Gender Responsive Substance Use Treatment for Women Christine Ullstrup, LCSW, CSAC, ICS VP Clinical Services Meta House, Milwaukee WI
Overview Relational-Cultural Model The Substance Use Experience The Impact of Trauma What is Gender Responsive Treatment
Residential
Outpatient
Transitional Housing
We need to understand that Women and Men are different and have distinct needs The Development of the Relational Cultural Theory 1970 Broverman- study determined that clinicians implicitly associated psychological maturity and health with stereotypical male characteristics AND identified normal female traits as being associated with psychological immaturity and dysfunction 1976 Jean Baker Miller at the Stone Center at Wellesley College Identified women s strong drive for affiliation as being valuable and a strength upon with to build
Relational Cultural Theory Disconnections occurs when the environment of relationships is unresponsive Healthy connections are growth enhancing. Relationships really matter for women
Relational Cultural Theory For women the sense of self is organized around making and maintain affiliations with other Emotional growth and development for women occurs through connections to others These connections are necessary for psychological growth and for health Poor emotional health comes from disconnections abusive relationships (relationships that are not authentic, empathic or mutual)
Substance Use for Women v Men Women tend to use substances to cope with the pain of non-mutual relationships Drug use is intended to help develop more intimate relationships Women Medicate feelings and manage symptoms in response to emotional pain, depression, stress and trauma Men it is part of general pattern of anti-social behavior, thrill seeking, and peer pressure
Women are more likely to: have a psychiatric co-occurring diagnosis for a mood disorder depression or anxiety (65%) have strong negative self-identity have extreme stress and lack of coping skills have more social stigma be caring for children and other family members be carrying on multiple roles and juggling their lives without the support of a significant other
Women have different physiological responses drugs and alcohol Women obtain higher blood alcohol levels more absorption and related disability from alcohol than men Cocaine produces higher peak plasma levels in women making them less sensitive to the effect Normal female hormone fluctuations greatly influence the response to drugs For some illicit drugs women proceed more rapidly to dependence then men
Context of Use Women and Men Men Introduced to drugs and alcohol by male peers Buy own drugs from people they do not know well Use IV drug alone and inject drugs themselves The problems and consequences of substance use for men tend to be societal and destructive to others Control access to and distribution of drugs Women Introduced to drugs and alcohol by boyfriend, spouse or partner Have drugs supplied to them by male partner or male physician Use drugs with male partner who has prepared drugs for use and dispense or inject them for the woman The problems and consequences of substance for women tend to be personal and self destructive Depend on partner to provide drugs
In US Women have a distinct patterns to their use of substances Tend to either abstain, use mildly or use substances in a problematic way Problematic substance use in women is almost always in response to a particular life stress
Problems and Consequences for Women related to Health More likely to develop liver disease with a: more serious form more rapid onset shorter drinking history lower level of alcohol Death comes more quickly Greater risk for African and Native Americans
Consequences Family & Relationships Partners and family members are much more likely to abandon the female substance user The children of the women are more likely to become involved in the child welfare system More likely to experience victimization in adulthood More likely to be victims of partner violence
Women and Legal Issues More likely to be involved with Child Welfare System When arrested have less information to exchange with law enforcements to lower time served More likely to be victimized while incarcerated
Men & Women in Treatment Men When they succeed tend to take credit When they fail they tend to blame others Describe relationship with therapist important If it feels utilitarian and aimed at problem solving In groups more competitive In groups looking for solutions Women When they succeed they talk about people behind them in journey and luck When they fail - tend to blame themselves Describe relationship with therapist important If based on trust and warmth needs to feel genuine and very concerned about judgment In groups more cooperative (accommodating) In groups looking for connection If in mixed groups this connection often turns sexually towards the men
Women and Re/lapses Women lapse less then men although they often have more risk factors Usually tied to negative mood state and/or interpersonal problems More vulnerable due to shifts in hormonal levels Women need a place they feel safe talking about all these things
Trauma In general population 36 to 51% of women report lifetime history of physical & sexual abuse For women with SUD 55 to 99% report lifetime history of physical & sexual abuse
Why Gender Matters Though women and men have much in common, sex and gender differences influence their lives and experiences Common difference's between men and women affect the treatment and recovery needs of women with SUDs
Lesbian, Bisexual and Transgender Women Are more likely to consume alcohol and in greater amounts. (Case et al., 2004; Cochran et al., 2001, 2004; Hughes & Wilsnack, 1997) Use alcohol, marijuana, prescription drugs, and tobacco more than heterosexual women and are likely to consume alcohol more frequently and in greater amounts. (Case et al., 2004; Cochran et al., 2004) Have higher rates of substance abuse and dependence compared with heterosexual women. (Bickelhaupt, 1995; Cochran et al., 2000; Diamant et al., 2000)
Women and the Military Women make up approximately 15 percent of the armed forces. (Office of the Deputy Assistant Secretary of Defense, 2013) Women who are in the military are at risk of additional trauma, including military sexual trauma (MST). Many also experience trauma prior to joining the military. Substance abuse among women veterans is high. Women with military experience often have higher than average work experience and education levels.
Why it is important to be Gender Responsive Gender-responsive services create an environment that reflects the understanding of the reality of women s lives and addresses women s issues. Gender-responsive services help improve the effectiveness of services for women and girls.
Addressing the Gender-specific Service needs What is it? Gender responsive is described as: of women with SUD Creating an environment through site selection, staff selection, program development, content, and material that reflects an understanding of the realities of women s lives and is responsive to the issues of the clients. (Covington, 2007)
Gender-responsive Principles The knowledge, models, and strategies of gender-responsive principles are grounded in five core components: 1. Addresses women s unique experiences 2. Is trauma informed 3. Uses relational approaches 4. Is comprehensive to address women s multiple needs 5. Provides a healing environment
Component 1 Person-centered and relevant to each woman s experiences Gender-responsive and culturally responsive; respectful Acknowledges that treatment needs of women are different and more complex than men Addresses those treatment needs of women
Component 2 Trauma Informed SAMHSA s four Rs of a trauma-informed approach: Realizes the widespread impact of trauma and understands potential paths for recovery Recognizes the signs and symptoms of trauma Responds by fully integrating knowledge about trauma into policies, procedures, and practices Resists re-traumatization
Component 3 Relational Overall Many women are relational and tend to prioritize relationships as a means of growth and development. Relational model = focus on connections Women recover in connection, not isolation. Relationships play a significant role in both the development and recovery from SUDs. Relationships or connections are central in women s lives as: Part of their identities Sources of self-esteem The context for decision-making and choices Support for day-to-day living and growth
Component 3 Relational Family/Partners Relational approaches to service: Are sensitive to the relationship/family history women bring into treatment both positive and negative. Take a family-focused perspective using a broad definition of family and encouraging a woman to define her family/support system. Are welcoming to children. Help a woman understand roles and dynamics, including examining her partner s influence on her substance use.
Component 4 Comprehensive overall A comprehensive approach treats the whole woman and her comprehensive needs, including the following: Physical and mental health Overall wellness Survival needs Child and family Employment/education Criminal justice requirements Recovery supports
Component 4 Comprehensive Mental Health Women are more likely than men to have co-occurring mental and substance use disorders. (SAMHSA, 2005a) Women are more likely than men to have multiple comorbidity, which is three or more psychiatric diagnoses in addition to an SUD. (Zilberman et al., 2003) Effective services include comprehensive assessment and either onsite integrated care or established relationships for referral to mental health services.
Component 4 Comprehensive Physical Health Women with SUDs are at an increased risk of many health-related consequences. Women with SUDs often do not receive routine exams or needed health services. Comprehensive services include physical health assessments and onsite, or referral to, primary health care to address health issues.
Component 4 Comprehensive Family Women often have care-taking responsibilities for children, siblings, or elders. Children and family members may need services. Women often need parenting education, family strengthening, relationship counseling, and other family resources.
Provide services in a safe and comfortable environment Offer women-only groups and activities Component 5 Healing Environment Be open to feedback from participants Offer staff training and development
Women Centered Curricula Stephanie Covington Beyond Anger and Violence: a Program for Women Beyond Violence: A prevention Program for Criminal Justice-Involved Women Healing Trauma Exploring Trauma Helping Women Recover * you can explore her website for more
Women Centered Curricula Lisa Najavits Seeking Safety: A Treatment Manual for PTSD and Substance Abuse Recovery from Trauma, Addiction, or Both: Strategies for Finding Your Best Self A Woman s Addiction Workbook : Your Guide to In-Depth Healing 8 Keys to Trauma and Addiction Recovery
Summary Following gender-responsive principles and creating treatment environments that are both gender responsive and trauma informed will improve the experience of women with SUDs and lead to more effective services and recovery. Providing staff members with ongoing gender-specific and trauma-informed training and supervision will help ensure they all understand and can implement the core competencies noted in this module.
Facility Does your building feel safe and welcoming upon entrance? (what makes it safe, what might get in the way of safety?) Is the building easy to locate? Can it be accessed by public transit? Would a woman feel safe walking to or from your location with children? How do staff greet people who enter the reception area? Are the receptionists friendly? Is privacy available while talking to the receptionists? Does the waiting room feel safe and welcoming? (If yes, what makes it feel this way?) Is the waiting room comfortable? Can people sit? what does it sound like? Is there enough space between chairs? Is there a space for children to play or books/toys for them? Consider the experience as people walk inside. How are the offices? Group rooms? Overall facility? Are there ways that the environment is not welcoming or reduces a sense of safety for women? Are there some low-cost ways that you could make the environment more welcoming or safe?
Questions?