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Substance Abuse in Women: Clinical


Substance Abuse in Women: Clinical & Program Issues in the Community & Criminal Justice System Joan E. Zweben, Ph.D. Executive Director, EBCRP Clinical Professor of ... – PowerPoint PPT presentation

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Title: Substance Abuse in Women: Clinical

Substance Abuse in Women Clinical Program
Issues in the Community Criminal Justice System
  • Joan E. Zweben, Ph.D.
  • Executive Director, EBCRP
  • Clinical Professor of Psychiatry UCSF
  • ADP Conference October 13, 2010

  • 1970s first focus on gender disparities and
    womens issues
  • 90 of articles on gender published since 1990
    (Back, 2007)
  • 24 of substance abuse treatment facilities now
    provide specific programs or groups for women
  • (SAMHSA Facility Locator, 2007)

  • Prevalence of AOD disorders greater in men
  • Gender differential is higher for alcohol use
    disorders than drug use disorders
  • Prescription drug abuse and tobacco use in women
    only slightly less than men
  • For adolescents, the gap disappeared for alcohol,
    marijuana, cocaine and cigarettes

Minority Women and Alcohol Use
  • Drinking patterns influenced by
  • Religious activity
  • Genetic risk/protective factors
  • Level of acculturation to U.S. society
  • Historical, social and policy variables
  • (Collins McNair, 2002)

African American Women
  • Relatively high rates of abstention and low rates
    of heavy drinking among black women
  • Most over 40 did not consume alcohol
  • High participation in religious activities is a
    protective factor
  • (Collins McNair, 2002)

Asian American Women
  • Regardless of national origin, Asian American
    women have low rates of alcohol use and problem
  • Facial flushing response (occurring in 47-85 of
    Asians) is a protective factor
  • ALDH2-2 leads to perspiration, headaches,
    palpitations, nausea, tachycardia, and facial
  • Women report being more embarrassed than the men
  • Acculturation promotes increased drinking (e.g.,
    Japanese women)
  • (Collins McNair, 2002)

Native American Women
  • Availability of distilled spirits, its use
    outside specific cultural contexts, and modeling
    of heavy drinking by Europeans promoted binge
  • Tribal policies about drinking on the reservation
    are influential
  • High density of alcohol outlets in poor urban
  • Marketing of high alcohol content to Native
    Americans (Crazy Horse)
  • (Collins McNair, 2002)

  • Often did not drink, or drank small amounts in
    country of origin, but drinking patterns changed
    more dramatically than male counterparts
  • More research on Mexicans than Puerto Ricans or
  • After three generations, the drinking patterns of
    Mexican-American women are similar to other U.S.
  • (Collins McNair, 2002)

Older Women
  • Risk Factors
  • Longer life expectancies
  • Many losses
  • Live alone longer
  • Less likely to be financially independent
  • More susceptible to the effects of alcohol,
    particularly as they age
  • (Blow Barry, 2002)

Women in the Military
  • Women Veterans of Iraq Afghanistan
  • Review of records from Defense Medical
    Surveillance System indicated 17.4 received
    specific mental health diagnosis (overall rate,
  • 22 suffered from military sexual trauma,
    compared with 1 of men
  • (Susan Storti, NIDA Conference 2010)

Diagnostic Screening Issues
  • Women tend to seek treatment at mental health or
    primary care clinics
  • Both substance abuse and psychiatric conditions
    are often undetected
  • A single question about last episode of drinking
    can increase detection in primary care settings

Psychosocial Influences
  • Women more likely to have role models in nuclear
    families and/or spouses who are alcohol dependent
  • Weight control is important factor in tobacco
  • Relapse factors women more likely to cite
    interpersonal and other stressors men more
    likely to report external temptations

Medical Comorbidity
Biological Factors
  • Alcohol
  • Enzymes lower concentration of gastric
  • Higher fat/water ratio
  • Drugs
  • Hormone fluctuation during menstrual cycle
  • Gender differential in brain activation by stress
    and drug cues

Course of Illness
  • Increased vulnerability to adverse consequences
  • Telescoped course
  • Females advance more rapidly from use to regular
    use to first treatment episode
  • Severity generally equivalent to males despite
    fewer years and smaller quantities
  • Biological and psychosocial factors contribute to
    this outcome

Biological Factors
  • Alcohol differences in bioavailability
  • Enzymes lower concentration of gastric alcohol
    dehydrogenase (enzyme that degrades alcohol in
    the stomach)
  • Higher fat/water ratio (smaller volume of total
    body water so alcohol is more concentrated)

Breast Cancer
  • Moderate consumption elevates the risk (linear
    relationship between drinks and risk)
  • Occurs with all forms of alcohol
  • Does alcohol raise estrogen levels?
  • Metabolism of ethanol leads to the generation of
    acetaldehyde (AA) and free radicals. Acetaldehyde
    is carcinogenic (e.g., GI tract cancers)
  • Research areas specific drinking patterns, body
    mass index, dietary factors, family hx breast
    cancer, use of HRT, tumor hormone receptor
    status, immune function status
  • (10th Special Report to
    Congress Alcohol Health)

Psychiatric Comorbidity
Psychiatric Comorbidity
  • More likely in girls and women
  • Anxiety disorders (especially PTSD)
  • Depression
  • Eating disorders
  • Borderline personality disorders
  • Onset more likely to precede the onset of the
    substance use disorder
  • More likely in boys and men
  • Antisocial personality disorder
  • Conduct disorder

  • Convergence of trauma, PTSD and SUDS particularly
  • Early life stress, esp sexual abuse, more common
    in girls
  • Higher risk of alcohol dependence in women
    exposed to violence in adulthood
  • AOD use elevates risk for victimization
  • Uncontrollable stress increases drug
    self-administration in animals

Treatment Issues
Gender Differences in Treatment I
  • Women less likely to enter treatment
  • Sociocultural stigma, lack of partner/family
  • Socioeconomic child care, pregnancy, fears about
    child custody
  • Children are a big motivator to enter treatment
    or avoid it
  • Availability of appropriate treatment for
    co-occurring disorders is important

Gender Differences II
  • Few differences in retention, outcome, or relapse
  • If there are differences, women have better
  • Show greater improvement in other domains (e.g.,
    medical), shorter relapse episodes, more likely
    to seek help following a relapse

Gender Differences III
  • No strong evidence that gender-specific
    treatments are more effective, but there are few
    controlled trials
  • Residential programs that include children have
    better retention rates
  • Gender is not a specific predictor overall, but
    specific treatment elements improve outcomes for
    various subgroups
  • (Greenfield et al 1006)

Key Services to Improve Outcomes for Women
  • Child care
  • Prenatal care
  • Supplemental services addressing women-focused
    topics (e.g., trauma history)
  • Mental health services psychotropic meds
  • Transportation
  • Women-only groups
  • Employment services (jobs with decent pay)

Documented Improvements
  • Length of stay treatment completion
  • Decreased use of substances
  • Reduced mental health symptoms
  • Improved birth outcomes
  • Employment
  • Self-reported health status
  • HIV risk reduction
  • (Ashley et al 2003 Greenfield et
    al, 2007)

Readiness to Change Start Where the Woman Is
  • Domestic violence
  • Emotional problems
  • Substance abuse
  • HIV risk behaviors
  • Rapidly address what the woman indicates as high
    priority, and build a bridge to the other
  • (Brown et al, 2000)

Treatment Culture
  • Female role models at all levels of hierarchy
  • Positive male role models available
  • Forthright feedback but not aggressive
  • Monitor the intensity, especially for women who
    are more disturbed
  • Sexual boundary issues

Women-Only vs Mixed Gender Programs
  • Most consistent difference provision of services
    related to pregnancy and parenting
  • Parenting classes
  • Childrens activities
  • Pediatric, prenatal, post-partum services
  • Also more likely to assist with housing,
    transportation, job training, practical skills
  • (Grella et al, 1999)

Women-Only Groups
  • Foster greater interaction, emotional and
    behavioral expression
  • More variability in interpersonal style
  • Women in mixed groups engage in a more
    restrictive type of behavior men show wider
    variability (and interrupt women more).
  • (Hodgkins et al, 1997)

Relapse Issues for Women
  • Untreated psychiatric disorders, especially
    depression and trauma sequelae (PTSD)
  • Intimate partner
  • Underestimating the stress of reunification or
    ongoing parenting
  • Isolation poor social support
  • High level of burden

Seeking SafetyEarly Treatment Stabilization
  • 25 sessions, group or individual format
  • Safety is the priority of this first stage tx
  • Treatment of PTSD and substance abuse are
    integrated, not separate
  • Restore ideals that have been lost
  • Denial, lying, false self to honesty
  • Irresponsibility, impulsivity to commitment

Seeking Safety (2)
  • Four areas of focus
  • Cognitive
  • Behavioral
  • Interpersonal
  • Case management
  • Grounding exercise to detach from emotional pain
  • Attention to therapist processes balance praise
    and accountability notice therapists reactions

Seeking Safety (3)Goals
  • Achieve abstinence from substances
  • Eliminate self-harm
  • Acquire trustworthy relationships
  • Gain control over overwhelming symptoms
  • Attain healthy self-care
  • Remove self from dangerous situations (e.g.,
    domestic abuse, unsafe sex)
  • (Najavits, 2002

Women in the Criminal Justice System
  • Women are the fastest growing segment of the CJ
    population in all components since 1990s
  • Majority are nonviolent offenders
  • Most are minority, esp black and Hispanic
  • Variety of medical problems, more severe than age
    matched counterparts

Children at High Risk
  • Most women offenders have children
  • Disproportionately linked to race
  • Family disorganization, financial hardship,
    exposure to abuse and trauma often predated
  • No reliable research to support the view that
    these children are more likely to be incarcerated
    as adults
  • Did have problematic school behavior and deviant
    peer influences

Family Contact
  • Family contact in prison is associated with lower
    rates of post release recidivism
  • Telephone restrictions significantly reduce
    family contact
  • Budget cuts have led to reduced visiting hours

Criminogenic Factors Targeted to Improve Outcomes
  • Antisocial values
  • Criminal peers
  • Dysfunctional families
  • Substance abuse
  • Criminal personality
  • Low self-control
  • Substance abuse treatment alone is not enough.

Treatment In Custody
  • S. Covington manuals specific for this population
  • Gender-responsive treatment showed better
    outcomes (Messina et al, JSAT 2010)
  • Community based continuing care improves outcomes
  • Safety issues women victimized by other inmates
    and custodial staff

Treatment in the Community
  • Re-entry courts as an alternative sanction
  • Second Chance, PROTOTYPES, intensive tx that
    addresses COD
  • Complex problems of women parolees often not

Barriers to Effective Treatment in the Community
  • Laws and regulations are designed for high risk
  • Difficult to get approval for educational
    activities outside the program
  • Computer access restricted
  • Exploitative requirements for telephone access
  • Prohibitions/restrictions on medications

  • Select appropriate evidence-based practices
    avoid pick from this list approach
  • Beware of rigid adherence to a model or EBP at
    the expense of individualized treatment planning
  • Carefully investigate whether appropriate
    services are available
  • Eliminate barriers to medication use for
    psychiatric or addictive disorders
  • Acknowledge that tx requires building capacity
    for independence avoid excess restrictions not
    required for public safety

  • Covington, S. (1999). Helping Women Recover. San
    Francisco Jossey Bass.
  • Covington, S. (2000). Helping women to recover
    Creating gender-specific treatment for
    substance-abusing women and girls in correctional
    settings. In M. McMahon (Ed.), Assessment to
    Assistance Programs for Women in Community
    Corrections (pp. 171-233). Latham, Maryland
    American Correctional Association.
  • Messina, N., Grella, C. E., Cartier, J.,
    Torres, S. (2010). A Randomized Experimental
    Study of Gender-Responsive Substance Abuse
    Treatment for Women in Prison. Journal of
    Substance Abuse Treatment, 38(2), 97-107.
  • Zweben, J. E. (2011). Women's Treatment in
    Criminal Justice Settings. In C. Leukefeld, J.
    Gregrich T. P. Gullotta (Eds.), Handbook on
    Evidence-Based Substance Abuse Treatment Practice
    in Criminal Justice Settings. New York, NY

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