Characterization of gender-focused support strategies in intensive outpatient alcohol and/or drugs programs from the team perspective

Abstract

Introduction  This paper presents the results of one of the components of a research project funded by FONIS, awarded to researchers from the University of Santiago, Chile (2023-2024). This study builds upon two previous investigations conducted in the Santiago Metropolitan Region (RM) on gender-based strategies that promote adherence and successful therapeutic discharge in intensive outpatient alcohol and/or drug treatment programs specifically for pregnant and/or postpartum women (PAI-M).

Objective  To characterize gender-focused support strategies that promote adherence and therapeutic discharge based on the intersubjective experiences of three technical-professional teams from PAI-M programs in the regions of RM, Valparaíso, and Bío.

Method  A qualitative study using a phenomenological design and semi-structured interviews with interdisciplinary PAI-M teams. Four dimensions were explored: local context, team functioning, perception of the problem, and gender-based adherence strategies.

Results  The teams are influenced by local contexts. Women face social judgment, transgenerational harm, and gender-based violence at family, social, and institutional levels. The strategies implemented from the initial contact with the women aim to build a committed bond, question gender mandates, and work with family and community networks to address these issues.

Conclusions  Gender-focused support strategies are essential to promote adherence and successful therapeutic discharge in PAI-M programs.

Keywords:
Women; Substance Abuse Treatment; Gender Perspective; Treatment Adherence

Resumen

Introducción  Se presentan los resultados de uno de los ejes del proyecto de investigación financiado por el FONIS adjudicado por investigadoras de la Universidad de Santiago de Chile (2023-2024). Esta investigación da continuidad a dos estudios anteriores realizados en la Región Metropolitana (RM) de Santiago, sobre estrategias con enfoque de género que favorecen la adherencia y alta terapéutica en programas ambulatorios intensivo de alcohol y/o drogas específico para mujeres en embarazo y/o post-parto (PAI-M).

Objetivo  Caracterizar las estrategias de acompañamiento con enfoque de género que favorecen la adherencia y alta terapéutica a partir de las experiencias intersubjetivas de tres equipos técnico-profesionales PAI-M de la RM, Valparaíso y Bío Bío.

Método  Estudio cualitativo mediante un diseño fenomenológico y entrevistas semiestructuradas a equipos interdisciplinares de PAI-M, abordando cuatro dimensiones asociadas al contexto local, funcionamiento del equipo, percepción del problema y estrategias de adherencia con enfoque de género.

Resultados  Los equipos están condicionados por los contextos locales, las mujeres experimentan el juicio social, daño transgeneracional y violencia de género a nivel familiar, social e institucional y las estrategias implementadas desde el primer contacto con las mujeres buscan construir un vínculo comprometido, problematizar los mandatos de género y trabajar con redes familiares y comunitarias para abordar estas problemáticas.

Conclusiones  Las estrategias de acompañamiento con enfoque de género son esenciales para favorecer la adherencia y alta terapéutica exitosa en los PAI-M.

Palabras clave:
Mujeres; Tratamiento de Abuso de Sustancias; Perspectiva de Género; Adherencia al Tratamiento

Resumo

Introdução  Este artigo apresenta os resultados de um dos eixos de um projeto de pesquisa financiado pelo FONIS, concedido a pesquisadoras da Universidade de Santiago do Chile (2023-2024). Este estudo dá continuidade a duas investigações anteriores realizadas na Região Metropolitana (RM) de Santiago, sobre estratégias com enfoque de gênero que favorecem a adesão e a alta terapêutica em programas ambulatoriais intensivos de tratamento de álcool e/ou drogas, específicos para mulheres grávidas e/ou no pós-parto (PAI-M).

Objetivo  Caracterizar as estratégias de acompanhamento com enfoque de gênero que favorecem a adesão e a alta terapêutica, a partir das experiências intersubjetivas de três equipes técnico-profissionais dos programas PAI-M nas regiões da RM, Valparaíso e Bío.

Método  Estudo qualitativo com desenho fenomenológico e entrevistas semiestruturadas com equipes interdisciplinares dos programas PAI-M. Foram abordadas quatro dimensões: contexto local, funcionamento da equipe, percepção do problema e estratégias de adesão com enfoque de gênero.

Resultados  As equipes são influenciadas pelos contextos locais. As mulheres enfrentam julgamento social, danos transgeracionais e violência de gênero em níveis familiar, social e institucional. As estratégias implementadas desde o primeiro contato com as mulheres buscam construir um vínculo comprometido, problematizar os mandatos de gênero e trabalhar com redes familiares e comunitárias para enfrentar essas problemáticas.

Conclusões  As estratégias de acompanhamento com enfoque de gênero são essenciais para favorecer a adesão e a alta terapêutica bem-sucedida nos PAI-M.

Palavras-chave:
Mulheres; Tratamento do Abuso de Substâncias; Perspectiva de Gênero; Adesão ao Tratamento

Introduction

According to the latest participatory public accounting report by Chile's National Service for the Prevention and Rehabilitation of Drug and Alcohol Use (SENDA), in 2022, specific programs aimed at women served 2,397 women over the age of 18 (SENDA, 2023). That same year, the Gender Unit was established with the aim of mainstreaming this approach into the country's drug demand reduction policies, and the first treatment program with specialized services for girls and adolescent women was lauched in the Metropolitan Region, both in residential and outpatient modalities. The challenge is significant, given that multiple experiences and studies indicate that women with problematic drug use face stigmatization processes shaped by their dual status as women and mothers (Benito-López et al., 2016; Vicent, 2020; Díaz et al., 2021; García Ferraro, 2019; Jeifetz, 2017; Otero, 2020; Palacios et al., 2022; Rowlands et al., 2018; Webb et al., 2022). Although alcohol and/or drug use is a serious public health problem, as it represents a risk behavior affecting the health and social functioning of the general population (MINSAL, 2022), it is necessary to broaden the understanding of the contexts in which problematic drug use occurs. Its impact is greater depending on social position, with evidence showing that in lower-income groups there is a higher prevalence and more severe consequences, highlighting the need to understand and address health inequalities as a global challenge (Couto et al., 2019). Likewise, gender particularly exposes women who use drugs to gender-based violence, with serious psychological, social, physical, and intergenerational consequences (Romo-Avilés et al., 2024). This reveals that substance use does not have the same physical, psychological, or social consequences for women as it does for men attending these programs (Jeifetz, 2017; Marmot & Wilkinson, 2006; Martínez & Calvo, 2024; Romero Mendoza et al., 1996; Setien, 2019; Tarlov, 1996).

In 2005, the National Service for the Prevention and Rehabilitation of Drug and Alcohol Use (SENDA) implemented a pilot program called the Women-Specific Intensive Outpatient Program (PAI-M). This initiative highlighted the complex realities women face when deciding to enter treatment, as well as the challenges involved in maintaining adherence and completing their therapeutic and social integration processes. Comparing the most recent technical evaluation reports published by SENDA in 2020 and 2021 (SENDA, 2021, 2020), which summarize the work carried out in 2019 and 2020, respectively, women-specific programs demonstrated improvements in adherence¹ outcomes and therapeutic discharges², with dropouts decreasing by 7.8% and administrative discharges by 0.5%, resulting in a total proportion of interrupted treatments of 31.8%. This figure not only highlights the challenges in achieving adherence to treatment programs but also reflects a marked gender gap in access to these services. Men continue to represent the majority of program participants, at 68%, compared to 31.7% of women, according to data from SENDA & MINSAL (SENDA, 2021). Regarding the scientific literature on these topics in Chile, current studies problematize the factors that hinder or facilitate women’s adherence in mixed residential centers (Martínez & Calvo, 2024). However, no studies have investigated gender-based intervention strategies and their connection to adherence and therapeutic discharge from the microsocial dimension, using a phenomenological design that focuses on the intersubjective experiences of PAI-M technical-professional teams from the different regions of Chile.

In this context, the present research continues a study carried out between 2020 and 2021 by a team of researchers from the University of Santiago de Chile, which highlighted the importance of inter- and transdisciplinary support strategies with a gender and human rights approach to reduce these gaps (Díaz et al., 2021; Palacios et al., 2022). That study characterized the PAI-M intervention model at El Pino Hospital in San Bernardo (Metropolitan Region), identifying that support strategies should aim to reconstruct women’s life projects, taking into account their biographical trajectories, particularly transgenerational family histories, motherhood and parenting experiences, as well as histories of substance use and gender-based violence, all of which have resulted in systematic violations of their rights. These strategies, in addition to enhancing adherence and therapeutic discharge, helped narrow health equity gaps and facilitated access to adequate care for pregnant or postpartum women living in vulnerable conditions and experiencing drug and/or alcohol use. The current research³, funded by the National Fund for Health Research and Development (FONIS), is part of ongoing efforts to generate proposals that, from a equity perspective, contribute to improving the health system’s response and addressing public health policies with a gender perspective.

In the context of this research, the authors understand the category of gender as associated not only with relations of subordination between men and women, but also with inequalities based on race, ethnicity, class, sexual orientation, age, and other factors (Ochoa Muñoz, 2019). This means that gender is not only a principle of social differentiation but also a generator of discrimination, inequalities, and asymmetries in rights and obligations (Lagarde, 2003; Lamas, 2009), which intersect and “[…] traverse singular and collective experiences in a fabric that is impossible to separate” (Correa García, 2023, p. 115). Studies indicate that women and girls face multiple forms of oppression, discrimination, and violence (Esteban, 2006), which allows us to understand that part of the origin of substance use lies in histories of structural, cultural, and direct violence (Galtung, 2016), resulting from cultural constructions that essentialize identity, sexuality, and motherhood. From a gender perspective, it is possible to identify how family histories and transgenerational harm can be reproduced through repeated experiences of violence, abuse, and substance use experienced by a significant number of women (Díaz et al., 2021). This requires understanding that substance use is always embedded in the daily lives of specific social groups, closely linked to the sociohistorical processes they experience (Troncoso Pérez et al., 2019). Women commonly face rejection, discrimination, and stigmatization from their own families, as well as from state institutions, private organizations, and the media, which is expressed through systems of control, the pathologization of their discomfort and pain, the fragmentation of their experiences, and the dehistoricization of their narratives (Fernández, 2021; Radford & Thiara, 2021). In other words, an addiction problem in a woman challenges cultural and social stereotypes regarding acceptable or normative expectations of femininity, constituting a threat to traditional female roles. According to Mies Vargas (2022), gender, understood as a social construct that defines behaviors and expectations based on the assigned gender in a given context, significantly impacts how women experience their rights, influencing not only the type to healthcare they receive, but also their social position, access to education, participation in the labor market, and the material resources available to them. Thus, it is essential and urgent to continue integrating and strengthening a gender perspective in public policies and care programs to broaden understanding of the multiple barriers women face in accessing services due to their social position (Martínez-Redondo & Arostegui Santamaría, 2023). Public service offerings must continue to consider aspects related to gender mandates and roles if sustainable progress toward access and adherence to treatment programs for women is to be achieved (Calvo et al., 2018; Houghton et al., 2022); otherwise, early dropouts will continue to rise, and institutional practices that demonstrate “[…] a pattern of discrimination or obstacles to the exercise and enjoyment of rights” will persist (Bodelón, 2015, p. 4).

This article describes gender-sensitive support strategies that promote adherence and therapeutic discharge in intensive outpatient alcohol and/or drug programs specifically for pregnant and/or postpartum women. These strategies highlight the intersubjective experiences of three technical and professional teams. The article seeks to promote the link between adherence and therapeutic discharge with gender-sensitive support strategies and to influence SENDA's public policy. It also develops a guide of recommendations to strengthen the teams' response capacity and relevant and timely decision-making, thus contributing to reducing the gender-based health inequality gradient affecting women who use alcohol and/or drugs.

Method

To achieve the objectives of this research, a qualitative approach was adopted, using an interpretive perspective and a phenomenological design. Phenomenological studies seek to understand social phenomena from the perspective of those who experience them, focusing on the everyday, experiential, and intersubjective dimensions, as well as the attitudes individuals adopt toward the events they encounter (Creswell & Poth, 2018; Hernández Sampieri & Mendoza Torres, 2018; Schütz, 2015). This study is grounded in the epistemological assumption that team members’ experiences—along with their opinions, narratives, and descriptions—reveal the essential aspects that shape and give meaning to those experiences (Creswell & Poth, 2018). Accordingly, it was important to examine the narratives constructed by team members about their gender-focused intervention practices and their interpretations of these practices. Although the gender approach is formally embedded in Public Policy, this general guideline does not capture the diverse ways in which the approach is implemented or how team members interpret and embody these orientations (Schütz, 2015). Moreover, the guidelines do not address the specific contexts in which intervention practices occur or the differences and similarities among the various Centers and Regions of the country. To address these issues, and in line with the phenomenological design, qualitative group interviews with a flexible, semi-structured format were conducted, complemented by thematic content analysis (Flick, 2015; Hernández Sampieri & Mendoza Torres, 2018).

Regarding sample characterization, the study was conducted in three regions of Chile with the highest rates of women in treatment for alcohol and drug use during pregnancy and postpartum within SENDA’s PAI-M programs: Metropolitan (47.5%), Valparaíso (8.2%), and Biobío (6.5%). The study population comprised three interdisciplinary PAI-M teams from these regions. Purposive sampling was employed to select the most relevant teams based on the research question and predefined structural representativeness criteria (Hernández Sampieri & Mendoza Torres, 2018). This sampling method was chosen due to the limited number of PAI-M programs in each region. The selected teams included psychologists, social workers, occupational therapists, psychiatrists, and rehabilitation technicians, all with experience in providing outpatient support to women undergoing treatment.

Teams from women’s residential programs, general intensive outpatient programs, and general residential programs were excluded, as these do not specifically serve pregnant and postpartum women. Similarly, teams from regions with fewer services and lower prevalence rates of alcohol and/or drug use among women were not included.

Regarding the sampling technique and field access, databases provided by SENDA and the contact network of the PAI-M team at El Pino Hospital—a national benchmark for its expertise in these programs—were used. These sources served as key informants and gatekeepers, facilitating access to the study field (Alejo & Osorio Acosta, 2016). Once the teams meeting the inclusion criteria were identified, the coordinators of each program were contacted to present the research and work proposal. Fieldwork was then organized, with two researchers assigned to lead the study in each region.

The analysis was performed using thematic content analysis (Andreú Abela, 2000; López Aranguren, 1990) and included coding using NVivo software. Regarding the type of coding, a priori categories were constructed, with a guiding emphasis related to the research objectives, consistent with common use in phenomenological studies (Flick, 2015). The use of a priori categories facilitated optimal scheduling of the interviews, given the limited time available for fieldwork, given the project's two-year funding. This approach guided the construction of the interview script, providing it with a flexible, semi-structured structure that allowed for a deeper understanding of the study's central themes. It also favored the emergence of new analytical categories, enriching the research with greater density and nuance regarding the teams' experiences with their gender-focused intervention practices.

In the analysis process, triangulation of multiple sources of information was employed, including observations at the centers, photographs, informal conversations, field notebooks, and interview transcripts (Hernández Sampieri & Mendoza Torres, 2018). Consistent with the phenomenological approach, this methodology facilitated the articulation of narratives linked to subjective experiences in intervention practices, enabling both the distinction of individual experiences and the identification of shared meaning structures (Hernández Sampieri & Mendoza Torres, 2018; Creswell & Poth, 2018).

After the initial analysis, a preliminary report was prepared and sent to the participating teams for review. Subsequently, a reflective meeting was held with the teams to discuss the preliminary findings and strengthen the reliability of the results (Charres, 2018; Creswell & Poth, 2018).

The methodological approach adopted enabled the analysis of the teams’ experiences across different territorial and organizational contexts, providing a comprehensive perspective on the implementation of the gender approach in intervention practices (Hernández Sampieri & Mendoza Torres, 2018; Creswell & Poth, 2018). This article presents the results from the category Characterization of the PAI-M teams’ gender-focused support strategies, which encompasses various dimensions of the intervention practice: context of the intervention, team functioning, notion of the problem, and gender-focused strategies that promote adherence and therapeutic discharge. These dimensions were designed to capture the potential relationship between the general guidelines of Public Policy and the specific, situated, and subjective experiences of team members, particularly regarding positive outcomes in adherence and therapeutic discharge in the regions where the study was conducted.

Results

In line with the objective of this article, the results correspond to the characterization of gender-focused support strategies in three PAI-M teams from the Metropolitan Region, Valparaíso, and Biobío. On average, the teams are composed of six members, including professionals in psychology, social work, occupational therapy, psychiatry, and rehabilitation technicians—mostly women—with work experience in the field ranging from three to fifteen years. Based on the construction of four dimensions of inquiry, it was possible to identify common meaning structures related to the local context of intervention practice, team functioning, the team’s notions regarding women’s substance use, and, finally, the gender-focused strategies that promote adherence and therapeutic discharge.

Local context of intervention practice in Intensive Outpatient Alcohol and/or Drug Programs specifically for pregnant and/or postpartum women

The narratives of the PAI-M teams indicate that the implementation of a gender approach in support processes is influenced by various factors, such as territorial location and sociodemographic context, as well as the specific characteristics of the women served in the programs, who face multiple economic, social, and cultural inequalities.

Although the SENDA–MINSAL Agreement establishes common technical guidelines, prior training in a gender approach is not required for team members, which affects the quality and depth of its application in therapeutic processes. High staff turnover, coupled with job insecurity, directly impacts the ability to sustain stable and continuous interventions, which are essential for building bonds of trust and emotional support—fundamental elements in working from a gender perspective.

In addition, the lack of funding to cover basic needs, such as transportation, limits women’s adherence to programs, particularly given that many lack economic autonomy or support networks for childcare. This situation highlights the need for gender-sensitive support strategies that address not only treatment itself but also the structural conditions that hinder women’s access to and retention in programs.

Yes, indeed, funding, particularly as an annex to the transportation item, yes, that doesn't appear anywhere. We constantly apply; well, we receive funding from SENDA, but we are constantly applying for competitive funds of various kinds. We don't have mobilization because, since we don't depend on the municipality, for example, or the health service, we don't have vehicles, for example, from the commune, etc. (Team Member 1, 2023).

Functioning of the technical-professional teams of the Intensive Outpatient Alcohol and/or Drug Programs specifically for pregnant and/or postpartum women

The functioning of the technical-professional teams in the PAI-M is governed by the guidelines of the SENDA-MINSAL Agreement. However, the effective implementation of a gender approach to care depends largely on the teams' ability to adapt their practices to the specific realities of the women who enter the program. It is recognized that many of them do so late, present more severe psychosocial damage than men, and have limited support networks, which requires gender-sensitive interventions that consider these conditions.

In this regard, the teams emphasize the importance of flexibility in implementing protocols, making adjustments that respond to the women’s unique needs. These adjustments include organizing service hours, allowing home visits when women cannot attend in person due to caregiving responsibilities, and adapting communication methods and therapeutic strategies. Such measures aim to promote adherence and retention in the program while respecting women’s autonomy and dignity—fundamental principles from both a gender and human rights perspective.

The intake flowchart, the intake of the program, is for adult women aged 18 and over, with moderate to severe biopsychosocial involvement and, obviously, with alcohol and drug use. Intake can be spontaneous [...] by phone, email, in person to request an appointment, or it can also be referrals from other centers in the treatment network [...] if there is a user who may have already met the therapeutic objectives but needs support [...] from another treatment center, another center in the network as well, for example, from Seremi, Clinics, CESFAM, Hospital, who refer many users who come to us from psychiatry, when they have attempted suicide and are investigating alcohol and drug use. They also refer us here from the Drug Treatment Court (Team Member 2, 2023).

The role of the referral therapist or case manager is key to sustaining these support processes, as they facilitate continuity of care, coordinate the different interventions, and serve as a reliable reference for women throughout their therapeutic journey. All of this requires sustained and committed work with a gender perspective, ensuring an environment of emotional support and promoting the reconstruction of support networks, which is essential for the well-being of both women and their children.

The teams’ understanding of women’s substance use in Intensive Outpatient Alcohol and/or Drug Programs specifically for pregnant and/or postpartum women

The technical teams indicate that alcohol consumption is highly normalized in Chilean society, which makes it difficult for women to recognize when their use becomes problematic. This is further reinforced by gender mandates that many have internalized, which impose expectations on their caregiving roles. In this context, women tend to minimize their consumption and justify it by reasoning that they are still fulfilling their maternal responsibilities, or even believe that drinking helps them interact better with their children. This denial or invisibilization of the problem, as reported by the teams, is one of the barriers they address during support processes from a gender perspective.

Look, I would say that alcohol consumption is much more normalized than, for example, cocaine use, and it is much harder for them to problematize it, because it is more ‘under the radar,’ or they minimize it when they arrive here. Like, ‘I drink when the kids are asleep,’ so it is much harder to work on problematizing that consumption in terms of the relationship or the impact it could have on the children. Why, because they give explanations like, ‘no, I drink when they’re sleeping… I don’t stop doing anything, I keep functioning the same,’ or I’ve even heard, ‘no, my daughter has just as much fun with me because I get happier, so we play more,’ for example (Team Member 1, 2023).

Furthermore, the teams highlight the presence of transgenerational patterns of substance use and violence, where the reproduction of histories of abuse, problematic substance use, and neglect of care is observed, especially among women of different generations (grandmothers, mothers, and daughters). This reinforces the need to understand substance use from a gender perspective, considering the history of violence, abuse, and exclusion that affects these women from an early age.

Gender-based violence emerges as a structural element in the life stories of most of the women served. One of the programs reports that 98.6% have experienced some form of violence, predominantly sexual and domestic. These often-silenced experiences intersect with problematic substance use and complex mental health diagnoses, requiring interventions that address gender-based violence as a determining factor.

Most of us, most of us, see it as an escape issue, linked to things that happened in childhood. We’re talking about women who have been using drugs since adolescence, even since childhood. There are very few—actually, I have just one—who started using much later, so to speak. The rest started when they were young. And they used different drugs: cocaine base, cocaine, mixtures of one and the other, polydrug use. [...] Lately, I’ve been surprised to find that most of them were first given drugs by their father—or their mother. And the other thing is that it’s cyclical; I see it perhaps more as a genetic issue: mother uses drugs, daughter uses drugs, grandmother uses drugs, mother uses drugs, daughter uses drugs, and so on… transgenerational (Team Member 3, 2023).

Likewise, women enter the programs already stigmatized by family, social, and institutional systems, facing moral judgment for their role as mothers. They are labeled as “bad women” or “bad mothers” for having used drugs during pregnancy. This stigma is linked to their biopsychosocial impairment—generally classified as moderate to severe—stemming from fragile family and social networks, experiences of abandonment or institutionalization, and sexual violence. It is also associated with the poor quality of their support networks, which, according to the teams, are often precarious; in some cases, family members are involved in drug trafficking networks or have criminal records. Many of these women have attempted previous treatment and abstinence without success, have minimal perception of control over their consumption, and have discontinued or abandoned their daily activities.

To begin with, our women arrive very damaged, deeply damaged by many situations. Not only those who come from the Chile Crece program, who arrive totally and absolutely demonized by the system for having used drugs during pregnancy, but also punished by a biomedical model that, logically, focuses solely on the child’s health and does not even look at the woman. [...] In addition, they generally present with complex trauma, having experienced many situations of abuse—sexual abuse at home, mistreatment of all kinds (Team Member 1, 2023).

Gender-related support strategies that promote adherence and treatment discharge

Support strategies to promote adherence and treatment discharge are implemented by the teams from the very first contact with the women. They stress the importance of offering a supportive, safe, and welcoming environment that fosters the development of a committed, trust-based relationship. A key component is adopting a nonjudgmental and flexible approach, presenting different treatment options adapted to each woman’s life circumstances. These strategies aim to provide safety and protection for both the women and their children. Some programs even have on-site educators to care for or stimulate the development of the children while their mothers receive care. Two programs also offer spaces where women can have meals, or they move sessions to the women’s homes when caregiving duties prevent them from attending. Teams identify this as a fundamental measure to prevent program dropouts.

Also, in relation to other resources or possibilities, we have the dining room and community mealtimes, which are part of our ongoing operations. We serve breakfast in the morning, and if clients need to come with their children, the children can have breakfast here too, as well as lunch and tea. If someone has a power outage at home, we can send them lunch from what we prepare during the day. We work through these situations with them, as X mentioned earlier, as part of their daily routine. These strategies help build relationships and also motivate them to come to the community and avoid dropping out of the program due to challenges like transportation (Team Member 1, 2023).

From the outset of the accompaniment process, welcoming and bonding strategies are highlighted as central to strengthening the therapeutic alliance. The teams agree that most women enter the programs carrying varying degrees of stigma, depending on the institutions they have previously interacted with, and experience fear, shame, and mistrust. This calls for the teams to distinguish themselves from other facilities by creating a safe, violence-free environment where women can experience alternative ways of relating. This process may take up to three months.

Progressively, the teams support processes that encourage women to critically examine the gender mandates imposed on them, the roles assigned to them as women-mothers, and even accompany them when they decide to pursue adoption or delegate caregiving responsibilities to other family members or institutions.

And from acceptance, from welcoming the user, I believe, many arrive with social stigma, stigma from the health system, judicial stigma, because they are women. In addition, some are mothers or pregnant women who use substances, and they come with that fear of starting treatment. Many arrive because they are mandated by the courts, so it becomes very important to work on building the bond from the beginning, rather than focusing solely on substance use. A lot of work is done, I believe, from the perspective of harm reduction at the start—minimizing harm from a risk-reduction standpoint and from connecting with the user, so she feels welcomed in this place, in this space where she will not be judged, and where the goal is to help her improve her quality of life (Team Member 1, 2023).

The accompaniment strategies implemented by the teams go beyond abstinence, focusing on harm reduction and strengthening the bond with the women to promote adherence to the program. These strategies address risk factors that may trigger relapses, as well as protection measures for the women and their children. To this end, a multidimensional assessment is carried out to identify the risks they are exposed to, including situations such as sexual violence by partners and others, unplanned pregnancies, and sexually transmitted infections (STIs). Factors that may increase the likelihood of relapse are also identified, such as special dates, family crises, or significant legal events.

In response to these risks, the teams provide information on the physical, psychological, and social effects of substance use in women and men, helping to develop coping strategies. They also work on protective measures for both the women themselves and others. In the case of pregnant women or those with young children in their care, the importance of their responsibilities and the risks associated with rights violations are reinforced. Accompaniment is based on a clear, transparent, understanding, and nonjudgmental attitude, avoiding any punitive or disciplinary approach.

A pregnant woman who is a heavy user of cocaine base, I mean, we don't justify it, right? But there is a sympathetic, non-punishing perspective (Team Member 2, 2023).

We are not an institution where they are going to punish her for not wanting to be a mother. I mean, here this is discussed with the girls; here we don't judge her based on what should be done. If they tell us they don't want full care, they want visits, that’s okay, that's your way of mothering and that's fine, it's how you're putting it. So, starting from there, a space of trust is created and a space where they are not being mistreated, so they are made visible in all their characteristics (Team Member 2, 2023).

Flexibility is revealed as a key strategy identified by the teams, allowing the programs to adapt to the daily reality of women, especially during the maternity stage. This involves implementing evening schedules, home visits, and the use of video calls, among other measures that address the unavoidable responsibilities that many cannot delegate, share, or abandon, such as childcare and household chores. For those who are also the primary breadwinners or providers for their families, the time restrictions imposed by work represent an additional challenge. In this context, adopting a gender perspective is essential, as various team members point out. Understanding these dynamics is essential to ensuring treatment adherence, as, in many cases, women are forced to prioritize their own livelihoods and that of their children over attending a rehabilitation program.

I mean, on market day, who goes to the market? Women. On that day our attendance drops, because a large percentage either work at the market or go there. So we know that Monday will generally have higher attendance, because usually they finish later since there’s no market. This is an understanding from a gender perspective. And, well, the example you gave—relapse prevention—is a clear space where it’s very important to look at it from that perspective (Team Member 1, 2023).

Finally, the teams emphasize that gender-focused support strategies should include both individual and group spaces where women can share and reflect on their life experiences. These moments of reflection are essential throughout the process, as they allow women to recognize themselves as subjects of rights, with the ability to make decisions and exercise greater power and control over their lives.

In addition, the teams address the specific inequalities women face, which are intensified by precarious cultural and socioeconomic contexts. The goal is to challenge and deconstruct the belief that their only identity is that of a “drug addict”, as this label contributes to normalizing social judgment, stigmatization, and the violence they experience in everyday life.

The gender approach has to do with deconstructing these social stereotypes […] gradually deconstructing these associated discourses, even those of the women who receive care from us […] many times [they say] ‘he hit me, but it’s because I stayed out all night, so, well, I kind of deserved it (Team Member 2, 2023).

Discussion

Based on the intersubjective experiences of three technical-professional teams from intensive outpatient alcohol and/or drug programs specifically for pregnant and/or postpartum women (PAI-M) in the Metropolitan Region, Valparaíso, and Biobío, gender-sensitive support strategies that promote adherence and therapeutic discharge are characterized. The purpose of this characterization is to allow other teams to capture and apply this information to strengthen their response capacity and make relevant, timely decisions, ultimately helping to reduce the gender-based health inequality gradient affecting women attending these programs. Similarly, this research can contribute to SENDA-MINSAL by presenting the scope and challenges experienced by these teams when implementing technical guidelines and ensuring access and exercises to the right to health for women from a gender perspective.

In this sense, the technical guidelines and standards defined by SENDA-MINSAL guide and structure the technical and administrative work of the teams within a flexible framework tailored to the local contexts in which they operate. The teams—mostly composed of social workers, psychologists, occupational therapists, psychiatrists, and rehabilitation technicians—have an interdisciplinary nature that enriches their approach (Díaz et al., 2021; Palacios et al., 2022). However, staffing varies depending on the management and administrative system of each center, with funding often representing a concern. At times, the lack of appropriate spaces for interventions or low salaries for professionals and technicians leads to demotivation, burnout, and increased turnover. Such instability affects the development of support strategies with a gender perspective during the reception and emotional support phase, as stable and continuous processes are required to establish a secure and trusting bond—especially when working with women who have a history of gender-based violence (Tardón Recio et al., 2022).

The teams clearly identify that problematic substance use among women entails a series of discriminations, inequalities, and asymmetries in the exercise of their rights (Lamas, 2009). This requires that programs adopt a gender perspective, taking into account the needs of women in treatment in all aspects and recognizing that every intervention has an impact on gender and gender relations—that is, interventions are not “neutral” (Chile, 2021). Furthermore, the teams agree on the importance of addressing the various physical, psychological, and social effects and consequences of substance use in both women and men (Jeifetz, 2017; Marmot & Wilkinson, 2006; Romero Mendoza et al., 1996; Setien, 2019; Tarlov, 1996), emphasizing that a significant number of women present lower motivation and higher rates of treatment failure, requiring additional effort to successfully complete their objectives (Martínez & Calvo, 2024).

Although team operations are organized according to a care flowchart established by SENDA-MINSAL, which defines phases, roles, and specific functions for each member, implementation must remain flexible and contextually adapted within this programmatic framework. The three teams recognize the relational, processual, and contingent nature of the realities experienced by women (Navarrete et al., 2021). Therefore, their starting point is to develop accompaniment strategies that are sensitive to women’s daily lives and vicissitudes. This requires going beyond traditional clinical spaces, offering flexible schedules, and conducting interventions in community settings, particularly in homes. Moreover, the women attending these programs often live in contexts of high vulnerability and complex biopsychosocial needs, making it essential to provide a welcoming and safe environment. It is noteworthy that a significant number of women have experienced stigmatization within health, justice, and social protection networks, serving as a control mechanism that ultimately promotes program dropout (Lee & Boeri, 2017). This aligns with studies showing that these networks tend to hold more stereotypical and negative social representations toward women and socially disadvantaged classes (Benito-López et al., 2016; Vicent, 2020; Marmot & Wilkinson, 2006; Romero Mendoza et al., 1996; Tarlov, 1996; Webb et al., 2022).

Regarding the most important support strategies for treatment adherence, teams emphasize providing a welcoming and emotionally supportive environment that is clear, understanding, safe, and nurturing. This framework enables the development of a committed, trust-based bond, allowing women to access a space that aligns with their needs and life contexts (Gil Claros, 2020). These supportive bonding strategies are central to fostering the therapeutic alliance and counteracting the social judgment women have experienced within their family and social networks. This approach also facilitates progressive reflection on the role of substance use within their family histories and the transgenerational harm to which most women have been exposed since childhood.

This perspective aligns with studies indicating that women’s experiences of violence and abuse during childhood are correlated with a higher probability of developing severe addictive disorders (Romo-Avilés et al., 2024; Tardón Recio et al., 2022). Other theories suggest that transgenerational harm is transmitted from those who originally experienced it (mothers and/or fathers) through their children to successive generations (grandchildren); in other words, social violence experienced by one generation is passed on with traumatic consequences (Radford & Thiara, 2021; Rincón et al., 2022). In light of these experiences of transgenerational violence, the teams highlight the importance of problematizing them to challenge their normalization and develop a comprehensive understanding of women’s life stories, recognizing the connection between recurring adverse events and substance use trajectories.

Support strategies should offer a framework of possibilities rather than social sanction or judgment and should provide spaces for reflection and the critique of patriarchal and hegemonic representations of motherhood—specifically, those that posit that a woman’s only path to fulfillment is as a “wife-mother” (Lagarde, 2003). These cultural representations of women are embedded in the patriarchal collective imagination, reinforcing the notion that motherhood is the sole avenue to happiness and must be fulfilled at all costs (Barragán Nájera, 2018). This reflective process is directed not only at women but also at their families and close networks, including health, social protection, and justice institutions, which also perpetuate these representations.

Among other relevant strategies within the programs, several examples are mentioned, such as providing safe spaces for them and their children, offering spaces for shelter and stimulation for their children, food spaces, schedule adjustments to accommodate work commitments or caregiving tasks, and home care when they lack support for these tasks, among others. All of these strategies interdependently consider the local context in which the programs are located, knowledge of women's daily lives, how self-stigmatization and stigmatization processes operate, the women's life histories, their family and community networks, the violence to which they are exposed, and the protective measures that should be considered. Therefore, the strategies described to promote adherence and therapeutic discharge from a gender perspective manage to make visible the subordination relationships in which these women have built their lives, not only between men and women, but also due to transgenerational harm, multiple gender-based violence, social class, and their problematic substance use situation (Ochoa Muñoz, 2019). This reflects the multiple discriminations and inequalities that women face (Lamas, 2009) and the way in which these overlap and permeate their lives, both individually and collectively (Correa García, 2023).

Conclusions

In conclusion, we summarize key recommendations that emerge from the characterization of gender-sensitive support strategies based on the experiences of three PAI-M teams. These recommendations aim to enrich the practice of other technical-professional teams and intersectoral networks addressing similar issues:

1. The importance of providing a safe space lies in commitment, active listening, and a clear, transparent, understanding, and non-judgmental attitude. Avoiding any punitive or disciplinary approach is essential, as this fosters an effective bonding process with women, particularly during the reception phase. Respectful and empathetic engagement on the part of the team is key to offering safety from the outset, creating an environment where women feel valued, respected, and secure. This type of bond establishes a dignified space in which women feel comfortable, at ease, and motivated to engage, always considering the uniqueness of their life context and previous experiences.

2. A comprehensive, flexible, and contextualized framework is essential to promoting program adherence, as it strengthens the connection with women by reframing situations or problems that, in other care settings, might be subject to punishment. This approach allows for an integrative analysis of difficulties, taking into account histories and living conditions, which fosters a broader understanding of their circumstances. To achieve this, teams must demonstrate flexibility and breadth in their care approaches, interdependently incorporating notions of gender, transgenerational harm, and gender-based violence. These aspects coexist in many of the women participating in these programs, making their understanding critical for effective intervention.

3. Making gender mandates visible and problematizing them is a crucial aspect of the treatment process, as it allows teams to highlight how these mandates are sources of discrimination and asymmetries in rights affecting women. Within the context of a patriarchal system, such mandates contribute to the justification of multiple forms of gender-based violence experienced by women throughout their lives, both structurally and culturally, as well as through direct acts of violence. Problematizing these experiences encourages reflection on the relationship between substance use and experiences of gender-based violence, such as abuse and mistreatment, enabling women to recognize the effects these experiences have had on their current lives and the challenges they face. Furthermore, this process of reflection should extend to families, close networks, and institutional systems, promoting collective understanding and an integrative approach.

4. Support from the team, taking into account women’s daily lives and specific living conditions, is fundamental. This approach allows for understanding the social and historical relationships that affect them, generating situated and deeply contextualized support. Implementing support strategies beyond the program space enables a closer comprehension of women’s homes, territories, and institutional networks, broadening understanding of their living situations and the risk factors to which they are exposed. Both networks and institutions must be engaged in processes of reflection and the deconstruction of social judgments and stigmatization toward women, assuming their role as guarantors of rights.

Finally, it is important to highlight that gender-based support strategies promote adherence and therapeutic discharge from intensive outpatient alcohol and/or drug programs specifically for pregnant and/or postpartum women, as reported by three PAI-M teams. The strategies described by these teams illustrate that the gender approach is not limited to addressing subordinate relationships between men and women, but also encompasses the discrimination, inequalities, and violations of rights that women experience due to problematic substance use, social class, transgenerational harm, and multiple forms of gender-based violence throughout their lives. This perspective requires a comprehensive understanding of problematic substance use, taking into account women’s daily lives and living conditions. Consequently, support strategies in PAI-M programs and institutional networks must be diversified, fostering spaces for reflection and the deconstruction of social judgments and processes of stigmatization. This study forms part of a set of recommendations intended to contribute to SENDA-MINSAL’s public policy and inform the decision-making of PAI-M teams, strengthening their capacity for timely and relevant responses to reduce the gender-based health inequality gradient affecting women with problematic alcohol and/or drug use.

• 1
  The World Health Organization (WHO) defines treatment adherence as compliance; that is, taking medication according to the prescribed dosage schedule; and persistence as taking medication over time.
• 2
  Discharge is considered once all established therapeutic goals have been met. The recovery process is prolonged. Thus, the patient is prone to multiple relapses even after successful treatment.
• 3
  This research is a publicly funded project under Fonis SA Project 22I00110. Project Title: "Guide of recommendations with a gender perspective to promote adherence and therapeutic discharge in intensive outpatient alcohol and/or drug programs specifically for pregnant and/or postpartum women."
• How to cite:
  Díaz-Leiva, M. M., Palacios Tolvett, M., Frías Torrejón, C., Arriagada Solis, M., Palomino, T., Silva Espinosa, G., & Aracena, P. (2025). Characterization of gender-focused support strategies in intensive outpatient alcohol and/or other drugs programs from the team perspective. Cadernos Brasileiros de Terapia Ocupacional, 33, e3955. https://doi.org/10.1590/2526-8910.cto405139552
• Data Availability
  The data that support the findings of this study are available from the corresponding author, upon reasonable request.
• Funding Source
  Project funded by the National Health Research Fund FONIS SA 22I00110 and the University of Santiago de Chile.

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Edited by

• Section editor
  Prof. Dr. Rodolfo Morrison

Data availability

The data that support the findings of this study are available from the corresponding author, upon reasonable request.

Publication Dates

• Publication in this collection
  01 Dec 2025
• Date of issue
  2025

History

• Received
  01 Feb 2024
• Reviewed
  10 Aug 2024
• Accepted
  02 June 2025