3.1 Personal barriers to seeking treatment.
Participants expressed doubt as a barrier, through responses that indicate an overall lack of belief and trust that treatment would be effective.
One urban client stated: ‘You could look at statistics and see how many people really succeed and come out of treatment and stay clean and live a productive life versus how many people just go right back. I think that is discouraging.’
Staff members agreed. For example, one staff member stated: ‘I guess you, you have to have the understanding that it’s not a lot of people that actually come out of these residential programs and make it…’
Failure to recognize and acknowledge that one’s substance use warrants treatment was at the heart of the responses that pointed to denial as a barrier to treatment.
Clients responded: ‘Not realizing what was the truth kept me…When you start maturing and getting older and you realize that you can’t sit around and smoke weed and do drugs all day and you can’t live a productive lifestyle...’
Staff added: ‘The disease itself. It’s a disease that tells you, you don’t have a disease. It tells you, you don’t have a problem.’
Self-choice was mentioned more frequently (49%) by all participants than any other barrier at the personal level. This was expressed in responses that indicate the belief that those who fail to seek treatment are actually choosing to not seek treatment based on personal level of readiness.
Some clients attributed this choice to a feeling of self-reliance. One client reported: ‘Well some people feel they don’t need it. So sometimes you feel like you can do it by yourself. Like in my case I felt like I could do it without treatment.’ Other clients believed the choice was rooted in wanting to maintain the status quo, adding: ‘Even though they know they need the help they don’t want to disrupt the family lifestyle so they think they can hold it off or hold it together.’ Several clients pointed to the need to hit ‘rock bottom’ before they would make the choice to seek treatment – as if they had to experience a sufficient amount of negative consequences in order to be motivated to seek treatment.
While staff members concurred with the concept of self-choice as a barrier, they tended to most frequently point to the need for clients to experience a ‘rock bottom’ before choosing treatment. One staff member stated: ‘If they don’t hit their bottom they don’t seek treatment…if the cons don’t outweigh the pros then they won’t seek treatment.’
Twenty-eight percent of all participants held a perception that an attachment to alcohol/drugs – needing the substance to cope/survive – was another key barrier to seeking treatment.
Some clients pointed out the strong hold that the substance had on them, saying: ‘The only thing you do turn to is the drug because it turns into your companion. It doesn’t tell you nothing, it soothes your pain, and it keeps you there and you can be there whenever you need it. So, the drug is filling a void. It’s the missing link that you think you’re missing.’
Staff members also pointed to the self-medicating attachment to the substance, saying: ‘People that use substance abusers [are] like runners, they like, run away, so how they run away from their feeling, they medicate their selves.’
Participants described how the negative societal perception of SUDs leads to internalized guilt, shame, and embarrassment to seek treatment – a barrier we defined as stigma.
Consistent with the views of others, one client stated: ‘Shame, guilt...I can’t see anything else that would stop them from…they embarrassed. They have low self-esteem.’
Staff members concurred with the idea of embarrassment, evidenced by responses such as: ‘The next barrier is that, it's a big stigma. So, you know, to admit that you have a problem and to go into a treatment is that mean that you’re weak.’
Participants also held the belief that those with SUDs are often unaware of treatment options/process. Although, within personal barriers, this was the least-often cited, still 11% of participants pointed to this lack of knowledge of the available treatment options and what to expect from the treatment process as being a barrier to seeking treatment.
One client expressed: ‘They don’t want to, or probably they don’t know that there is help out there. They don’t have enough resources.’
Staff members agreed, with one staff member reporting: ‘I think that first of all many don’t know what resources are available or how to get referred or some of them don’t know that they can self-refer.’
3.2 Interpersonal barriers to seeking treatment
Statements were classified as interpersonal barriers when participants spoke of negative social support. Like the views held by others, one client highlighted the peer pressure people often face, stating: ‘Pride, peer pressure, because their friends are all getting high. Now you figure that you want to stop, but they’re like, ‘Why you gone stop? We can all be high. Come on back, buy two’…’
Staff members’ responses acknowledged the difficulty for individuals who live in environments wherein substance use is a normal part of life. One staff member stated: ‘I think the population I have worked with, it has been primarily that this is the normal behavior for the society in which they generally spend time, is to use.’
3.3 Structural barriers to seeking treatment
While personal barriers and interpersonal barriers are more subjective in nature, structural barriers – cited by 24% of participants – are more concrete.
Some participant responses spoke to a general inaccessibility of treatment. One client pointed to the physical inaccessibility of treatment, stating: ‘I was sick, and it was easier to use than to go to the hospital. The same drugs they were giving me in the hospital, I was getting on the street.’ Another client brought attention to the lack of financial access to treatment, reporting: ‘Money and resources were the main issue. I had health insurance and that helped me into treatment at first but um, uh, you know. Like after care and all that stuff, I started reaching a cap on my insurance and then I paid for it.’
Staff members agreed, but also pointed out the ways a lack of finances can create an indirect barrier to treatment, saying: ‘A lot of times it’s not having an ID or verifiable address. In order to get those you have to have a birth certificate, which they sometimes don’t have, mostly don’t have. In order to get those you need cash.’
Ten percent of rural participants cited admission difficulty compared to only 2% of urban staff and clients. Clients reported being eager to enter treatment, but unable to do so because of waitlists, represented in the following statement by one client: ‘Probably waitlists. That was the biggest thing. … I’m sure you’ve probably heard that from more than one person. A lot of people.’
Staff members were aware of waitlists being a barrier, but also brought attention to the idea that admission prerequisites can also present a barrier to treatment, adding: ‘On our assessment sheets we require that they have their PPD’s and their blood pressure. … they can’t be on any benzos or anything because you can’t take suboxone with benzos. But some of them are on methadone and they have to be below 30mg or less. So we run into a problem because I have to have them tapered down to that amount before I can bring them in here.’
Nine percent of participants indicated that, based on one’s family and work responsibilities, treatment may seem unfeasible. Female clients were more aware of family responsibilities as a barrier, evidenced by one client stating: ‘A lot of women don’t come to treatment…because they got kids and who are they going to leave their kids with, and how are they going to see their kids if you’re not going to support them?’ Male clients often pointed to job insecurity as a barrier, stating: ‘I didn’t want to miss work, for real. Work was part of it. And I didn’t know if they were going to hold my job. That was the biggest thing...’
Staff members also focused on family responsibilities, stating: ‘But – so some people have elderly family or elderly relative or, you know, someone they have to care of, or they've always been a, a caregiver – and that may stop them from coming in because they need to be there for their family.’ Another staff member highlighted the need to address the barrier of childcare, sharing: ‘The other thing we are providing when they are here receiving services is childcare…you can bring children up through 12 so that won’t be a barrier to getting the help that you need.’