Although there is growing awareness, understanding, and
acceptance among health professionals and the public
that alcoholism and other drug addictions are major public
health issues, negative attitudes and misconceptions concerning women
and substance abuse still abound. These attitudes and misconceptions
often pose silent barriers to treatment for women. Women with substance
abuse problems are often reluctant to admit their need for treatment.
They may fear social rejection or loss of their children or they may have
internalized the prevailing social attitudes toward addiction. Furthermore,
for many women, poverty and related socioeconomic conditions, often
compounded by discrimination based on race, psychiatric disorders,
ethnicity, disability, sexual orientation, and/or age, create additional
problems that may further inhibit them from seeking treatment.
A woman who needs treatment for a substance abuse problem may
be deterred by the relative lack of treatment services designed specifically
for women. Women with children may be discouraged by the shortage of
treatment services that include provisions for child care if they must leave
their children in unreliable hands to enter treatment. A successful outreach
program must recognize these factors as barriers to treatment and ensure
that the treatment program addresses them.
To develop an outreach program for women with substance
abuse problems, it is important to acknowledge that substance abusing
women are represented in all ages, races, cultures, ethnic groups,
educational levels, and socioeconomic status, as described in Chapter 2.
To be successful, outreach efforts must recognize these differences and
target specific populations.
This chapter addresses these issues by:
· describing barriers to outreach and treatment;
· describing barriers to outreach and treatment for specific
population groups; and
· presenting general approaches to outreach.
4.1 Barriers to
Outreach and Treatment
Women often confront
barriers to finding, entering, and completing substance abuse treatment
programs. Society imposes some of the barriers. Others are internal within the
woman herself. Some barriers are unique to special populations, but many are
relevant to women of different ages, races, and socioeconomic status. There are
generally three types of barriers:
· Generic, systemic barriers that are not gender-specific (e.g.,
racism, classism, aversion to behavior perceived as "devi
ant," lack of community-based social support services);
· Gender-specific barriers (e.g., lack of geographically acces
sible treatment services for women; lack of child care); and
· Internalized reaction to either the generic or gender-specific
barriers, or other individual experiences or issues faced by an
individual woman (e.g., the client's belief that she is indis
pensable and cannot leave home to seek treatment).
In practice, specific barriers often cross these general types. Barriers that
cut across different populations are in this section; those that are unique to
special populations are presented in Section 4.3.
Economic inequality. Women earn $0.70 for every $1.00 earned by men, are much more
likely to be single heads of households, and are much
more likely to live in poverty. The cost of treatment may be a significant
obstacle for uninsured and low income women who need treatment for
substance abuse and its related problems.
By the end of 1993, nearly 40 million Americans had no health
insurance. In 1989, the most recent year for which gender breakdowns of
such
uninsured Americans are available, 15 percent of American women had no
health insurance coverage (compared with 16 percent of men) and 7.6
percent of women were covered by Medicaid (compared with 5.2 percent
of men).' Women who are insured by programs such as Medicaid often
find it difficult to locate a program that will accept this type of payment.
Furthermore, even if a woman has insurance, it may not cover
alcohol or other drug treatment, or there may be limits to either the setting
of care or the number and types of services (e.g., detoxification days or
therapy sessions that may be covered in a lifetime). The coverage or
entitlement program may also require a co-payment that the woman cannot
afford. Because of the lower incomes of women in comparison to men,
health insurance factors significantly affect financial access to care.
Social Stigmatization. Women who have substance abuse problems
are often perceived as less "socially acceptable" than their male
counter
parts. They are, therefore, less likely to disclose their need for treatment
and more likely to have sustained periods during which substance abuse is
not diagnosed or is misdiagnosed. In our society a substance-abusing
woman is often considered a second-class citizen. She may also be seen as
sexually promiscuous and weak-willed because of her alcohol and
other
drug abuse .2 Social
stigma exacerbates denial, a primary barrier to out-
reach. Outreach workers need to engage women in discussions that will
overcome the psychological and emotional results of social stigma.
In certain cultures, the fear of social stigmatization may be
particu
larly strong. For example:
Women of color [who abuse alcohol] share a double stigma
as alcoholics and as minority women. For a woman of color
who is also lesbian, the stigma and isolation is further
compounded. Women of color are usually alone or in a
small minority in either minority programs dominated by
men or women's programs dominated by Caucasian
women. 3
Thus, women of color
experience many layers of stigmatization:
gender, race/ethnicity, culture, and substance abuse.
Women generally encour age men who have substance abuse problems
to enter treatment. However,
women's partners, family members, and friends often enable women to
continue their substance abuse by denying the existence of the problem or
its seriousness rather than encouraging them to seek treatment. Women are
more likely to bear the primary responsibility for care of their family
members, in part because they are four times as likely as men to be the
head of a single parent household with children. Therefore, women face
practical considerations surrounding a decision to enter treatment, espe
cially inpatient or residential care, that men do not confront as frequently.
Institutional mechanisms that identify and sometimes help men
with substance abuse problems are not as readily available as outreach
vehicles to women. For example, women who need treatment are less
likely than are men to be identified in the workplace because proportionally
fewer are employed (63 percent of women were employed in 1990 in
comparison to 75 percent of men).' Although the number of adolescent
girls and adult women in the criminal justice system is increasing (there has
been a 200 percent
increase in the women's prison population in the past 8 years), prisons for men
are more likely to have medical services, substance abuse treatment, and other
support services than are those for women. However, women have more contact
with staff from social services (welfare), Head Start, shelters, hospitals
(when giving birth), and emergency rooms (when battered). The personnel
employed by these institutions need to be trained to identify substance-abusing
women.
Cultural Values
and Norms.
Until fairly recently, cultural differences have been largely
ignored in addressing treatment issues. Today, it is understood that to treat
women with substance abuse problems successfully a program must have a certain
level of "cultural competency."
Culture, as defined in Cultural Competence for
Evaluators, is the
shared values, norms, traditions, customs, arts, history, folklore, and
institutions of a group of people. Within this perspective and from this
definition, cultural competence is a set of academic and interpersonal skills
that allow individuals to increase their understanding and appreciation of
cultural differences and similarities within, among, and between groups. This
requires a willingness and ability to draw on community-based values,
traditions, and customs, and to work with knowledgeable persons of and from the
community to develop focused interventions and other supports.'
As Orlandi has noted,
Cultures do not remain the same indefinitely. Cultural subgroups
exert an influence over and are influenced by individuals who are members of
those groups as well as other cultural groups with whom these subgroups come
into contact.b
114 Outreach to
and Identification of Women
It is important to
note that cultural competency is a key issue in
attracting women of color into treatment programs:
Women of
color fear not only outright racism but a treat
ment system insensitive to their cultural and ethnic values
which may also have little sensitivity to the special needs of
women ' The culturally liberated caregiver acknowledges
the
reality of racism without allowing it to be an excuse for
the
client's self-destructive behavior.
This can
apply to other populations as well, including lesbians, women with
disabilities, and women who have been or are prostitutes.
Family
Responsibilities. Many
women will not enroll in outpatient treatment programs unless they can arrange
adequate supervision for their children. Women entering inpatient treatment who
leave their children in someone else's care may fear losing custody of their
children. This is particularly true for the following women:
· women already in the criminal justice system who believe disclosure
of a substance abuse problem will be the "last
straw" as far as custody is
concerned;
· pregnant women who fear being called "unfit mothers"
or
facing legal sanctions for using drugs while pregnant;
· women subjected to domestic violence who fear that no one
will protect their children;
· homeless women who fear that Child Protective Services
will remove their children from their custody;
· lesbians who are concerned that disclosure of their lifestyle
will result in losing custody of their children;
· women with disabilities who,
even without the stigma of
substance abuse, are often
perceived as unable to fulfill the
parenting role; and
· any woman with children who
does not have a family or
support system to care for her children while she is in treatment.
The treatment
program staff should be aware that the degree of fear
experienced by these women (expressed or not) may depend on the cultural
"value" placed on children and the role of children in the
family.
Thus if a
program does not provide child care, neither inpatient nor
outpatient treatment is truly available to women with children, who are the
majority of substance abusing women. To attract women with children, the
treatment program should do at least one of the following:
· investigate and evaluate the possibility of providing full or .
partial child care on the premises during the mother's
treatment process and meet the necessary licensing require
ments for providing such care;
· recruit volunteers among program staff, women in the final
stages of treatment, family members, retired persons or
senior citizens, interns from local schools and places of
worship, and members of self-help groups to staff the child
care program; and
· compile and distribute a directory of free or low-cost licensed
day care service providers in the community and explore financial subsidies to
improve access.
Denial. Denial is a primary characteristic of addiction. Outreach
programs may, in fact, be the first step in helping a woman break through
denial. Reaching out to a woman and engaging her in a process of acknowledging
a need for help is a prerequisite for effective treatment. A
woman who acknowledges
that she needs help is much more empowered to
accept and remain in treatment.
Women's
Fears.
Substance-abusing women have many fears that
must be addressed in designing and implementing outreach strategies.
These
include the following:
Fear of Rejection. Many women live in great fear of
being rejected
and abandoned by loved ones, friends, and by others, for example co
workers. They believe their loved ones may reject them if they learn that
their mother, spouse, daughter, partner, friend, or sibling is addicted to
alcohol and/or other drugs. Some adolescent girls and adult women also
believe that a treatment program or its staff will reject them. They may
fear rejection because they are "too bad," they engage in life styles
not
approved of by society.
Fear of
rejection may be particularly pronounced among adoles
cents, especially those in the criminal justice system, whose families may
have already rejected them. Also, women with AIDS or women who are
HIV-positive may fear rejection if they have already felt rejected by health
care providers, employers, family, and friends once they revealed their
medical status.
Fear of
Becoming Abstinent or Getting Well. For women who
have developed few if any coping skills (e.g., assertiveness skills, stress
management techniques), the idea of facing life without the temporary
relief and/or escape that alcohol and other drugs offer at least in the early
stages of use may be overwhelming. During the outreach phase, these
women need assurance that it is possible not only to face life but to enjoy it
without the "help" of mood-altering or mind-altering chemicals. Using
recovering women as role models in the outreach program can provide this
