Your Choice for Recovery and Change…. 3800 Packard Road Suite 210 Ann Arbor, MI 48108

1. Your Choice for Recovery and Change…. 3800 Packard Road Suite 210 Ann Arbor, MI 48108

2. Women and Addiction Gender Responsiveness in Services for Substance Use Disorders Julie Cushman LMSW, ACSW, CAADC

3. Objectives • 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.

4. Need ForGender Responsive Services • Course of illness different than men/Telescope Effect • Females 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 disorders • Parental Stress • Trauma History • Specific Barriers

5. Barriers to Treatment

6. Barriers to Treatment • 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.

7. Systemic Barriers • Lack of decision-making power • Limited awareness of gender differences • Lack of knowledge of women with substance use problems and their treatment needs • Lack of appropriate gender-responsive and low-cost, evidence-based treatment models • Differences in the organization and funding of health services • Need for a comprehensive array of services

8. Structural Barriers • Childcare • Transportation • Services for pregnant women • Location & cost of treatment programs • Rigid program schedules • Waiting lists

9. Structural Barriers Continued • Denial of admission to women using psychoactive medication • Service coordination • Lack of identification, referral, & intervention in primary care and other sectors • Lack of diagnosis or misdiagnosis • Information on treatment options • Physical safety

10. Social, Cultural, & Personal Barriers • Fear of leaving children/losing custody of children • Lack of support from family or partners • Family history of substance abuse • Involvement with substance abusing partners • Substance use perceived as solution, not problem • Lack of information of services (Straussner, 2004) • Lack of confidence in the effectiveness of treatment • Stigma, shame, & guilt • Low self-esteem • Trauma History

11. Barriers to Intervention Social Service Agencies Physician Supervisor Attitudes Reluctance to address Not able to assess, diagnosis Gaps in referral network Punitive Family Friends Teacher Enforcement agencies

12. Gender Responsiveness in Outreach, Screening & Assessment

13. Outreach • Go where women can be found • Focus on reducing stigma • Encourage women to seek treatment by acknowledging their struggles as well as their efforts at coping in their environment • “Love women into treatment”

14. Screening and Assessment • 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.

15. Screening and Assessment • 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.)

16. Gender Responsiveness in Treatment

17. History of Substance Abuse Field • 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

19. Evolution of Treatment 1960s Generic Treatment – male as client 1970s Gender Differences – biological, parenting, psychosocial 1980s Gender Specific – separate facilities, childcare or child live-in, transportation, special groups or services 1990s-2000s Gender Responsive – trauma informed, relational theory, strengths-based

20. Gender Responsive Treatment Definition Creating 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)

21. Guiding Principles • 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

22. Guiding Principles (continued) • 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

23. Trauma Informed Services • Take the trauma into account • Avoid triggering trauma reactions and/or traumatizing the individual • Adjust 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)

24. Effective Treatment • Adequate treatment period is crucial • Individual & group counseling (women only) • Co-occurring disorders treated in an integrated way • Medication as needed • Uses 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

25. Factors That Influence Retention for Women In Treatment • 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

26. Factors That Influence Retention for Women In Treatment (Continued) • 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

27. Outcomes 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)

28. ACTIVITY“PUTTING IT ALL TOGETHER” 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.

31. An “Ideal” System for AOD Prevention and Treatment for Women Women Informed Health Promotion Universal Prevention All Women Women with Risk Factors Women-Focused Selected & Indicated Prevention Women Developing AOD problems Better & Earlier Outreach & Case Finding, Accurate Screening and Assessment, Brief Treatment, Engagement More Women- Informed, Friendly & Centered Services & Programs Better Outcomes Less Relapse Fewer Women with AOD Problems & their Consequences Assessment Fewer Barriers to Treatment Women in Need Of Treatment

32. Questions/Comments

33. References • 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

34. References • 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: • 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