1. IMPROVING SUBSTANCE USE TREATMENT AND SUPPORT FOR FIRST NATIONS AND INUIT WOMEN IN CANADA Preventing Fetal Alcohol Spectrum Disorder

2. This presentation captures discussions held in 2010, in a “virtual community” which included participants from three areas of Canada: 1) Manitoba and Saskatchewan, 2) Ontario, and 3) Yukon, NWT, Nunavut, northern Quebec and Labrador. We wanted to capture a sense of the rich diversity of the experiences of Inuit and First Nations women living in urban, rural, and remote settings. Context

3. Approach Research on promising or “wise” practices in women’s substance use treatment and the prevention of Fetal Alcohol Spectrum Disorder The wisdom of those who are working on these issues with First Nations and Inuit women across Canada Our approach was to bring together: WITH

4. 1. Barriers to treatment and prevention 2. Continuum of support 3. Recommendations This presentation will cover:

5. BARRIERS TO TREATMENT AND PREVENTION 4 types of barriers

6. There are significant barriers to treatment and prevention for First Nations and Inuit girls and women: 1. Personal and interpersonal barriers 2. Community or social barriers 3. Structural or program barriers 4. Systemic barriers Barriers to Treatment and Prevention

7. Mother’s Alcohol Use Mother’s nutrition Mother’s stress level Mother’s access to prenatal care Mother’s use of other drugs Mother’s overall health Poverty Racial Discrimination Age Context/Isolation Experience of Loss Policy on Mothering Resilience Exposure to Violence Genetics It’s Not Only About Alcohol Poole, N. (2003). Mother and Child Reunion: Preventing Fetal Alcohol Spectrum Disorder by Promoting Women's Health. Vancouver, BC: BCCEWH

8. 1. Personal and interpersonal barriers  Fear of the implications for seeking treatment (child apprehension, stigma, isolation in the community, separation from family)  Experience of trauma and violence, including childhood abuse and adult sexual assault  Stigma, shame and guilt

9. 2. Community barriers  Lack of confidentiality/privacy within small communities  Lack of awareness and education about women’s substance use and FASD  In some communities, the overall level of substance use is so high, it makes it difficult for women to see the need for help or be supported to reduce/stop using

10. 3. Program barriers  Lack of tailored programming addressing culture, creating safety, and addressing women-specific health impacts of substance use  Lack of child care for women attending treatment, and lack of linked treatment for mothers and children  Access issues such as availability of programs in or near one’s community, transportation barriers  Program criteria barriers  Lack of community-based supports (pre and post treatment)

11. 4. Systemic barriers  Women pushed to go to treatment to regain custody of their children, even though they are not ready, or substance is not their key problem  Fragmentation of services, such as separating violence and addictions treatment services  Lack of priority for funding of women-specific treatment programs  Lack of continuity in support, health promotion and prevention initiatives

12. 1. What, if anything, would you add to list of barriers? 2. What is most pressing for your community/program/service at this time? Integration & reflection

13. CONTINUUM OF SUPPORT

14. 1. Awareness building/stigma reduction 2. Discussion and brief intervention 3. Outreach and engagement 4. Specialized holistic support 5. Structured treatment 6. Ongoing support in the community and community wide change 6 Levels of Support

15. From Poole, N., Gelb, K., & Trainor, J. (March 2009). Substance Use Treatment and Support for First Nations and Inuit Women at Risk of Having a Child Affected by FASD. Vancouver, BC: British Columbia Centre of Excellence for Women's Health. Continuum of Care Model for First Nations and Inuit Women with Substance Use Concerns Continuum of Support Many examples of promising work being done in communities across Canada were identified. These examples fall within six levels of needed treatment and support that have been found to be helpful to FASD prevention

16. 1. Awareness Building & Stigma Reduction

17. Considerations  It is important to balance stating the risks of drinking in pregnancy on one hand, and showing that change is possible (and help is available) on the other hand.  Because women who have substance use problems have been portrayed as ‘bad mothers’ and especially for women with histories of trauma, it is important to convey that they will be welcomed and treated with respect when they come for treatment and support.

18. Promising practices Awareness building and stigma reduction Creating broad based community development and inclusion programs have shown promise in building awareness and reducing stigma. In many communities, women have taken leadership on changing community alcohol policy, educating via community radio and other community wide strategies.

19. Practices in action Building awareness and reducing stigma 1. Positive messaging as in the BC Aboriginal Network on Disability posters 2. Community-based workshops led by Pauktuutit, that support discussion of the issues, and the processing of grief and loss in a social and supportive way 3. Use of community radio - Inuulitsivik Health Centre 4. Using Asset Mapping as a tool to help communities identify their strengths and develop a plan of action

20. 2. Discussion & Brief Intervention

21. Considerations  A wide range of service providers need to take a role in discussing alcohol with women, not only addictions experts. Drinking is stigmatized, it can be helpful to include alcohol use in discussions of other health and social issues facing women.  Training for service providers in approaches that are based on guiding, listening, and supporting readiness can be useful. Training about FASD, the specific impact of alcohol on women’s bodies, and women-centred treatment approaches may also be needed.  Women may be afraid to speak of alcohol use, for fear of losing custody of their children - discussion of how her information will be shared or used is important.

22. Promising practices Discussion of substance use Increasingly service providers and researchers have demonstrated that this “front end” approach to discussing substance use with women, and engaging women in care – more than substance use treatment itself – is central to assisting women with substance use problems at risk of having a child affected by FASD. (Health Canada, 2006, p.75)

23. Practices in action Discussion of alcohol with women  Use of the Medicine Wheel Difference Game to assist women in identifying and planning the changes they would like to make in their substance use and related life areas. (Elsipogtog First Nation in New Brunswick )  Pauktuutit’s work in delivering community based training for both professionals and women, on a range of women’s health issues including FASD prevention, teen pregnancy, tobacco reduction, violence and sexual health.  Using motivational interviewing, an evidence-based communication style to support change in a collaborative, guiding way.

24. 3. Outreach and Engagement

25. Considerations 1. Respectful 2. Relational 3. Self-Determining 4. Woman-Centered 5. Harm Reduction Oriented 6. Trauma Informed 7. Health Promoting 8. Culturally Safe 9. Supportive of Mothering 10. Uses a Disability Lens www.canfasd.ca/networkActionTeams/womens-health-determinants.aspx Systems and services need to shift to welcome and engage women. 10 fundamental components of FASD prevention include that systems/services are:

26. Promising practices Outreach and Engagement Adjusting our approaches to engaging women in care on the part of service systems, rather than making it the responsibility of women who are facing substance use and related health and social problems to show up ready for help, has been shown to be critical to an effective approach to preventing FASD.

27. Practices in action Enhanced outreach  In urban settings – Anishnawbe Health Centre’s Circle of Care Program and programs like Sheway in Vancouver who use welcoming engagement practices, create safety and do not make decreasing or stopping substance use a condition of service access  In rural and remote settings – Peer support and health promotion for girls and women such as kitchen table gatherings (Qu’Appelle Valley) and outreach work being done by mentoring programs across Canada

28. Nutritional Support and Services Advocacy and Support on Access, Custody and other Legal issues Support/ Counselling on Substance Use/Misuse issues Advocacy and Support on Housing & Parenting issues Support to build networks - both friendship and ongoing service support networks Healthy Babies, Infant/Child Development Support in reducing exposure to violence and building supportive relationships Support on HIV, Hepatitis C and STD issues Pre and postnatal Medical Care and Nursing Services Drop In Out Reach Crisis Intervention Advocacy Support Connecting with other services Reducing barriers to care Sheway Project

29. 4. Specialized Holistic Support

30. Considerations  Beyond providing outreach, there are many ways in which we can make it easier for women with alcohol and other substance use problems to come for treatment – our community-based support can have a holistic focus, can span ages, involve community members, and be informed by what we know about the impact of trauma.

31. Promising practices Holistic support 1) gender-specific healing and recovery 2) trauma-based healing and recovery 3) longer-term, phased, flexible and diverse options 4) partnership approach 5) strength-based “empowerment” model The Women and Children’s Healing and Recovery Program (WCHRP) in Yellowknife was created to assist women who have experienced trauma, on their journey to wellness. Ten themes were identified for holistic support: 6) holistic approach 7) continuum of care 8) healing needs of children 9) family-focused and linked to healing for men, children and youth 10) community-based and culturally sensitive (Four Worlds Centre for Development Learning, July 2003)

32. Practices in action Minwaashin model The Minwaashin Lodge in Ottawa works from a life cycle model with programming for women, children and family members of all ages. The Lifecycle Service Model illustrates a holistic, integrated and culturally safe approach to violence prevention, trauma recovery and balanced well-being. Developmentally appropriate programming specific to each of the four stages of the lifecycle is interwoven with ceremony and cultural teachings that promote mental, physical, emotional and spiritual well-being in individuals, families, communities and Nations. The vision of this service model derived from Traditional Knowledge is to restore women’s agency and authority in family and community life.

33. 5. Structured Treatment

34. Considerations  Most on-reserve treatment provision accessible to First Nations women is delivered through outpatient counselling. It is challenging for outpatient counsellors alone to provide the level of support that has been found to be helpful for pregnant women and mothers at highest risk.  Need to define and expand options for First Nations and Inuit women living in the north  Need to broaden understanding of ‘treatment’ - as a process rather than a place, that includes a range of holistic supports

35. Promising practices Structured Treatment Structured treatment can also include day, mobile, land-based and residential treatment. Women need access to treatment on the community level (and beyond) which: o includes cultural components; o addresses coexisting trauma/violence and mental health concerns with addictions; and o links the support of mothers with their children.

36. Practices in action Principle-based treatment approach Through their collaborative work, Dr. Colleen Anne Dell and a large research team, have identified key principles to guide treatment providers in supporting Aboriginal women healing from illicit substance use: RE-CLAIM R = Recognition E =Empathy C =Communication & Care L =Link to spirituality A =Acceptance I =Inspiration M =Momentum See a description of these attributes at http://www.addictionresearchchair.com/creating- knowledge/national/cihr-research-project/view-our-findings-through-posters/http://www.addictionresearchchair.com/creating- knowledge/national/cihr-research-project/view-our-findings-through-posters/

37. Promising practices in action From Chansonneuve, D. (2005). Reclaiming Connections: Understanding Residential Trauma Among Aboriginal People. www.ahf.ca/pages/download/28_ 101 Many aspects of healing from trauma can be supported through community based services, assisting people with substance use concerns

38. Practices in action Treatment for women with FASD  Whole-person  Culturally sensitive and appropriate  Multi-systems, multi-disciplinary & collaborative  Shift in timeframes; focus on readiness  Aftercare and/or follow up support  Celebration of small steps and accomplishments  Importance of HOPE Research led by Dr. Deborah Rutman, University of Victoria has identified promising, substance use treatment approaches for women living with FASD. They include: For more info see http://socialwork.uvic.ca/research/projects.htmhttp://socialwork.uvic.ca/research/projects.htm

39. 6. Ongoing Support in the Community

40. Considerations Awareness, leadership and action are critically needed:  Multi-audience education is needed to build awareness of, and respect for, the treatment and support needs of First Nations and Inuit women who are at risk of having a child affected by FASD.  There was a sense that it is time for leadership and action to improve access to and quality of treatment for women (that as the Zapatista women have identified in their work for dignity, “ya basta” / that’s enough)

41. 1. Where does your service/program/role fit on the continuum of support? 2. Considering this same continuum, what is working well in your community? What, if anything, might be done differently? Integration & reflection

42. RECOMMENDATIONS

43. Recommendations Recommendations were made in 5 areas: 1. Increasing capacity and coordination of those on the community level who are in a position to discuss alcohol with women and help women find the optimal combination of support to make possible their healing, growth and recovery 2. Improving access to treatment and related supports for women, through for example, expansion of treatment and support options on the community level, careful linkage with treatment outside the community.

44. Recommendations 3. Supporting mothers with substance use problems in their abilities to retain custody of their children, and to heal, grow and recover within community-based treatment programs that have childcare and children’s treatment programming 4. Integrating support on violence and trauma with treatment on substance use, so that women are able to make the connections among these experiences, and are not retraumatized in the course of treatment 5. Building awareness of, and respect for, the treatment and support needs of First Nations and Inuit women who are at risk of having a child affected by FASD

45. After reviewing these recommendations, what if anything, might be the next step for your community/program/service etc.? Integration & reflection

46. Conclusion  This Moving Forward project is an example of leadership with the goal of improving treatment.  We hope to continue to work with leaders who are working to improve treatment through NNADAP programs and through Inuit mental health strategies in the north. Writings by Aboriginal women are capturing the ever-growing leadership of First Nations and Inuit women in Canada on treatment and related issues.

47. Contact: The written report on this virtual community’s work may be downloaded from www.coalescing-vc.org For more information…