The role of an Aboriginal women's group in meeting the high needs of clients attending outpatient alcohol and other drug treatment
- KS Kylie Lee PhD BMus(Hons), NHMRC Postdoctoral Fellow in Aboriginal and Torres Strait Health, Angela Dawson PhD BA(Hons), Research Fellow, Katherine M Conigrave FAChAM FAFPHM PhD, Addiction Medicine Specialist and Professor.
Introduction and Aims
Support groups are typically offered as part of specialist alcohol or other drug treatment. However, their usefulness with Indigenous Australians has not been examined. This paper provides a profile of Aboriginal women attending an inner city outpatient alcohol and other drug treatment service, insight into how effective women and staff perceive the support group to be at meeting their needs and suggestions for improvements.
Design and Methods
Structured interviews were conducted with 24 Aboriginal female clients of an outpatient treatment service and with 21 staff from across that service and the local Aboriginal Medical Service. Client interviews also assessed alcohol consumption and mental health risk (Indigenous Risk Impact Screen).
Clients reported social and health indicators illustrating disadvantage and complex needs. Most clients and staff perceived the group to be useful and easily accessible. The participants discussed positive elements including opportunities for shared experience in a non-judgemental environment, practical support and health education. Staff reported how the safe, relaxed environment of the group helped with early identification of issues and user-friendly pathways for treatment access. Suggested improvements included greater involvement from Aboriginal staff and community members and enhanced communication with other staff.
Discussion and Conclusions
Clients and staff recognised the usefulness of the group, including the opportunities it provided for socialisation and early intervention. Comprehensive research is needed to determine the types and sources of support that best assist Aboriginal women with substance use disorders. [Lee KS K, Dawson A, Conigrave K M. The role of an Aboriginal women's group in meeting the high needs of clients attending outpatient alcohol and other drug treatment. Drug Alcohol Rev 2013;32:618–626]
Alcohol and other drugs (AOD) cause significant disruption for many Aboriginal and Torres Strait Islander (Indigenous) communities across Australia [1, 2]. Similar issues often arise for other Indigenous nations that have been colonised . Misuse stems from a complex mix of issues including trans-generational effects of post-colonisation , grief from early deaths , high rates of imprisonment  and comorbid health conditions [2, 6]. Despite Indigenous Australians comprising less than 3% (2.7%) of the Australian population, one in eight episodes for AOD treatment was received by this group nationally (2010–2011) . There is limited evidence to guide adaptation or development of AOD treatment for Indigenous populations [2, 8].
Mutual support groups (e.g. 12-step programs such as Alcoholics Anonymous  and cognitive behavioural therapy groups such as SMART Recovery ) are often integrated into specialist treatment of substance use disorders in general populations . Of these, 12-step groups are the most prevalent and have been associated with a range of positive substance use outcomes . Among Indigenous Australians, support groups have broad anecdotal benefits in health [10, 13-16] and community [16-18] settings. However, these have rarely been formally evaluated or documented in peer-reviewed literature [19, 20]. Aboriginal men's groups have been reported to be effective in addressing community priorities (including alcohol use) in remote and regional Queensland [21, 22], although these groups were situated in a community rather than treatment setting and not all members had an alcohol problem. There is limited understanding of the role of therapeutic groups in treatment of Indigenous Australians.
A small survey of urban Indigenous Australians [New South Wales (NSW)] receiving community-based alcohol education found that nearly as many individuals indicated they would seek group support as individual counselling (n = 9, 23.7% vs. n = 10, 26.3%) for help about alcohol . However, it is not clear what this group support should encompass and how this should be offered in a treatment setting.
Australian government strategy states that AOD treatment services for Indigenous Australians should be culturally appropriate and designed in consultation with communities . Flexibility and friendliness in service delivery has been reported to be important (e.g. friendly reception staff, easy to get help without a booking and non-judgemental) [24-26]. In NSW, an evaluation of an inner city outpatient treatment facility recommended incorporation of support groups and more integrated health care involving family to better engage with its Aboriginal clients .
To help understand how best to provide group support for Indigenous Australians with substance use disorders, this paper sets out a profile of clients attending a support group for Aboriginal women that is attached to an urban outpatient treatment service  and describes how women and staff perceive this support group to be meeting women's needs and their suggestions for its improvement.
The study was approved by the Human Research Ethics Committees of Sydney Local Health District and the Aboriginal Health and Medical Research Council (NSW). This mixed method study involved the concurrent collection of quantitative and qualitative data. An interviewer delivered structured interview comprised of instruments to measure alcohol consumption [questions based on Alcohol Use Disorders Identification Test – Consumption (AUDIT-C)] and mental health risk [using the Indigenous Risk Impact Screen (IRIS)] and open questions to explore client experiences of the support.
The outpatient AOD treatment service is attached to a teaching hospital in Sydney, NSW. A multidisciplinary team including doctors (e.g. addiction medicine, psychiatry, gastroenterology and pain), nurses and counsellors treat clients with a range of substance use disorders. An opioid substitution treatment program (OSTP) is available. A shared care arrangement with the local Aboriginal Medical Service is offered. Of the service's current caseload, approximately 215 clients are female. One in every eight of these female clients is Aboriginal (n = 27/215, 12.6%) and of these, four in five (n = 22/27, 81.5%) receive OSTP dosing at the service.
About the Aboriginal women's group
Since September 2004, the Aboriginal women's group has been offered one morning a week for three hours. Aboriginal women requested the group be established following their positive experience of gathering together to provide feedback on the service . This current evaluation was requested by clients and staff to assess how well the group is working and how it could be improved.
Two female staff members facilitate the group: a senior Aboriginal woman with experience in AOD work and a non-Aboriginal counsellor. Aboriginal health promotion, health education, early childhood and mental health workers employed by the same health district periodically attend as support staff. A non-Aboriginal volunteer assists with child minding. Other staff members may drop-in to greet the group or are invited to lead discussion on specific topics.
The group is conducted in a large dedicated Aboriginal space alongside counselling rooms, with access through reception via a locked main door. The group format changes depending on the number of clients and demand but includes informal conversation, art and craft, and recreational and educational activities (e.g. on treatment options, parenting, first aid or financial management). Children are welcome, and lunch is provided.
The study methods were guided by an advisory group of staff from the outpatient service (Aboriginal and non-Aboriginal) and local Aboriginal Medical Service. Three female interviewers (including KL) were not involved in running the group or in treatment delivery.
Forty-five structured face-to-face interviews were conducted: 24 with Aboriginal female clients and 21 with staff (outpatient service: 17 females and two males, five Aboriginal; Aboriginal Medical Service: two males, non-Aboriginal) to examine their perceptions of the group's usefulness and to make suggestions to improve group operation.
Alcohol consumption questions were based on AUDIT-C, but the order and presentation were modified to suit Aboriginal study participants [23, 27] in consultation with the study's advisory group. Face-to-face administration of the AUDIT-C has not been validated with Indigenous populations. Limited numeracy, a culture of sharing alcohol and a common interpretation of the term ‘to drink’ as ‘to drink very heavily’ , leads to potential difficulty using the instrument in this context . For this reason, question 2 on the AUDIT, on quantity of alcohol consumed, was asked before question 1 (on frequency of use), in a conversational style and using phrases common among local Aboriginal people . Specifically, if clients consumed any alcohol, they were asked: ‘What do you usually drink when you have a drink?’. Additional questions assessed the container size, strength of alcohol and how much was typically shared with others . They were then asked: ‘How often do you drink?’ (coded as never, monthly or less, 2–4 times a month, 2–3 times a week, 4 + times a week). In addition, clients were asked a modification of AUDIT question 3: ‘How often would you have four or more standard drinks each time you drink?’ (coded as never, monthly or less, 2–4 times a month, 2–3 times a week, 4 + times a week). A cut off ≥4 drinks consumed per session  was used to identify participants at risk of injury from drinking.
Mental health risk was assessed using the IRIS mental health items, a screening tool validated for use among Indigenous Australians in remote, rural, regional and urban Queensland . Other client characteristics sought included: age, frequency of group attendance, relationship status, number of children, highest level of education, employment status, treatment being received and duration of this.
Clients were recruited for interview by the Aboriginal case worker, nursing staff and women's group facilitators. The Aboriginal case worker, who is well known to clients, introduced interested individuals to an interviewer. Clients sought for interview included those who: never attend, regularly attend or formerly attended the group (approximately equal numbers from each group). Clients were given a $20 department/supermarket store chain voucher as reimbursement for participation.
Interviews (20–90 min) were conducted individually in private at the treatment service (June–July 2012). For practical reasons, five staff interviews were conducted over the phone, Skype or email.
Derived variables and analysis
Quantitative data on client characteristics
Detail from the alcohol history was used to calculate the number of standard drinks typically consumed per occasion. This was then recoded to match the response categories on question 2 of the AUDIT (1–2, 3–4, 5–6, 7–9, ≥10 standard drinks). To assist with international comparability, responses to the original AUDIT question 3 were also derived (‘How often do you have 6 + drinks each time you drink’) from the drinking history. Based on these data, an AUDIT-C score was calculated (≥4, as a positive score) .
Responses on IRIS mental health items were coded according to the scoring protocol , and a binary variable was created to describe scores above the risk cut-off (≥11).
Qualitative data of the group perceptions
To explore participants' views of the group, a descriptive qualitative method was adopted to analyse responses to open questions. Interview transcripts were imported into Nvivo (Nvivo Version 10, QSR International, Doncaster, Australia) and analysed thematically, a technique that involves the interpretation of descriptive data to elucidate the meanings of participants' experiences . The analysis began with two researchers (KL and AD) independently coding the data using a process of constant comparison . This involved inductive category coding to describe and tabulate the data as per study aims alongside a simultaneous comparison of experiences across all the transcripts . The researchers met to discuss category coding and compare and refine categories until consensus was reached on key themes and sub-themes. Models were generated to map patterns across the data. Differences between clients and staff were noted.
Profile of Aboriginal female clients interviewed
The 24 clients interviewed had a median age of 29.5 years (range: 21–48 years). The majority identified as being from New South Wales, had completed up to year nine at school and one was employed. Three in five had some or all of their children not living under their care (e.g. removal by child protection). More interviews were conducted with women who attended the group weekly or occasionally, compared with those who had previously or never attended (Table 1).
Table 1. Characteristics of female clients (n = 24) interviewed at an inner city outpatient drug and alcohol treatment service in New South Wales, Australia
|Age (years)|| || |
|Origin|| || |
|Elsewhere in Australia||2||8.3|
|Women's group attendance|| || |
|Relationship status|| || |
|Currently has a partner||11||45.8|
|Highest level of education|| || |
|Year 8 or below||3||12.5|
|Employment status|| || |
|Receiving treatment* for problems with|| || |
|Length of treatment (months; range, median)||1–192 (30)|
|Standard drinks consumed per occasion|| || |
|Range, median||5–33 (6.3)|
|AUDIT-C|| || |
|Positive score (≥4)||13||54.2|
|Total score (range, mean)||5–9 (3.6)|
|Children|| || |
|Does not have children||4||16.7|
|Children live at home||8||33.3|
|Children live with someone else (i.e. a relative or placed in other care)||12||50.0|
|Indigenous Risk Impact Screen (IRIS)|| || |
|High-risk score for mental health and well being (≥11)||18||75.0|
|Total score for mental health and well being risk (range, mean)||9–19 (14)|
AOD treatment status
Twenty-one participants were on OSTP (n = 21/24, 87.5%). A small number reported receiving treatment for other drugs (Table 1). The median length of continuous treatment was 30 months (range: 1–192 months).
Consumption per occasion was polarised between non-drinkers (n = 11/24, 45.8%) and those who drink 4 + standard drinks per occasion (n = 13/24, 54.2%; range: 5–33 standard drinks). Of the drinkers, the majority (n = 10/13; 76.9%) consumed 10 + standard drinks per occasion. Drinkers described episodic rather than daily use (n = 9/13, 69.2% consuming monthly or less often versus n = 4/13, 30.8% consuming 2–3 times weekly). Of the drinkers, all received a positive score on the AUDIT-C.
Mental health risk cut-off
Three in every four participants scored above the IRIS cut-off for mental health risk (≥11, n = 18/24, 75%).
Profile of staff interviewed
Forty-three percent of the staff interviewed (n = 9) regularly attended the group, for example, as a facilitator, Aboriginal support worker, health educator or volunteer. The remaining staff regularly interacted with the client group but had indirect involvement with the group (n = 12, 57%), for example, working as a health professional, in-take officer, administrative assistant or staff manager.
Perceived usefulness of the group
No substantial differences were noted between clients who attended the group and those who had previously attended or who had never attended. The key themes were: relaxation and socialisation; the opportunity to share experiences and receive group support in a family atmosphere; receiving practical support and building new skills; self-esteem and identity; and early intervention and providing a pathway to treatment.
Clients and staff described how the group provided an alternative activity to substance misuse:
Helped me take my mind off the drug I was coming off. (client)
I made friends with women here and they respect me … this lifts me up. (client)
The group was something for clients to look forward to and provided a sense of stability and structure:
Offers female clients a sense of stability—they can unwind, vent and start to change behaviours. (staff)
While staff were on hand if particular issues arose, the value of having an environment where clients could come together to unwind and relax was emphasised.
Clients and staff described the opportunity offered to the women to share experiences and learn from each other in a safe environment. Support offered in a ‘family’ atmosphere helped clients feel like they were not alone:
It is good knowing that I am not the only person in my situation—who is a former user on treatment and a parent and a mother. (client)
Practical support and building new skills, self-esteem and identity
Clients and staff described how the group provided opportunities for clients to address a range of issues (e.g. financial, housing, child protection and court):
Helps you organise things like with court or community services. Gives more practical support compared with just talking one-on-one that happens in counselling. (client)
If group facilitators or other staff were unable to answer a client's question, additional help was sought.
Clients learned how to approach and engage with relevant agencies (e.g. health, housing and justice) and improve problem-solving skills:
Many didn't realise how easy it was to access [different] services now, from the information given at the group, they now know who to ring [for help]. (staff)
Clients felt that the group helped them build confidence to address issues:
[In the group I learn how to] best cope in difficult situations and circumstances. (client)
Building self-efficacy was strongly linked to descriptions of client identity as: women; mothers, aunties or grandmothers; community members; help-seekers at an AOD treatment facility; and being of Aboriginal heritage:
Build skills of the ladies and help them feel good about themselves so they can move to the next level in life. (staff)
The majority of staff described how the group provided positive role modelling opportunities for clients:
The group can give an opportunity for ladies to learn new ways to relate to each other … This includes emotional learning too, as some women have not had the opportunity in their life to understand and identify what they are feeling, let alone know how to cope with this feeling and to address it. (staff)
Staff described how a safe, relaxed environment helped identify client issues and user-friendly treatment pathways. For example, in one group session, staff identified a client with severe benzodiazepine dependence and major physical health issues. A same-day medical assessment and subsequent hospital admission was organised. The group invited staff to deliver health education, providing opportunities for participants and staff to interact in a more relaxed environment than the usual ‘medicalised’ treatment setting:
[The group is] a good way to link in staff with ladies in an informal way. (staff)
Suggested group improvements
No substantial differences in suggestions were noted between clients who attended the group and those who had previously attended or never attended. The key themes were: story sharing, communication with staff, structural issues and empowering clients through the group.
Clients and staff suggested increasing opportunities to share stories and learn from other women's experiences, in line with Aboriginal traditions of storytelling, and contrasting with didactic health education. Many clients described how stories inspire and motivate them:
A lot of Elders have passed on, who would teach through story telling. Group allows for us to help forward things—knowledge from the past and from our own experience about what you need to do to live. (client)
Women said that staff could answer questions or dispel myths that might arise during story sharing. It was felt that inviting more staff (Aboriginal and non-Aboriginal) and Aboriginal community members to attend the group would enhance this approach:
Try to invite people from Aboriginal community to talk to the ladies—this will also show the ladies that the community is supporting them. (staff)
Suggestions for potential guests included: elders, local artists, mothers who cope with everyday life stresses and women who have successfully completed AOD treatment. Some staff felt that story sharing, and the skill development that comes from it, should be facilitated in an unstructured manner as opposed to using a curriculum-based approach:
Don't do [the structured curriculum] anything that resembles school. (staff)
Staff suggested the group should be better integrated within the treatment service through defined mechanisms for staff communication during clinical handover:
Better communication flow [is needed] between group facilitators and [the whole service] about [client] issues and concerns. (staff)
Staff recommended more opportunities for informal interaction during the group in order to help show the service's human face and strengthen rapport with clients.
Staff suggestions about infrastructure to improve the group operation included addressing security issues, an accessible outdoor play area for children, an accessible outdoor smoking area and gates to limit child access to other treatment areas. All interviewees agreed the location in the treatment facility had the benefit of convenience for clients already attending the service.
Staff felt that client ownership of the group should be encouraged and described situations when active client involvement was achieved. To accomplish this, clients and staff proposed that the group's direction should be guided by clients with discreet support and encouragement from staff:
Ask the women what they want to do—and so encourage ownership by women of the group (staff)
The best thing would be to have a combination of both a casual support group with no planned programs and then an occasional planned program. (client)
The majority of clients who attended the group supported this view. Those who had never attended the group also supported this view based on experience of other support groups.
To our knowledge, this is the first published report describing the role of an Australian Aboriginal support group in meeting the complex needs of clients attending an outpatient AOD treatment service. The sample size of 24 represented 89% of Aboriginal women attending the service, suggesting the perceived willingness to be involved in service improvement. Alcohol consumption was consistently higher than recommended Australian guidelines  in those who drank. Three-quarters of the study population were found to be at risk of mental health issues based on IRIS scores . Despite these challenges , the median treatment length of over two years for women on OSTP (n = 22/24) was 1.5 times longer than the length reported by heroin-dependent users in a large Australian study . Clients reported many benefits from attending the women's group, including opportunity to share experiences with other women going through similar experiences. The group's relaxed setting was reported to promote the earlier detection of issues and treatment access.
Previous reports have described considerable stigma experienced by Indigenous Australians and women in general  attending AOD treatment [2, 5, 24]. Data here illustrate the perceived positive role of a women's group located in a treatment setting. The relaxed environment, socialisation and friendship opportunities offered by the group appeared to provide a sense of hope and mutual support in the face of complex challenges . Similar to the concept of ‘shared dialogues’ employed in an Aboriginal specific residential rehabilitation setting , this approach appeared to nurture each client's connection with other group members . It also appeared to help rebuild clients' identity and assist them to plan their lives as non-drug taking individuals. Both clients and staff saw a need to further enhance cultural identity of group members in the study setting, for example, through regular involvement from Aboriginal staff and community members  (including elders ), along with greater client input in the group's direction . This is consistent with the perceived importance of participation in traditional teachings and sharing cultural stories described in a health promotion program for older First Nations Canadian women .
A distinctive feature of this support group reported by staff, not previously described in the literature, is its context within a ‘medicalised’ outpatient treatment setting. In addition to mainstream treatment offered at this service (e.g. access to a doctor, nurse or counsellor), the group offers opportunities for socialisation and drop-in; for early detection of issues, which is particularly important with this population [28, 34]; relevant referral pathways; and structured education. Other Indigenous support groups previously described have been delivered outside treatment settings [10, 13, 20, 42, 43] or have adapted non-Indigenous models for Indigenous settings (e.g. SMART Recovery) . In contrast, the group described in this paper provides a range of comprehensive support similar to that regularly delivered in an outpatient treatment setting but in a relaxed and informal way and uses a model that was developed specifically for this client group .
Group empowerment approaches that value client participation and direction over didactic approaches have been shown to be important in disease prevention and health promotion programs in developing countries , in primary health care internationally  and in community mobilisation efforts targeting Indigenous Australian men . These approaches appear to improve health status [49, 50] and build individuals' problem solving skills . Facilitation that promotes participatory decision making is considered one of the most important characteristics in promoting group participation . In the study setting, the socio-cultural opportunity provided by the group appeared to be the foundation upon which the group is based. Some women also sought to build personal skills and some appreciated the therapeutic benefits received in the group setting. For an empowerment approach to be further incorporated, the group would need to be guided to a greater extent by clients to encourage their learning and self-development. It would also need to have clear boundaries for group expectations to ensure that women's needs are met regardless of whether they attend regularly or on a ‘drop-in’ basis. Furthermore, discreet staff support would be needed to ensure the group is directed by the needs of the women who attend [38, 52]. However, some clients may have no interest in guiding group direction but may simply enjoy attending.
A limitation of this research is that only a small number of Aboriginal female clients were interviewed (n = 24); however, this represented the majority of Aboriginal women attending the service (89%). Social desirability bias may have influenced client responses, and none of the interviewers were from an Indigenous Australian heritage. However, every effort was made to help respondents feel at ease during interviews, and for stigmatised issues related to substance use, clients sometimes desire the anonymity of talking to an ‘outsider’ not of their community .
AUDIT-C has not been validated for use with an Indigenous Australian population and, based on clinical and community experience with Indigenous Australians [23, 27], the ordering and delivery of questions were amended, and AUDIT-C responses were derived for questions 2 and 3 from the participant's drinking history. It is unlikely that asking question 3 on the AUDIT-C separately would have identified further risky drinkers, because all but one individual reported having ≥6 drinks per occasion. The IRIS has been validated for use among Indigenous Australians, including those in urban settings , and is widely used as a screening tool with Indigenous Australians. Only the IRIS mental health risk questions were asked and not the AOD questions, which could have altered its accuracy. Objective evaluation of the effectiveness of such a group on treatment outcomes would be valuable, but methodology would need to distinguish benefits of group participation from other aspects of treatment.
In this treatment setting, clients and staff highly valued group support tailored to the needs of Aboriginal women. The group offered comprehensive support not received in this otherwise ‘medicalised’ outpatient treatment setting. The nurturing group environment appeared to assist these women, alongside other services offered at the treatment service, to meaningfully address AOD and other issues. This type of group support shows promise and should be made available in other outpatient treatment settings.
Declaration of interest
One author (KC) was employed by the treatment service subject to this study but was not involved in the running of the group. This author was not involved in collection or analysis of qualitative data, or review of identifiable material.
We appreciate the help of Katherine Jeffress, Sarah Hutchinson, Lynette Simpson, Cathy Heyes, Keren Kiel, Bradley Freeburn, Mira Branezac and the staff and clients interviewed. Dr Kylie Lee is supported by a National Health and Medical Research Council Postdoctoral Research Fellowship in Aboriginal and Torres Strait Islander Health.