Outreach to and Identification of Women 111

assurance, as will involvement in recreational programs related to stress management.

Fear of Dealing with Authority Figures. This fear may be particularly pronounced for these types of women:

· women from economically or racially disadvantaged

populations;

· women who have had negative experiences in trying to

obtain social services (housing, medical care, food stamps,

job training, etc.);

· women in the criminal justice system who see the system as

punitive rather than rehabilitative, women with criminal

records and/or outstanding warrants, and women who have

engaged in illegal activities to support their addiction;

female adolescents who have had behavioral problems;

illegal aliens who fear deportation (and fear that registering

anywhere will mean that the government will find them,

whether a program is government-funded or not); and

- women who have been victims of incest or sexual abuse.

To address these concerns, outreach programs should develop relationships with departments of education, local legal aid offices, law offices, and other relevant agencies to identify individuals who are sensitive to the needs of women who abuse alcohol and/or other substances. These individuals could then be "gatekeepers" for referrals to that agency and could also visit the program periodically to meet with women in treatment. By conducting training sessions for the staffs of these agencies, the outreach program would sensitize them to the needs of women in treatment. The program could then advertise the availability of these services in its outreach materials.

Outreach to and Identification of Women 119

4.2 Barriers to Outreach Unique to Population Groups

This section briefly describes barriers to outreach that are unique to specific groups of women, including the following:

age groups (adolescents and older women); pregnant and postpartum women; ethnic and racial minority populations; and other specific groups of women.

4.2.1 Age Groups

This section summarizes information about outreach strategies targeting adolescent girls (aged 12-18) and older women (65 and older).

Adolescent Girls

The outreach information in this section addresses the concerns of both male and female adolescents because most of the available literature does not specifically address outreach to adolescent girls. It is important to note that this information may also apply to adolescents residing in programs with their mothers.

Some obstacles to reaching high-risk teenagers, which apply to both boys and girls, include the following:9

· a false sense of bravado and willingness to take risks, coupled with a fear of being branded as "sick." This can lead to a normalizing of substance abuse;

120 Outreach to and Identification of Women

· feelings of ambivalence and confusion about alcohol because
of conflicting messages about alcohol use in the home, in
society and within peer groups;
· skepticism, distrust and fear of continued rejection based on
the individual's history of treatment and of poor family
relationships;
· hopelessness among young people in inner cities regarding
the possibility of ever having a worthwhile future with a
decent job; and the presence in some inner-city neighborhoods of an open,
accessible drug culture without apparent social sanctions, and
the easy way in which large sums of money can be obtained
by those who deal in drugs.

' Many high-risk youth have had lifelong difficulties trying to "fit in"

and to find a sense of belonging with their families, at school, and with

peers. These youth may be harder to reach because they resist traditional

authority. Some may have a low literacy level. If so, materials targeting

this population are most effective if written on a third or fourth grade level.

Before designing and implementing outreach programs for adolescent girls, it is important to assess the community and learn as much as possible about the particular environment in which the girls live. According to Resnick and Wojcicki:

understanding key adolescent issues is critical in planning intervention activities. Effective outreach programs make contact with high-risk youth in settings where they are most comfortable. Youth at high risk for use of alcohol and other drugs tend to be alienated from traditional institutions and, thus, difficult to reach through conventional approaches."

Outreach to and Identification of Women 121

Outreach to adolescents is often conducted through existing community youth organizations, such as places of worship, parent organizations, and schools. However, some adolescents at risk for or already involved in the use or abuse of alcohol and other drugs have dropped out of school or are not involved with community groups. In such cases, an effective outreach approach is to "hang out" and distribute literature in locations in which adolescents congregate, including fast food restaurants, street corners, and shopping malls. Outreach activities should focus on places where adolescent girls may seek services, such as family planning and STD clinics, general health care clinics, and welfare and other social agency offices. Networking with probation, parole, and correctional officers and with youth workers or community activists involved in outreach to gangs can help identify adolescent girls who need substance abuse treatment services.

Beyond distribution of literature, more creative, youth-oriented strategies should be implemented. These strategies may include involvement in the following activities:

street theater performed at locations frequented by youth; rap videos and music; distributing colorful, eye catching T-shirts; and - special events at recreation centers or juvenile detention

centers.

Activities and services need to be appealing to young people to encourage their participation. The National Council on Alcoholism and Drug Dependence, the AIDS Clearinghouse, and other agencies have produced many informative brochures, posters, and other material for youth. These materials can be distributed with information from the treatment program.

122 Outreach to and Identification of Women

Outreach workers need to be specifically trained to identify youth at
risk and to speak with them using their vocabulary; peer outreach can be
utilized where feasible and appropriate. By knowing how to communicate
with adolescents, outreach workers can encourage potential clients to seek
help.

Older Women

In general, neither the early- nor late-onset cases of alcohol and/or
other drug abuse among older people come to the attention of the substance
abuse treatment professional through the usual referral networks (courts,
employers, spouses, families). Older women may be isolated from their
community and family because they may no longer drive, may have retired
from their jobs, and may be living alone because of separation or death.
Widows may be a particularly vulnerable population for alcohol and
prescription drug abuse.
Therefore, the primary route of intervention may be through the
health care system, including the health care provider(s) and the acute care
setting where older women seek treatment for age-related health problems.
However, physicians and other primary health care practitioners often do
not diagnose substance abuse problems within the older female population,
in part because of insufficient specialized training in addictions. Many
physicians do not fully understand the potential consequences of alcohol
and other drug interactions in this age group. Even when problems are
recognized, many physicians, other health care workers, and family mem
bers are reluctant to intervene because of the mistaken notion that the
woman's age precludes change or that withdrawal from the substance
would cause her undue stress. Some family members even believe that the
older woman is easier to deal with when she is numbed by alcohol and
other drugs. Finally, family members and friends may have little knowl-
edge about how alcohol, prescription drugs, and over-the-counter (OTC)
preparations may affect their loved one's mood and physical condition.
Many substance abuse treatment professionals are unfamiliar with
the senior services network (and vice versa); thus, the network of senior
services is underutilized in outreach and program development. Specific
programming for older women has not, for the most part, become standard

in substance abuse treatment programs. This is true partly because the
proportion of substance-abusing women in older age groups is significantly
lower than that of younger age groups. Also, because alcohol and other
drug use patterns, lifestyles, and environments of older women are often
different from those of many younger women, they may not readily fit into
programs designed to treat younger substance-abusing women.

Outreach and identification must be modified to attract the older
woman with a substance abuse problem. Many women in this age range
are socialized to believe that you do not "air your dirty laundry in public,"
and you do not to talk about problems. This makes outreach, access,
treatment, and coordinating care more difficult. It also should be empha
sized that women 65 and older have significantly varying physical and
mental health states. Some "older" women of 75 or 80 may be in better
health than women who are younger, although this is less likely to be true
for women who abused alcohol or other drugs for long periods. As with
other issues and populations, culture may play a role in outreach to this
population.
Specific outreach strategies for older women include the following:

· establish relationships with social service agencies and

community organizations to work with older women.

Arrange to distribute flyers through these agencies and

conduct seminars about substance abuse among older

women for their staff;

· arrange workshops and special events at adult day care

centers and at meetings or activities sponsored by groups,

such as the American Association of Retired Persons, Gray

Panthers, and the Older Women's League;

· meet with physicians who primarily serve older women to

discuss substance abuse problems in this age group and to

discuss drug interactions;

· train health aides who work with older women about alcohol

and substance abuse;

· conduct seminars or workshops through state and local

medical and nursing associations on substance abuse prob

lems among older women;

· develop a list of signs and symptoms that are consistent with

substance abuse in older women. The list of indicators

should include the following: combined use of alcohol/

prescnption/OTC medications; broken bones associated with

falls or accidents; gaps in memory; cognitive impairment;

trembling; weight loss; fatigue; insomnia; malnutrition;

incontinence; aggression; depression; general debility;

inadequate self-care/poor hygiene; lack of physical exercise;

social isolation; and difficulty controlling such diseases as

diabetes, gout, or angina. The list should be designed for

use by primary care providers and should describe the

possible array of indicators that may warrant further investi

gation of substance abuse or misuse; and

· maintain a list of older women in recovery who are willing

to share their stories with other women in the program.

Pregnant and Postpartum Women

It is important to reach out and enroll substance abusing women in treatment when they are pregnant. However, it is often difficult to do so because of complex societal and medical problems. Frequently, pregnant and postpartum women who use and abuse alcohol and other drugs are
much more severely stigmatized than women who are not pregnant. There
fore, they may deny their drug use, its possible effects and their need for
help. Pregnant and postpartum women, particularly young poor women,
often afraid of the medical and social welfare system and/or personnel
within these systems because they have had negative experiences with
them. A recent report by experts in the field and issued with support from

CSAT, the Treatment Improvement Protocol (TIP) for pregnant substance
abusing women, provides information about these issues."

Government agencies and the public are increasingly concerned
about the use of both legal and illegal drugs by pregnant women. Some
groups have taken or proposed punitive actions (including jail sentences)
against substance-abusing women who are pregnant and women of
childbearing age who are using cocaine and/or crack cocaine. Many states
require hospitals to report pregnant women suspected of heavy alcohol and
other drug use to local public health authorities or the criminal justice
system when the women present for delivery. This reporting may cause
women to be even more wary of acknowledging that they have a problem.
In fact, it may result in some women avoiding prenatal care and hospital
delivery, particularly if they have other children who are in the custody of
Child Protective Services (CPS) or who are living with relatives. The
women then fear the loss of their children. In many states, CPS, foster care
placements, and review boards base their decisions on whether to return a
child to his/her mother on the length of time the child is away from the
mother. This serves as a deterrent to women seeking effective long-term
substance abuse treatment if child care is not available in such treatment
programs.

Strategies to encourage pregnant and postpartum women and
adolescent girls to enter treatment include the following:

· develop and advertise specific services for pregnant and
postpartum women. Materials should include information
about the program's 'social services and child care provisions
offered at or through the treatment program;

· conduct outreach activities in places such as WIC programs,
ob/gyn clinics, family planning centers, well-baby clinics,
departments of social services, Head Start offices, and Le
Leche League chapters;

· develop and show videotaped stories of other pregnant
women who have successfully completed substance abuse
treatment;

· provide education on the relevance of seeking treatment
before delivery; and

· educate physicians, midwives, and other health professionals
about treatment resources and the importance of identifying
of substance-abusing women within their patient populations.

Many women who seek treatment for substance abuse problems
were teenagers when giving birth to their first children. Outreach to this
population of mothers needs to co-occur with the development of specific
programs for them. Intervening with the woman and the child(ren) she has
at present, rather than waiting until subsequent children are born, is critical.
The possibility of having their children reunited with them is often
an incentive for mothers to enter treatment. Under supervision, mothers can
learn effective parenting skills, become drug-free and experience improved
relationships with their children. This not only provides further incentive
for the mothers to enter treatment, it unburdens foster care systems by
assuring the safety of the child in a therapeutic milieu. This reunification
model is often not emphasized.