Rethinking the Way We Deliver Addiction Treatment to Women

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Rethinking the Way We Deliver Addiction Treatment
to Women 

• Fostering Recovery through Empowerment and a
  Customer Focus

Carla A. Green, Ph.D., MPH Center for Health
Research, Kaiser Permanente Northwest Womens
Alliance to Strengthen Treatment and Retention
Substance Abuse Treatment and Recovery
Conference September 17, 2007
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Background What we know about women and
substance abuse treatment

• Over their lifetimes, women with substance
  problems are less likely to seek treatment than
  men
• Women experience more barriers to treatment entry
  and to staying clean and sober than men because
  they
• Lack social support from those in their networks
• Experience more negative influences from
  drug-using romantic partners
• Are more likely to live in poverty
• Have more responsibilities for children and
  childcare
• Have more mental health problems
• Have greater needs for weekend and evening
  services
• Greenfield, S.F., Brooks, A.J., Gordon, S.M.,
  Green, C.A., Kropp, F., McHugh, R.K., Lincoln,
  M., Hien, D, Miele, G.M. (2007). Substance
  abuse treatment entry, retention, and outcome in
  women A review of the literature. Drug
  Alcohol Dependence, 86, 1-21

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What we know about women and substance abuse
treatment (continued)

• Women are more likely to seek treatment in
  non-specialty addiction treatment settings
• Some subgroups of women may need specially
  designed services
• Older women
• Women from specific ethnic or minority groups
• Women in the perinatal period
• Women with eating disorders
• Women who are victims of violence
• Once in treatment, women do as well as or better
  than men
• For these reasons getting them in is critical

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Background Myths(1) that Affect Approaches to
Substance Abuse Treatment for Women

• Myth Drug addiction is voluntary
• Reality Because drug use starts as a voluntary
  activity we forget that substances change us
  physiologically
• What was once voluntary becomes involuntary and
  compulsive
• Reality Environment is critical in acquiring
  addictions and in the relapse process
• Stresses and strains can affect use and relapse
• Women experience more because of poverty and
  child-rearing
• Drug use in social networks can be hard to resist
• Women are influenced more than men by loved ones
  who use or continue to use
• Women have less social support for entering and
  continuing in treatment
• (1)Adapted from Leshner, A.I. (1999) Principles
  of Drug Addiction Treatment A Research-Based
  Guide. National Institute on Drug Abuse, National
  Institute of Health

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Effects of believing, even in small ways, that
addiction is voluntary

• We treat people with addictions differently than
  we treat people with other conditions
• This is stigmatizing
• We blame them for relapsing
• We deny treatment following relapse
• We deny treatment because of poor treatment
  compliance
• Women may be more sensitive to these stigmatizing
  experiences

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Myths Their Effects (continued)

• Myth Drug addiction results from poor character
• Reality Addiction changes behavior because it
  changes brain functioning
• We perceive these changes as changes in character
  that are permanent, but character is not fixed
• Current character is not past character, nor is
  it future character
• Negative effects in treatment settings
• Punitive approaches, including shaming for past
  behaviors and for relapses
• Again, women may be more sensitive to these
  experiences

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Myths Their Effects (continued)

• Myth You have to want drug treatment for it to
  be effective
• Reality
• People who are pressured to attend treatment do
  at least as well, if not better, than others in
  treatment
• Many who are not sure about treatment can be
  engaged and will enter treatment if properly
  approached
• Forcing people to overcome barriers to accessing
  treatment does produce a group that is selected
  for the greatest motivation, BUT
• Keeps others out of treatmentmany of them women
• Those who are less assertive
• Those who have more life-related barriers to
  overcome

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Myths Their Effects (continued)

• Negative effects in treatment settings
• We deny treatment unless people prove that they
  really want it (e.g., we make them call every
  day or every week until an opening is available)
• We dont design treatment programs to draw people
  in, rather
• We make it difficult to find out about services
  (what is your programs telephone system like?)
• We limit access (how long is your waiting list?)

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Results of these myths on women

• Women seek care in settings that arent equipped
  to treat addictions (e.g., psychiatric settings)
• Women avoid treatment overall
• Women who try to seek care may not be able to
  attend because
• Care is not available when they are
• Services that meet their needs are not available
• Child care
• Transportation
• Mental health services

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An Alternative Approach?

• Focus on the customer and personal empowerment
• Person-centered, collaborative care improves
  outcomes for chronic conditions
• Empowering women in clinical settings may help
  them develop better control and power in the rest
  of their lives
• As womens personal control and power increase,
  women will be more likely to
• Overcome the barriers they experience to staying
  clean and sober
• Improve their quality of life, thus reducing the
  risk of relapse

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An Alternative Approach (continued)

• Learning from other fields and areas to inform
  our approach and improve treatment access and
  treatment experiences
• Stress processes and stress management
• Happiness and quality of life research
• Effects of environment on behavior
• Developmental processes, including adult learning
• Identity, healing, and adaptation to chronic
  illness
• Motivation
• Consumer empowerment and collaborative care
• Process improvement for businesses

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An Alternative Approach to Recovery
Environment Resources Strains
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Recovery Processes
Environment Resources Strains
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Recovery Processes Development,
Learning, Healing Adaptation

• Recovery is a long-term process, inextricably
  intertwined with
• Normal human development
• Intellectual growth learning
• Experience
• Healing
• We need to see recovery in the context of a whole
  person and his/her life and development
• Recovery cant be just the absence of substance
  abuse problems or people will not have a life
  worth living

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Recovery Processes Development,
Learning, Healing Adaptation

• Normal growth development can be disrupted by
  substance abuse and mental health problems, but
  they still continue
• Individuals are learning and adapting, even when
  it doesnt seem that they are
• People often need to learn from multiple
  modalities (from others, visually, by trying it
  out, from books)
• People often need to try things multiple
  timeseach episode of treatment, each relapse, is
  an opportunity for learning

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Recovery Processes Development,
Learning, Healing Adaptation

• Adaptation is the behavioral manifestation of
  learning, development, and personal growth
• In addiction treatment
• We are teaching methods for adapting to and
  maintaining a drug-free lifestyle
• But if this is all, it isnt enough
• Life must be more than the absence of addiction
• We need to help people catch up when their
  development has been disrupted and to move toward
  a life that is rewarding to them

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Processes of Adaptation to Chronic Illnesses

• Can research on adapting to chronic illness
  inform our understanding of recovery from
  addictions?
• Common responses to initial illness symptoms,
  receiving diagnoses, and functional
  limitations/impairments results in complicated
  processes of
• Denial
• Acceptance
• Identification
• Adaptation

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Adapting to chronic illness

• People with chronic illnesses often
• Distance themselves from their illness and
  diagnoses
• Deny that they have a serious illness
• Deny that their illness is chronic
• Begin to recognize that their bodies are altered
  and accept their illness as real, allowing them
  to account for symptoms and life changes
• Feel estranged from the person they have become,
  betrayed by their own bodies, or guilty for not
  meeting normal standards for activities,
  functioning or appearance.
• Learn about the chronicity of their illness and
  its effects on daily life as they deal with
  symptoms and repeated acute crises
• Compare their present condition with their past
  condition, weigh the risks of continuing regular
  activities, then alter those activities
• Become immersed in their illness
• Eventually find ways to take stock, embrace their
  illness, recover a sense of a valuable self, and
  achieve a better quality of life
• from Charmaz,19911994199519992000)

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Implications for Substance Abuse Treatment

• Treatment may need to target specific
  developmental tasks
• Particularly if substance abuse began before
  reasonable adult functioning was established
• Denial may be a normal part of the process of
  adaptation to having a chronic, stigmatized
  problem
• Helping clinicians and families reframe denial as
  a normal part of adaptation may reduce stigma and
  negative assessments
• Addict or alcoholic identities may be a
  critical step in learning about what it means to
  have a chronic substance abuse problem
• We can recognize this as an important step in the
  healing process, then help people move beyond
  this stage

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Implications for Substance Abuse Treatment

• Timing of particular treatment efforts should
  depend on where an individual is in this
  (non-linear) adaptation process
• We do this to some extent with
• Motivational enhancement
• Stage of change approaches, and
• Stepped care, but
• More comprehensive, whole-person, approaches
  could help us target individuals specific needs
  when they are needed
• For example, if a woman cant leave an unhealthy
  home environment without a job, the most
  important way to support recovery might be
  vocational rehabilitation

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Facilitating Adaptation Sources of
Motivation
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Hope, Optimism, Meaning

• People need to
• have hope that they can recover
• be optimistic that they can build, rebuild, and
  maintain a meaningful life
• have some source of meaning in their lives
• Spiritual
• Close relationships (often disrupted by substance
  abuse)
• Activitieswork, school, volunteer, family,
  hobbies

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Implications for Substance Abuse Treatment

• Current system characteristics can undermine hope
  and optimism
• Long waiting lists
• Poor coordination of care for those with medical
  or mental health problems, or those transitioning
  from detox
• The more complex the problems, the more likely
  care will be fragmented
• The more fragmented the care, the more likely
  these most vulnerable people will fall through
  the cracks
• High staff turnover/low continuity of care
• Continuity of care is critical in developing the
  kind of collaborative clinician-client alliances
  that are necessary to foster the kind of trust
  and hope that support good disease management

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Implications for Substance Abuse Treatment

• To foster hope for recovery, we need to
• Learn to coordinate services for people who need
  them
• Improve access to care
• Work to keep treatment staff to improve
  continuity of care so that clients can build
  relationships with clinicians
• Help clients carefully time the introduction or
  reintroduction of meaningful activities to
  improve their quality of life

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Prerequisites for Action
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Agency, Control Autonomy

• To recover, each person must be able to
• Envision a goal
• Set priorities among possible actions and goals
• Plan methods of achieving those actions or goals
• Act in concert with those plans
• Substance abuse problems interfere with
  agencythe ability to progress through these
  steps
• Incarceration, legal or other mandates, and
  strict treatment program regulations, can
  interfere with the control autonomy necessary
  for action
• Agency is also necessary for managing any chronic
  illness

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Agency

• Agency should be seen as a strength that can be
  developed, or attenuated, over time
• Agency is affected by experiences and outcomes
• Successes increase agency (and hope)
• Lack of control, autonomy, or opportunity can
• Failures interfere with agency (and hope)
• Thwart the best-constructed plans of a motivated
  actor
• Reduce hope and optimism for the future
• Agency can be rebuilt, even if a person starts
  with responsibility for only micro-level
  decisions
• (from Davidson Strauss)

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Implications for Substance Abuse Treatment
Research

• Collaborative relationships with clinicians
  counselors provide the foundation for developing
  agency
• These relationships require
• client empowerment
• consumer involvement in program development and
  evaluation
• We also need to find ways to reconcile
  client-centered and client-directed treatment
  with evidence based practices and manualized
  approaches

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Capacity Competence Dysfunction
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Competence Dysfunction

• Recovery must build on competencies
• Taking stock of strengths and weaknesses is part
  of the process of adapting to chronic illness
• When functioning is limited, clinicians clients
  can become overly focused on dysfunction and
  risk, missing strengths desires that
• Improve motivation
• Increase hope
• Lead to meaningful activities

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Competence Dysfunction

• Balancing risks while continuing to progress is
  difficult work
• People often overextend, relapse, then try again
• Using a chronic disease, collaborative, framework
  facilitates learning, personal empowerment, and
  return to treatment following relapse

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Environment, Resources, Strains
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Environment, Resources, Strains

• Provide the context in which recovery occurs
• Broad pervasive
• Financial
• Emotional
• Opportunities
• Stigma discrimination
• Substance abuse treatment mental health care
  can be resources or strains
• This depends on how care is organized, delivered,
  and financed

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Resources Strains

• Strains result from resource loss
• Stress resistance is bolstered by resources
  resource gains
• Resources of one kind can offset resource loss of
  another kind
• Loss spirals can occur when resources are so low
  that stores arent adequate to offset losses
• Losses, and investments that do not pay off, can
  lead to demoralization, low self-esteem,
  depression, loss of hope
  
• (adapted from Hobfall)

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Implications for Substance Abuse Treatment
Research

• Individuals with substance abuse and mental
  health problems are at increased risk of resource
  loss
• We know little about preventing resource loss, or
  helping people to maintain resources
• We often rely on low turning points or hitting
  bottom to enhance motivation
• Need to learn how to intervene effectively before
  devastating losses occur
• Addressing other strains may free up energy for
  recovery

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Implications for Substance Abuse Research
Treatment

• Early treatment could include resource loss
  prevention to
• Help to engage the client in treatment by
  addressing issues that s/he sees as important
• Employment problems
• Family problems etc.
• Prevent losses that make recovery more difficult
• Increase resources that facilitate recovery

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Learning from process improvement

• Personal empowerment, agency, and control can
  also be enhanced when treatment agencies adopt a
  customer focus
• Process improvement techniques, including
  walk-through exercises can
• help identify agency characteristics and
  processes that are cumbersome, frustrating, or
  demoralizing for clients and staff
• help agencies streamline procedures to reduce
  staff workload and improve client experiences
• improve the work environment and staff worklife,
  reducing turnover
• improve client access and retention, and
  therefore, the bottom line

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Conclusions

• Adopting an approach that focuses on empowering
  clients and addressing their individual needs has
  the potential to
• Improve access and retention in treatment,
  particularly for women
• Improve long-term outcomes
• Increase treatment agency capacity
• Improve the quality of staffs work and the
  quality of their worklife