‘As 52 per cent of the population, sometimes our needs aren’t thought about in a specialised, specific way,’ Trevi chief executive Hannah Shead told this year’s DDN conference session on stigma and women’s services. ‘We can sit and talk about this stuff for ever, but we need to see things change.’
According to OHID’s Adult substance misuse treatment statistics 2020 to 2021, around two thirds of people in drug treatment are men and one third women, while in alcohol treatment it’s roughly 60/40. As the Women’s Treatment Working Group points out, although the number of women dying a drug-related death has risen by almost 80 per cent over the last decade, the figures for women seeking treatment have remained mostly unchanged (www.drinkanddrugsnews.com/new-group-champions-womens-right-to-high-quality-services/). So what’s deterring them – is it still the stigma?
Chaotic services
‘It’s an uncomfortable conversation for many people to have, but the stigma is huge,’ says Sophie Carter, head of the family justice team at the Centre for Justice Innovation – an organisation that recently published a report warning that many women were experiencing ‘chaotic’ and ‘intimidating’ treatment services (DDN, November, page 5). ‘Whether we like it or not, it’s perfectly acceptable in society for a father to not be the primary carer for their child, but for a mother to not be the primary carer – or not be seen as a fit parent – is much more significant.’
It’s long been pointed out that services are still not set up for women with caring responsibilities, and while individual practitioners are ‘committed to getting it right, the reality of how it’s set up doesn’t always allow that,’ says Carter. So is it the case that, as so with many things, treatment services have basically been designed with men in mind? ‘I think it is, and I know practitioners recognise that, but the reality of what steps you can take – from a day-to-day point of view all the way through to changing your strategies and partnerships – is not always easy.’ Things have been improving in recent years, and there are some excellent women’s services, but it does remain very much a postcode lottery. ‘Not just that, but a transport and accessibility lottery alongside it,’ she points out.
Trauma responses
Closely connected to questions of stigma are women’s responses to trauma, and the behaviours that can often result from that. These can be difficult to manage, and many services still aren’t set up in a way that allows the building of the relationships needed to do that, and with women ‘stigmatised again for not fitting into the processes’ as a result.
People frequently talk about a trauma-informed approach, but how many services are genuinely geared up to deliver that – with staff who are properly trained and capable? ‘That’s a good question, because it can be a bit of a buzzword. How you translate that into day-to-day practice is the most important part. The realities of commissioning – access to resources, being able to signpost to relevant services, non-attendance and outreach policies – are not always designed to match the knowledge that practitioners have. So there’s still a lot of work to be done around how you can upskill organisations as a whole to have that trauma awareness, and understand those interlinking factors for women coming into services.’
One of the report’s recommendations is training all key workers to recognise and respond appropriately to signs of domestic abuse and sexual violence – how far along that road are we at the moment? ‘Probably not as far as we’d like. With the increased funding coming in, the whole point was to try to reduce practitioner caseloads, and increase access to the most appropriate psychosocial interventions. That’s where you’d hope to see changes, but we’re only really at the beginning of that.’
Women are clearly very unlikely to talk about trauma or abuse in mixed-sex groups, or to male drug workers, and yet frequently that’s all that’s on offer – apart from perhaps a token women’s group for an hour a week. ‘There’s a lot of recognition that you’d like to be able to offer a female key worker, but again you’re looking at recruitment, staff, those retention issues – it comes back to individual services’ resources,’ she says.
But it remains the case that, even for people without those underlying trauma issues, there’s the inescapable fact that overwhelmingly male settings – particularly group work or fellowship meetings – can be intimidating spaces for women. Is this taken into account enough? ‘Probably not – it’s difficult because of the actual buildings to set up women-only spaces, but you can have things like women-only days – there are ways around those barriers.’
Uncomfortable truths
Worryingly, the report also highlighted something that’s discussed anecdotally but not often officially acknowledged – that, as one drug worker told the authors, ‘You do tend to get a lot of predatory males attending services as well – over the years it was sort of like a hunting ground.’ Why isn’t there more acknowledgement of this?
‘I think a lot of the research on women’s services is often carried out in silos as well, looking at one particular area, whereas I think this piece of research has been able to really pull together all of the different factors. But it is a reality, sadly, in the same way that dealers will wait for people leaving prison.’
Again these can be very uncomfortable conversations, she acknowledges. ‘There can be a sense of helplessness around it. As practitioners, what can we realistically do when managing caseloads and we only have one building with one entrance – you can’t always walk a woman into to her session if your clinic is back-to-back and overrunning, and you don’t always know who’s a risk because they probably haven’t told you the names of the people who’ve harmed or abused them.’ And none of this is new, she points out. ‘Fifteen years ago as a member of staff in treatment services I’d have cars pull up next to me, either dealing or expecting to pick me up for sex work – the look of panic when they realised I had a badge on, or I knew their name and could flag it to the police.’
Reality and risk
All of this means that it’s still not uncommon for women to only manage a couple of appointments before being reported as having ‘disengaged’, she says. ‘But I do think now we’re better able to discuss these experiences because we’re seeing people accessing recovery services as more than an “addict” or “criminal” or “problem”, or someone who’s just not motivated or presenting with “challenging behaviour”. The benefit of the growing awareness around trauma and adverse experiences is we’re much more open to understanding the reality and risks women face, the systemic factors in a woman’s life, and to seeing behaviours and choices through the lens of trauma.’
The centre is now pulling together some wider policy and practice recommendations for commissioning teams that can be translated into action, with a view to publication next year. ‘It’s about really being able to see women in the context of their family, their community, their environment, and those influences. So it’s not just about silos in terms of access to treatment, but the risk of just seeing a woman only as someone who uses substances – without all the other influences. That feels like a really important message for practitioners to start with straight away.’
Joined-up approach
The report points out that even where there is good support available in the local area, drug services often still don’t have those links with other organisations like women’s centres and mental health charities, again something that can come down to commissioning pathways and funding streams. And while it’s not the case across the board, for many services it’s ‘still very much “you come to us for drug and alcohol, you go to them for mental health, you go up the road if you want to look at accessing domestic abuse support”,’ she says. ‘If we’re saying it’s already difficult for a woman to access one treatment service, we’re now expecting her to overcome the barriers to get through the door of three of them – and that just doesn’t work.’ DDN
Exploring women’s experience of drug and alcohol treatment in the West Midlands at justiceinnovation.org/publications/exploring-womens-experience-drug-and-alcohol-treatment-west-midlands