Rethinking the Way We Deliver Addiction Treatment to Women Fostering Recovery through Empowerment

and a Customer FocusCarla A. Green, Ph.D., MPH

Center for Health Research, Kaiser Permanente NorthwestWomen’s Alliance to Strengthen Treatment and Retention Substance Abuse Treatment and Recovery Conference

September 17, 2007

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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

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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

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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

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Effects of believing, even in small ways, that addiction is voluntary

We treat people with addictions differently than we treat people with other conditionsThis is stigmatizing

We blame them for relapsing We deny treatment following relapseWe deny treatment because of poor treatment

complianceWomen may be more sensitive to these

stigmatizing experiences

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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

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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

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Myths & Their Effects (continued)

Negative effects in treatment settingsWe 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?)

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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

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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

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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

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An Alternative Approach to Recovery

Environment

Resources Strains

Recovery Processes:Development

Learning Healing

Adaptation

Sources of Motivation:

HopeOptimism Meaning

Capacity:Competence Dysfunction

Prerequisites for Action:

AgencyControl

Autonomy

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Recovery Processes

Environment

Resources Strains

Recovery Processes:Development

Learning Healing

Adaptation

Sources of Motivation:

HopeOptimism Meaning

Capacity:Competence Dysfunction

Prerequisites for Action:

AgencyControl

Autonomy

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Recovery Processes: Development, Learning, Healing & Adaptation

Recovery is a long-term process, inextricably intertwined with Normal human development Intellectual growth & learningExperienceHealing

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

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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 arePeople 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

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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

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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:

DenialAcceptance IdentificationAdaptation

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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)

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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

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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

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Facilitating Adaptation: Sources of Motivation

Environment

Resources Strains

Recovery Processes:Development

Learning Healing

Adaptation

Sources of Motivation:

HopeOptimism Meaning

Capacity:Competence Dysfunction

Prerequisites for Action:

AgencyControl

Autonomy

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Hope, Optimism, Meaning

People need to have hope that they can recoverbe optimistic that they can build, rebuild, and

maintain a meaningful lifehave some source of meaning in their lives

SpiritualClose relationships (often disrupted by substance

abuse)Activities—work, school, volunteer, family,

hobbies

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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

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Implications for Substance Abuse Treatment

To foster hope for recovery, we need toLearn to coordinate services for people who

need them Improve access to careWork 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

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Prerequisites for Action

Environment

Resources Strains

Recovery Processes:Development

Learning Healing

Adaptation

Sources of Motivation:

HopeOptimism Meaning

Capacity:Competence Dysfunction

Prerequisites for Action:

AgencyControl

Autonomy

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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

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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)

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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

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Capacity: Competence & Dysfunction

Environment

Resources Strains

Recovery Processes:Development

Learning Healing

Adaptation

Sources of Motivation:

HopeOptimism Meaning

Capacity:Competence Dysfunction

Prerequisites for Action:

AgencyControl

Autonomy

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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

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Competence & Dysfunction

Balancing risks while continuing to progress is difficult work People often overextend, relapse, then

try againUsing a chronic disease, collaborative,

framework facilitates learning, personal empowerment, and return to treatment following relapse

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Environment, Resources, Strains

Environment

Resources Strains

Recovery Processes:Development

Learning Healing

Adaptation

Sources of Motivation:

HopeOptimism Meaning

Capacity:Competence Dysfunction

Prerequisites for Action:

AgencyControl

Autonomy

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Environment, Resources, Strains

Provide the context in which recovery occursBroad & pervasive

Financial Emotional OpportunitiesStigma & discriminationSubstance abuse treatment & mental health care

can be resources or strains This depends on how care is organized, delivered, and

financed

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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)

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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

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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 problemsFamily problems etc.

Prevent losses that make recovery more difficult

Increase resources that facilitate recovery

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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

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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