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Gender Responsiveness in Services for Substance Use Disorders

Julie Cushman LMSW, ACSW, CAADC

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Identify at least three barriers that impact a women’s ability to obtain services for substance use disorders.

Identify at least five ways the professional can assist in overcoming barriers to services.

Increase knowledge of a least three ways professionals can create gender responsive programming.

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Course of illness different than men/Telescope EffectFemales advance more rapidly & escalate into

addiction faster.Metabolic differences- experience negative

physiological consequences sooner with less use.More medical, psychiatric and social consequences.

Treatment needs different & more complex than men. Co-existing psychiatric disordersParental StressTrauma HistorySpecific Barriers

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Systemic - impede the development of services that respond to women’s needs.

Structural - policies and practices at the service or program level that make it difficult for women to access substance use treatment.

Social, Cultural, & Personal - related to the social and cultural norms that exist, which include women’s roles and behavior that is considered appropriate; women’s lack of empowerment in many societies; and societal and community norms and attitudes about women who have substance use problems.

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Lack of decision-making powerLimited awareness of gender differencesLack of knowledge of women with substance

use problems and their treatment needsLack of appropriate gender-responsive and

low-cost, evidence-based treatment modelsDifferences in the organization and funding

of health servicesNeed for a comprehensive array of services

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Childcare TransportationServices for pregnant womenLocation & cost of treatment programsRigid program schedulesWaiting lists

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Denial of admission to women using psychoactive medication

Service coordinationLack of identification, referral, &

intervention in primary care and other sectors• Lack of diagnosis or misdiagnosis

Information on treatment optionsPhysical safety

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Fear of leaving children/losing custody of childrenLack of support from family or partners

• Family history of substance abuse• Involvement with substance abusing partners

Substance use perceived as solution, not problemLack of information of services (Straussner, 2004) Lack of confidence in the effectiveness of treatmentStigma, shame, & guiltLow self-esteemTrauma History

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Physician

Family

Teacher

Enforcement agencies

Friends

Supervisor

Social Service Agencies

Attitudes

Reluctance to address

Not able to assess, diagnosis

Gaps in referral network

Punitive

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Go where women can be foundFocus on reducing stigmaEncourage women to seek treatment by

acknowledging their struggles as well as their efforts at coping in their environment

“Love women into treatment”

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Addiction is not an isolated disease • Women have a variety of issues and needs such as economic independence, gender-role expectations, low self worth, etc.

Interactions of biological, psychological, cognitive, social development and environmental variables are all considered

Identify benefits of harm reduction services.

Current instruments may not take into account gender differences.

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Women are heterogeneous and diverse• Require a comprehensive assessment to identify and

meet individual needs that is made from a biopsychosocial and sociocultural perspective

• External factors: Cultural, Religion, Family, Peers• Social factors: Situation, social relations, social

structures

Misuse, Abuse & Dependency - Result of external

forces that act as social stressors (unemployment,

poverty, violence, etc.)

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Developed primarily by men concerned with types of problems experienced more frequently by men• Basic assumptions and program

models/services tend to be male responsive

Despite 30 years of research and advocacy, AOD services remain more accessible and appropriate for men in most locations

Concerns about women are often primarily related to pregnancy

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1960sGeneric Treatment – male as client1970sGender Differences – biological, parenting,

psychosocial1980sGender Specific – separate facilities,

childcare or child live-in, transportation, special groups or services

1990s-2000sGender Responsive – trauma informed,

relational theory, strengths-based19

DefinitionCreating an environment through site

selection, staff selection, program development, content, and material that reflects an understanding of the realities of the lives of women and girls and that

addresses and responds to their strengths and challenges.

Source: Bloom, Owen & Covington (2004)

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Acknowledge that gender makes a difference

Create an environment based on safety, respect and dignity

Develop policies, practices and programs that are relational and promote healthy connections to children, family, significant others and the community

Attend to the relevance and influence of various caregiver roles women often assume

Source: Bloom, Owen, and Covington, 2003; TIP 51: Addressing the Specific Needs of Women

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Address substance use, trauma and mental health issues through comprehensive, integrated and culturally relevant services

Validation of behaviors that have allowed survival to reduce shame and guilt

Provide women with opportunities to improve their socioeconomic status

Recognize societal attitudes towards women who abuse substances; stigma and stereotypes

Establish a system of comprehensive and collaborative, community services

Source: Bloom, Owen, and Covington, 2003; TIP 51: Addressing the Specific Needs of Women 22

Take the trauma into accountAvoid triggering trauma reactions and/or

traumatizing the individualAdjust the behavior of workers and the

organization to support the individual’s coping capacity

Allow survivors to manage their trauma symptoms successfully to promote access, retention and benefit from services

Source: Fallot and Harris (2001)

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Adequate treatment period is crucialIndividual & group counseling (women only)Co-occurring disorders treated in an

integrated wayMedication as neededUses components of Feminist Theory, Self-

in-Relation Theory, the Empowerment Model and Strengths Perspective

Recovery is a long term process & frequently requires multiple treatment episodes

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Supportive therapy - warmth, empathy, connection during crisis

Confrontation based on awareness, understanding and trust

Collaborative approach with client that is active, optimistic and builds on client’s strengths and ability to solve problems

Treatment shares with client what has helped others in the past and client is the expert on what will work for her

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Type of Treatment Services• Gender specific groups• Various services all in one location• Initially receive greater intensive care• Individual counseling• On-site childcare and transportation

Therapeutic Alliance & Counselor Characteristics• Trust & Warmth vs. Problem-Solving

approach• Female staff 26

Women in gender-specialized programs:

Use more services throughout treatment than women in traditional coed program

Have higher rates of abstinence

More likely to see themselves as doing well in treatment

Twice as likely to complete gender specialized program

Source: Nelson-Zupko, et al (1996), Messina et al (2012)27

Identify the types of barriers for entering and engaging in substance use treatment (systemic, structural, and cultural, social and personal barriers) in the following vignette and ways to overcome these barriers.

Lisa is a 28-year-old, single/never married, Hispanic, mother of three children (ages 2, 4, 7, and 10). She has a history of alcohol and opioid dependence and became pregnant with her youngest son while using Vicodin. She is currently taking Suboxone that she is getting from an ex-boyfriend. She is residing with an acquaintance in a rural area, has unreliable transportation. She has no close friendships. She has a family history of addiction. She called a substance use treatment agency in her community but was unable to schedule an appointment due to not having childcare for her youngest two children.

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All Women

Women withRisk Factors

Women Developing AOD problems

Women in NeedOf Treatment

Women Informed Health PromotionUniversal Prevention

Women-Focused Selected & Indicated Prevention

Better & Earlier Outreach & Case Finding, Accurate Screening and Assessment, Brief Treatment, Engagement

AssessmentFewer Barriers to Treatment

More Women-Informed, Friendly& CenteredServices & Programs

Better OutcomesLess Relapse

Fewer Women with AOD Problems & their Consequences

An “Ideal” System for AOD Prevention and Treatment for Women

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Questions/Comments

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Binswanger, I. A., Merrill, J. O., Krueger, P. M., White, M. C., Booth, R. E., & Elmore, J. G. (2010). Gender differences in chronic medical, psychiatric, and substance-dependence disorders among jail inmates. American Journal of Public Health, 100, 476-482.

Bloom, B., Owen B., & Covington, S. (2003). Genders-responsive Strategies: Research, Practice, and Guiding Principles for Women Offenders. Washington, DC: National Institute of Corrections.

Bloom, B., Owen, B., & Covington, S. (2004). Women offenders and gendered effects of public policy. Review of Policy Research, 21, 31-48.

Center for Disease Control : http//www.cdc.gov Fallot, R., and Harris, M. (2001) A trauma-informed approach to screening and

assessment New Directions for Mental Health Services 89, 23–31. Grella, C. (2008). From generic to gender-responsive treatment: Changes in social

policies, treatment services, and outcomes of women in substance abuse treatment. Journal of Psychoactive Drugs, 40, 327-343.

http//www.elementsbehaviorhealth.com/addiction-treatment/women-have-special-needs-in-substacne-abuse-treatment/

http//www.ncadi.samhsa.gov Messina, N., Calhoun, S., and Warda, U. (2012) Gender-Responsive Drug Court

Treatment: A Randomized Controlled Trial. Criminal Justice and Behavior 39(12):1539-1558

National Eating Disorder Association: http://www.nationaleatingdisorders.org National Institute on Drug Abuse: http://www.drugabuse.gov 33

Nelson-Zlupko, L., Dore, M. M., Kauffman, E., & Kaltenbach, K. (1996). Women in recovery: Their perceptions of treatment effectiveness. Journal of Substance Abuse Treatment, 13, 51-59.

Sherman, Carl.,(June 2006) NIDA NOTES 20(6). Straussner, S.L. (Ed.). (2004). Clinical work with substance-abusing clients. 2nd

ed. New York: The Guilford Press. Substance Abuse and Mental Health Services Administration:

http://www.samhsa.gov U.S. Department of Health and Human Services: TIP 51-Substacne Abuse

Treatment: Addressing the Specific Needs of Women. http://www.samhsa.gov Women Under the Influence. (2009, May 28). New York City, NY: Columbia

University. Retrieved July 24, 2009 from, http://www.casacolumbia.org/absolutenm/templates/Publications.aspx?articlesid=421&zoneid=52

pictures/graphs obtained from Google Images

Resources:Resources: Stephanie Covington, Helping Women Recover: allows women to examine their

relationships and support systems Lisa Najavits, Seeking Safety and Woman’s Addiction Workbook: assists women

in understanding healthy and unhealthy boundaries, strategies for identifying persons who can be positive (supportive) or negative (destructive) influences on their recovery, tactics for enhancing or minimizing those influences and activities to enhance support from other women

Monique Cohen, Counseling Addicted Women: A Practical Guide : provides client and staff activities surrounding relationship issues 34