Recognizing and Supporting the Unique Needs of Women in Treatment and Recovery: What Behavioral Health Providers Can Do

Alcohol-related Deaths Among Women in the U.S.

A recent report released January 8, 2020 by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) reported that the number of death certificates mentioning alcohol more than doubled from 35,914 in 1999 to 72,558 in 2017, and rates of death involving alcohol have increased more for women (85%) than men (35%). There is evidence that even one drink per day of alcohol contributes to the risk of breast cancer and women seem to have higher risks than men for cardiovascular diseases, liver disease, alcohol use disorder and other health risks of alcohol than men (White, et al., 2020). Authors of the report are also concerned that alcohol-related deaths among women are “vastly underreported” since the study only looked at death certificates mentioning alcohol and that the mention of alcohol involvement often does not appear on death certificates.

Unique Needs of Women in Treatment and Recovery

Women have unique biological, psychological, social and developmental factors that must be addressed within treatment and recovery settings. Women also have unique risk factors regarding initiation and development of substance use disorders (SUDs). For information, tips, and tools for treatment of substance use disorder in women read the CASAT OnDemand blog post on Treatment Improvement Protocol (TIP) 51, Substance Abuse Treatment: Addressing The Specific Needs Of Women,  a chapter by chapter review (SAMHSA, 2009). Other ways of meeting the unique needs of women in treatment and recovery are covered in resources mentioned in the CASAT OnDemand blog post Cultural and Linguistic Competence: A Resource Review for Behavioral Health Providers.

A specific list of the reasons for treatment and recovery needs specific to women broken down by category is provided in the KAP Key for TIP 51 and are as follows:

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 childcare 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
5. expectations, and socioeconomic hardships.
6. Despite the unique challenges they face, women are more likely to engage in help-seeking behavior and to attend treatment after admission.
7. Women report more interpersonal stressful life events.
8. Women often take different paths in accessing treatment for substance use disorders.
9. Women have unique client–counselor expectations and relational needs related to treatment.
10. Women are uniquely discriminated against with regard to substance abuse.

Developmental

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

Risk Factors for SUDs Specific to Women

Risk factors associated with initiation of substance use and the development of SUDs among women include the following (SAMHSA, 2009):

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 over responsibility 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.

Barriers to Engaging in Treatment

According to information provided in Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51, “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.” Specific barriers to equitable treatment and recovery services fall into the following categories:

• Intrapersonal: Individual factors including health problems, psychological issues, cognitive functioning, motivational status, treatment readiness, etc.
• Interpersonal: Relational issues including significant relationships, family dynamics, support systems, etc.
• Sociocultural: Social factors including cultural differences; the role of stigma, bias, and racism; societal attitudes; disparity in health services; attitudes of healthcare providers toward women; and others.
• Structural: Program characteristics including treatment policies and procedures, program design, and treatment restrictions.
• Systemic: Larger systems including Federal, State, and local agencies that generate public policies and laws; businesses including health insurance companies; and environmental factors such as the economy, drug trafficking patterns, etc.

What Can Behavioral Health Providers Do?

Behavioral health providers already gather information of specific risk factors linked to initiation of use, people of introduction, and other client characteristics that can help them to identify barriers that clients experience or may experience, and that they can address in treatment and recovery. To further ensure gender responsive treatment and recovery services for women, providers can follow the following core principles for gender responsive treatment for women:

• 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.

Training and Professional Development from CASAT Learning

For Training and professional development specific to the treatment and recovery needs of women, there are a variety of resources available. CASAT Learning offers several training opportunities on this topic.

A self-paced, online course is available for 1.5 CEUs entitled: Supporting Women in Recovery: A Trauma -Informed Approach to Substance Use Treatment

The presenter, Gabriela Zapata-Alma, LCSW, CADC, is the Director of Policy and Practice for Domestic Violence and Substance Use at the National Center on Domestic Violence, Trauma & Mental Health, as well as faculty at The University of Chicago, where they coordinate the Advanced Alcohol and Other Drug Counselor certification program.

Workshop Description: “Women with substance use concerns often experience unique barriers to treatment and specialized needs that go unmet within traditional treatment settings, including: experiences of trauma and intimate partner violence, co-occurring health conditions, increased economic instability, family and parenting needs, medication assisted treatment during pregnancy, and gender-specific risk factors. This trans-inclusive workshop defines what it means for services to be comprehensive, trauma-informed, and gender responsive for women; identifies issues to consider when working with women, including women who are pregnant or parenting; and discusses how to apply gender-responsive care in the delivery of behavioral health treatment and recovery services in order to improve outcomes for women and their families.”

To register visit the CASAT Learning Website.

Another training opportunity from CASAT Learning is for behavioral health providers who are Responding to Intimate Partner Violence in Treatment and Recovery Services:

“It has long been recognized that abuse by an intimate partner can have traumatic mental health and substance use effects. Research has found high rates of both past and current intimate partner violence (IPV) among people in substance use disorder and mental health treatment settings. A growing body of evidence has found that abuse is often targeted at a partner’s substance use and mental health in deliberate attempts to undermine and control survivors and keep them from achieving their recovery goals. These forms of abuse, known as substance use coercion and mental health coercion, not only jeopardize the well-being of survivors and their children, but also compromise the effectiveness of mental health and substance use disorder treatment. All of this is further complicated by escalating rates and severity of IPV during the COVID-19 pandemic. This session will provide treatment and recovery specialists with a conceptual framework for understanding survivors’ patterns of substance use within the context of IPV, will prepare practitioners to recognize and respond to substance use coercion and mental health coercion within treatment and recovery services, and will equip practitioners with strategies and resources tobetter serve survivors and their children.”

To register visit the CASAT Learning Website.

Additional Training and Resources

Numerous products and resources can be found on the National Addiction Technology Transfer Center (ATTC) Network website, including toolkits, print media, multimedia, websites, curriculum packages, eNewsletters, blogs, interactive resources, mobile apps, and presentation slides. To learn more about the ATTC Network Mission & Vision, a slideshow is available on the ATTC Network website.

The CASAT OnDemand Resources & Downloads page has resources relevant for women’s treatment and recovery and new materials and links are uploaded on a regular basis.

References

Aaron White, PhD, I-Jen P. Castle, PhD, Ralph Hingson, ScD, Patricia Powell, PhD. Using death certificates to explore changes in alcohol-related mortality in the United States, 1999–2017 Alcoholism: Clinical and Experimental Research. Published online January 8, 2020.

Substance Abuse and Mental Health Services Administration. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS Publication No. (SMA) 13-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

Substance Abuse and Mental Health Services Administration. KAP Key based on Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series, No. 51. HHS Publication No. (SMA) 13-4426. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2009.

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