CONTENTS

Introduction

Other TIPs that are Relevant to These KAP Keys

Gender-Responsive Treatment Principles

Women’s Biopsychosocial Uniqueness

Risk Factors of Initiation

Six Patterns Associated With Women’s Substance Use

Screening

Screening and Assessment Considerations

Mental Health Screening for Women

Services and Programmatic Considerations: A Checklist

Women-Specific Predictors of Relapse and Reactions to Relapse

Clinical Knowledge Checklist for Treating Women Who Have Substance Use Disorders

Ordering Information

INTRODUCTION

KAP Keys were developed to accompany the Treatment Improvement Protocol (TIP) series published by the Substance Abuse and Mental Health Services Administration (SAMHSA). These Knowledge Application Program (KAP) Keys are based entirely on TIP 51 and are designed to meet the needs of the busy clinician for concise, easily accessed “how-to” information.

TIP 51 draws on the systemic framework of Bronfenbrenner’s ecological theory* and the Center for Substance Abuse Treatment’s Comprehensive Substance Abuse Treatment Model for Women and Children (see Appendix B in TIP 51 for more information on this model). It is based on clinical practice and research centered on women. It is not derived primarily by comparing women with men. The knowledge, models, and strategies presented in the complete TIP are grounded in women’s experiences and their unique biopsychosocial and cultural needs.

For more information on the topics in these KAP Keys, readers are referred to TIP 51.

*Bronfenbrenner, U. (1989). Ecological systems theory. Annals of Child Development, 6, 187–249.

OTHER TIPS THAT ARE RELEVANT TO THESE KAP KEYS

TIP 25, Substance Abuse Treatment and Domestic Violence SMA 12-4076

TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders SMA 13-3992

TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery SMA 13-4353

TIP 56, Addressing the Specific Behavioral Health Needs of Men SMA 13-4736

GENDER-RESPONSIVE TREATMENT PRINCIPLES

- Acknowledge the importance and role of socioeconomic issues and differences among women.

- Promote cultural competence specific to women.

- Recognize the role and significance of relationships in women’s lives.

- Address women’s unique health concerns.

- Endorse a developmental perspective.

- Attend to the relevance and influence of various caregiver roles that women often assume throughout the course of their lives.

- Recognize that ascribed roles and gender expectations across cultures affect societal attitudes toward women who abuse substances.

- Adopt a trauma-informed perspective.

- Use a strengths-based model for women’s treatment.

- Incorporate an integrated, multidisciplinary approach to women’s treatment.

- Maintain a gender-responsive treatment environment across settings.

- Support the development of gender competence specific to women’s issues.

WOMEN’S BIOPSYCHOSOCIAL UNIQUENESS

Biological and Psychological

1. Women have different physical responses to substances.

2. Women with substance use disorders have greater susceptibility to as well as earlier onset of serious medical problems and disorders.

3. Women who abuse substances have specific health issues and medical needs related to gynecology.

4. Pregnancy is a significant concern when treating women who have substance use disorders.

5. Women who abuse substances are more likely than other women to have co-occurring disorders, including mental and substance use disorders.

6. Women who have substance use disorders are more likely to have been physically or sexually traumatized and subjected to interpersonal violence.

Social

1. Significant relationships and family histories play integral roles in the initiation, patterns of use, and continuation of substance abuse for women.

2. Significant relationships and adult family members may substantially influence women’s behavior associated with treatment seeking, support for recovery, and relapse.

3. For women, pregnancy, parenting, and child care influence alcohol and drug consumption and increase the likelihood of entering and completing substance abuse treatment.

4. Women are more likely to encounter obstacles across the continuum of care as a result of caregiver roles, gender expectations, and socioeconomic hardships.

5. Despite the unique challenges they face, women are more likely to engage in help-seeking behavior and to attend treatment after admission.

6. Women report more interpersonal stressful life events.

7. Women often take different paths in accessing treatment for substance use disorders.

8. Women have unique client–counselor expectations and relational needs related to treatment.

9. Women are uniquely discriminated against with regard to substance abuse.

Developmental

1. Women have unique life-course issues and events (e.g., prenancy; menopause; often having the primary responsibilities of providing care to parents, parents-in-law, and dependent children).

RISK FACTORS OF INITIATION

Risk Factors Associated With Initiation of Substance Use and the Development of Substance Use Disorders Among Women

1. Women are affected by familial substance abuse as much as men; the prevalence of substance use disorders is 10 to 50 times higher among women with a parent who abuses substances than among women whose parents do not.

2. Women who are dependent on substances are more likely to have a history of overresponsibility in their family of origin.

3. Adverse childhood experiences significantly increase the likelihood of early initiation of use among women.

4. Women who are dependent on illicit drugs are more likely than men who are dependent on illicit drugs to have partners who use illicit drugs.

5. Premorbid personality risk factors lay the foundation for substance abuse among women (e.g., anxiety, difficulty in regulating affect and behavior, low self-worth).

6. A history of traumatic events including, but not limited to, sexual and physical assaults, childhood sexual and physical abuse, and domestic violence are significantly associated with initiation of substance use and the development of substance use disorders among women.

7. Women are more likely than men to have co-occurring mental and substance use disorders.

8. For women, anxiety disorders and major depression are associated with substance use, abuse, and dependence and are the most common co-occurring diagnoses. Other common mental disorders in women with substance use disorders are eating disorders and posttraumatic stress disorder (PTSD), a common result of violence and trauma.

SIX PATTERNS ASSOCIATED WITH WOMEN’S SUBSTANCE USE

1. Narrowing of the Gender Gap: In comparing men’s and women’s rates of alcohol use across 10 years, there is evidence of the gender gap narrowing.

2. People of Introduction and Relationship Status: Women are more likely to be introduced to and initiate alcohol and drug use through significant relationships.

3. Drug Injection and Relationships: Even though women are less likely to inject drugs than men, research suggests that women move from other modes of use to injecting at a faster rate than men.

4. Earlier Patterns Foreshadow Later Problems: Drinking low to moderate levels of alcohol in early adulthood is a predictor of later heavy drinking and alcohol-related substance use disorders among women. In addition to amount of alcohol intake, frequency of use is associated with increased risk of alcohol dependence.

5. Responsibilities and Pattern of Use: Women are more likely to alter their pattern of use temporarily in response to caregiver responsibilities.

6. Progression and Consequences of Use: Women experience an effect called telescoping, whereby they progress faster than men from initial use to alcohol and drug-related consequences even when using a similar or lesser amount of substances.

SCREENING

The most important things to screen for when working with women include:

- Substance abuse.

- Pregnancy.

- Immediate risks related to serious intoxication or withdrawal.

- Immediate risks for self-harm, suicide, and violence.

- Past and present history of violence and trauma, including sexual victimization and interpersonal violence.

- Past and present mental disorders, including PTSD and other anxiety disorders, mood disorders, and eating disorders.

- Health conditions, including, but not limited to, HIV/AIDS, hepatitis, tuberculosis, and sexually transmitted diseases (STDs).

SCREENING AND ASSESSMENT CONSIDERATIONS

- How screenings and assessments are conducted is as important as the information gathered. Screening and assessment are often the initial contact between a woman and the treatment system. They can either help build a trusting relationship or create a barrier to engaging in further services.

- Self-administered tools may be more likely to elicit honest answers; this is especially true regarding questions related to drug and alcohol use.

- Face-to-face screening interviews have not always been successful in detecting alcohol and drug use in women, especially if the counselor is uncomfortable with the questions.

- Routinely, substance abuse screening and assessment tools are less likely to identify women as having substance abuse problems than they are to identify men as having substance abuse problems.

- Screening and assessment instruments should be examined to determine if they were developed using female populations. If not, counselors need to explore whether or not there are other instruments that may be more suitable to address specific evaluation needs.

MENTAL HEALTH SCREENING FOR WOMEN

- Women need to be routinely screened for depressive, eating, and anxiety disorders, including PTSD.

- Women tend to report higher levels of anxiety and somatic symptoms associated with depression than men.

- Gathering explicit details about traumatic experiences may make women uncomfortable. This information does not need to be addressed early on in treatment.

- For some women, drugs have had a secondary effect and purpose (i.e., weight management). Be aware that weight gain during recovery can be a concern and a relapse risk factor for women; clinical and health psychoeducation and intervention surrounding body image, weight management, nutrition, and healthy lifestyle habits are essential ingredients in treatment for women.

- Bulimia nervosa is the most common eating disorder among women in substance abuse treatment. Counselors should become knowledgeable about the specific behavioral patterns associated with this disorder (e.g., compensatory and excessive exercise for overeating, routine pattern of leaving after meals, persistent smell of vomit on the woman’s breath or in a particular bathroom, taking extra food from the dining room, hoarding food).

- Be aware that women with bulimia nervosa are usually of normal weight.

SERVICES AND PROGRAMMATIC CONSIDERATIONS: A CHECKLIST

As with any treatment, the focus should be on the whole person. The following services and programmatic considerations are recommended by the TIP 51 consensus panel and reinforced by some State standards. These services may be warranted across the continuum of care, beginning with early intervention and extending to continuing care services.

Medical Services

- Gynecological care

- Family planning

- Prenatal care

- Pediatric care

- HIV/AIDS services

- Treatment for infectious diseases, including viral hepatitis

- Nicotine cessation treatment services

Health Promotion

- Nutritional counseling

- Educational services about reproductive health

- Wellness programs

- Education on sleep and dental hygiene

- Education about STDs and other infectious diseases (e.g., viral hepatitis, HIV/AIDS)

- Preventive healthcare education

Psychoeducation

- Sexuality education

- Assertiveness skills training

- Education on the effects of alcohol and drugs on prenatal and child development

- Prenatal education

Gender-Specific Needs

- Women-only programming (e.g., is the client likely to benefit more from a same-sex versus mixed-gender program due to trauma history, pattern of withdrawal among men, and other issues?)

- Services (including health services) specific to lesbian and bisexual women

Cultural and Language Needs

- Culturally appropriate programming

- Availability of interpreter services or treatment services in native language

Life Skills

- Money management and budgeting

- Stress reduction and coping skills training

Family and Child-Related Services

- Childcare services, including homework assistance in conjunction with outpatient services

- Children’s programming, including nurseries and preschool programs

- Family treatment services, including psychoeducation surrounding addiction and its impact on family functioning

- Couples counseling and relationship enrichment recovery groups

- Parent/child services, including age-appropriate programs for children and education for mothers about child safety; parenting education; nutrition; children’s substance abuse prevention curriculum; and children’s mental health needs, including recreational activities, school, and other related activities

Comprehensive Case Management

- Linkages to welfare system, employment opportunities, and housing

- Integration of stipulations from child welfare, Temporary Assistance for Needy Families, probation and parole, and other systems

- Intensive case management, including case management for children

- Transportation services

- Domestic violence services, including referral to safe houses

- Legal services

- Assistance in establishing financial arrangements or accessing funding for treatment services

- Assistance in obtaining high school equivalency credentials or further education, career counseling, and vocational training, including job readiness training to prepare women to leave the program and support themselves and their families

- Assistance in locating appropriate housing in preparation for discharge, including referral to transitional living or supervised housing

Mental Health Services

- Trauma-informed and trauma-specific services

- Eating disorder and nutrition services

- Services for other co-occurring disorders, including access to psychological and pharmacological treatments for mood and anxiety disorders

- Children’s mental health services

Disability Services

- Resources for learning disability assessments

- Accommodations for specific disabilities

- Services to accommodate illiteracy

Staff and Program Development Considerations

- Strong female role models in terms of both leadership and personal recovery

- Peer support

- Adequate staffing to meet added program demands for women and children

- Staff training and gender competence in working with women

- Staff training and program development centered on incorporating cultural and ethnic influences on parenting styles, attitudes toward discipline, children’s diet, level of parenting supervision, and adherence to medical treatment

- Flexible scheduling and staff coordination

- Adequate time for parent–child bonding and interactions in daily program schedule

- Administrative commitment to addressing the unique needs of women in treatment

- Staff training and administrative policies to support the integration of treatment services with clients on methadone maintenance

- Culturally appropriate programming that matches specific socialization and cultural practices for women

WOMEN-SPECIFIC PREDICTORS OF RELAPSE AND REACTIONS TO RELAPSE

Improving Transitions and Retention Rates for Women

Programs that maintain relationships or connections with women throughout their treatment and during step-down transitions from more intensive to less intensive treatment appear paramount in maintaining high levels of retention. Using supportive telephone calls to maintain contact with women between residential and outpatient addiction treatment is an effective strategy.

Women-Specific Predictors of Relapse and Reactions to Relapse

Relapse Risks Unique to Women

Women are more likely to relapse if they report or display:

- Interpersonal problems and conflicts.

- Low self-worth that is connected to intimate relationships.

- Severe untreated childhood trauma.

- Strong negative affect.

- Symptoms of depression.

- Greater difficulty in severing ties with other people who use.

- Failure to establish a new network of friends.

- Lack of relapse prevention coping skills.

Women’s Reactions to Relapse

During or after relapse, women are more likely than men to:

- Relapse in the company of others and particularly with female friends or a significant other.

- Escalate use after initial relapse, which is associated with greater severity of childhood trauma.

- Seek help.

- Experience slightly shorter relapse episodes.

- Report depressed mood.

CLINICAL KNOWLEDGE CHECKLIST FOR TREATING WOMEN WHO HAVE SUBSTANCE USE DISORDERS

- Be culturally informed and knowledgeable.

- Be trauma informed, and have awareness of the prevalence and impact of trauma on women’s lives.

- Understand the psychological growth and development of women.

- Recognize the centrality of relationships for women, particularly parenting and social roles and the socialization process.

- Be knowledgeable about the physiology of women as it relates to substance use and abuse.

- Understand the etiology of substance abuse in women.

- Be familiar with the co-occurring disorders that commonly occur in women.

- Understand the context of abuse and patterns of use for women.

- Identify the consequences of substance abuse (e.g., legal, general health, infectious diseases, influence of and effects on family and relationships, psychological).

- Understand the treatment and recovery experience of women.

- Identify family dynamics (e.g., family of origin, parenting, child development).

- Be familiar with women’s processes of recovery.

- Be knowledgeable about the following:

- Relapse prevention for women.

- Relapse triggers, such as family reunification.

- Recovery resources.

- Maintaining a safe place for the client.

- Understand issues related to sexuality, sexual orientation, and gender identity for women and their relationship to substance abuse.

- Know confidentiality rules and guidelines.

Ordering Information

TIP 51 Substance Abuse Treatment: Addressing the Specific Needs of Women

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Do not reproduce or distribute this publication for a fee without specific, written authorization from the Office of Communications, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services.

HHS Publication No. (SMA) 14-4844
First Printed 2014
Reprinted 2014