health care needs or provide appropriate “aftercare” to prevent relapse. 

Recommendations 
.. Help secure funding so that the Nursing Consortium can provide on-site 
health care and health education. We have approached the Nursing 
Consortium. Nurses and midwives are the most appropriate health care 
providers for this population, and have histories of providing care in residential 
facilities such as homeless shelters. In addition, mapping indicated that the 
existing nursing centers are located in proximity with the residential programs. At 
this time, the nursing programs are not “federally qualified health centers” 
(FQHC) and have reimbursement rates that are too low to provide the services of 
a FQHC. Two approaches to the problem are underway: (1) The Nursing 
Consortium has prepared a foundation proposal to provide onsite care and 
education at the residential treatment centers, and ongoing connection to centers 
upon graduation. With the current enhancement of services underway, we think 
we can convince a foundation to fund these services, provided a sustainability 
plan can be developed. (2) Sustainability will include plans to have the nursing 
centers become eligible to be FQHCs. We have learned that nursing centers can 
currently qualify for FQHC if they collaborate with local community health 
centers. 
.. Create an “aftercare” specialist who will be a troubleshooter for women 
leaving residential treatment. This position would be designed to be a bridge 
for the consumer back to the place of greatest safety and success. It is also 
hoped that the aftercare specialist will be able to develop an alumni group that 
can eventually be used as mentors for recovery and hopefully develop leadership 
for more public advocacy. This position would not be designed to be a case 
manager or supplant existing case management services nor interfere with 
current “step down” treatment. 
.. Need for systems-wide training in trauma is necessary so providers and 
consumers can fully understand the behavioral impact and self-medication 
that flows from the traumatic injuries of sexual and physical abuse: The 
staff in the network of women’s treatment services should have comprehensive 
training to help them understand the interaction of violence-induced trauma and 
substance abuse and the impact on the organization of working with traumatized 
women and children 

Finding 9 
Lack of childcare and transportation are serious barriers to obtaining outpatient 
treatment. 
Recommendations 
.. Provide actual transportation to outpatient programs in the following ways. 
• Provide funding for vans or other van services, 
• Provide funding for taxi vouchers 
• Implement the ICM (Intensive Case Management) model that mental 
health and MPP (Maximizing Participation Project) use which includes 
transporting clients to appointments; 
.. Provide babysitters at home or set up on-site child care at treatment 
centers: Provide babysitters at home for woman who are exhausted and unable 
to travel to treatment or set up on-site child care, preferably therapeutic child care 
at treatment centers 
.. Provide more behavioral health mobile therapy options for mothers who 
cannot physically get to treatment. 

Finding 10 
The mental health problems of pregnant and postpartum women and children are 
not appropriately addressed by the behavioral health system. 

Recommendations 
.. Open a residential program, preferably associated with a psychiatric 
facility, for severely mentally ill pregnant and postpartum women and their 
children. 
.. Assure that mental health providers are properly trained in the field and 
practice of trauma. 
.. Create group therapy opportunities for women. 
______________________________________________________________________ 
APPOINT A TASK FORCE TO MONITOR THE IMPLEMENTATION OF THE 
RECOMMENDATIONS OF THIS REPORT. 

My mom and dad fought 
so much they left blood 
on the walls. 

I was caught in the cycle 
of probation and jail time 
and drugs. I’m in 
treatment now…

I started drinking at 17 because my 
boyfriend wanted to touch me and I 
couldn’t stand being touched because my 
father molested me. I thought if I took a 
drink, it would be easier and that was the 
only way I could allow my boyfriend to 
touch me. I have been in a fog ever since. 

After you complete 
treatment you just get cut 
off from services and six 
months is not enough time 
to heal your life and your 
child’s life. 

I was five when I took my first 
drink. My family was all 
drinking and so I didn’t know 
any better.”

The program is too short 
– it took so many years to 
get into addiction and they 
are expected to get out in 
9 months. 

Women wept openly at a 
Working Group Meeting on child 
custody proceedings when they 
learned that it was highly unlikely 
that they would regain custody of 
their children. 

She finished six months of our residential 
treatment program and was living on her 
own when her abuser came after her. 
Our counselor called the Domestic 
Violence hotline and there was no room 
at the Women Against Abuse Shelter. 
She didn’t want to go to a homeless 
shelter because she was afraid she would 
start using again. He killed her. 
I have a lot of guilt about my 
children who were put into 
foster care and adopted. I feel 
like I could have done 
something.

My life is still on hold because 
I owe money to PHA therefore 
I cannot get public housing 
and my children are acting out 
because they are stuck in the 
system with me. 

I was hanging around with prostitutes 
and realized I was just like them. I had 
always felt superior to them because I 
did not have to do tricks to get my 
drugs. But now I was like them.

“What’s CBH?” 
question posed by OB 
physician during a 
focus group. 
I was losing everything, 
including my baby and 
that’s when I knew that 
I had to get into 
treatment. 

I need to get my life 
together so I can be 
with my son. 


…we all ‘know’ these 
women need to hit 
bottom before they 
will benefit from 
treatment. I’ve seen 
it again and again… 
I don’t care what you 
say the research says, 
I don’t believe it …

My whole family is alcoholic. 
My son is alcoholic and his 
children are being raised by 
a woman in recovery.

I haven’t used… now what?

I was sick of being sick 
and tired.

You can call your report “four dead 
babies” because I know of four cases 
where appropriate services simply were 
not available for mentally ill new mothers 
and everyone knew it before anything 
harmful happened to the baby. One 
woman was referred to us, but it soon 
became apparent her severe mental health 
problems prevented her from functioning 
in a therapeutic community. When she 
decompensated and was sent to an 
emergency psychiatric placement, I told 
the caseworker that she was unable to 
care for her newborn. I later learned she 
was sent home, because there was no 
other facility for her and the baby. The 
baby died.