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Service Providers and

Treatment Access Issues

Shirley D. Coletti, D.H.L.

INTRODUCTION

Traditionally, drug treatment programs have focused on white

male addicts and the resources needed to help them in their recovery

(Vannicelli 1984). Early efforts to identify the treatment needs of

women concentrated on studying white heroin-addicted women (Colten

et al. 1979). Only in recent years has increasing attention been given

to the treatment of women of childbearing age and the resources they

need to recover from addiction.

It is now generally accepted that there are differences between

men and women in the sociocultural factors that contribute to their

substance use (Lex 1991). Because men and women are socialized

differently, women frequently have fewer assertiveness skills and need

more supportive networks to remain alcohol- or other drug-free (Marsh

and Miller 1985). In U.S. society, women’s social status usually derives

from men, and the drugs they use are often obtained from men (Boyd

1993). Often, female addicts report having been sexually abused

(Wildwind and Samson 1981, pp. 109-163). Family substance abuse,

sexual abuse, age of first depressive symptoms, and age of first illicit

drug use have been found to be significantly correlated for women

(Boyd 1993).

To be successful in drawing women into treatment, it is necessary

to be cognizant of gender differences. Problems specific to many female

substance abusers include low self-esteem (Reed 1990) and late entry

into recovery that is often prompted by the criminal justice system or

child protective service agencies (Haller 1991). A study of pregnant

and postpartum women in substance abuse treatment facilities in the

southeastern United States identified the major barriers faced by women

enrolling in treatment as self-perceived rather than logistical or systemic

in nature. Major barriers included issues such as fear of losing their

children, shame, depression, and denial (Gehshan 1993). Women may

fear that their partners will abuse them or leave them if they seek
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treatment services (Center for Substance Abuse Prevention 1993). In

addition to these self-imposed obstacles, other identified barriers include

lack of money, waiting lists for treatment slots, limited service availability for pregnant women, lack of child care, unsafe housing, and lack of

transportation (Gehshan 1993; Chasnoff 1993).

Women seek treatment for a variety of reasons, including family

pressure, concern for their children, and pressure from the legal system

(Gehshan 1993). Women have a host of problems that are different

from the problems men face when attempting to enter treatment.

Therefore, there are many reasons to believe that treatment services

for substance-abusing women should be different from those for men.

One of the most difficult aspects of treatment is identifying substanceabusing women and drawing them into care (Haller 1991). Active

recruitment and outreach efforts are needed to help women overcome

self-imposed barriers and enter substance abuse treatment programs.

Programs should be designed to meet the needs of women.

In the State of Florida, as in many other States, it is illegal to use

drugs while pregnant (Florida Statute 397), and substance-abusing

women face the possibility of having their newborns taken away from

them at birth if the infants have positive urine toxicology screens. As a

result, pregnant substance abusers are often suspicious of the “system.”

Many access prenatal care late in their pregnancies or present at the time

of delivery, having received no prenatal care because of that suspicion.

These parents often fear social service agencies, protective service

personnel, strangers, talking about personal issues, and labeling (Kumpfer

1991, pp. 87-95). Nontraditional outreach methods using former

addicts, aggressive outreach techniques, and immediate response may be

effective in reducing preadmission hurdles (Brown 1991, pp. 1-26).

Moreover, substance-abusing women frequently lack knowledge regarding treatment service availability and the means by which to access that

service. This naivete, coupled with their fear of the system, often

constitutes the principal barrier in getting them into a treatment center.

Environmental factors, such as single parenthood and lack of social

support, may have a negative effect on an individual’s ability to enter

treatment (Freier et al. 1991). Most drug-using women face problems

other than their addiction. They frequently have numerous financial,

legal, health, social, and psychological problems, including poor housing,

inadequate income, lack of education, and emotional difficulties. Sexual
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or other physical abuse during childhood is common among these

women (Regan et al. 1984, p. 330). In addition, many have histories

that include abusive or violent relationships with men (Gehshan 1993).

Substance-abusing women with lower levels of self-esteem and

higher levels of emotional distress have more difficulty participating in

drug treatment and are pessimistic about the prospect of making positive

changes in their lives (Reed and Moise 1979, pp. 114-128).

WHAT MAY WORK AND WHY

Substance-abusing women often view treatment as a way to avert

the negative consequences of their drug use, such as loss of child custody

or incarceration. Generally, they are ready to enter treatment only at a

crisis point in their lives when they need stabilization. It is only after

critical factors, such as housing, child care, transportation, and medical

assistance, are satisfactorily provided that female addicts can focus on

their addiction (Haller 1991). Assisting a woman in accessing these

other services can help establish trust between her and her counselor

or case manager. Special emphasis should be placed on the engagement

of women at each step of the treatment entry process: outreach, referral,

and intake (Longshore et al. 1993).

Providing women with preadmission intervention services that

reduce real and perceived barriers to treatment and increase their ability

to adjust to a program can help them follow through with treatment

recommendations. Furnishing early intervention services to women

who are on a waiting list for treatment can influence their willingness

to enroll in treatment services (Katz 1963).

The provision of “up-front” case management services designed to

help stabilize a woman and make the transition to treatment easier can

increase retention rates (Haller 1991). Helping potential clients overcome fear means the development of a relationship of mutual trust

and respect that often requires much time and effort. For example, if

a woman is afraid that State intervention may lead to the loss of custody

of her children, these fears might be overcome if she is provided with

information about how such laws and program regulations affect her.

Explaining the confidentiality regulations of the agency and the reporting requirements for child abuse and neglect in a way that demonstrates

that the clinician has the program participant’s welfare in mind can

assist in establishing trust (Kumpfer 1991, pp. 87-95).
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Children are an important force in the lives of addicted parents,

either as a motivation to halt drug use or as an additional strain at a time

when parents, particularly mothers, need to focus on their own needs for

treatment. The provision of comprehensive services, before and during

the enrollment period for substance abuse treatment services, has proven

successful in dealing with personal problems of substance-abusing mothers. This outreach approach also facilitates the successful treatment of

program participants, particularly mothers of small children (Eldred et al.

1974).

Moreover, a substance abuse counselor’s or case manager’s therapeutic

style may affect treatment outcome. Clients of those counselors who

possess “accurate empathy” generally have better treatment outcomes,

and therapist empathy has been identified as a key element in successful

brief interventions (Miller 1992). Empathy is the imaginative projection

of one’s own consciousness into another being to increase one’s understanding of the other’s situation. The amount of empathy received by

the client is considered one of the most salient elements in the treatment

relationship; lack of empathy frequently has led clients to prematurely

withdraw from treatment (Katz 1963).

It also is vital that program staff members be trained to be “ethnically

competent,” defined as having the ability to conduct an individual’s

professional work so that it is comparable with the behavior and expectations that members of a culture recognize as appropriate among themselves (Green 1982). Characteristics of ethnic competence include

having an awareness of one’s own cultural limitations, being open to

cultural differences, using cultural resources, acknowledging cultural

integrity, and possessing a client-oriented, systematic learning style

(Green 1982).

Operation PAR, Inc. (Parental Awareness and Responsibility), is

involved in research and training in the area of maternal substance

abuse and offers a continuum of services to a population of drug-abusing

mothers that includes early intervention services, case management

services, outpatient treatment, day treatment, short- and long-term

residential treatment, detoxification services, and methadone maintenance. Operation PAR also provides early intervention developmental

day-care services to children younger than 5 years whose mothers are

Operation PAR clients. At Operation PAR, it is believed that female

substance abusers who receive preadmission crisis intervention services
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designed to facilitate their entry into treatment are more likely to enroll

in treatment services.

The goals of the clinician are to reduce barriers and make clients

feel at ease when entering treatment. A key component of this process

is the establishment of an alliance between the clinician and the potential program participant. Confrontational techniques must be avoided.

Confrontation is considered counterproductive in work with women

(Underhill 1986). The objective is to establish rapport and then trust.

At Operation PAR, it is standard practice for a clinician to assist

a woman in meeting any immediate crisis intervention needs such as

housing, food, or clothing, before administering the Operation PAR

biopsychosocial assessment. Once rapport has been established and

the clinician is viewed as an advocate rather than an adversary, the

assessment is conducted.

Operation PAR’s philosophy is that clinicians must play a

nonjudgmental advocacy role to assist women in accessing substance

abuse treatment services. The prospective client must view the clinician

as her advocate. This can be accomplished by assisting the woman with

accessing any services she needs, such as child care, transportation, and

medical care. After a basis of trust has been developed, a woman should

be given a thorough biopsychosocial assessment that measures crucial

life domain areas to determine the level and intensity of substance abuse

treatment needed. She must be made aware of her treatment options;

a tour of the treatment facility prior to enrollment often will assist in

lessening some of her fears. It also is recommended that intervention

workers provide followup contact and remain the woman’s advocates

until she is stabilized in treatment.

It is Operation PAR’s philosophy that, ideally, female counselors

should work with women. Although that is not always possible, it is

crucial that women assist women in accessing substance abuse treatment

services because men are often viewed as the perpetrators of the sexual

and other physical abuse so many substance-abusing women have

experienced (Burman 1992).

REFERENCES

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Burman, S. A model for women’s alcohol/drug treatment. Alcohol Treat Q

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AUTHOR

Shirley D. Coletti, D.H.L.

President

Operation PAR, Inc.

Pinellas Business Center, Administrative Offices

10901-C Roosevelt Boulevard, Suite 1000

St. Petersburg, FL 33716

(813) 570-5080 (Tel)

(813) 570-5083 (Fax)

opadm@gte.net (E-mail)