Treatment Improvement Protocol (TIP) 51, Substance Abuse Treatment: Addressing the Specific Needs of Women

Treatment Improvement Protocol (TIP) 51, Substance Abuse Treatment: Addressing the Specific Needs of Women, assists providers in offering treatment to women living with substance use disorders. It reviews gender-specific research and best practices, such as common patterns of initial use and specific treatment issues and strategies.


Treatment Improvement Protocols (TIPs) are developed by the Center for Substance Abuse Treatment (CSAT), of the Substance Abuse and Mental Health Services Administration (SAMHSA) at the U.S. Department of Health and Human Services (HHS), and are the results of efforts to develop topic-specific best-practice guidelines for behavioral health providers. TIP manuals represent the consensus of a panel of clinical, research, and administrative experts who draw upon their experience and knowledge to “convey ‘front-line’ information quickly but responsibly” and provide citations for research that supports approaches. Tip manuals are updated periodically to reflect new research in the field. Research is ongoing in any field and updates may not necessarily keep pace with research. That is the case for TIP 51, originally published in 2009, with updates in 2010, 2012, and 2013. The most recent citations are from 2009. TIP 51 was developed primarily for substance abuse treatment clinicians and counselors who work with women. This document can also be useful for administrators, educators, researchers, policymakers, consumers, and healthcare and social service personnel who work with women with substance use disorders.

Overview of Chapters

Chapter 1: Creating the Context

From the first chapter, it is important to note that the consensus panel recognized the importance of approaching the goal of effective substance abuse treatment for women in a way that acknowledges the multiple contexts of their lives. The contexts named include a woman’s social and economic environment; her relationships with family, extended family, and support systems; and the impact of both gender and culture, but goes on to enumerate additional systems which impact women’s lives and the bidirectional nature of those influences as well as the influence of chronology, or life events. The basis for this approach includes two early systemic models: Bronfenbrenner’s ecological model and the Interrelated Elements in CSAT’s Comprehensive Substance Abuse Treatment Model for Women and Their Children (Bronfenbrenner, 1989; USDHHS CSAT, 1999). The adoption of this conceptual framework led to the following gender responsive treatment principles for gender responsive and effective substance abuse treatment for women:

  • 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.
  • Utilize a strengths-based model for women’s treatment.
  • Incorporate an integrated and multidisciplinary approach to women’s treatment.
  • Maintain a gender-responsive treatment environment across settings.
  • Support the development of gender-competency specific to women’s issues.

The first chapter goes on to focus on the evidence and provides citations suggesting that women are biologically and psychologically unique in at least six ways that treatment providers need to be aware of and attentive to across the continuum of care:

  1. Women have different physical responses to substances. Smaller quantities of alcohol cause intoxication for women due to higher blood alcohol concentrations, more body fat, and lower volume of body fluid. Women also develop substance use disorders and associated health problems more quickly than men.
  2. Women with substance use disorder have greater susceptibility to as well as earlier onset of serious medical problems and disorders. A few specific issues are that alcohol significantly increases the risk of breast and other cancers, osteoporosis, peripheral neuropathy, and cognitive impairments for women. Women develop cirrhosis, heart muscle and nerve damage with fewer years of heavy drinking than men.
  3. Women who abuse substances have specific health issues and medical needs related to gynecology. Heave alcohol consumption is linked to infertility and irregular menstrual cycles and women over 40 with substance use disorders are less likely to receive routine screenings for early detection and prevention.
  4. In treating women of childbearing age who have a substance use disorder, pregnancy is a significant concern. Women who use alcohol and other substances sometimes mistake signs of early pregnancy with symptoms of use or withdrawal and tend to seek care later in their pregnancies. Detoxification and use of medications to treat substance use disorders can cause serious complications.
  5. Women who abuse substances are more likely than other women to have co-occurring disorders. Symptoms of depression, agoraphobia, panic attacks, posttraumatic stress and eating disorders are just some of the co-occurring disorders more likely to precede or occur in women with 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. There is a higher prevalence of sexual or physical abuse, domestic violence, and childhood trauma in women in general and in particularly in women with substance use disorders.

In establishing principles for treatment of women with substance use disorders and highlighting six issues for providers to be aware of and address, Chapter 1 establishes the context of women’s lives and sets the stage for introducing the women themselves and their diverse cultures, ethnicities, and sexual orientations. TIP 51 is inclusive of women of all ages, all stages of life, pregnant, parenting, or childless, from all socioeconomic and historical backgrounds. Behavioral health providers should be able to find the women sitting before them within the pages of TIP 51.

Chapter 2: Patterns of Use: From Initiation to Treatment

Chapter two presents a variety of factors that impact substance abuse initiation by women, including relationships, genetics, history of trauma or abuse, familial substance abuse, and mental health disorders. Six patterns of use among women are identified by research:

  1. Narrowing of the Gender Gap – particularly among younger adult females, the traditional gender gap in rates of use is shrinking.
  2. People of Introduction and Relationship Status – Women have a higher rate of introduction to and initiation of use through relationships with significant others than men.
  3. Drug Injection and Relationships – Although the rate of injection of drugs during first use is lower in women, they are quicker to begin injection drug use after first using and are more likely to inject with and borrow needles and equipment from a significant other.
  4. Earlier Patterns Reflect Later Problems – Consumption of low to moderate amounts of alcohol as a young adult is a predictor of heavy drinking and alcohol-related disorders among women in later life. Frequency of use is also associated with alcohol dependence for women.
  5. Responsibilities and Pattern of Use – Women are likely to temporarily reduce or suspend alcohol or drug use due to caregiving responsibilities.
  6. Progression and Consequences of Use – Women can experience “telescoping”, progressing from initial use to alcohol and drug-related consequences, more quickly than men, and are biologically more vulnerable to negative consequences of use than men.

Within this chapter, unique characteristics of treatment admissions and some specific advice for clinicians and administrators is given regarding how to handle their unique concerns in ways that will motivate them and support their recovery.

Chapter 3: Physiological Effects of Alcohol, Drugs, and Tobacco on Women

This chapter covers physiologic effects of alcohol and other drugs on both women and their fetuses if they are pregnant and the physical effects and health consequences. The impacts of ethnicity and culture; sexual orientation; socioeconomic status and homelessness; developmental issues and aging; and co-occurring disorders are covered, providing specific physical consequences to different organ systems. One excellent tool is a sample lecture outline for educating clients on the physiological effects of alcohol.

Chapter 4: Screening and Assessment

While this chapter is not comprehensive and does not make recommendations for specific screening tools that are appropriate for women, it does provide examples and descriptions of some that are commonly used for women. More importantly, the chapter makes a clear distinction between screening and assessment. While not offering any specific protocol for providing feedback, referral, and follow-up during or after screening, the importance of those steps as part of a process is emphasized since screening alone does not constitute and intervention. Screening often leads to assessment and whenever possible instruments should be those established for applicable population groups and sensitive to the cultural values, language, literacy level, and other elements specific to each client. The process of screening and assessment should also include instruments for relevant physical and mental disorders and for other issues such as risk for self-harm, risk of harm to others, history of childhood trauma, interpersonal violence, and eating disorders. The Advice to Clinicians section contains General Guidelines of Assessment for Women that will be very useful for behavioral health providers. A list of TIP manuals that provide relevant information for providing treatment for women is also provided.

Chapter 5: Treatment Engagement, Placement, and Planning

While barriers to treatment are common for women, this chapter devotes considerable time to promoting strategies for overcoming or compensating for a variety of obstacles, including intrapersonal, interpersonal, sociocultural, structural, and systems obstacles. Several strategies for helping women overcome barriers to treatment are provided in the Clinical Tools and Activities section of this chapter. Due to the many factors and considerations that may impact initiating and maintaining treatment and recovery, a list of Services Needed in Women’s Substance Abuse Treatment is also provided with accompanying levels of care so that treatment and recovery can be supported by case management.

Chapter 6: Substance Abuse Among Specific Population Groups and Setting

In addition to the health issues that are specific to women or that occur disproportionately in women, women who are members of certain population groups or are in specific settings require consideration of those factors and a recognition not only of how negative impacts can be addressed, but also of the elements that can uniquely support resiliency, successful treatment, and recovery maintenance. This chapter contains specific advice to clinicians and administrators for substance abuse treatment in the clinical setting, program development, and staff training for the following populations and settings:

  • Hispanic/Latina Women
  • African American Women
  • Asian- and Pacific-American Women
  • American Indian and Alaska-Native Women
  • Lesbian and Bisexual Women
  • Older Women
  • Women in Rural Areas
  • Additional resources are provided for other special populations and setting, such as women with physical and cognitive disabilities, women in the criminal justice system, and women who are homeless.

Chapter 7: Substance Abuse Treatment for Women

Women have gender-specific factors which research shows influence retention rates during substance abuse treatment. Some of the factors that are covered in this chapter are sociodemographics, criminal justice and child protective services referral and involvement, pregnancy, treatment environment and theoretical approach, type of treatment services, therapeutic alliance and counselor characteristics, and client’s confidence in the process. Chapter seven examines each of these factors along with treatment issues and needs specific to women, such as relationships and the need for connection, the influence of the family, the importance of partner relationships, a woman’s sexuality, pregnancy, parenting, trauma, interpersonal violence history of sexual or physical abuse, and co-occurring disorders, and identifies specific research, resources, and advice for each need. The Notes to Clinicians outline important issues to remember and a few tips for helping to address them. One example is the tips for PTSD Symptoms containing symptoms that may be experienced, what the client may be feeling at that time, and clinical suggestions for addressing the symptoms and feelings.

Chapter 8: Recovery Management and Administrative Considerations

This chapter gives vital information about the importance of continuity during transitions in levels of treatment, awareness of interpersonal problems, symptoms of depressions, stress reactions to early childhood trauma, and low self-worth and the equal importance of addressing those issues because of the risk the pose for relapse. Key to being aware of and resolving these issues is the advice to treatment clinicians and administrators to include training of all staff within the treatment and recovery communities.

Takeaways from TIP 51

Tip 51 is a foundational document for any behavioral health provider of substance use disorder treatment and recovery services for women. While the manual has not been recently updated with current research, it provides an empirically based and concise compilation of unique issues to be aware of that must be addressed in successfully treating women for substance use disorder. Knowing what the issues are is the only way to insure being aware of them during the treatment process and of being able to resolve them. The tips, tools, theoretical approaches, and advice from researchers and clinicians are an excellent knowledge base. There are many additional resources which have been developed since TIP 51 was last revised that provide the means for behavioral health providers to expand their knowledge, awareness, and skills in the treatment of substance use disorders in women. Many of the documents and websites can be found in the Resources and Downloads section of CASAT OnDemand.


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

McCaul, M. E., Roach, D., Hasin, D. S., Weisner, C., Chang, G., & Sinha, R. (2019). Alcohol and women: A brief overview. Alcoholism: Clinical and Experimental Research, 43(5), 774-779. doi:10.1111/acer.13985

U.S. Department of Health and Human Services. Center for Substance Abuse Treatment comprehensive treatment model for alcohol and other drug abusing women and their children. Blending Perspectives and Building Common Ground: A Report to Congress on Substance Abuse and Child Protection: Appendix B. Washington, D.C.: U.S. Government Printing Office, 1999.

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