Rethinking the Way We Deliver Addiction Treatment to Women

1. 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 Women’s Alliance to Strengthen Treatment and Retention Substance Abuse Treatment and Recovery Conference September 17, 2007

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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 treatment—many of them women • Those who are less assertive • Those who have more life-related barriers to overcome

8. 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 don’t design treatment programs to draw people in, rather • We make it difficult to find out about services (what is your program’s telephone system like?) • We limit access (how long is your waiting list?)

9. Results of these myths on women • Women seek care in settings that aren’t 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

10. 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 women’s 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

11. 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

12. Prerequisites for Action: Agency Control Autonomy Sources of Motivation: Hope Optimism Meaning Recovery Processes: Development Learning Healing Adaptation Capacity: Competence Dysfunction An Alternative Approach to Recovery Environment ResourcesStrains

13. Prerequisites for Action: Agency Control Autonomy Sources of Motivation: Hope Optimism Meaning Recovery Processes: Development Learning Healing Adaptation Capacity: Competence Dysfunction Recovery Processes Environment ResourcesStrains

14. 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 can’t be just the absence of substance abuse problems or people will not have a life worth living

15. 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 doesn’t 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 times—each episode of treatment, each relapse, is an opportunity for learning

16. 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 isn’t 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

17. 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

18. 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,1991;1994;1995;1999;2000)

19. 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

20. 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 can’t leave an unhealthy home environment without a job, the most important way to support recovery might be vocational rehabilitation

21. Environment ResourcesStrains Prerequisites for Action: Agency Control Autonomy Sources of Motivation: Hope Optimism Meaning Recovery Processes: Development Learning Healing Adaptation Capacity: Competence Dysfunction Facilitating Adaptation: Sources of Motivation

22. 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) • Activities—work, school, volunteer, family, hobbies

23. 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

24. 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

25. Environment ResourcesStrains Prerequisites for Action: Agency Control Autonomy Sources of Motivation: Hope Optimism Meaning Recovery Processes: Development Learning Healing Adaptation Capacity: Competence Dysfunction Prerequisites for Action

26. 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 agency—the 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

27. 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)

28. 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

29. Environment ResourcesStrains Prerequisites for Action: Agency Control Autonomy Sources of Motivation: Hope Optimism Meaning Recovery Processes: Development Learning Healing Adaptation Capacity: Competence Dysfunction Capacity: Competence & Dysfunction

30. 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

31. 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

32. Environment ResourcesStrains Prerequisites for Action: Agency Control Autonomy Sources of Motivation: Hope Optimism Meaning Recovery Processes: Development Learning Healing Adaptation Capacity: Competence Dysfunction Environment, Resources, Strains

33. 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

34. 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 aren’t 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)

35. 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

36. 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

37. 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

38. 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 staff’s work and the quality of their worklife