Strategy: Success Stories
To counter stigma, counselors might provide clients with stories or information about women who have achieved and maintained recovery, such as Marty Mann (www.ncadd.org) or Betty Ford. These stories can be used to stimulate group discussions or could be a part of regular client readings.
Strategy: Barriers to Treatment Assessment Tool
Counselors can gain significant information pertaining to current, potential, or perceived barriers through evaluation. Beyond a comprehensive psychosocial history, counselors and administrators can gain insight into the current obstacles to treatment (for review, see Allen's Barriers to Treatment, Appendix D).
Strategy: Decisional Balancing Exercise
The decisional balancing exercise was designed to identify cognitive appraisals associated with benefits and costs of substance use (Cunningham et al. 1997). Both cognitive–behavioral therapy and motivational interviewing endorse this strategy. By easily adapting this activity to analyze pros and cons associated with entering treatment or not entering treatment, counselors are more likely to discover barriers that were not identified in the initial assessment. Counselors may want to demonstrate the activity by using examples, such as the pros and cons of going on a diet or not smoking. This exercise is not a simple pros-and-cons list for one side of the argument, but rather it involves looking at the benefits and costs for both sides of the argument; e.g., pros and cons for going on a diet as well as pros and cons for not going on a diet. This is an important aspect of this exercise. While many issues can be identified with one side of the argument, there are often other subtle issues that are acknowledged by discussing both sides of the argument. Following is the format for the decisional balancing exercise involving the pros and cons of entering or not entering substance abuse treatment.
Strategy: Finishing the Story Exercise
Counselors can “reframe” a woman's misgivings about treatment so she may see that the feared outcome of seeking or staying in treatment is, in reality, the likely outcome of ending or not starting treatment. For example, a woman who fears she will lose her children if she enters or stays in treatment should be asked to look into the future. This exercise might clarify for her that continued addiction virtually guarantees that she will lose her children in the long run, whereas treatment and recovery will most likely ensure a long-term and stable relationship with her children. By asking the woman to imagine how her story will end if she continues to use substances, she is less likely to glorify her current use and more likely to withstand the common hassles associated with initiating and engaging in treatment.
Strategy: Caregiver Portrait
Women typically assume caregiver roles that may prevent, complicate, or interfere with treatment. They may feel they should not leave their spouse or significant other and fear the consequences of doing so. In entering treatment, they may express worry because they carry the burden of primary caretaker for their parents, children, or other relatives. They may feel that they are being disloyal to friends and family members for leaving them—believing the message that their substance abuse problem is “not that bad.” Women may also maintain primary financial responsibilities for housing and food for others and fear they will not be able to provide support during treatment. In addition, they may worry about child care during treatment regardless of treatment level. Hence, beyond identifying these concerns and potential barriers, it is important to provide a way to discuss these as well as to determine their level of importance based on their perception.
In a group setting, first introduce the idea that everyone has specific and perceived obstacles that can interfere with treatment and it is important to give a voice to these challenges. Next, state that at least one or two people will have an opportunity to create a visual picture of these obstacles—similar to taking a family picture. Next, ask a woman to identify each current or potential obstacle to treatment and assign each obstacle to a particular group member. Emphasize to group members that if they are selected to participate, they don't need to say anything in this assigned role. This decreases anxiety and hesitancy in participating.
After the obstacles are assigned, ask the client to arrange the obstacles (group members) as if she were a photographer setting up a family portrait. Remind her to arrange (only verbally directing other group members) the portrait in one area of the room according to how important she perceives the obstacles, e.g., placing the most challenging or fearful barriers in front of others. Next, have the client discuss each obstacle and the rationale for her placement. As the exercise unfolds, obstacles may end up being rearranged in the picture. In addition, counselors may want to help the client identify feelings related to specific obstacles in the picture by walking around the portrait. Other strategies may be used in conjunction with this activity including problemsolving, cognitive restructuring, or motivational interviewing strategies. However, it is often best to keep it simple and to encourage other group members to do the same exercise. You can involve the entire group through discussion or by using a paper-pencil drawing that demonstrates their barriers. While this exercise is ideal for group, you can modify it by using a paper-pencil drawing for individual sessions.
Note: To reinforce appropriate boundaries, remind participants not to touch others during the exercise.
