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Cat. No.: H49-153/2001E
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List of Tables
Table 1: Geographical Distribution of Key Experts
Table 2: Role of Key Experts: Women's Best Practice Study
Table 3: Types of Organizations Represented: Women's Best Practice Study
Table 4: General Barriers to Women's Treatment: Key Expert Perspectives
Table 5: Barriers Associated with Specific Groups
Table 6: Elements of an Effective Program Publicity Strategy
Table 7: Client, Outreach, Contact and Engagement
Table 8: Overall Principles and Values of Treatment: Key Expert Perspectives
Table 9: Optimum Treatment Approaches: Key Expert Perspectives
Table 10: Summary of Core Elements of Effective Treatment for Women
Table 11: Best Practices to Support Treatment Retention: Summary of Key Expert Perspectives
Table 12: Critical Services Identified by Key Experts
Table 13: Defining Effective Drug Use Treatment
Table 14: Model Program Elements
Janet C. Currie, Focus Consultants for Canada's Drug Strategy Division Health Canada
Project Director: Janet Currie
Special Consultant to the Project:
Research Staff: Susanna Jani Joanne Myers Peggie-Ann Kirk
Charlotte Coddington Geoff Gosson
Translation of document:
Les Traductions Houle Inc.
We would like to thank the following people for their assistance with this project:
This report identifies elements of best practice in the treatment and rehabilitation of women with substance use problems. Best practices are identified and described in the areas of: client outreach, contact and engagement, treatment principles, specific approaches and methods, client retention in treatment, treatment organization and duration, delivery of adjunctive services, and measurement of treatment effectiveness. Recommendations for best practices are based on the results of interviews with 40 key experts and a review of current literature related to these topic areas. Interviews with key experts and the review of the literature also addressed barriers to treatment for women.
The report briefly summarizes patterns and impacts of women's substance use. Characteristics of specialized population groups, such as pregnant and parenting women, Aboriginal and ethno-cultural minority women are also described.
Personal, interpersonal, societal and program-related barriers applicable to women requiring treatment are identified. Shame and guilt, fear of being isolated and of losing children, program limitations such as inadequate referral and outreach, and the limited availability of cost-free, flexible programming are some of the general barriers identified.
A range of specific barriers to treatment are described as applying to specialized population groups. For example, pregnant and parenting women are more affected by structural (lack of child care services) and personal (fear, guilt and shame which are intensified by the social stigma attached to mothers who use substances) barriers. Ethno-cultural women appear to be more affected by socio-cultural structures and beliefs which discourage acknowledgement of substance use disorders or utilization of formal helping systems.
The report describes 13 underlying principles of treatment, including the importance of offering a menu of treatment and related support options, the value of an approach that considers all aspects of a woman's life, including emotional, psychological and spiritual elements, and approaches that are women-centered, empowering and support connections between women.
The importance of addressing interrelated health issues, a gender-sensitive approach, client education, the value of using a "relational" model of treatment, a practical skill-building orientation, addressing family issues, a harm reduction approach, and a realistic view of relapse prevention and management are some of the treatment methods and approaches identified as best practices by key experts and within the literature.
Although the literature related to basic organization or structure of treatment is inconclusive, key experts, in general, prefer out-patient settings with residential treatment being available for women with more severe problems of long duration or those living in unsafe environments. There was consensus that the establishment of optimal treatment duration is dependent on careful assessment of client needs and matching clients to the range of treatment options, including brief treatment which has been found to be an effective approach for some women.
The report also identifies adjunctive services most critical to women's treatment and recommends structures for delivering these services.
Finally, the report addresses the issue of the measurement of treatment outcomes and effectiveness. Both the literature and key experts suggest that treatment "success" needs to be viewed and measured in a multi-dimensional way using a range of "quality of life" measures, client self-assessment, as well as reductions in substance use.
Summary tables of key expert-identified best practice elements are included in the report.
This report is organized into two main sections. Section I provides an introduction and background to the project, including study definitions, parameters and limitations of the project. Section II provides the results of the project, including results of both key expert interviews and outcomes of the literature review. Each sub-section is organized by topic area. Both key expert opinion and summaries of the available literature are presented within each of the topic areas.
This project on best practices related to substance abuse treatment for women was initiated by Health Canada as part of a three-year research agenda approved by the Federal/Provincial/Territorial Committee on Alcohol and Other Drug Issues.
The project was carried out under the direction of an advisory committee: the Working Group on Accountability and Evaluation Framework and Research Agenda of the Federal/Provincial/Territorial Committee on Alcohol and Other Drug Issues. The mandate of the working group is to develop recommendations for an accountability and evaluation framework for the Alcohol and Drug Treatment and Rehabilitation (ADTR) Program and to oversee the development and implementation of a research agenda which would stimulate innovative substance abuse treatment and rehabilitation programs by identifying best practices, evaluating model treatment and rehabilitation programs, conducting research on emerging issues, and disseminating leading-edge information across the country.
This project is being undertaken simultaneously with another project on best practices for the treatment and rehabilitation of youth with substance use problems. Both projects build on initial work undertaken by Health Canada in collaboration with the provinces and territories to address best practices in treatment and rehabilitation published as: Best Practices - Substance Abuse Treatment and Rehabilitation (Health Canada, 1999).
This report is organized into two main sections. Section I provides an introduction and background to the project, including project definitions, parameters and limitations. Section II provides the results of the project, including results of both key expert interviews and the literature review. Each sub-section is organized by topic area. Both key expert opinion and summaries of the available literature are presented within each of the topic areas.
The overall goal of this project is to:
The objective is:
Within this overall framework, the project addressed the following specific questions:
The project used two primary sources of information to identify best practices related to women's treatment. These were:
These sources are described in detail below.
Key experts were initially identified by members of the federal/provincial/territorial advisory group to the project and recommended on the basis of their familiarity with a broad range of women's treatment approaches and expertise in identifying optimal elements of treatment. Key experts comprised:
Forty alcohol and drug treatment experts participated in the interviews. They represented all areas of Canada, with the exception of Newfoundland and Yukon. Several key experts from the United States were also interviewed.
Key experts represented a variety of backgrounds, most were directors or coordinators of programs. The location and notes of key experts are shown in Tables 1 and 2.
|Location||Total Number of Key
Table 1 footnotes
|Prince Edward Island||1|
|Role||Number of Key Experts|
|Director of treatment program||16|
|Clinical or policy consultant||7|
|Other (related service provider)||1|
A range of treatment organizations was represented in the study. The types of programs represented by clinicians and program directors are described in Table 3.Footnote 1
|Type of Program||Number of Key Experts|
|Primarily detox programs||1|
|Multi-level programs (residential and out-patient) (in some cases includes detox)||11|
|Intensive day program||3|
|Policy and program development (range of services)||7|
|Other (e.g. research) range of services||6|
Key experts were interviewed by telephone using a detailed interview format consisting of qualitative questions. The interviews identified:
The interviews also addressed:
Key experts were given the opportunity to explore each question in depth, according to their own knowledge, expertise and background. Not all key experts responded to each question. In three cases, key experts requested to be interviewed in a group. Group responses were amalgamated into a "single" respondent response.
Quotes from key experts are used extensively throughout this document to illustrate or enlarge upon key issues. Quotes retain the vocabulary and emphasis of key experts.
Potential key experts were initially contacted by telephone. A fax was then sent explaining the background, purpose and content of the interview in more detail. The interviews ranged from 45 minutes to 2 hours in length; average interview length was approximately 1 hour 20 minutes. A fax was sent after the completion of each interview thanking participants for their participation.
A focussed literature review, primarily involving recent (post 1990) literature, was carried out in order to a provide a research-based perspective related to the topic areas defined above (Section 2.0). The literature review was not intended to provide an extensive overview of the experiences, issues and outcomes of women in treatment. While some general information is provided on patterns of use or characteristics of women misusing substances, this is provided only as background material. The review was based on sources that summarize research and evaluation data which identify best practices. Sources included:
The available literature has a number of limitations. These include:
A variety of resources, broad-based bibliographic and specialized bibliographic searches were used to produce the initial reference resources for the literature review. These included:
This project focusses on the barriers to treatment and best practices involved in the effective treatment of women in general. Key experts were also asked to identify best practices in relation to the following groups with specialized needs. The groups defined by the project authority were women who are:
With the exception of the section on barriers to treatment (where respondents made specific comments related to these groups), in most cases key expert comments applied to all of the specialized groups. Where group-specific best practices are identified, these are noted in the text.
The terms of reference for this project did not address the treatment barriers or needs of specialized groups such as the elderly, women with disabilities or lesbians. A number of key experts who participated in the project emphasized that lesbians face unique personal, societal and program barriers and require a somewhat specialized treatment environment and approach. However, the needs and experiences of this group were not explored systematically with key experts.
For the purposes of this report, treatment is defined as an organized set of approaches and strategies which assist clients to reduce or eliminate problematic use of alcohol or drugs and which support healthy personal and interpersonal functioning. Although the term "drug and alcohol treatment" implies a single entity, in fact, it includes a complex and variable network of services. As defined in Canada's Drug Strategy document, treatment and rehabilitation services in Canada include:
detoxification services, early identification and intervention, assessment and referral, basic counselling and case management, therapeutic intervention, aftercare and clinical follow-up. Treatment is offered on an out-patient, day-patient or in-patient basis, including short-term and long-term residential care. (Health Canada, 1998:9)
The definition of best practice as it relates to program delivery in the health field has been approached with varying degrees of rigour. Within health care, the application of the idea of "best practice" has ranged from simply publishing particular practices under the rubric of "best," . . . to engaging in a systematic identification of what would constitute "best" within a particular health issue or practice area, . . . to a rigorous research-based investigation to identify evidence associated with particular practices, (Varcoe, 1998:4). For the purposes of this project, best practice is defined as a consensus of key expert opinion on the approaches and elements of treatment which appear to result in the most successful treatment outcomes for women. Using this definition, best practice is clearly based on key expert experience, judgment and perspective. The literature review provides further support to the views and conclusions of key experts.
In order to capture the major themes, a "consensus response" was considered to be one in which at least four key experts (not from the same organization) were in agreement. A stronger degree of consensus is indicated in the text. Some opinions and recommendations with less support are included if they illustrated or expanded upon a major theme. Due to the open-ended nature of the questionnaire and the fact that answers were not probed to achieve consensus, exact numbers of key experts reporting are indicated for each response.
Historically, substance use patterns among women have varied and the societal interpretation of these patterns has had impacts on attitudes toward women's use of substances as well as on treatment responses. In the 17th and 18th centuries, Cooper (1991) noted that alcohol was consumed by men, women and children and was not considered morally "wrong" or dangerous. In the 50-year period from 1776 to 1826, North American society's view of drinking changed; alcohol came to be considered "demonic" and unsafe. By the end of the 19th century, drinking was deemed a "lower class" activity and, among women, was associated with prostitution or "loose morals." However, alcohol and certain drugs were still included in commonly-used medications well into the 20th century (Hewitt et al., 1995).
Until the mid-1970s, the extent of heavy drinking among women in general was considered to be minimal, and there was a paucity of research exploring substance misuse. For example, "between 1970 and 1984, women represented only 8% of subjects in alcoholism studies" (Cooper, 1991:1). Though, in comparison with men, women are less likely to report heavy drinking occasions and alcohol-related problems (36% of those reporting alcohol-related problems are women) (Canadian Centre on Substance Abuse and Centre for Addiction and Mental Health, 1999), there are still concerns that women are under-represented in substance abuse treatment settings. In the 1980s, women made up only 20% of clients in treatment.
The emphasis on male substance use patterns and treatment for men has resulted in a "male as norm bias," which has judged women who require treatment more harshly, and has limited the exploration of gender-specific treatment approaches (Finkelstein et al., 1997).
Recent Canadian research (Health Canada, 1995; Health Canada, 1997, Canadian Centre on Substance Abuse and Centre for Addiction and Mental Health, 1999) identifies the following patterns of substance use among women.
Substance use impacts on women in a variety of ways, many unique to gender. A review of the literature suggests the following general themes:
Specific characteristics appear to be associated with women who misuse alcohol or drugs. These are causative, rather than associated factors:
One of the most important differences between men and women is that they identify different reasons for using drugs or alcohol. Women typically see drugs/alcohol use as a method of coping with specific crises or personal problems. This perception determines their definition of "problem," identification of needs and their approach to seeking help.
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.
Key experts identified barriers to treatment in four main areas:
Key experts identified four main personal barriers impeding access to treatment:
Being emotionally dependent they fear the loss of the relationship - they're terrified to be alone.
There was a significant level of key expert consensus around two interpersonal barriers affecting access to treatment.
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.
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.
Key experts also believe that women are more seriously penalized by society (e.g. threatened with loss of children) for seeking treatment.
Key experts described a wide range of structural/program barriers related to treatment availability, organization and flexibility.
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.
Key experts identified the following barriers as specific to pregnant and parenting women.
Older kids (7 - 8) are parenting themselves at such a young age-they need help to learn how to be children again.
Key experts identified the following barriers as specific to Aboriginal women.
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.
Key experts identified four main barriers affecting ethno-cultural minority women. These are:
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.
Three major barriers to treatment were identified by key experts.
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.
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:
There's a whole stigma attached-they can't be open, yet program says that they have to be open.
The social services for these women are almost non-existent.
Key experts identified many barriers affecting women with concurrent disorders. There was consensus around the following issues:
A woman comes in (to a mental health service) with acute depression and anxiety and is suicidal-often the dependency is overlooked.
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.
There's the belief they don't fit in-isolation, hopelessness and helplessness.
Respondents identified four barriers affecting women in the prison system.
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.
Women who are marginalized or homeless face a range of barriers affecting treatment.
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.
According to key experts, barriers to treatment experienced by women living in rural communities include:
They are afraid to be identified by neighbours. They even fear picking up a pamphlet because someone will see and spread the news.
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.
There are confidentiality issues-some of their own family members may be employed at the treatment centres.
Intervention in programs are bigger than what they need because they have to go to residential centres.
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.
|Group||Barriers Identified by Key Respondents|
|Pregnant and parenting
|- Fear of losing children
- Need for child care services
- Stigma attached to mothers misusing substances
- Fear, guilt, grief and shame
- Lack of specific programming for pregnancy and child birth issues
|Aboriginal women||- Cultural differences
- Lack of aboriginal specific programming
- Lack of aboriginal staffing
- Lack of gender-specific programming
|Ethno-cultural minority women||- Language barriers
- Denial of women's substance use
- Cultural beliefs and practices which support denial
- Reliance on informal problem-solving methods
- Male-dominated cultures
- Lack of culturally specific programming
- Lack of culturally appropriate and effective street outreach
|Women who inject drugs||- Shame, judgment, discrimination
- Long-term health problems
- Lack of appropriate programs (harm reduction model, detox services,
- Lack of programs for sex trade workers
|Women with HIV/AIDS||- Fear of acknowledging disease to treatment staff
- Ostracized by other clients
- Multiple health problems
- Feelings of hopelessness
|Women with concurrent
mental health disorders
|- Inadequate diagnostic/assessment services
- Lack of coordination/integration between mental health/addictions systems
|Women in prison or involved
in criminal justice system
|- Lack of prison-based services
- Restricted access to community-based programs
- Inability to use treatment effectively
- Lack of continuity between prison-based and community programming
|- Poverty, lack of housing and other basic needs
- Lack of appropriate "gateways" to treatment
- Isolation (program's inability to maintain contact)
|Women living in rural
- Lack of local services
- Lack of knowledge of services
- Lack of privacy/confidentiality
- High costs of accessing services (transportation, child care)
Most people with alcohol/drug use problems do not enter treatment (Grant, 1997). Of those who do, the ratio of men accessing specialized treatment is much higher than for women (Schober and Annis, 1996). There is evidence in the literature that a woman's pathway to treatment is unique and her experience and interpretation of barriers complex.
There is also extensive literature which identifies barriers to treatment experienced by women with alcohol/drug use problems. Although these barriers are categorized somewhat differently, a summary of barriers applying to all women is presented below: (Beckman and Amaro, 1986; Thom, 1986; Thom, 1986, 1987; Cooper, 1991; Wilsnack, 1991; Cunningham and Sobell,1993; Ja and Aoki, 1993; Planning for Change, 1993; Saskatchewan Alcohol and Drug Abuse Commission, 1993; Allen, 1994; Beckman, 1994b; Schober and Annis, 1996; Copeland, 1997; Finkelstein et al., 1997; Grant, 1997; Klein et al., 1997).
The barriers described in the literature broadly reflect the themes identified by key experts, although the literature emphasizes to a greater degree barriers related to "gateways" or entry points into treatment.
The literature identifies the following personal/internal barriers which affect women's access to treatment.
Thom (1987), in a study of gender differences in seeking treatment for alcohol problems, found that women did not regard alcohol as a primary problem and had considerable reservations about the relevance of treatment to their needs.
If women are more likely to rely on referrals by family or friends or learn about the treatment programs through advertisements or word of mouth, then the results of this study suggest a need to expand the more conventional referral routes for women (Grant, 1997: 370).
Because of these differences, women are less likely than men to initially seek help from alcohol or other chemical dependency services. Instead, women are more likely to consult their physician or mental health services when they have problems. Substance use problems may not be appropriately identified.
Beckman and Amaro (1986) noted that women perceive greater social costs associated with entering alcohol treatment. Almost 50% (versus 20% of men) described problems with family, friends or money as disincentives to entering treatment.
Women also encounter more opposition from family and friends during the months prior to treatment entry. Studies also found that women are often encouraged to keep on drinking by spouses or partners who themselves have alcohol use problems (Wilsnack, 1991).
Structural and program barriers also act as disincentives to women entering treatment. These barriers include:
(Program) responses could include improved outreach, referral networks or advertising of services specifically targeting women who may be unaware of the range of services. The provision of more detailed information about programs may allay any fears potential clients, their partners and/or families may have about what treatment involves. (Swift and Copeland, 1996:217)
Traditional treatment programs tend to reflect traditional male values such as the importance of the male work ethos and the need for men to be in full-time employment. This may be communicated covertly through the organization of programs on a day-to-day basis (Smith, 1992:8)
There is also an increased incidence of depression, anxiety and post traumatic stress disorders among women with alcohol use problems. The presence of these disorders means that women are more likely to seek help at general mental health centres which may not be a direct pathway to treatment (Schober and Annis, 1996). Even with identification and referral, women may be less willing to identify their problems as substance abuse related.
Other structural/program barriers identified in the literature include:
The literature does not address, in detail, barriers experienced by all the sub-groups identified in this study. However, a summary of available literature related to some of these groups is presented below.
Finkelstein (1994), in a study of treatment needs of pregnant women, identified two major barriers experienced by this group.
In a study of 47 women (40% of whom were Aboriginal) who had problems with alcohol or other drugs and who were pregnant or parenting (children under the age of 16) in Vancouver and Prince George, British Columbia, Poole and Issac (1999) described seven main barriers identified by respondents. These included both personal and structural barriers:
These differences result in the lack of a coordinated approach, inadequate diagnoses and inconsistencies in treatment provision.
There is a lack of specific data that identifies barriers experienced by Aboriginal women. Results from a Canadian national conference on women and chemical dependencies (Planning for Change, 1993) concluded that the following barriers were most significant for this group:
A Health Canada study of immigrant women and substance use (Health Canada,1996a) identified a number of issues related to service access and barriers for an immigrant woman experiencing a substance use problem. These included lack of expertise and resources on the part of both mainstream health organizations and immigrant aid or ethno-cultural organizations to address women's substance use problems; lack of information or misinformation about availability of culturally appropriate services, which often resulted in inappropriate referrals or women being referred back and forth between a mainstream health organization and an ethno-cultural organization; unrealistic expectations by mainstream organizations about the ability and resources of ethno-cultural/immigrant aid organizations to provide substance abuse treatment.
As a result of these barriers, the report noted that immigrant women with substance use problems may receive no help or information, or if they do it may be in an unfamiliar language or in their own language but from people who are inexperienced in the area of substance use problems, or from a perspective that does not take into account their cultural reality and/or their needs as women.
Ja and Aoki (1993), in a study of barriers to treatment for Asian-AmericanFootnote 4 women identified some additional barriers:
A Health Canada study: Rural Women and Substance Use: Issues and Implications for Programming (Health Canada, 1996b), identified a number of program and service issues, including:
"People with problems want to talk to their peers"(Health Canada, 1996c). Rural women with substance use problems may have difficulty finding a helping person who is familiar with rural life and its problems.
Additional barriers identified in a study of illegal drug use among rural adults (Robertson and Donnermeyer, 1997) included distance and lack of transportation as major barriers to treatment utilization. The chronic poverty conditions within many rural areas makes access by clients to early intervention difficult. Costs associated with treatment are also a disincentive (e.g. transportation, payment for board and lodging in residential programs).
A general lack of treatment or related programs for women within correctional settings was described as the major barrier for this sub-group.
In Canada, 56% of the female prison population is estimated to have been involved in drug-related crimes (Lightfoot and Lambert as cited in Lightfoot et al., 1996b). At the federal level, Correctional Service of Canada provides treatment both at the institutional and community level. However, no specific information was available on the extent, scope and content of treatment for women in provincial correctional settings.
A recent publication, Substance Abuse Treatment for Women Offenders: Guide to Promising Practices, from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA), (1999), summarizes the research on women offenders with substance abuse problems and provides guidelines for women-centred treatment in a correctional setting, including the system issues and barriers that need to be addressed. This publication is available on-line as well as in hard copy from SAMHSA.
No specific data related to barriers experienced by women who are street involved or homeless were found in the literature. Milby et al., in a study of both male and female homeless substance abusers, suggested that the state of homelessness fundamentally compromises a person's ability to respond favourably to treatment.
Perhaps the need for some rest and sleep, food and shelter from weather are prepotent over the need for treatment of a substance abuse problem. (Milby et al., 1996:40)
This study showed that day treatment plus work therapy and housing support led to improved treatment outcomes. The provision of a multi-dimensional support system appears to be most critical for dismantling barriers to this group.
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.
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.
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.
Through prevention done in the schools, kids bring home an invitation to parents inviting them to workshops.
Teen women are at high risk of getting into drugs and prostitution so having a Youth Worker at the friendship centre is really beneficial.
Provide some consultations to these workers: Street workers, van workers, mental health workers.
Go right into their homes-in a community is easy-do a survey (door to door) with help in community (to provide publicity).
Aboriginal women-going into their site (cultural centre) is very important-they see providers' interests that way.
Go into the jails and hospitals to see them.
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.
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.
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 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.
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.
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:
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.
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).
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)
Key experts identified 13 basic treatment principles and values which underlie the effective treatment of women with substance use problems. These principles and values address structural, organizational and philosophical elements of treatment.
|Treatment Principles and Values||Key Expert Quotes|
|Treatment for women should be based on choice (a "menu" of choices and a variety of options).||Offer a variety, extensive menu.|
|Treatment should support a harm reduction approach.||Lapsing is to be expected and can be explored. Use addiction management approach--don't have to adopt abstinence model.|
|Treatment should address all aspects of a woman's life.||Look at the person's whole being, not just the addiction. Use a holistic approach.|
|Treatment should address practical needs (housing, transportation, child care and job training).||Address issues around parenting ... , job training ..., provide child care.|
|Treatment should support connections between women.||Help make connections with other women, other mothers. Empowering women to help them support each other.|
|Treatment should be gender specific (i.e. completely gender specific or gender-specific component of a co-ed program).||Do specific women's programming. Do women-focussed, gender-specific programming.|
|Treatment should be supportive, egalitarian and non-hierarchical.||Groups of women receiving help from female treatment providers, working and growing together in an atmosphere of equality.|
|Treatment should support the empowerment of women.||Trust and respect women's ways of knowing and being in the world--honour clients' power with, rather than power over--women are the experts.|
|Treatment should be respectful and staff should empathize with and support the dignity of clients.||Empathy for clients--not shaming or condescending.|
|Treatment should be client driven and based on individual client needs.||Good treatment providers help clients achieve what they are seeking and then support. Women directed. Involving her in the planning and goals builds self-esteem, counteracts the depression.|
|Treatment should facilitate the education and awareness of clients.||Provide literature, women need to read. Hope and information, important in early treatment.|
|Treatment should be based on client strengths, not deficits.||Real valuing of client strengths/strength-based approach.|
|Treatment should incorporate a woman-centred approach.||Feminist approach (e.g. awareness of women's social conditions, experience of inequality, victimization, embedded in a background of women's experiences).|
It was difficult to differentiate treatment principles from a discussion of issues such as treatment structure, approaches or methods in the literature. However, many of the principles identified by key experts (e.g. empowerment and harm reduction approaches) are supported by the literature review.
Finkelstein noted that most
"models of care (for pregnant and parenting women) have been developed without thought given to the underlying conceptual or philosophical framework and service intent" (Finkelstein, 1993:1286). Given the concern with developing new service models for pregnant and parenting women with substance abuse problems (and their children), she suggested that
"a first step in the development of such models would be to agree on certain guiding principles as a foundation" (Finkelstein, 1993:1286). She identified seven principles (see below) related to the focus and organization of treatment. Although they are discussed in relation to pregnant and parenting women, most of the principles apply to all women requiring treatment.
Principles of Treatment (Organization and Focus of Treatment)
According to Schliebner (1994), gender sensitivity is the most important underlying principle of treatment. Gender-sensitive treatment comprises:
Covington (1998a) also stressed the valuing of relationships as an underlying principle of treatment. Relational theory emphasizes the importance of relationships to women. True connections are mutual, empathic, creative, energy-releasing, empowering and essential for fostering women's growth. Effective services for women need to be based on relational theory, be gender specific, consider life experiences and incorporate a holistic theory of addictions and a theory of trauma.
Creamer and McMurtrie (1998), in a study of special needs of pregnant and parenting women in recovery, described several underlying principles/values:
Key expert opinions and the literature identify the empowerment principle as fundamental to best practice. The empowerment approach is composed of the following elements (Kasl, 1995):
While many specific components of the empowerment model are associated with best practice, there is a lack of empirical research which assesses treatment outcomes based on this approach.
Key experts were asked to identify specific substance abuse treatment approaches and methods which result in treatment success. These were discussed in relation to four broad areas.
Key experts identified seven elements of best practice to address physical health needs.
No single approach is adequate. A variety of services needs to be available.
Give educational approach (i.e. substance abuse and eating is a triangle - make connections).
High degree of education should be done through group and individual work-done with professional and non-professional staff.
Have a nutrition counsellor on site, eat in a certain way to help withdrawal symptoms-need good nutrition plan. The residents themselves are involved in food preparations (i.e. budgeting, food temperature and maintaining good eating habit).
If treatment program does not have on-site staff trained in health issues, you need a good referral network, key is to have a good referral network.
In residential setting have a house physician. Have nursing staff to test, educate, help identify problems.
Although key experts identified many best practices to address emotional (including mental health) issues, there was consensus on only four approaches. Most of these approaches relate to mild to moderate mental health problems such as mild depression, anxiety and low self-esteem rather than more severe mental health disorders such as schizophrenia and severe depression.
In general, group work was considered to be the optimal method to explore personal issues. Groups provide empowerment opportunities for women, peer support and education. A smaller number of key experts identified one-to-one therapy as an important element of practice, especially to help women prepare for group work or in cases where women prefer one-to-one counselling as an adjunct to group work.
Key experts identified client education as an effective approach to address emotional issues. Education is a powerful tool to explore issues such as:
In addition, key experts identified the value of teaching life skills to this group. Life skills may include vocational skills, stress management, anxiety-reducing strategies, anger management and goal setting.
In terms of broad approaches, respondents identified a broad multi-dimensional approach to treatment (bio-psycho-social) as being the most effective.
There was consensus around a number of approaches to address the interpersonal needs of clients. Best practices include:
Need a place for women and men to go-into their own gender-specific group to explore issues, and then couples counselling.
Try to get people in her life involved-she comes in with partner and family.
If it comes up within group about how to get back into the workforce, so they'll go with it and put on a workshop and bring in some resource people who will show them how to write résumés, etc.
The person will be different when she goes back without self-destructive behaviour and interaction with the family will be different, so practice is important.
Key experts identified best practices that support relapse prevention and management. Consensus occurred around general approaches rather than specific techniques. Best practices consist of:
A recognition among staff (addressed through program design) that relapse is likely to occur and can be a positive impetus for exploring client growth and change.
. . . big piece in here (our program) is to normalize it (relapse). We know that women slip (the rate is very high), so number one let them know it will happen-be aware of it and then develop new healthier ways of coping.
A focussed approach to relapse prevention and management . This includes the building of relapse prevention understanding and techniques into treatment from the point of program intake.
Addressing relapse prevention involves helping clients understand:
Help clients observe triggers, plan what to do, practice how going to respond-a way to change behaviours.
Provide lots of support in early recovery-encourage them to go to AA and get a relationship with sober women.
Need to look at the context of their environment (home, money) for relapse prevention, if supports not in place, plans won't work.
|Issues Addressed||Best Practice: Key Expert Perspectives|
|Physical health issues||
(mental health issues)
Treatment approaches and methods are discussed broadly in the literature and may include structural approaches, treatment methods, treatment organization or staff characteristics.
Eliany and Rush noted that 50% to 60% of all patients (both male and female) in treatment show improvement, although," there is no one treatment modality that has emerged as superior to all other approaches. (Eliany and Rush, 1992:79)
A review of several large-scale (U.S.) treatment effectiveness studies concluded that treatment is effective (although dropout is the rule). Successful (drug abuse) treatment includes a range of elements, such as:
This study suggested that all these elements " rather than the specific treatment models, determine whether a program will be successful in treating individual clients and affecting the broader, social community problems that exist because of drug abuse." (Office of the U.S. National Drug Control Policy, 1996:18)
In relation to women's treatment, Lightfoot et al. have noted it is difficult to determine the most effective treatment approaches for individual clients:
Deciding whether or not a particular treatment is effective is an extremely complex task. Substance users vary dramatically at the beginning of treatment . . . descriptions of treatment interventions are frequently vague and implementation evaluation is seldom addressed. There is little agreement as to what treatment outcome objectives should include, and what constitutes success in terms of substance abuse treatment is hotly debated. (Lightfoot et al., 1996b:189)
The women's treatment literature identifies several broad approaches which are associated with treatment effectiveness (e.g. multi-component treatment models). Many of these have not yet been empirically demonstrated in the literature.
There are a number of programs throughout the country that are attempting to set up comprehensive treatment models. To date, due to both a lack of funding, as well as the newness of some of these programs, there has been little evaluation of their effectiveness (Finkelstein, 1993:1289 - 1290)
In a review of seven comparative studies of treatment and seven randomized studies, Lightfoot et al. concluded that:
Although these studies are few in number-a common finding appears to be that women do well, compared with men, in treatments that offer training in self-management, develop coping and relapse prevention skills and address personal needs. (Lightfoot et al., 1996b:195 - 196)
This section provides a description of the following treatment approaches commonly associated with effective treatment outcomes and identified in the literature:
a) Multi-component Treatment Model
There is a strong consensus in the literature that effective treatment must include a range of direct and indirect treatment services to address a range of client needs (biological, mental health, peer, family and personal). Reed (1987), Zankowski (1987), Finkelstein, (1993), Drabble (1996), Nelson-Zlupko et al. (1996), Swift and Copeland (1996), identified the core service areas which they consider integral to effective treatment. These have been summarized and annotated below (Table 10). Not all these services need to be provided within one program; however, the services need to be made available within a comprehensive and integrated system. Finkelstein (1993) described over 50 components of this comprehensive care system for women, many of which are described below. However, she noted that:
There is little discussion or agreement in the literature as to how such disparate services should be linked into the model. (Hagen et al. as cited in Finkelstein, 1993:1289)
b) Gender-sensitive or Gender-specific Treatment
Substance abuse research has revealed that the impact of substances on women and their treatment needs differ from those of men.
Health problems caused by alcohol/drug misuse have a more rapid onset and become more serious in a shorter period of time.
Women who misuse substances are also more likely to have a history of victimization. Research has also noted that women respond differently than men to treatment settings. Jarvis, in a meta-analysis of 20 outcome studies that distinguish between men and women, concluded that women in treatment tend to act differently in co-ed treatment settings and to minimize their focus on treatment issues.
Females in mixed-sex groups showed less (sic) interactions with other women, a decreased amount of discussion about home and family and less overall interaction. (Jarvis, 1992:1255)
In a study of a co-ed hospital-based treatment program, Zankowski (1987) speculated that the low completion rate among women clients was due to a lack of gender-specific programming. The program was restructured to include the following gender-specific components:
The inclusion of these elements increased the completion rate of women clients.
Nelson-Zlupko et al. (1996), in a study of treatment experiences of 24 women in recovery, reinforced the importance of women requiring a forum for expression of women's needs and experiences. Eighty percent of her subjects found discussion of women's issues very helpful or helpful; 75% found women-only groups very helpful or helpful. The women, all of whom had received treatment in women-specialized programs as well as traditional programs, preferred the former. Copeland and Hall (1992), in a retrospective study of predictors of treatment dropout of 360 women seeking alcohol/drug treatment, found that certain groups of women were more likely to complete treatment at specialized gender-sensitive treatment services.
Women with a history of sexual abuse in childhood appear to have an increased need for a physically and emotionally safe environment as their trust has been seriously violated in the past. (Copeland and Hall, 1992:809)
For lesbians and women with dependent children, " attendance at a specialist women's service reduced the incidence of dropout" (Copeland and Hall, 1992:833).
In a study of 267 women who had received treatment, Swift and Copeland (1996) found that the women, who had been in women-only treatment positively endorsed women-specific programming. Within the larger sample of all women who had received treatment (N=217), 42% did not have strong feelings about co-ed or women-only treatment. Eighteen percent liked socializing with men; 11% felt mixed programs were more balanced. However, 11% felt unsafe in co-ed programs. Ten percent who had previously dropped out of treatment said they would have stayed longer if there had been fewer male clients.
Dahlgren and Willander (1989) reported that participants in a specialized all-female program were more likely to report abstinence at 12-month and 2-year follow-ups than women in a control group undergoing treatment at a " traditional" mixed-sex treatment centre.
c) Use of Cognitive-Behavioural Approach
Although the cognitive-behavioural approach to treatment was broadly supported by key experts, no specific empirical data assessing the efficacy of this approach, specifically with women, was found. In a review of the treatment outcome effectiveness evaluation literature (related to both men and women), Eliany and Rush noted that: behaviourally oriented treatment approaches for alcohol problems have received the most support from evaluation studies.
In general terms, the evidence confirms one of the expectations drawn from social learning theory that " performance-based" treatment methods are superior to more traditional, " verbally-based" methods such as psychotherapy or education. Behavioural approaches that are generally supported by the literature include family and marital therapy, aversive therapy, contingency management, and broad-spectrum treatment focusing on relaxation training, stress management and a range of skills training (e.g., social skills, problem-solving skills). (Eliany and Rush, 1992:79)
Similarly, in a recent review of the literature (Health Canada, 1999) examining the effectiveness of treatment modalities, good evidence of effect was associated with the following behavioural modalities. Many of these are identified as elements within an " empowerment" approach:
d) Use of Pharmacologic Agents Where Required (and in cases of women who are pregnant and inject drugs)
Hagen et al. stated that alcohol/drug treatment providers often show a negative bias toward using psychotropic drugs, although there may be indications for their use in some cases. In a study of impediments to a comprehensive treatment model, she suggests that there are clear advantages to using psychotropic medications:
Psychotropic medications assist in reducing depression while the woman learns to cope with emotions she has previously medicate.... with legal drugs (e.g. alcohol). (Hagan et al. 1994:168)
The literature also identifies methadone maintenance therapy as an important treatment approach for women who are heroin drug users. Methadone assists in the management of withdrawal from heroin, reduces criminal involvement, improves physical and psychological well-being and enables opiate users to focus on social and vocational rehabilitation (Office of the U.S. National Drug Control Policy, 1996).
Svikas et al. (1997), in a study of incentives for pregnant, drug-dependent women, found that methadone-maintained women attended nearly two times more days in treatment than non-methadone-maintained women and stayed in treatment longer. Hagan et al. (1994) noted that methadone may be a useful tool for clients to control cravings and life chaos. Methadone may also ensure better prenatal outcomes (although methadone use during pregnancy requires careful monitoring). Laken et al. (1996), in a non-comparison study, isolated five factors that. contributed to retention for a group of pregnant women and found that the use of methadone (provided to women addicted to heroin), organized case management and transportation to treatment were three of the factors that contributed most strongly to retention in treatment.
e) Collaborative and Case Management Approach
Laken et al. (1996) identified strong case management as a key element of effective substance abuse treatment for pregnant women. She defined the following components as integral to a strong case management approach.
f) Appropriate Client Treatment Matching
The literature supports the importance of matching treatment approaches with the needs of people with substance use problems. Mattson and Allen (as cited in Waltman, 1995) concluded that matching of clients' needs to treatment increases the treatment success rate by 10%. Treatment matching appears to work best for people with moderately severe substance use problems.
Waltman considered the following tasks as most important to consider when matching clients to treatment:
g) Provision of (Practical) Adjunctive Services
Milby et al. (1996), in a study of the homeless (primarily using crack cocaine), 20% of whom were women, found that therapy enhanced with specific practical supports was more likely to engage clients in treatment, although long-term retention rates for the groups involved in this study were low.
h) Positive, Hopeful and Empathic Staffing
In a survey of 24 women in recovery, Nelson-Zlupko et al., found that the quality of staff/client interactions was described as the most important factor within substance abuse treatment settings.
The gender, age, race and substance abuse history of the counsellor, while viewed as important characteristics, were collectively perceived as less important than the extent to which the counsellor treated them with dignity, respect and genuine concern. (Nelson-Zlupko et al., 1996:55)
Experiences with good counsellors were perceived by clients as connected to increased use of treatment and even sobriety. In a general study of client dropout from treatment, Allerman, O'Brien and McLellan (as cited in Waltman, 1995) identified three staff characteristics associated with client dropout from treatment:
i) Specialized Staff Training
Staff with specific skills and training may be required to provide treatment to groups with specialized needs. Women with concurrent disorders require such specialized skills. Grella, in a study of women with concurrent psychiatric and substance (drug/alcohol) abuse disorders, found that both substance abuse treatment and mental health staff required specialized skills.
[Treatment] Staff . . . need training on psychiatric assessment and diagnosis, pharmacologic treatment approaches, stages of recovery in mental illness and the effects of trauma. Mental health treatment staff need training in detoxification procedures and effects, assessment of addiction and differences in types of addiction, role of self-help and 12-step programs and stages of recovery from addictions. (Grella, 1996:331)
j) Empowerment Model
Drabble surveyed treatment providers with the objective of identifying the elements of an effective residential recovery program for women with alcohol use problems. She found that the empowerment model was closely associated with positive treatment experiences and outcomes.
Respondents tended to identify the concept of empowerment as critical to the recovering individual as well as important to the philosophical basis and design of programs. (Drabble, 1996:17)
Although broader in focus, Strantz and Welch (1995), in a study of treatment retention among postpartum women, found that a multi-dimensional model which incorporated the philosophy of women's empowerment was most closely associated with treatment retention.
Treatment type was a very strong predictor of treatment retention and outcome. Almost half of the women admitted to the (intensive) program completed treatment; compared to one out of five from the (non-intensive) program. The (intensive) program incorporated a myriad of elements, such as a cognitive-behavioural approach; an empowerment of women philosophy; parenting role models and support; professional/paraprofessional, mostly female staff; and comprehensive support services such as childcare, transportation and medical, social and educational services. (Strantz and Welch, 1995:372)
k) Addressing Sexual Abuse and Other Experiences of Victimization
Research has reported that women requiring treatment are frequently survivors of sexual abuse (rates vary from 34% - 86% depending on the study). Carson, Council and Volk (as cited in Jarvis, 1992), Copeland and Hall, (1992); Russell and Wilsnack (as cited in Drabble, 1996) found that a history of incest was associated with low self-esteem, particularly for women who are alcohol dependent. Young (1990) suggested that there is a strong relationship between incest experiences and substance misuse.
Miller et al. in a study of the interrelationships between experiences of childhood victimization and the development of women's alcohol-related problems, found that two thirds of the women with alcohol use problems had experienced some form of childhood sexual abuse as compared to one fifth or one third of two other samples without alcohol use problems. Nearly half (45%) of the sample, identified as having alcohol-related problems, compared to 13% and 18% of the non-drinking samples, reported severe paternal violence. The rates of childhood victimization were significantly greater for women in treatment with alcohol-related problems when compared to women in mental health treatment without alcohol-related problems.
Thus, even when holding the treatment conditions constant, childhood victimization has a specific connection to the development of women's alcohol-related problems. These findings remained significant even when controlling for demographic and family background differences, including parental alcohol-related problems (Miller et al., 1993:115).
l) Addressing Family Issues
Drabble (1996) noted that educational sessions and group counselling around partner and parenting issues were considered by clinicians she interviewed as a core treatment component for women with alcohol use problems. However, Swift and Copeland's (1996) study on treatment needs (identified by women themselves) determined only that the provision of child care services would have increased retention in treatment (family counselling was not identified).
Seventy-six percent of 24 women in recovery (Nelson-Zlupko et al., 1996) described family counselling as a helpful component of services. However, other services such as transportation, help obtaining food, housing and clothing and recreational services were rated as helpful by a high percentage of the women clients.
m) Additional Elements of Best Practice
Other approaches, such as harm reduction and the relational model, identified by key experts are not, at this time, addressed in the empirical research, although elements of these models (client choice, importance placed on family and child relationships) have been addressed to some degree in this document.
Key experts were asked to identify the treatment approaches, methods or organizational structures that supported women staying in treatment. Most of the issues identified have already been described in previous Sections 8.0 and 9.0; thus, they are summarized below. Literature relating to this topic is also covered in these sections and is not replicated here.
Key experts stressed the importance of client/treatment matching as one of the most critical elements of client retention in treatment. Program staff need to assess, in collaboration with clients, their specific needs and provide resources and approaches which meet those needs without using a pre-formulated plan. Needs may not always be interpreted or described in the same way by staff and clients. Flexibility and choice must be offered.
Key experts identified the following forms of treatment as integral to this continuum of services.
Out-patient or Residential Models. Where respondents did identify preferences, the out-patient treatment model was considered to be most effective for the majority of clients:
Women living in their own environment (if safe): that's good for them, less artificial. It allows them to work on other areas of their lives.
One key expert noted that the goals of residential treatment could be accommodated in many out-patient settings. Again, an opportunity for choice is an important factor.
Often women go to residential care because they are not offered choice-what works is what the client thinks will work (e.g., they have a new (intensive) program that is two days/week). In the past, these women would have gone into long-term residential treatment which would take away their lives.
However, several key experts noted that residential care needs to be available for women with more severe problems, or for those living in unsafe environments. "Residential" could also include short-term "crisis beds."
For many women, by the time they get into treatment it has gone on for a long time, and by then she needs longer-term in-patient care.
Need some crisis beds in a safe environment-for example, if over a weekend a woman feels like she just can't handle things, then there would be some very short-term beds available.
Treatment should be women focussed, but not all women see this. Some women enjoy co-ed AA, but in the end their true sense brings them to women-specific programs.
Deficiencies of a co-ed setting include a lack of focus on women's experiences and issues and exposure of women to an unsafe treatment environment.
Co-ed treatment may create unhealthy relationship dynamics-increased attention-seeking behaviour (vulnerability looks pleasing). Not possible to feel safe in a co-ed environment. Relationships likely-would take focus off self-(should be) discouraged in early recovery.
There was some degree of consensus on the value of mixed-group treatment in specific situations.
Co-ed treatment may enhance awareness that male/female emotions are similar and reduce over-generalizations about men and enhance healthy understanding of men. May enhance likelihood of productive therapy - potential for growth and healing.
According to another respondent:
When session is informational, co-ed is positive; when session is process-oriented, needs to be gender-specific.
One key expert suggested that there needs to be support to both gender-specific and gender-sensitive programming.
Need to find way to deal with women on two levels: gender-specific programming and more gender sensitivity in every program. Programs that have both genders say their programs are better, more flexible, women doing better, men doing better.
Mixed gender later on in treatment can be helpful. Women are going to have to think about how to behave with men-need to work on it, practice it. But need to be explicit re timing of when to include men in the program. Don't throw the women into mixed setting. Have an all-women's setting to talk about how they are going to act in mixed setting. Then, in pairs they go into a mixed group, come back to women's group and discuss how it went.
There was a strong consensus that residential treatment should not be less than four weeks in length with many key experts advocating a standard length of at least five weeks. Out-patient would require three to six months or longer (up to one to two years in some cases). However, respondents stressed that flexibility is the key to planning treatment length, not rigid standardization.
The literature says four to five weeks, but must have a system where you phase people in and out of intensity - standards don't always work.
There was no evidence for the superiority of in-patient over out-patient treatment of alcohol abuse, although particular types of patients may be treated more effectively in in-patient settings. (Finney et al., 1996:1774)
Finney et al. analysed 14 studies that examined in-patient versus out-patient treatment. No differentiation was made for men or women. Only seven studies found treatment setting effects.
. . . the significant results were mixed, with five studies finding in-patient/residential treatment to be superior and two finding day hospital treatment to be more effective. (Finney et al., 1996:1793)
However, a more important factor resulting in positive outcomes (regardless of setting) is the intensity of treatment provided. Finney et al. noted that research is still lacking in the area, especially in relation to variations on traditional out-patient and in-patient settings.
. . . studies are needed that compare different forms of residential treatment or different forms of out-patient treatment . . . studies of alternatives within each type of setting should examine potential mediators and moderators of effects. For example, it may be that in-patient treatment is more effective for people with serious medical or psychiatric impairment because it reduces such symptoms more than does residential treatment. (Finney et al., 1996:1792 - 1793)
Kissin (as cited in Finney et al., 1996) reported that socially competent patients experienced better outcomes in out-patient treatment whereas socially unstable patients had better outcomes following in-patient treatment. Strantz et al. (1995), in a study of postpartum women, found that an intensive day treatment model was more effective for crack-dependent women than a conventional out-patient counselling model in terms of client retention treatment.
Dahlgren and Willander (1989) compared 200 women in gender-specific treatment with women attending treatment at mixed-sex centres. Women treated in the specialized unit showed significant improvements (in comparison to women in mixed-sex treatment) in the following areas:
More women from the women-only treatment group managed to drink in a "cautious, social way" without apparent negative impacts during the observation period (one to two years) after treatment.
There is evidence that women and men respond differently to treatment when men are involved. Aries (as cited in Jarvis, 1992) compared women and men in same-sex and mixed-sex groups. She reported that:
Females in mixed-sex groups showed less interaction with other women, a decreased amount of discussion about home and family, and less overall interaction.
All female groups showed a greater flexibility in the rank order of speaking, more one-to-one interactions and self-revelations about feelings and relationships. (Jarvis, 1992:1255)
Duckert and Johnson (as cited in Jarvis, 1992), in a study of alcohol-dependent subjects, showed that:
Male groups were reported to be more task oriented while females used the group setting to discuss life issues, arrange contact outside treatment and to organize practical assistance with child care and transport. (Jarvis, 1992:1255)
Considering the importance of group connections and family issues to women, the implicit conclusion is that the group dynamics occurring in a mixed group may have deleterious effects. Baily (cited in Jarvis, 1992) speculated that women may derive emotional and social support from all-female groups. The need for support is highlighted by studies that identify the social costs and isolation experienced by women entering treatment. (Beckman and Amaro, 1986)
Swift and Copeland (1996), in a study of 267 women who had received assistance for alcohol and drug abuse, found that of the women who had attended women-only programs, 40% valued the programs as a way to relate to other women and 35% felt the programs were more safe. Only 8% were concerned that the programs did not reflect the reality of the mixed-sex world. Forty-two percent had no strong feelings about mixed-sex programs, although 11% felt uncomfortable or unsafe in such programs.
In a comparison of predictors of treatment dropout of women seeking treatment in a specialist and mixed-sex setting, Copeland and Hall (1992) concluded that personal variables were most likely to be associated with treatment dropout. For lesbian women, women with a history of sexual assault in childhood, and those with dependent children attendance at a gender-specific treatment facility led to lower dropout rates.
Again, there is limited literature addressing optimum treatment length specifically related to treatment for women. The establishment of optimum treatment duration is related to factors such as client need, substance use characteristics, and costs associated with treatment.
Miller and Hester (as cited in Eliany and Rush, 1992) compared outcomes of short and long in-patient stays and found that shorter stays were as effective as long-term stays. Some studies using non-random, matching designs have suggested that longer treatment may have a modest advantage.
Mosher et al. (cited in Spooner et al., 1996) compared 200 men and women with alcohol use problems assigned to 9-day and 30-day residential programs. At 3-and 6-month follow-ups, there were no differences between the groups in terms of abstinence. Page and Schwab (as cited in Spooner et al., 1996) compared the effect of a 3- and 5-week residential program. The results showed little difference in client drinking at 6-month follow-up.
In a review of Treatment Outcome Perspective Data, Condelli and Hubbard (1994) analyzed the relationship of time spent in treatment to treatment outcome. The research considered both male and female clients in therapeutic communities. The research found that the longer clients who used drugs spent in therapeutic communities, the less likely they were to use heroin, cocaine, marijuana and psychotherapeutic drugs and the more likely they were to be employed full time and to have committed no predatory crimes during the follow-up year.
Gerstein and Harwood (as cited in Simpson et al., 1997) noted that length of stay in community-based drug abuse treatment is one of the best predictors of treatment outcomes. Simpson et al., in a study of 435 patients after discharge from three methadone treatment programs, found that:
Daily opioid users who spent a year or longer in methadone treatment were five times more likely than patients with shorter treatment to have better behavioural outcomes at follow-up. (Simpson et al., 1997:238)
Previous findings from national treatment programs also suggest that 12 months is a significant retention threshold for methadone treatment. However, Simpson et al. noted that there were patients with relatively brief treatment exposure who also showed improvement over time.
Long et al. (1998) compared the effectiveness and cost-effectiveness of a five-week in-patient and two-week in-patient and day patient design for male and female alcohol-dependent patients. Abstinence or non-problem drinking was achieved by 55.6% of all participants at one year. There was no correlation between program delivery and outcome, suggesting that the shorter program is only more cost-effective. The sample was moderately socially stable, suggesting that this group may be over-treated in more intensive programs.
Sanchez-Craig et al. (1989) found some evidence for the efficacy of brief alcohol treatment approaches for women who met the criteria for this type of intervention. Her study compared the relative effectiveness of three brief approaches:
At 3, 6 and 12-month follow-ups, females were generally more successful than males in reducing their days of drinking after using the brief approaches described in the manual. They were more successful in using the "guidelines" and "manual" approaches than men and showed better outcomes.
The variability of the literature clearly suggests that relationships between treatment outcomes and duration are based more on appropriate client/treatment matching rather than a standardized approach. As noted by Eliany and Rush:
One of the overriding conclusions from the review of this literature is that, given the diversity of the population seeking treatment, not all types of interventions or programs will necessarily be effective for all types of individuals in need of assistance. (Eliany and Rush, 1992:67)
The literature related to women's treatment strongly endorses the importance of a multi-component set of services, a "menu" of options for women requiring treatment (see Section 9.0). These resources may be accessed by clients within or through programs. Respondents were asked to identify the most important adjunctive services (see Table 12.)
Key experts identified a strong collaborative approach between program staff and other resources and professionals as the best method of assisting clients to access support services. The components of the collaboration were described as being based on:
A collaborative approach to utilizing resources is the basis for effective case management where there is a central entry point followed by case planning, case management and follow-up. Key experts also recommended the development of a range of in-house programs and resources to address needs. In-house child care, some educational health and general resources (transportation costs) were sometimes provided by programs themselves.
Integrate some into the treatment program (e.g. handling of dual diagnoses, sexual abuse, eating disorders) but some need to be addressed in the community, some need to be addressed in post-treatment as well.
Key experts also felt a client empowerment approach helps clients to access and use services.
Inform client about resources. Do not do the leg work for them--instead, empower them by clarifying what they want and instructing them on resources. Put client in control to make choices and accept consequences.
Best practices are always judged in relation to a concept or concepts of "what works" for clients in treatment. Key experts were asked to identify the factors which need to be measured in order to demonstrate treatment effectiveness.
Many key experts noted that measuring treatment effectiveness was a problematic area, in part due to difficulties they experienced tracking clients post-treatment and a lack of clarity on what measurement indicators to use. Key experts believe in a multidimensional approach to treatment assessment but are not sure how to weigh or integrate factors in order to provide a "complete picture" of client outcomes. There is also the recognition that many aspects of treatment impact are qualitative and that there are few standardized tools available to measure qualitative outcomes. In addition, pressures to use standardized (quantitative) tools are growing.
Need a standardized way of measuring outcomes-from intake-very difficult to measure abstract things in concrete ways funders want.
Some key experts noted that not using abstinence as a "final" treatment outcome measure has made treatment outcome measurement more complicated.
If we're not going to use abstinence as a measure, then we need to measure how and why they are using-need to make judgment on the harm being done. Need to focus on context and consequences of use-look for reductions in amount used, signs of controlled use, signs woman is thinking about negative consequences, reactions, safety of children . . .
Key experts identified the following areas to be considered in a comprehensive assessment of client outcomes after treatment:
There is a lack of data addressing outcome measurement within women's treatment. According to Finkelstein et al.:
Outcome data on gender-specific programming remains scarce as most of the (U.S.) programs with evaluation components, primarily federally- funded, have not yet completed their evaluation process. (Finkelstein et al., 1997:25)There is the recognition that outcome indicators need to measure more than abstinence. A broader view of outcome measures would include:
The Treatment Outcome Perspective Study summarized in the Treatment Protocol Effectiveness Study (Office of the U.S. National Drug Control Policy, 1996), which reviewed major national research results and solicited clinical and research opinion, identified the most relevant outcome measures (see Table 13).
|Reduced use of primary drug||Abstinence
(Longer) length of time to relapse
Reduced frequency of use
Reduced amount of drug used in total and during
each episode of use
|Improved functioning of drug users in terms of employment||Increased numbers of days worked
Enrolment in training programs or school (if required)
|Improved educational status||Increased numbers of days (in school)
Enrollment in training programs or school (if required)
|Improved medical status and general improvement in health||Fewer hospitalizations
Fewer doctor visit
Fewer emergency room visits
|Improved mental health status||Improved mood recognition
Reduced psychotic status
Improved personality traits
Reduced need for mental health treatment
|Improved non-criminal public safety factors||Reduced incidence of drug-related motor vehicle accidents, emergency room visits, fines|
The following indicators of treatment effectiveness were cited as being particularly applicable to men and women with more serious drug problems:
The timing of measurement of outcomes is another important methodological issue. Hser et al., in a study of gender and ethnic differences in responsiveness to methadone maintenance, examined multi-outcome longitudinal data in relation to temporal patterns to assess treatment success (rather than single-point-in-time comparisons). He concluded that:
Society is concerned with drug abuse not only because it causes health problems for individual addicts, usually at public expense, but also because it is associated with various other social and criminal consequences. Therefore, multiple outcome measures, including several aspects of drug use, social functioning, and criminal justice system involvement, should be examined in any intervention evaluation study. In addition, because the pattern of chronic compulsive narcotics use typically involves relapse after a period of abstinence in an often-repeated cycle, evaluation findings based on the single criterion of abstinence at a single observation point are inadequate; in fact, they may be artificially distorted simply by the length of the follow-up observation. A more reasonable evaluation approach is to reflect each of these multiple outcome measures as a probability function over time; a further step involves identifying explanatory factors or predictors that may contribute to the observed probability functions. Survivorship analysis provides a useful technique for the statistical analysis of those types of duration measures. (Hser et al., 1990-91:1310)
Changes in outcome measurement must be predicated on new expectations of treatment and clients. Merrill believed that society's expectations of
"total and permanent abstinence are too high."
Treatment is expected to be a combination of an antibiotic and a vaccine: complete cure and no chance of relapse. In part, this results from the fact that society views substance use disorders as acute problems, rather than as chronic disease with acute episodes. (Merrill, 1998:175)
To address this, Merrill concluded that:
We must move away from looking at this at the individual level of someone permanently stopping drug use, and, instead start applying outcome criteria appropriate to other chronic medical candidates and viewing these outcomes from the broader societal level. (Merrill, 1998:175)
Preliminary research (Merrill, 1998) indicates that while methadone maintenance may not completely eliminate heroin use, the HIV seroconversion rates are lower for those in treatment. A second study (Alterman as cited in Merrill, 1998) indicates that the number of times a client has been in treatment is significantly correlated with reduction in recidivism. These outcome results reinforce the value of looking at outcomes in a more flexible and multi-dimensional (and less clinical) way.
The attached table provides a summary of the model program elements as described by respondents with references to supporting literature. Literature references may not equate exactly with the elements identified so it is advised that readers review these within the text.
The best practice elements defined in this table are based on respondent comments. In some cases, the literature suggested other issues, included in the text but not in the table.
|Underlying Principles of Treatment (All Components)||
|General Component of
|Program Accessibility||Principles of Treatment||Approach and Methods||Outreach|
|Client Contact and Engagement||
|Approach and Methods||Outreach||Family|
|Approach and Methods||Outreach||Staff/ Client
|Approach and Methods||Outreach||Staff/ Client
|Services required: (See Menu of Options above)
|Organization of Adjunctive Services||
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Only broad descriptions of programs were provided by respondents.
Treatment cost may vary jurisdiction to jurisdiction. In some provinces there are no costs for treatment services.
Alcohol/drug treatment is provided within the federal correctional system.
These conclusions may not apply to other ethnno-cultural minority groups.
In this section and those that follow, tables of effective programming elements are not in order of importance.
Are elements of the empowerment approach.
For forther information, see Best Practices - Substance Abuse Treatment and Rehabilitation (Health Canada, 1999)