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Best Practices: Treatment and Rehabilitation for Women with Substance Use Problems
6. General Barriers To Treatment
6.1 Introduction
Barriers are those factors which impede entry into treatment or impede treatment continuation (Smith, 1992:8). It is recognized in the literature that although women more readily seek help for health and social problems than men, they are less likely to approach specialized treatment programs, at least initially (Thom, 1986; Schober and Annis, 1996). The following sections describe barriers associated with access to specialized substance abuse treatment services.
6.2 General Barriers to Treatment: Key Expert Perspectives
Key experts identified barriers to treatment in four main areas:
- personal barriers-related to a woman's personal attitudes or situations;
- interpersonal barriers-related to family or peer relationships and attitudes;
- societal barriers-related to broader community/societal attitudes or barriers;
- program/structural barriers related to program organization or structure.
Key experts identified four main personal barriers impeding access to treatment:
- Shame and guilt. Key experts noted that there is a high level of shame and guilt experienced by women who acknowledge problems with alcohol and other drugs. This shame is associated with society's rigid role definition of "a good mother" and
- historical attitudes toward women who drink. Many women incorporate these attitudes and feel shame for not meeting what they perceive to be society's expectations.
- Problems acknowledging the impact of use. Women may have difficulties acknowledging problems with alcohol and other drugs. Sometimes they do not recognize the severity or impact of their substance misuse; there may also exist a certain stereotype of alcohol problems which is rejected as not being applicable.
- Fear of losing love and support or of being isolated. Key experts indicated that many women fear acknowledging substance use problems and attempting treatment because they fear isolation, loss of love, support and security. These fears are exacerbated by the dependence many women experience within relationships.
Being emotionally dependent they fear the loss of the relationship - they're terrified to be alone.
- Being overwhelmed by other personal issues and problems. For a significant number of women with alcohol/drug problems, addressing these problems is not a priority when considered in relation to other personal problems such as substandard housing, spousal violence or general impoverishment.
There was a significant level of key expert consensus around two interpersonal barriers affecting access to treatment.
- Fear of losing children. Most key experts identified women's fears of losing their children to their partners or child welfare as a central reason for not accessing treatment. Key experts described this fear as "immense." Many women have total responsibility for their children. They fear having to give their children to child welfare (in order to enter residential treatment) and "never getting them back."
These women have no recourse but to depend on Health and Social Services and have their kids put in care-the fear of having kids apprehended and having their "history" tainted after having their kids in care.
- Lack of family support. A lack of support from a husband, partner or family is another barrier for women needing treatment. The lack of support may be based on the family's denial or shame or on an abusive relationship which supports dependency.
Partners are sometimes abusive and women often get into drugs with a male partner and the male is still using and may not want her to get treatment.
6.2.3 Community/Social Barriers
Key experts also believe that women are more seriously penalized by society (e.g. threatened with loss of children) for seeking treatment.
- Social stigma. Key experts believe that, in general, society views women who misuse substances more harshly than men. This makes the open acknowledgement of problems and needs difficult.
6.2.4 Structural/Program Barriers
Key experts described a wide range of structural/program barriers related to treatment availability, organization and flexibility.
- Lack of reliable and low cost child care. According to respondents, women worry about finding appropriate and inexpensive child care while they are in treatment. "What do I do with my kids?" is a primary consideration for women contemplating treatment.
- Costs associated with treatment. For some women, there are direct (partial fees) or associated (child care, transportation, wage loss) costs which make involvement in treatment difficult.* The geographical isolation of some women increases the burden of these costs. There is also typically no way to compensate for the wages of working women (who may be the sole support parent) while they are in treatment.
While some programs may provide adjunctive services (e.g. child care) at minimal or no cost, many lack the funding to provide these services.
There's a lack of funding for treatment centres and a lack of funding for those agencies providing transport, child care and in-house infant centres.
Along with child care, transportation costs were highlighted as significant barriers.
- Lack of appropriate treatment services for women. There was a strong consensus of opinion among key experts that a fundamental barrier for women is the overall lack of treatment services available to women who require or request them. Canadian key experts cited the lack of the following types of services:
- women-centred, gender-specific services (or treatment with clearly defined components for women);
- services which are safe and provide protection from harassment and fear; - Treatment cost may vary jurisdiction to jurisdiction. In some provinces there are no costs for treatment services.
- services which are widely distributed and geographically accessible;
- services which are cost free. - A lack of flexible services. There was also a strong degree of consensus among key experts that treatment services often lack flexibility and are not able to meet the real needs of women. Treatment should:
- have flexible entry criteria and not insist on complete abstinence at intake;
Policies that dictate amount of time a woman must be clean before (she) can access program/have to cure self before allowed into treatment (do not support treatment access).
- offer flexible scheduling (alternative treatment schedules, 24-hour intake, short-term programming) which respects the personal and working needs of women and their families;
Women are usually offered day-time programs, perhaps they need evening programs.
- be immediately responsive to women when they have identified a need or willingness to participate in treatment. - Insufficient and inaccessible program information. Respondents noted that women are often unaware of the treatment options that exist, or of what is included in treatment. This lack of awareness is more common within sub-group populations (e.g. ethno-cultural minority or isolated and rural women). Programs lack effective outreach and publicity strategies to overcome these barriers (see Section 7.0 Client Outreach, Contact and Engagement).
6.3 Barriers Experienced by Specific Groups: Key Expert Perspectives
6.3.1 Pregnant and Parenting Women
Key experts identified the following barriers as specific to pregnant and parenting women.
- Fear of losing children. The possibility of losing children, of having to put children in foster care or of having a record with Health or Social Services which could jeopardize the family in the future were noted as the primary barriers for this group.
- Lack of specialized child care services. Women who are parents may need child care services in order to participate in treatment.
- Lack of specialized support or treatment services for children. Children also may require specialized treatment services which address the impacts of parental substance misuse.
Older kids (7 - 8) are parenting themselves at such a young age-they need help to learn how to be children again.
- Stigma attached to mothers misusing substances. Mothers who misuse substances are judged more harshly than other women. Although this is a general attitude, it is also manifested by some others in the treatment field (e.g. some treatment staff and allied professionals).
- Internal feelings of fear, guilt, grief and shame. Although key experts noted that all women have shame and guilt around substance use, these feelings are intensified in women who are pregnant and who are concerned about the harm they may have brought to the fetus or to their children. This fear and guilt may result in difficulty acknowledging a substance use problem or in avoidance of treatment.
- Lack of specific programming for pregnant women. Key experts noted that pregnant women have specific programming needs which cannot be met in traditional women's programs. They typically require:
- priority admission;
- attention to medical problems which may result from pregnancy;
- information and education around prenatal health, child birth and postpartum care;
- information and services related to fetal alcohol syndrome/fetal alcohol effects (FAS/FAE).
Key experts identified the following barriers as specific to Aboriginal women.
- Cultural barriers and lack of Aboriginal specific programming. Aboriginal women have specific ways of interpreting life and change that are often not understood or incorporated by mainstream programs. These typically include attention to spiritual values and participation in traditional ceremonies such as healing circles or sweat lodges. Aboriginal women may also be more comfortable with oral traditions and value contact with elders. As well as not being culturally appropriate, most programs lack Aboriginal staff.
- Lack of gender-specific programming. According to key experts, gender-specific programming is particularly important for Aboriginal women. Gender-specific programming is seen to provide more safety, freedom from harassment and the opportunity to explore past relationships more openly.
- Lack of community support and modelling. Aboriginal women may come from communities where there is a lack of support for recovery or where their own efforts in recovery go unrecognized. The use of positive Aboriginal role models needs to be enhanced.
Several key experts noted that the political structure of some Aboriginal communities is male dominated. This context may result in women's issues being minimized or discourage women from speaking out about their problems.
6.3.3 Ethno-cultural Minority Women
Key experts identified four main barriers affecting ethno-cultural minority women. These are:
- Cultural structures, beliefs or values which discourage acknowledgement of alcohol and drug problems or seeking formal treatment. Women may live in cultural environments that do not acknowledge the existence of women's drinking or drug use. Prohibitions against substance misuse among women may be so strong that women are afraid to acknowledge problems with substance use.
There are cultural taboos about women using alcohol and drugs. A woman came in for treatment and she said that she could not tell her family or cultural community that she had a drinking problem as drinking itself was unacceptable.
In societies where men are the head of the household, women may fear the implications of speaking out. Other women may support this pattern of denial.
We're dealing with cultural aspects with families that restrict them getting into treatment. In some cultures, spouses and mothers-in-law don't allow this.
In some cultures, it is expected that internal, informal methods will be used to address problems.
- Language barriers. Language barriers significantly affect access to treatment. Programs typically lack ethno-cultural minority staff and translation is both costly and difficult to arrange.
- Lack of culturally specific programming. Key experts described an overall lack of treatment programming specifically designed for minority women which addresses language and cultural barriers. Programs which do exist are not culturally responsive due to a lack of ethno-cultural minority staffing, inability to address language issues or incorporate cultural content.
- Lack of effective, culturally appropriate outreach. Key experts noted that ethno-cultural minority women tend to be isolated and not be in touch with
"mainstream" health treatment or social service agencies. Outreach needs to focus on developing connections to organizations that support minorities in order to increase accessibility.
Three major barriers to treatment were identified by key experts.
- High degree of stigmatization by society, other clients and staff. Key experts noted women who inject drugs are highly stigmatized within the drug culture. They are perceived as the "lowest" in the drug-using hierarchy by other drug users because of their lifestyles and involvement in other risk-taking behaviours (e.g. prostitution).
Women who inject drugs experience these negative attitudes as judgmental and discriminatory. Perceived attitudes of staff and other clients may be a disincentive to treatment involvement.
- Occurrence of serious and/or multiple health problems. Many people who inject drugs have serious long-term problems such as HIV/hepatitis, which the staff may not be able to address within traditional treatment settings. Staff also may not have the training to deal with the serious medical or social problems presented by this group.
- Lack of appropriate treatment to meet specialized needs. Key experts noted that there is a lack of creative and relevant treatment programs available to women who inject drugs. Treatment approaches which would be more relevant to this group include:
- a harm reduction rather than abstinence approach, particularly at the treatment intake stage;
- greater availability of methadone maintenance;
- longer and more appropriate withdrawal management services (particularly stressed as being required in remote and/or northern communities);
- specialized treatment resources for sex trade workers.
6.3.5 Women Living with HIV/AIDS and Hepatitis C
Women with HIV/AIDS face barriers to treatment related to the isolation and stigma connected to their disease. Key experts described the most significant barriers for this group as:
- Fear of acknowledging the disease to treatment providers or to others in treatment.
Clients with AIDS are not certain how they will be accepted in treatment. Although most staff are well informed, some may fear clients with HIV/AIDS or lack understanding of the disease. Those with HIV/AIDS also fear acknowledging the disease to other clients who may ostracize them.
There's a whole stigma attached-they can't be open, yet program says that they have to be open.
- Isolation. Respondents described women with HIV/AIDS as being isolated and lacking in support. They are often homeless, find it difficult to connect with other women and lack support systems and community resources that can address their needs.
The social services for these women are almost non-existent.
- Hopelessness. Respondents noted that a sense of hopelessness is a barrier to active treatment involvement of this group. The overall outlook and values of these clients are quite different ("Why care when you are dying anyway?"). An abstinence-based philosophy may be the least appropriate for this group.
6.3.6 Women with Concurrent Substance Use and Mental Health Disorders
Key experts identified many barriers affecting women with concurrent disorders. There was consensus around the following issues:
- Inadequate diagnostic services/poor or incomplete diagnoses. A large number of key experts noted that women with mental health disorders are poorly diagnosed at intake by both the mental health and alcohol/drug treatment systems. Substance abuse programs may not have the staff expertise to provide comprehensive mental health assessments. Mental health staff may overlook addictions problems.
A woman comes in (to a mental health service) with acute depression and anxiety and is suicidal-often the dependency is overlooked.
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There is a lack of training in psychiatry for alcohol and drug counsellors. Interplay between mental health and alcohol and drug abuse is not understood by counsellors. They think that if alcohol and drugs are eliminated, then mental health issues will go away.
- Lack of coordination and integration between mental health and addictions services. Key experts noted that there is a lack of coordination between the mental health and addictions systems which affects client access to treatment. This is characterized by:
- a lack of staff in both systems who are trained to recognize and assess both problems;
- a lack of system "agreement" on which problem or issue needs to be treated first;
- a lack of ability of addictions programs to clinically manage or support women who may be taking medication;
- a lack of coordination between systems which leads to clients being bounced back and forth between systems. - Isolation. Women with concurrent problems are highly isolated. They often lack personal and family support and may fear entering treatment which involves outreach to others.
There's the belief they don't fit in-isolation, hopelessness and helplessness.
6.3.7 Women in Prison or Involved with the Criminal Justice System
Respondents identified four barriers affecting women in the prison system.
- Lack of services within the prison system. It was the perception of key experts that women who are incarcerated have limited access to treatment services in prison settings.* Where treatment services do exist, they may not specifically be designed to meet the needs of women.
- Restricted accessibility. Key experts noted that women may be restricted from accessing programs, both from the criminal justice system and community program side. The criminal justice system may make access to treatment difficult for clients while they are involved with the legal system. Parole or probation staff may not refer to community-based treatment resources because of workload problems. Treatment programs themselves may restrict entry to women until their prison term is completed.
Many agencies insist that prison terms be finished before (a woman's) treatment starts, (the pattern) should be reversed, (programs) need to go into the prisons.
- Inability of clients to use treatment effectively. Key experts noted that women from prison settings have more difficulty becoming involved in treatment because of adjustment issues faced in the community. They may have unrealistic expectations of recovery or difficulties handling treatment expectations (they may be lacking in self-discipline or be unable to set or follow through on goals).
- Lack of continuity between programming within the prison setting and those in the community. Key experts noted that there may be a lack of continuity between programming within the prison setting and programming in the community.
- Lack of trust in treatment staff and setting. Some key experts noted that women who have been involved in the criminal justice system have difficulty trusting the treatment environment which requires openness and disclosure. Programs (both correctional or within community-based settings) may be perceived as being part of a punitive system. As a result, treatment compliance may be poor.
6.3.8 Marginalized/Homeless Women
Women who are marginalized or homeless face a range of barriers affecting treatment.
- Poverty, lack of housing and need for other basic life supports. Poverty and lack of housing are major impediments to treatment. Women who are struggling to meet basic needs do not search out treatment. A lack of money for transportation, food and telephone all contribute to isolation. Key experts also stressed that clients are unlikely to access treatment without safe and secure housing.
- Lack of appropriate "gateways" to treatment. Key experts noted that homeless women are unlikely (for reasons cited above and contributing problems such as the presence of concurrent disorders) to access traditional out-patient or residential treatment. It is difficult for them to make appointments or travel to offices of social workers or other professionals. They require the provision of immediate "upfront" resources (e.g. outreach or storefront services) and are alienated by formal, more highly structured or rigid programs.
There is a lack of formal efforts to address their alcohol and drug issues without going as far as full treatment (e.g. day stabilization program where women can drop in on a daily basis). Steps are too big for them to take.
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Isolation. Women who live on the street are often isolated due to poverty, lack of housing or the presence of concurrent disorders. This isolation makes contact with treatment services difficult.
It's difficult to access treatment without a phone, difficult to call, difficult to follow up.***
Isolated-if not connected to social services, don't know what programs are available.
6.3.9 Women Living in Rural Communities
According to key experts, barriers to treatment experienced by women living in rural communities include:
- Lack of confidentiality and privacy. Acknowledgement of alcohol/drug problems is particularly difficult in small communities where social networks are small and interconnected, and where there is a lack of privacy and confidentiality. By acknowledging problems with alcohol or drugs, women risk not only their own reputations but those of their families and children.
They are afraid to be identified by neighbours. They even fear picking up a pamphlet because someone will see and spread the news.
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The issue of accessing treatment in small towns is confidentiality-and if they leave their community to go to residential treatment there are still questions about where they are.
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There are confidentiality issues-some of their own family members may be employed at the treatment centres.
- Isolation/Lack of awareness of services. Women who live in rural or geographically remote communities are isolated and may not be aware of or able to access services.
- A lack of transportation (or the funds to pay for transportation). A lack of transportation to treatment is a major barrier for rural women.
- A lack of services which are accessible, flexible and women oriented. There are fewer treatment services of any type available to rural women. Rural women also lack services which are flexible and responsive to their needs.
Intervention in programs are bigger than what they need because they have to go to residential centres.
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There aren't enough flexible services-most rural women would prefer out patient services and these are not available in rural areas.
To access services, women are often compelled to leave their communities and assume the costs associated with housing, transportation and child care. In many cases, adjustment to a different (urban) setting is difficult.
* Alcohol/drug treatment is provided within the federal correctional system.
