Outreach to and Identification of Women 137

Women with Disabilities. Women with physical and mental health disabilities, who often face double discrimination based on disability and gender" and who have limited socially sanctioned roles, 16 are underrepresented in treatment programs for a variety of reasons. Barriers to women with disabilities receiving needed substance abuse treatment services include the following:

· social isolation because of transportation, architecture, and
communication barriers as well as negative social attitudes
toward people with disabilities;
· enabling behavior by physicians, family, and friends
who feel frustrated by their inability to "fix" the woman's
disability and unwittingly encourage the use of alcohol and
other drugs;"
· failure to identify substance abuse problems since
abuse-related behaviors are mistakenly attributed to the
disability;"

· lack of access to treatment services. Historic patterns of
segregation have deprived women and men with disabilities in an
access to the same range of substance abuse treatment
services and programs available to their nondisabled peers.

To reach women with disabilities, treatment programs must engage in an active, highly visible outreach campaign. One idea is to include women with disabilities or representatives from advocacy groups on the program's advisory board. Another idea is to work with representatives from local independent living centers, which are advocacy organizations governed and staffed by people with disabilities and located throughout the country. These representatives can help treatment programs become a presence in the disability community by serving as spokespersons at meetings and events, by serving as liaisons between programs and disability agencies, and by referring clients to the program.

Advisory board members can also help design outreach materials in
a range of formats that will be accessible to women with diverse disabili
ties. For example, brochures should be made available in braille, large
print, and on audiotape to reach women with visual disabilities. They
should also be available in simplified language to reach women with intel
lectual or learning disabilities. Public service announcements (PSAs) on
television should be available with open or closed captions to reach women
who are deaf. All materials should provide information on the accessibility
of the facility and program to people with disabilities. Using images of
women with disabilities in program publicity also sends a strong message
of inclusion.
Networking with disability and rehabilitation organizations is
another useful outreach strategy. Such organizations often have limited
I)isuhilily aware- awareness of the signs and symptoms of substance abuse and may benefit
from training in the identification of substance abuse problems and referral
strategies. Their staff, in turn, may serve as a resource to the organization
on disability issues.
Disability awareness training for all staff members is critical, not
only to develop effective outreach strategies, but also to ensure that women
with disabilities remain in treatment past the intake stage. Training should
include an opportunity for staff to explore their own attitudes toward
disability, since stereotypes and negative assumptions can be a major
barrier to effective treatment.
Staff members need to learn how disability relates to gender and the
relationship of both disability and gender bias to substance abuse. Informa
tion on substance abuse issues for different types of disability groups is also
useful.'-" Ideally, the trainers should include women with disabilities. This
is particularly important when staff members have had limited exposure to
people with disabilities.

Finally, programs should become familiar with the requirements of
the Americans with Disabilities Act (ADA) which prohibits discrimination
against people with disabilities. The ADA applies to all substance abuse
treatment programs regardless of size as service providers." Privately-run
treatment programs are covered under the public accommodations section
of the law (Title 111), and government-run programs are covered under state
and local government provisions (Title 11). Knowledge of the law is
essential to ensure compliance as well as effective outreach. The law
mandates that people with disabilities be served in the most integrated
settings possible. To ensure nondiscrimination, the law establishes a series
of specific requirements covering such areas as 1) eligibility criteria;
2) policies, practices, and procedures; 3) auxiliary aides and services for
people with communication disabilities; and 4) architectural access. To
obtain a full description of the law and its requirements, program adminis
trators are advised to consult the growing body of available resources. 2'
Local disability advocacy groups are additional sources of information.

Women and Adolescent Girls in the Criminal Justice System.

Data show that most women in the criminal justice system are involved or have
been involved in substance abuse. However, reaching these women for
treatment requires overcoming many barriers, including their fear of self-
disclosure, legal sanctions, and losing custody of their children. While
many young women in particular fear self-disclosure (especially to adults who may be judgmental about their behaviors), women in the criminal
justice system generally fear that disclosing their need for substance abuse result in
treatment will result in additional sanctions, including increased time on
probation or parole, incarceration, a transfer to higher security or longer
term facilities, or severance of their parental rights. Commonly, women
who have lost or are in danger of losing custody of their children as a result
of incarceration are cut off from the most potent motivation for them to
enter treatment. Also, the laws on child abuse in many states require
outreach workers to report women suspected of criminal negligence to
local public health and/or criminal justice system authorities. When this occurs, the outreach worker becomes an adversary rather than an advocate for the woman, defeating the purpose of outreach. Moreover, a number of systemic factors in the criminal justice system impede the treatment process for women and should be considered as part of outreach. These include the fact that women are often given "flat time" in local jails, which frequently lack substance abuse treatment services (and general health and mental health services). The local jails also may not have adequate systems of referral for women to substance abuse treatment (and other support systems) following release.

Often, by the time women are in the criminal justice system, traditional sources that might have supported their entry into substance abuse treatment have failed repeatedly. Treatment may also have failed, and these women are likely to believe that no other way of life is possible. The combination of fear and cynicism make it unlikely that they will voluntarily seek treatment. Criminal justice system personnel often view incarcerated women more negatively than incarcerated men. This further stigmatizes women, creates resistance among women to seek treatment, and creates resistance among treatment staff and the criminal justice system staff to provide women-specific services.

Many of the criminal justice system personnel have little knowledge or training in the identification of substance abuse problems in women. Furthermore, they may not be aware of the daily realities of a substanceabusing woman's life and therefore may not be sensitive to her needs. They may also be unaware of the scope of women's issues as related to substance abuse and criminal behavior. These issues may include prostitution and rape, incest, or other sexual abuse.

Although some level of treatment services is available either directly or indirectly through referrals in many jails and prisons, the services are generally considered inadequate. Referral to treatment as an alternative to incarceration is increasingly used in communities throughout the country, but these arrangements frequently do not have sufficient contact with other health and social service providers. In fact, there is a general lack of coordination among social service, substance abuse treatment, medical, and criminal justice agencies. This fragmentation and lack of coordination deters women with substance abuse problems from seeking treatment and has made it difficult to establish "user-friendly" support networks for women and adolescent girls in the system.

Strategies to engage women in the criminal justice system include the following:

· establish relationships with parole, probation, third-party

custody, advocacy, and other agencies and organizations

from which clients can be referred; and

· hold meetings in detention centers for women of all ages.

Provide them with written and audio visual materials.

CSAT currently funds a few demonstration projects involving the treatment of women in the criminal justice system. The evaluation of these projects will provide valuable information to plan and implement both outreach and treatment services.

4.3 General Approaches to Effective Outreach Programs

Designing and implementing effective outreach programs for
women requires an understanding of the basic principles of marketing
social programs. These include defining the product, creating an effective
message, and delivering the message to the target audiences. Trained
outreach workers and strong community contacts are essential. Most
importantly, comprehensive services that meet women's needs must be
developed and made available. Finally, it is important to note that many alcoholic and drug-addicted individuals have brief moments when they show a willingness to acknowledge their problem and seek treatment for it. Outreach professionals must take advantage of these opportunities whenever they occur. For example, asking a woman seeking treatment to come back "tomorrow" or "next week" is dismissing an opportunity, and/or may actually place her in danger.

4.3.1 Staffing the Outreach Program

Outreach workers who go into the community play a critical role in the success of the treatment program's outreach. Therefore, they need to be familiar with the community in which they work, both geographically and culturally. They must understand and be sensitive to the reality of women's lives and the many "pretreatment" issues women must face. In addition, they must understand the process of addiction and agree with their program's philosophy. Outreach workers must also convey respect and demonstrate support for women. They need to be able to describe to potential clients the problem of substance abuse and the opportunities offered by the treatment program in concise and understandable terms. Moreover, all program staff members should receive communication skills and outreach training because, in a sense, every contact outside the treatment program is a form of outreach.

Treatment programs have several options in staffing the outreach program:

· train existing program staff in outreach techniques;

· hire a former client or community resident who is a trained

outreach worker with experience in or knowledge of sub

stance abuse;

. contract with a community-based organization that has trained outreach workers in the community; or

· a combination of the above.

Because different skills are needed for clinical work than for

outreach, the latter three options may be preferable.

Program directors and administrators

4.3.2 The Product: Designing a Program that Actually Meets the
Needs of the Women in the Target Population

To develop effective outreach strategies and identify women who
need treatment, program directors and administrators must understand and
accept the importance of customized outreach that uses gender-specific
strategies based on existing knowledge and techniques. They must be
willing to examine critically whether the current structure of the program
helps or hinders outreach and to allocate the necessary staff and other
resources to achieve outreach goals.
Before initiating outreach activities, the program staff and outreach
workers must:

· identify the women to be reached within the community and
understand their perspectives; and

· set specific program goals and objectives for treating
women.

Outreach may be conducted in many different ways. Each program
should assess its own resources, both human and financial, before deciding
which outreach strategies to employ. The strategies suggested below vary
in terms of cost and complexity, but they can be applied or adapted for
women of different ages, ethnic groups, and other specific populations.

Specifically, experts recommend that outreach personnel do the following:

· collect and analyze available demographic data to form an

accurate and comprehensive picture of the extent and nature

of substance abuse problems among population groups in the

community;

· examine whether the structure of the program's advisory

board, board of directors, and staff is appropriate for the

client population, and whether those individuals understand

the impact of substance abuse on women. Add women of

color, older women, women in rural areas, women with

disabilities, and women who are bilingual, bicultural, or

lesbians as appropriate to ensure that the board and staff

represent a cross-section of women in the community;

· solicit ideas from health, mental health, disability/rehabilita

tion, legal, and social service personnel in the community

who are in contact with the target population. Also, solicit

ideas from women in recovery who can share their own

experiences and concerns about treatment, and from the

program staff;

· form teams from these groups and have them develop

common goals, shared values, and agreements on how to

approach treatment for women and adolescent girls who

have abused alcohol and other drugs; ensure that directions

and guidelines are consistent and that they foster trust and

interest in treatment; and

· examine the language that the program uses to ensure that it:

helps women understand addiction as a health issue; does

not reinforce low self-esteem or powerlessness; does not

further stigmatize women by insinuating that addiction is a

moral failing; and helps them to understand their anger and

express it in healthy ways.

Outreach to and Identification of Women 145

Beyond recognizing the obstacles to treatment that women face, the
program must be architecturally' economically' geographically' and cultur
ally accessible. Strategies to accomplish this goal include the following:

have a sliding-fee scale based on the woman's own ability to
pay, if a fee is charged;
arrange for safe, reliable, and low cost transportation to and
from the facility. Provide bus or subway tokens for adoles
cents and low-income clients and, if necessary, request an
extra bus stop by the facility or an extension of hours for bus
service. If possible, have a donated vehicle available on-site
or make arrangements to use a vehicle maintained by a local
community organization or place of worship.
for older women, work with the appropriate senior
services agency to add bus routes that deliver passengers
to the treatment facility; then schedule activities for seniors
accordingly. Ensure that women with disabilities have
accessible transportation. Explore a car-pool or other
transportation for women who do not have access to public
transportation;
ensure that the individual program and facilities comply
with the ADA requirements and that the staff is responsive
to disability-related issues;
ensure that the substance abuse services offered (or for
which it makes referrals) are indeed available and respon
sive to the clients. A treatment program must develop a
reputation for "keeping promises" in the community and to
the women in its target population. It is important to ensure
that this reputation is one that will attract women into
treatment and that the program's success in this area is
described in outreach efforts;
recognize that providing treatment services to women is an
evolutionary process that can be adapted based on the
information gained from the program itself and from outside
sources. In this regard, evaluation and feedback are extremely important aspects of treatment, but they have not been readily integrated into the treatment process or specifically into outreach. Part of the difficulty may be in misunderstanding these processes, which can be defined in two ways:

1. evaluate the degree to which the program is meeting its

goals and objectives. The process usually involves a variety

of methods, including review of client records and follow-up

of clients after treatment;

2. obtain feedback as part of the formal or informal process of

collecting subjective and objective information from clients

and staff, and use these opinions in the treatment process and

in program management.

To ensure that evaluation and feedback support the outreach process, the program should hold regular staff discussions on perceptions of the program's strengths and weaknesses and solicit feedback from clients, community, and others. These discussions should include staff commentary on the program structure and various components of the program, including outreach. The program also should establish a policy that encourages women in the treatment program to provide input into the outreach program to learn what works and to build their self-esteem. Evaluation is further discussed in Chapter 7.

4.3.3 The Message: Make it Compelling and Appealing to the Targeted Women

Substance abuse should be described as a health care issue, focusing, for example, on how substance abuse affects women's bodies. The message can also create an awareness that, for many women, the emotional and/or spiritual consequences of substance abuse led them to seek out or be receptive to treatment. Publications and media and community presenta-