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Center for Substance Abuse Treatment. Substance Abuse Treatment: Addressing the Specific Needs of Women. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2009. (Treatment Improvement Protocol (TIP) Series, No. 51.)

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Substance Abuse Treatment: Addressing the Specific Needs of Women.

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Executive Summary

Clinicians and program administrators are increasingly aware of the important differences between men and women with regard to the physical effects of substance use and the specific issues related to substance use disorders. They are also recognizing that these differences have an impact on treatment—that gender does make a difference. When women’s specific needs are addressed from the outset, improved treatment engagement, retention, and outcomes are the result.

This TIP endorses a biopsychosociocultural framework based on clinical practice and research centered on women. By placing emphasis on the importance of context, many topics examine the role of factors that influence women’s substance use from initiation of use to engagement of continuing care treatment services, i.e., relationships, gender socialization, and culture. The knowledge and models presented here are grounded in women’s experiences, built on women’s strengths, and based on best, promising, or research-based practices. The primary goal of this TIP is to assist substance abuse treatment providers in offering effective, up-to-date treatment to adult women with substance use disorders.

The TIP is organized into eight chapters. The following section summarizes the content of each chapter to present an overview of this publication.

Creating the Context

The consensus panel for this TIP proposes that substance abuse treatment for women be approached from a perspective that encompasses the contexts of women’s lives. These contexts include a woman’s social and economic environment; her relationships with family, extended family, and support systems; and the impact of gender and culture. As a framework to explore women’s substance use disorders, treatment needs, and treatment approaches, this TIP adopted two systemic models: Bronfenbrenner’s ecological model and CSAT’s Comprehensive Substance Abuse Treatment Model for Women and Their Children. Both models endorse the relevance and influence of multisystems and their bidirectional influence upon women’s lives.

What makes gender an important clinical issue in substance abuse treatment? Are there gender differences in the development and pattern of substance use disorders? Do these differences warrant specific treatment approaches? To date, there is considerable evidence denoting that gender differences do exist, and these differences begin with early risk factors for substance use and extend throughout the course of treatment and recovery. Grounded in research, this TIP begins with unique biopsychosocial and developmental issues of women that create or intensify gender differences across the continuum of care. Knowledge of these unique factors is essential for treatment providers to fully understand the contexts of women’s lives and their needs.

Based on the premise and knowledge that women are biopsychosocially unique in ways that are relevant to substance use, substance use disorders, and substance abuse treatment, this consensus panel endorses core principles for gender responsive treatment for women, such as—

  • Acknowledging the importance as well as the role of the socioeconomic issues and differences among women.
  • Promoting cultural competence specific to women.
  • Recognizing the role as well as the significance of relationships in women’s lives.
  • Addressing women’s unique health concerns.
  • Endorsing a developmental perspective.
  • Attending to the relevance and influence of various caregiver roles that women often assume throughout the course of their lives.
  • Recognizing that ascribed roles and gender expectations across cultures affect societal attitudes toward women who abuse substances.
  • Adopting a trauma-informed perspective.
  • Using a strengths-based model for women’s treatment.
  • Incorporating an integrated and multidisciplinary approach to women’s treatment.
  • Maintaining a gender responsive treatment environment across settings.
  • Supporting the development of gender competency specific to women’s issues.

Patterns of Use: From Initiation to Treatment

Numerous factors influence the reasons for initiation of substance use among women, and a number of these factors are more prevalent among women than men. Women often report that stress, negative affect, and relationships precipitate initial use. In fact, women are often introduced to substance use by a significant relationship such as boyfriend, family member, or close friend. Though genetics also may be a significant risk factor for women, more research supports familial influence—a combination of genetic and environment effects. Less is known about familial influence of illicit drugs, but parental alcohol use increases the prevalence of alcohol use disorders among women by at least 50 percent. Family of origin characteristics play a role too. Exposure to chaotic, argumentative, and violent households, or being expected to take on adult responsibilities as a child, are other factors associated with initiation and prevalence of substance use disorders among the female population.

Women are significantly influenced by relationships, relationship status, and the effects of a partner’s substance abuse. Women dependent on substances are more likely to have partners who have substance use disorders. At times, women perceive shared drug use with their partner as a means of connection or of maintaining the relationship. Often, rituals surrounding drug use are initiated by a male partner, and women bear more risk in contracting HIV/AIDS and hepatitis by sharing needles or having sexual relationships with men who inject drugs. Relationship status similarly influences use and potential development of substance use disorders. Marriage appears protective, whereas separated, never married, or divorced women are at greater risk for use and the development of substance use disorders. Relationship influence does not stop at the point of treatment entry; relationships also significantly influence treatment engagement, retention, and outcome among women.

Other risk factors associated with initiation of use and the prevalence of substance use disorders include sensation-seeking, symptoms of depression and anxiety, posttraumatic stress and eating disorders, and difficulty in regulating affect. Women with a history of trauma, including interpersonal and childhood sexual abuse, are highly represented in substance abuse samples. In addition, sociocultural issues play a significant role across the continuum beginning with enhanced risk for substance use. Degree of acculturation, experiences of discrimination, and socioeconomic status are prominent risk factors from the outset but continue to influence women’s substance use, health status, treatment access, and help-seeking behavior.

Among women, six patterns of substance use clearly emerge from empirical data. First, the gender gap is narrowing for substance use across ethnicities, particularly among young women. Second, women are more likely to be introduced to and initiate substance use through significant relationships, while marital status appears to play a protective role. Third, women accelerate to injecting drugs at a faster rate than men, and rituals and high-risk behaviors surrounding drug injection are directly influenced by significant relationships. Fourth, women’s earlier patterns of use (including age of initiation, amount, and frequency) are positively associated with higher risks for dependency. Next, women are more likely to temporarily alter their pattern of use in response to caregiver responsibilities. And last, women progress faster from initiation of use to the development of substance-related adverse consequences.

Substance use is not as prevalent among women as it is among men, but women are as likely as men to develop substance use disorders after initiation. Women who are pregnant are likely to reduce or remain abstinent during pregnancy; however, continued use is associated with a wide range of issues and effects—from less prenatal care to potential irreparable harm to the child from fetal exposure. Among those entering treatment, women are more likely to report drug use as the main reason for admission.

Physiological Effects of Alcohol, Drugs, and Tobacco on Women

Women develop substance use disorders in less time than men. Some factors that either influence or compound the physiological effects of drugs and alcohol include ethnicity, health disparity, socioeconomic status, developmental issues, aging, and co-occurring conditions. Although research on the physiological effects of alcohol and illicit drugs on women is limited and often inconclusive, significant differences have been found in the way women and men metabolize alcohol. Women have more complications and more severe problems from alcohol use than do men, and these complications and problems develop more rapidly. This phenomenon is known as “telescoping.” Complications include liver disease and other organ damage; cardiac-related conditions such as hypertension; reproductive consequences; osteoporosis; cognitive and other neurological effects; breast and other cancers; and greater susceptibility and progression of infections and infectious diseases, including HIV/AIDS and hepatitis C virus (HCV).

Although many physiological effects of licit and illicit drugs have not been well studied, research has shown that abuse of substances such as stimulants, opioids, and some prescription (e.g., anxiolytics, narcotic analgesics) and over-the-counter (e.g., laxatives, diuretics, diet pills) drugs causes adverse effects on women’s menstrual cycles and gastrointestinal, neuromuscular, and cardiac systems, among others. With regard to nicotine use, women who smoke increase their risk of lung cancer. Currently, cancer is the second leading cause of death among women, with mortality rates higher for lung cancer than breast cancer. Other physiological consequences of tobacco use include, but are not limited to, increased risks for peptic ulcers, Crohn’s disease, estrogen deficiencies, strokes, and atherosclerosis. Women who smoke are more likely to have chronic obstructive pulmonary disease and coronary heart disease.

Women who use alcohol, drugs, or tobacco while pregnant or nursing expose their fetuses or infants to these substances as well. The most thoroughly examined effect of alcohol on birth outcomes is fetal alcohol syndrome, which involves growth retardation, central nervous system and neurodevelopmental abnormalities, and craniofacial abnormalities. Alcohol and drug use by pregnant women is associated with many complications, including spontaneous abortion, prematurity, low birth weight, premature separation of the placenta from the uterine wall, neonatal abstinence syndrome, and fetal abnormalities. Likewise, women who are pregnant and use tobacco are more likely to deliver premature and low birth weight infants.

Screening and Assessment

Understanding the extent and nature of a woman’s substance use disorder and its interaction with other areas of her life is essential for accurate diagnosis and successful treatment. This understanding can be acquired through screening and assessment. Screening is typically a brief process for identifying whether certain conditions may exist and usually involves a limited set of questions to establish whether a more thorough evaluation and referral(s) are needed. Sociocultural factors—ethnicity, culture, acculturation level, language, and socioeconomic status—are particularly relevant in screening and assessment selection, in determining the appropriateness of the instruments, and in interpreting the subsequent results. Sociocultural and socioeconomic characteristics of the client can affect testing expectations and behavior of both the counselor and client during the screening and assessment process; e.g., the client’s distrust and subsequent reluctance in the testing process or the counselor’s expectation that a woman with lower socioeconomic status will have a positive screening for alcohol or drug use.

For women, general alcohol and drug screening that determines current or at-risk status for drug and alcohol use during pregnancy is essential. However, healthcare professionals sometimes overlook the necessity of drug and alcohol screening for older, Asian, and/or middle- and upper-class women who are pregnant. Screening is more likely based on preconceived beliefs concerning greater prevalence of substance abuse among women from diverse ethnic groups. Counselors and intake personnel may also alter their behavior when working with diverse populations, such as eye contact, body language, and communication styles, that ultimately affect clients’ responses and trust in the screening process.

Other screenings involve the determination of co-occurring risks, conditions, or disorders, including general mental disorders, mood and anxiety disorders, risk of harm to self or others, history of childhood trauma and interpersonal violence, and eating disorders. Considering women’s likely involvement with health care providers, screening for substance use and abuse should be a standard practice. Yet, the implementation of screening, regardless of setting, is only as good as the protocol in providing feedback, referral, and follow-up. Screening is not an intervention. What makes the difference is how a woman’s positive endorsement of screening questions leads to feedback, referral, further assessment, and intervention, if warranted.

The difference between screening and assessment is that assessment examines several domains in a client’s life in detail so that diagnoses can be made for substance use disorders and possible co-occurring mental disorders. Assessment is an ongoing process in which the counselor forms an increasingly clearer picture of the client’s issues, how they can best be addressed, and how the client is changing over time. An assessment interview, such as a structured psychosocial interview, an unstructured psychosocial and cultural history, and/or the Addiction Severity Index, needs sufficient time to complete. The degree to which it is possible or advisable to probe in depth in different areas of functioning depends on the individual issues, the needs of the woman, the complexity of her issues, and the level of rapport between the client and clinician. Equally important, assessment processes should explore coping styles, strengths, and available support systems. An assessment process would not be complete without a health assessment and medical examination.

In sum, screening and assessment for women must be approached from a perspective that allows for and affirms cultural relevance and strengths. Whenever possible, instruments that have norms established for specific population groups should be used. Counselors’ sensitivity to the clients’ cultural values and beliefs, language, acculturation level, literacy level, and emotional ability to respond facilitates the assessment process and helps women engage in treatment.

Treatment Engagement, Placement, and Planning

Women face many obstacles and challenges in engaging in treatment services: lack of collaboration among social service systems, limited options for women who are pregnant, lack of culturally congruent programming, few resources for women with children, fear of loss of child custody, and the stigma of substance abuse. On one hand, intake personnel and counselors can help women tackle and overcome personal barriers to treatment (such as issues of motivation and shame); yet, on the other hand, programming and administrative policies must address obstacles surrounding program structure, interagency coordination, and service delivery to improve treatment engagement. In recent years, more effective engagement strategies have been implemented. Outreach services, pretreatment intervention groups, and comprehensive and coordinated case management can effectively address the numerous barriers and the array of complex problems that women often express in their role as caregivers.

Treatment placement decisions are based not only on the woman’s individual needs and the severity of her substance use disorder but also on the treatment options available in the community, her financial circumstances, and available healthcare coverage. To determine treatment placement, the American Society of Addiction Medicine’s Patient Placement Criteria, Second Edition Revised (ASAM’s PPC-2R), are used widely, and the levels determined by these criteria are useful to standardize treatment placement. To date, empirical literature supporting specific placement criteria for women is limited. The treatment levels suggested by the consensus panel and supported by ASAM criteria include pretreatment or early intervention; detoxification; outpatient treatment; intensive outpatient treatment (IOT); residential and inpatient treatment; and medically managed, intensive inpatient treatment. Specific placement criteria must also account for pregnancy, child placement, and children services. Treatment services for women must extend beyond standard care to address specific needs for women, pregnant women, and women with children such as medical services, health promotion, life skills, family- and child-related treatment services, comprehensive and coordinated case management, and mental health services.

When clients participate fully in decisions related to treatment, they are more likely to understand the process and develop realistic expectations of treatment. Active involvement of clients in all aspects of treatment planning and placement significantly contributes to both recovery and empowerment and is essential to the development of meaningful, effective services for women.

Substance Abuse Among Specific Population Groups and Settings

Women who are of different racial and ethnic groups, different sexual orientations, in the criminal justice system, living in rural areas, older, and who speak languages other than English are among the population groups that may experience unique challenges that affect their substance use or abuse and its treatment.

The risk for substance abuse and its consequences and optimal processes for treatment and recovery differ by gender, race, ethnicity, sexual orientation, and other factors. The complex interplay of culture and health—as well as the influence of differing attitudes toward, definitions of, and beliefs about health and substance use among cultural groups—affects the psychosocial development of women and their alcohol, drug, and tobacco use and abuse. Women’s risks for substance abuse are understood best in the social and historical context in which the influences of gender, race and ethnicity, education, economic status, age, geographic location, sexual orientation, and other factors converge. Understanding group differences across segments of the population of women is critical to designing and implementing effective substance abuse treatment programs for women.

Training helps staff members recognize the individual and group strengths and resiliency factors that can assist women from diverse identity groups in recovery. These include beliefs regarding health care and substance abuse; the value the individual or identity group places on family and spirituality; the effects of group history on current behaviors; how women are socialized in a particular culture; and the flexibility of gender norms, communication styles, rituals, the status of women, the stigma the group or individual faces, and attitudes toward self-disclosure and help-seeking behavior.

Substance Abuse Treatment for Women

Gender does not appear to predict retention in substance abuse treatment. Women are as likely as men to stay in treatment once treatment is initiated. Factors that encourage a woman to stay in treatment include supportive therapy, a collaborative therapeutic alliance, onsite child care and children services, and other integrated and comprehensive treatment services. Sociodemographics also play a role in treatment retention. Studies suggest that support and participation of significant others, being older, and having at least a high school education are important factors that improve retention. Criminal justice system or child protective service involvement also is associated with longer lengths of treatment. Women are more likely to stay in treatment if they have had prior successful experiences in other life areas and possess confidence in the treatment process and outcome. Although pregnancy may motivate women in initiating treatment, studies suggest that pregnant women do not stay in treatment as long and that retention may be significantly affected by stage of pregnancy and the presence of co-occurring psychiatric disorders.

Limited research is available highlighting specific therapeutic approaches for women outside of trauma-informed services. In recent years, more attention has been given to effective women’s treatment programming across systems with considerable emphasis on integrated care and the identification of specific treatment issues and needs for women. Gender specific factors that influence the treatment process and recovery evolve around the importance of relationships, the influence of family, the role of substance use in sexuality, the prevalence and history of trauma and violence, and common patterns of co-occurring disorders. Among women with substance use and co-occurring mental disorders, diagnoses of posttraumatic stress and other anxiety disorders, postpartum depression and other mood disorders, and eating disorders are more prevalent than among men who are in treatment for substance use disorders. Consequently, clinical strategies, treatment programming, and administrative treatment policies must address these issues to adequately treat women. Likewise, women often need clinical and treatment services tailored to effectively address pregnancy, child care, children services, and parenting skills.

Recovery Management and Administrative Considerations

Empirical data suggest that women are as likely as men to attend continuing care services. Transition from a more intensive level of care to less intensive services has proven to be challenging for all clients, but evidence suggests that women will continue with services if they stay within the same agency and/or effort is made to connect them to the new service provider prior to transition.

Gender does not consistently predict treatment outcome. For example, women have comparable abstinent rates with men and are as likely to complete treatment. Even so, women are more likely to have positive treatment outcomes in the following ways: less incarceration, higher rates of employment, and more established recovery-oriented social support systems. Women and men do not differ in relapse rates. It is more likely that individual characteristics hold the key in determining who may be a greater risk for relapse. However, there is a delineation of the types of risks and triggers that make women versus men more vulnerable to relapse, and women exhibit different emotional and behavioral responses during and after relapse. Women report more interpersonal problems and strong negative affect, including symptoms of depression, severe traumatic stress reactions to early childhood trauma, and low self-worth, as precipitants of relapse. They also display a lack of coping skills, greater difficulty in severing their connections with individuals who use, and a failure in establishing new recovery-oriented friends. Conversely, women who relapse are more likely to seek help and have shorter relapse episodes.

Other considerations in providing treatment to women involve programmatic and administrative issues. First, full participation of clients as partners in treatment is important, and both the program and client will benefit if they are involved in program development and serve in an advisory capacity. Programs will likely improve the quality of services and clients will benefit from an increase in self-efficacy, the attainment of specific skills, and a reduced stigma from substance abuse treatment. Gender-responsive treatment involves a safe and non-punitive atmosphere, where staff hold a hopeful and positive attitude toward women and show investment in learning about women’s experiences, treatment needs, and appropriate interventions. Administrators need to invest in staff training and supervision and show a commitment to training beyond immediate services. Training should include other social and healthcare facilities and personnel within the community to enhance awareness, identify women with substance use disorders, and increase appropriate referrals. As research, programming, and clinical experience expand along gender lines in substance abuse treatment, clinicians and administrators alike will have considerable opportunities in adapting new standards of care for women.

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