Best Practices: Treatment and Rehabilitation for Women with Substance Use Problems

7. Client Outreach, Contact and Engagement^*

7.1 Client Outreach, Contact and Engagement: Key Expert Perspectives

The literature suggests that women typically do not contact specialized treatment services directly but are referred through mental health, social services, health organizations or their own physicians. This appears to be due to factors such as shame, stigma and denial or the way substance misuse is defined. Key experts identified a number of best practices to support women's early engagement in treatment.

• In this section and those that follow, tables of effective programming elements are not in order of importance
• The development of a multi-dimensional publicity/outreach strategy which is informative, accessible and non-stigmatizing. There was a strong degree of key expert consensus that outreach strategies needed to be carefully formulated to address women's needs and fears. The elements of an effective treatment publicity strategy are described below.

As noted by one key expert, program publicity should provide women with a sense of empowerment.

Don't say "you have a problem" but very specifically address the behaviour and say "here is what you can do about it." Give women some control, some helpful information.

• The building of a collaborative approach with physicians which would strengthen referrals. Physicians are typically a first point of contact for women experiencing health or mental health problems. However, physicians make comparatively few referrals to specialized treatment programs.
  

Health care workers need to "end the conspiracy of silence" after these women go to see their physicians, and the physicians need to screen for dependencies.

• The creation of strong linkages with other community organizations serving women.
  Linkages could include training and support of treatment-related staff, exchange of information (about client needs and characteristics or program resources) or placement of workers in other organizations.
  

Through prevention done in the schools, kids bring home an invitation to parents inviting them to workshops.

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Teen women are at high risk of getting into drugs and prostitution so having a Youth Worker at the friendship centre is really beneficial.

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Provide some consultations to these workers: Street workers, van workers, mental health workers.

• Direct outreach to sites where potential clients live or work. The physical presence of workers on the street is particularly important for Aboriginal, street involved or ethno-cultural minority women.
  

Go right into their homes-in a community is easy-do a survey (door to door) with help in community (to provide publicity).

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Aboriginal women-going into their site (cultural centre) is very important-they see providers' interests that way.

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Go into the jails and hospitals to see them.

• Provision of a menu of treatment and treatment-related services. Key experts stressed the importance of providing a menu of options which women can assess and select according to their needs.
  

Have flexible options (in-patient, day treatment out-patient) and let women choose the option, based on what her life is like.

Options should be based on a range of choices not solely related to treatment.

Give them what they are asking for when they need it-really listen to what she's asking for and give it to her in the order she asks.

• The provision of treatment which has flexible and open entry criteria (non-abstinence related). Abstinence should not be a requirement at the treatment contact stage. An acceptance of the woman's current situation, an understanding of relapse and a focus on harm reduction are more appropriate at the treatment engagement stage.
• The provision of women-centred, culturally appropriate treatment. There was strong consensus around the need for women-centred programming which addresses women's situations, needs and values. Treatment should also respect cultural and language differences and incorporate culturally responsive elements.
• The provision of realistic and realizable treatment information. Initial treatment information and expectations must not overwhelm women. Treatment goals should be realistic and plans to achieve them realizable.
• The need for an "empowerment" approach to treatment. Key experts identified an "empowerment" approach as the most effective way of attracting women to and engaging them in treatment. The elements of this empowerment model (as described by respondents) include:

- giving women the opportunity to define their own needs;
- respecting women's choices;
- helping women access the range of treatment options they require;
- using a Stages of Change model to explore where women are at and where they want to go;
- staff trusting in the ability of women to make positive life decisions;
- helping women to reframe their experiences in a non-judgmental way.

Conceptualize behaviour rather than label it-have women understand their using in terms of how they cope with their lives-validate their experiences, their addiction as a coping mechanism rather than shaming them.

• Provision of timely and (structurally) accessible treatment. Key experts also stressed the importance of providing easily accessible and timely services through:
  - the provision of practical supports which help them access treatment (bus, transport costs);
  - user-friendly treatment structures (e.g. one-stop shopping for treatment services).

7.2 Treatment Outreach, Contact and Engagement: Literature Review

The literature on treatment contact and engagement is integrated with the literature identifying barriers and optimal treatment approaches. An extrapolation of this literature identifies the following best practices in the area of treatment outreach and engagement.

• The importance of active assistance with treatment referral and entry. Booth et al. (1992), in a study of treatment entry of males and females who inject opiates, found that the active assistance of staff at treatment entry (scheduling intakes, assistance with providing transportation and waiving admission fees) was more closely associated with treatment entry than a less proactive approach (although overall rates of treatment retention for this group were low).
• The importance of active contact with community outreach workers. Booth et al. (1992) also concluded that clients who had had contact with community outreach workers were more likely to have entered treatment than others.
• Use of high-intensity referrals. Loneck et al. (1997) found that "high-intensity referrals" are more effective than "low-intensity" referrals at engaging and retaining women in treatment. A high-intensity referral is a therapeutic technique where members of a woman's social network use an intensive approach to discuss the impacts of drinking. Members of the network are trained and impacts are expressed with care and concern. This approach strengthens client motivation in a non-judgmental way.

The authors note that some high-intensity techniques can be coercive. Appropriate safeguards must be put in place to ensure that these techniques do not perpetrate oppressive relationships.

• Education of and liaison with key referral sources. Thom (1986), Smith (1992) and Allen (1994) noted that women's pathways to treatment differ from those of men in several ways.
  

Women tend to seek help at non-specialized services for general and specific reasons. They are more positive about health and social services. In general, women:

Use the services of mental health hospitals, community mental health centres, general hospital in-patient and out-patient psychiatric facilities more than men do. (Russo and Sobel as cited in Smith, 1992:4)

They are also less likely than men to seek help initially at specialized agencies. "Instead women prefer consulting physicians or mental health clinic staff . . . (where) their problem is less likely to be diagnosed as alcohol abuse." (Beckman, 1994b:208)

There are also differences in treatment engagement within different classes of women.

Female alcoholics used services in ways similar in (sic) other groups in terms of socio-economic status; that is, middle and upper class female drinkers were more likely to seek medical and psychiatric services for their alcohol problems. Women of lower socio-economic groups presenting with multiple problems turned to professional health care only when informal systems were exhausted (Marsh and Miller as cited in Smith, 1992:4).

Smith (1992) noted that general practitioners fail to detect alcohol problems or misdiagnose a substantial proportion of patients with alcohol use disorders. In a study by Thom and Tellez (as cited in Smith, 1992), doctors were asked about their approaches to patients with alcohol problems. Because doctors felt largely pessimistic about resolving the problem, they were inclined to look for other explanations for drinking problems which do not require treatment.

• Agency characteristics. Certain agency characteristics appear to be associated with client engagement in treatment.

Swift and Copeland (1996), in a national survey of treatment needs and experiences of 267 Australian women who had received treatment, identified the following program characteristics as important to women:

• reputation of treatment program or recommendations from someone else (23%);
• location of agency close to home (16%);
• low cost and approach of program (11%);
• women-only orientation of program or safety (6%);
• provision of child care (8%).
  
  

 Provision of family counselling. Women are often discouraged from taking part in treatment because of family opposition, inability to perceive drug use as problematic or because partners also misuse substances (Thom, 1987).

The opposition of family members to treatment and, consequently, the disruption of family relationships are part of the "social costs" associated by many women with alcoholism treatment. (Beckman, 1994b:208)

Family therapy may play an important part in involving resistant family members in the treatment process (Smith, 1992). Sommers and Travis (as cited in Schliebner, 1994) noted that involvement of family and friends can support family and assist women to explore new self-concepts. However, Beckman (1994b) noted that the family support in treatment must be empowering to women.

• Broad approach to outreach. Finkelstein et al. (1997) identified the following broad outreach strategies as being most effective. Strategies include both a process to address barriers and appropriate deployment of staff. Outreach strategies include:
  - determining an outreach response which addresses the specific barriers women face. This would involve a detailed analysis of barriers and exploration of appropriate responses to these barriers;
  - training professional caregivers in the early identification of client problems and needs;
  - making community presentations on substance misuse and program resources;
  - employing community outreach workers.

She particularly noted the importance of assisting health care professionals to screen and refer women.

Reed (1987) also stressed the importance of a broad approach to outreach.

Outreach should target these people who see women regularly (hairdressers), who work with their children or who have some influence with them (e.g., clergy, key family members).

Many women respond well to direct outreach efforts (e.g., TV spots, ads) (Reed, 1987:160).

• Provision of direct resources to those who require treatment. Provision of direct resources is also related to client engagement. Hagan et al. (1994) noted that women often experience poverty and role devaluation. In one study of admissions, it was found that the provision of housing in lower-income groups of drug-dependent women may be associated with positive engagement in treatment and assist in the initial stages of recovery.
  
• Accessibility and availability of treatment. Waltman (1995) identified several pre-conditions for effective treatment (for both men and women) related to treatment accessibility. The elements of accessibility include:
  - immediacy of treatment-treatment begins at the referral stage;
  - availability-open admission;
  - convenience-close to population, near public transportation, availability of satellite offices;
  - accommodation of needs-informal drop-ins, services offered every day of the week, 24-hour services, provision of adjunctive services;
  - acceptability-staff who can address cultural needs, strong linkage with community groups, program components which meet special needs.
  

• Flexibility of treatment. Flexible treatment services are particularly important to certain populations such as women with concurrent substance use and mental health disorders. Grella noted that:
  

Individuals with co-occurring psychiatric and substance abuse disorders often follow a pattern of service utilization that has been characterized as "interrupted treatment." An ability to move in and out of treatment and ease of access to services are necessary to engaging or re-engaging women who are pregnant and parenting and who have co-occurring disorders. (Grella, 1996:329)

• Culturally appropriate treatment. Ja and Aoki (1993) noted that cultural adaptations within mainstream programs may not be sufficient to engage ethno-cultural minority groups in treatment. Treatment programs may need to be highly ethnic specific (to include ethno-cultural minority staff and cultural practices)