Helping Substance-Abusing Women of Vulnerable Populations: Effective Treatment Principles and Strategies 9780231511919

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Helping Substance-Abusing Women of Vulnerable Populations

Helping Substance-Abusing Women of Vulnerable Populations

Effective Treatment Principles and Strategies

An-Pyng Sun

COLUMBIA UNIVERSITY PRESS

NEW YORK

Columbia University Press Publishers Since  New York Chichester, West Sussex Copyright ©  Columbia University Press All rights reserved Library of Congress Cataloging-in-Publication Data Sun, An-Pyng. Helping substance-abusing women of vulnerable populations : effective treatment principles and strategies / An-Pyng Sun. p. cm. Includes bibliographical references and index. ISBN ---- (hard cover : alk. paper)—ISBN ---- (e-book) . Women—Substance abuse. . Marginality, Social. I. Title. HV.W.S .—dc

 

o Columbia University Press books are printed on permanent and durable acid-free paper. This book is printed on paper with recycled content. Printed in the United States of America c           References to Internet Web sites (URLs) were accurate at the time of writing. Neither the author nor Columbia University Press is responsible for URLs that may have expired or changed since the manuscript was prepared.

To my Higher Power, my God; my father, Lei Sun; my mother, Kwei-In Chang; my husband, Dr. Jong-Shang Liu; and my two beloved daughters, Tracy Liu and Margaret Liu

Contents

Preface Acknowledgments PART ONE

ix xv

Helping Substance-Abusing Women in General Chapter  . Chapter  . Chapter  . Chapter  .

Introduction: History, Epidemiology, and Consequences Etiologies and Risk Factors Factors in Successful Treatment Programs for Women Treatment Methods

3 35 58 72

PART TWO Helping the Six Specific Vulnerable Populations

Chapter . Chapter  . Chapter  . Chapter  . Chapter  . Chapter  .

Pregnant Women Adolescent Girls Older Women Homeless Women Street Prostitutes Lesbians

101 134 177 209 243 264

Appendixes Appendix A . Screening Tools Appendix B . Relapse Among Substance-Abusing Women Appendix C . Turning the Child Welfare System’s Involvement from Crisis into Opportunity

299

References Index

349 399

313 335

Preface

H

aving been a direct-practice practitioner working with substanceabusing clients, I found that a practitioner can greatly benefit from a book that is easy to comprehend and that presents in one volume relevant, up-to-date research from professional journals and sources about effective practice strategies for helping specific client populations. Most practitioners are busy with clients. It would be impractical to expect them to patiently search the many professional databases to locate pertinent research findings. In addition, many practitioners and policymakers have complained that research articles often are filled with jargon, equations, and complicated methodologies that they can’t understand (Wilcox et al. ). Nonetheless, most practitioners welcome comprehensible ideas and knowledge based on credible studies that address effective or “best” (or “better”) practice strategies for helping clients. Program administrators, policymakers, and students engaged in efforts to help specific client populations also experience this dilemma. I was previously a counselor / social worker working with substanceabusing clients and their families in New York City. I later moved to academia and have taught courses in research methods and substance abuse and conducted research studies in the area of substance abuse. Having been both a practitioner and a researcher for the past fifteen years, I here provide for practitioners (generalists and AOD—alcohol and other drugs—specialists), students, policymakers, and program administrators (social service or AOD treatment) a comprehensive resource that includes practical instructions regarding effective practice with substance-abusing women of vulnerable populations. The information in this volume is based on currently available empirical studies of () the characteristics and nature of AOD problems among women of the identified vulnerable populations, () theories and risk factors

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related to the women’s AOD problems, and () effective treatment guidelines and strategies for helping them. I have chosen substance-abusing women instead of substance-abusing men or the general population because not many books have focused on this group. Most address the general population and often center on men. As I discuss in chapters  and , it is well established that the experiences and treatment needs of substanceabusing women are different from those of substance-abusing men. Although there are a few books available that target substance-abusing women (for example, those by Shulamith Lala Ashenberg Straussner and Stephanie Brown [] and Monique Cohen []), and although they do make great contributions in informing practitioners, policymakers, and students, there is room for more books with this focus. The major difference between this book and those of Straussner and Cohen is that I use empirical research findings.

An Emphasis on Evidence-Based Practice In this book I link research with practice by emphasizing evidence-based practice and synthesizing empirical study findings, offering options for empirically based effective treatment guidelines and strategies. I searched major professional databases, including PubMed, PsycINFO, Sociological Abstracts, Social Work Abstracts, and ERIC, to locate relevant empirical studies. Because of the wide range of issues and themes involved, it is not feasible to present detailed discussions for all of them contained in each chapter. Interested readers are encouraged to refer to the relevant original studies (cited in the text and listed in the references section) for further study. Roberts, Yeager, and Regehr (: ) stated, citing Solomon, that evidencebased practice () bases “practice decisions on empirically based evidence as to the interventions or intervention strategies that are likely to produce the desired outcomes” and () evaluates “the implementation of these interventions to ensure that they are being implemented as intended and that the intended outcomes are achieved, with no unintended negative consequences.” This book focuses mainly on the first component of evidence-based practice, in that it provides treatment guidelines and strategies based on empirical research. I encourage readers who adopt these guidelines and strategies also to implement the second component of evidence-based practice: to assess their treatment outcomes in order to ascertain whether the intended outcomes have been achieved.

The Components and Structure of the Book The book has three major components—part , part , and three appendixes— with part  being the core of it. Part  and the appendixes are included because they supplement part  and enable readers to achieve a more basic understanding of

Preface

xi

women’s substance abuse problems and treatment. For students or generalist practitioners in the fields of social work, psychology, or criminal justice who have had relatively less AOD-related training (despite frequent encounters with substanceabusing clients), all three components are recommended. For specialists who have been working in AOD treatment programs and who are already familiar with the basic AOD treatment methods but wish to learn more about substance-abusing women in the six specific vulnerable populations discussed here, an emphasis on part  will be useful. Part , with four chapters, serves as a foundation for an understanding of the needs of substance-abusing women overall and effective treatment for them. After readers gain basic knowledge in part , they move to part , which presents specific treatment guidelines and strategies for working with each client population. Chapter  introduces the historical background of AOD problems and treatment for women in the United States, explains the biological and psychosocial consequences of AOD misuse and abuse among women, and presents the epidemiology of women’s AOD use / abuse / dependence. Chapter  discusses gender-specific etiologies and risk factors related to the occurrence of AOD-use disorders. Chapter  presents five “program factors” that contribute to successful AOD treatment retention and outcomes for women, and chapter  presents the seven basic AOD treatment methods and approaches. Each of the six chapters of part  addresses effective treatment guidelines and strategies for working with substance-abusing women of one of the six identified vulnerable populations. Chapters , , and  focus on three developmentally vulnerable populations: substance-abusing pregnant women, substance-abusing adolescent girls, and substance-abusing older women, respectively. Chapters  and  target two socially vulnerable populations: substance-abusing homeless women and street-walking prostitutes. Chapter  addresses substance-abusing lesbians, whose AOD problems may often be related to both their developmental (e.g., “coming-out”) and social (e.g., homophobia and heterosexism) vulnerabilities. The appendixes provide further useful information. Appendix A contains relevant AOD screening tools. Appendix B is an empirical qualitative study of relapse among substance-abusing women. Appendix C is an empirical qualitative study of substance-abusing mothers in the child welfare system. Appendixes B and C offer readers a close-up of the world in which substance-abusing women live. If the chapters in parts  and  are analogous to forests (inferences are based on a review of multiple empirical studies, mostly quantitative in nature), appendixes B and C are like individual trees, or close-ups (also empirical studies, but qualitative in nature). The “forest” provides a big picture of the statistics and characteristics, trends, theories, themes, issues, and treatment guidelines to help readers understand women’s substance abuse. The “trees,” on the other hand, allow readers to have a more intimate and in-depth look at an individual woman’s daily life,

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experiences, and worldview, to hear her voice and her story, and to understand her struggles, dilemmas, despairs, strengths, and triumphs in a more direct and meaningful way.

Why These Six Groups of Women Were Chosen Substance-abusing, vulnerable female populations are not limited to the six groups selected for attention in this volume. Two factors governed the selection process. First, the women in the groups chosen may not seek AOD-specific treatment from AOD specialists and treatment programs. They are more likely to be involved with social service agencies, to be caught in the criminal justice system, or to seek nonAOD-specific treatment and services in community service centers. Therefore, generalists in the fields of social work, criminal justice, and psychology are likely to encounter them and to need guidance for their treatment. Second, these six populations of women experience developmental and social vulnerabilities, as well as being at high risk for AOD and the impact of AOD. The first three groups are affected by vulnerabilities related to their developmental processes. Pregnant women are considered vulnerable because of the involvement of a fetus who is dependent on his or her mother. In addition, although AOD use / abuse during pregnancy may occur among women in all walks of life, women with a socioeconomically vulnerable background may be more likely to engage in risky AOD-using (such as binge or heavy drinking) during pregnancy than other women (Burd et al. ; Grangé et al. ; Leonardson and Loudenburg ; see also chapter ). Although the threshold is unknown and it may be that any level of alcohol use can cause fetal alcohol syndrome, the literature suggests that binge drinking or heavy drinking is more damaging to the fetus than non-binge / non-heavy drinking. Teenage girls and older women are vulnerable because they are at points of transition in their development during which confusion, uncertainty, and dependence / independence issues often arise (for example, role identity issues among adolescent girls and loss issues among older women), and without sufficient internal resources to deal with these issues, they will need access to external support. The next two groups were selected because of the vulnerabilities inherent in their impoverished socioeconomic situations and their low social status and marginal position in society. Both homeless women and street-walking prostitutes exist outside mainstream society, which discriminates against them because of their work in a stigmatized occupation or the dysfunctional lifestyle that deprives them of even the basic need of shelter. And those in the sixth group, lesbians and other non-heterosexual women, are vulnerable developmentally as well as socially. The “coming-out” process may impose extreme pressure, negative feelings (e.g., guilt and shame), and struggle because of possible internalized heterosexism and homophobia. Society’s formal discrimination through the denial of lesbians’ legal

Preface

xiii

rights and its informal discrimination through rejection of their lifestyle further exacerbate the women’s vulnerabilities. Each of the six groups experiences high AOD risks and / or the potentially vast negative impacts, for both themselves and their offspring, that result from AOD abuse. Among pregnant women, prenatal and postnatal AOD exposure can have tremendously detrimental and irreversible effects upon fetuses and infants (such as fetal alcohol syndrome). Recent figures show that rates of AOD abuse / dependence among teenage girls are now equivalent to those of teenage boys (about . percent of females aged – and . percent of males aged – have “past year substance dependence or abuse”), while women of all other age groups remain behind their male counterparts (Substance Abuse and Mental Health Services Administration [SAMHSA] b:). Further, teenage girls and older women both experience developmental transition issues and struggle for independence, which may increase their risks for AOD use and abuse (Frissell ). Three other characteristics of older women are pertinent for this selection: () they are the largest consumer group for prescription drugs and over-the-counter drugs (Kaufman et al. ) and therefore are at higher risk of prescription drug misuse as well as alcohol-drug interaction effects; () the aging process may have weakened their physical condition, resulting in an amplified negative AOD impact (Blow, Oslin, and Barry ; Meier and Seitz ); and () baby boomers are now entering older adulthood, and they are known to have higher rates of AOD use than their counterparts in previous cohorts (Office of Applied Studies [OAS] ). Both street-walking prostitutes and homeless women have higher AOD rates than those of their non-prostitute and non-homeless counterparts. Research has shown that many, although not all, street-walking prostitutes drift to prostitution because of their AOD addiction problems (Cusick ; Dalla’s review ; Goldstein ). Homeless women are more likely than low-income housed women to be afflicted with AOD problems (Bassuk et al. ; Wenzel et al. ). Studies also show that lesbian and other non-heterosexual women have higher AOD rates, are at higher risk for AOD, and / or are more likely to experience negative social consequences of AOD than heterosexual women (Cochran et al. ; Drabble, Midanik, and Trocki ).

Acknowledgments

I

would like to thank all the women I have interviewed for my projects and all the clients and families I have worked with; they inspired me to write this book. I would also like to thank Dr. Patricia Alpert, Candy Kidd, Jani Martell, Robert Waterbury, Dr. Lesley Dickson, MD, Lauren Dockett, and the revieweres for their helpful comments. An-Pyng Sun University of Nevada Las Vegas Associate Professor of Social Work

Helping Substance-Abusing Women of Vulnerable Populations

PART O N E

Helping Substance-Abusing Women in General

Chapter 

Introduction History, Epidemiology, and Consequences

T

his chapter introduces three areas of basic knowledge: () the historical background of women’s substance abuse* and treatment in the United States, as this shows the origin of the current issues in women’s substance abuse and treatment and why such issues developed; () the epidemiology of women’s AOD use, abuse, and dependence, as revealed by today’s scientific data, as this portrays objectively the current scope and characteristics of the problem; and () the physiological and psychosocial impact and consequences of women’s AOD abuse and misuse, as this demonstrates the significance of women’s AOD problems and related implications.

The Historical Background Society’s Denial of Women’s AOD Problems Often practitioners in the AOD treatment field describe their not-soready-to-change clients as being “in denial.” The “denial” concept can actually adequately describe both American society’s traditional perception of women’s substance abuse and its response to such abuse. Joseph Califano, a former U.S. secretary of health, education, and welfare, said, “The magnitude of substance abuse among women and the full scope of its repercussions have been ‘masked by national denial’” (Blumenthal :). Brown () stated that women addicts have always existed but have simply not been acknowledged, and therefore *Note: Unless indicated otherwise, the term “substance abuse” in this book refers to an overall problematic use of substances and may include substance dependence, substance abuse, and substance misuse.

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Helping Substance-Abusing Women in General

“the ‘history’ of women and addiction has been an absence of history, with some exceptions” (). Two factors may explain society’s denial of women’s AOD problems. The first has to do with society’s gender role expectations and its suppression of women’s drinking. Such an attitude drove women to become “hidden” and “indirect” drinkers. As a consequence, the society was unaware of and even denied women’s drinking problems. The second factor is society’s biased definition of drug abuse problems, which views such abuse as a problem only if it results in crime and deviance and if it threatens society. This definition, which happens to match the profile of men’s drug abuse problems better than it does women’s, has created “benign neglect” with respect to women’s drug problems, as drug abuse among women is often more iatrogenic in nature and involves mainly petty crimes that are not threatening to society (Kandall ). Like women’s drinking problems, women’s drug problems have been deemphasized and even denied by society. These two attitudes have had significant implications for women’s AOD treatment. For example, even today—as in the past—women who seek AOD treatment are stigmatized. They are likely to feel shame and guilt; they are less likely to be identified, recruited, and / or referred for treatment; programs are less likely to provide women-specific services, thus adversely affecting retention and treatment outcomes; and AOD research is less likely to include women in samples, and thus less is known about the unique nature and characteristics of their AOD problems and treatment needs.

Gender Role Expectation and Its Suppression of Women’s Drinking During the nineteenth century society highly disapproved of drinking among women because such behavior did not conform to Victorian-era gender role expectations for women. (On the other hand, morphine and opium addiction among women was much more tolerated at the time, since such practices were viewed as more genteel and feminine than drinking [Straussner and Attia ].) Drinking during the nineteenth and very early twentieth centuries was heavily associated with the “saloon” culture and manliness—i.e., intemperance, aggression, autonomy, and dominance (Brown ; Rotskoff ). Rotskoff cited Jack London’s autobiographical novel, John Barleycorn, and many of his narratives to illustrate the drinking culture at the time: “Drink was the badge of manhood.” “Wherever life ran free and great, there men drank.” “Romance and adventure seemed always to go down the street locked arm in arm with John Barleycorn.” “Men talked with great voices, laughed great laughs, and there was an atmosphere of greatness” (Rotskoff :). All of these behaviors were incompatible with the Victorian morality prescribed for a female or “lady.” Women were supposed to be caretakers and homebodies, submissive and passive (Brown ). Women who violated the norm might be subject to severe punishment. Carter’s () literature review showed that alcoholic or chronically drunk women could lose their children, be sent to institutions, or be subjected to involuntary hysterectomies.

Introduction

5

The nineteenth-century woman who drank thus could not afford to be obvious about it; she had to hide her drinking (Brown ). Drinking in public or simply for the sake of drinking was viewed as sexually imprudent and maternally irresponsible. It was, however, acceptable to consume alcohol for culinary and medicinal purposes (Brown ; Carter ; Sandmaier ). Women were allowed to—and many did—take patent medications such as Lydia Pinkham’s Vegetable Compound, which was available over the counter, to deal with illnesses, pain, and aches. Some of the medications were as much as % alcohol (Brown ; Sandmaier ; Straussner and Attia ). The turn of the twentieth century marked the start of a new era in American women’s drinking culture as the nineteenth century’s homosocial-centered and saloon drinking gave way to a more gender-relaxed, heterosocial drinking practice. Increasingly, more women drank in public, and heterosocial drinking continued even in the face of Prohibition (–) (Rotskoff ). Many factors facilitated this change: () the revolution in urban recreation, which meant that many sites of leisure activities—such as movie palaces and dance halls—attracted both men and women of various ethnic groups and social classes (Rotskoff ), thus promoting a heterosocial climate, whether or not drinking was involved; () World War I (–), which recruited many men and resulted in many women entering the workforce and experiencing greater independence and autonomy; () the arrival of Sigmund Freud’s theories “about the appropriateness of sexual expression” and the belief that “alcohol helped this expression” (Straussner and Attia :); and () the creation of cocktail drinks and the cocktail party at home. Rotskoff noted that the poor quality of illicit alcohol (due to Prohibition) made cocktails popular. Cocktails also facilitated the domestication and feminization of drinking by adding sugar, fruit juice, soda water, and other garnishes that tamed the effects of liquor (Rotskoff ). However, American society’s attitude toward women’s drinking was ambivalent and unstable despite the emergence of the heterosocial drinking climate, which, in fact, “did not entirely efface the special status of drinking as a male activity” but rather “supplemented and sometimes competed with traditional male drinking bastions,” just as did the notion that “cocktails may have domesticated hard liquor, but hard liquor itself retained its gendered connotations as a masculine beverage” (Rotskoff :). Carter’s review () showed that women’s drinking during the s and s was still discouraged by the temperance movement, Prohibition, and the Great Depression and was still perceived as being associated with sexual misconduct and a lack of femininity. The Great Depression in the s sent women back home from the workforce, and many “new” or “liberated” women experienced reduced autonomy and retreated to traditional sex roles. Subsequently they stopped drinking or drank less openly (Carter ). Despite the repeal of Prohibition in , many people still regarded women’s drinking as unacceptable (Straussner and Attia ). A survey of women conducted by Ladies’ Home

6

Helping Substance-Abusing Women in General

Journal in  indicated that most women were against women’s drinking. That study showed that most women “would not teach their daughters to drink, although [they] did not object to alcohol use by their sons” and that more than half of them thought “it was wrong for women to drink at all” (Sandmaier :). Harsh treatment of alcoholic women in the nineteenth century was extended to the early- and even the mid-twentieth century. Straussner and Attia () cited White’s interviews of alcoholic women who were sent to state psychiatric settings during the s and s. White noted that medical charts confirmed that the women were discharged only after agreeing to be sterilized. World War II (–) created many new opportunities for women, and as they attained greater financial gains and independence, their drinking rate increased (Straussner and Attia ). Again, however, the end of the war forced many women to leave their employment. Some responded to such sex-biased expectations by consuming more alcohol (Hymowitz and Weissman, cited in Carter ). During the s and s, the women’s movement, combined with the expanded commercial advertising for alcohol, had a unique impact on attitudes toward women’s drinking (Carter ). A Gallup poll showed that the drinking rate among U.S. women rose % between  and  (from % to %), whereas among men it rose only % (from % to %) (Sandmaier ). Despite the fact that women’s drinking has become more common and is perceived as less “deviant” now, society has continued to use a double standard to judge and treat women’s drinking. Carter () gave examples: Women “were offered half-price drinks on ladies’ nights but risked having their personal or professional reputations viewed disparagingly if they drank to excess or could not contain themselves” (). A drunk man might be viewed as “the life of the party,” whereas a drunk woman was often considered “loose” (). A recovering man might be praised, whereas a recovering woman often might hardly escape blame for her previous lifestyle (van Wormer, cited in Carter ). In summary, gender role expectations have deeply affected how American society views and treats women’s drinking. Society suppressed women’s drinking during the nineteenth century and continued using a double standard to judge women’s drinking problems versus men’s in the twentieth century, and even in the early twenty-first century. These attitudes have fostered a climate of secrecy or hidden drinking among women and have stigmatized women who seek treatment. Women have thus been deprived of opportunities for treatment and recovery. Contemporary society has overall been able to deny the existence of women’s drinking problems. Carter’s review () showed that this denial has been manifested in various systems of twentieth-century society. For example, employers have been more likely to refer male employees who need alcoholism treatment for professional help but have ignored female employees who need such help. The criminal justice system has been more likely to charge men than women for alcohol-related

Introduction

7

traffic offenses or to refer men for treatment while referring women to relatives. Blume and Zilberman () stated that physicians and health care systems often fail to identify and treat their female alcoholic patients. Even the women’s families and the women themselves may deny the existence of women’s drinking problems and avoid treatment.

Society’s Biased Definition of “Drug Abuse Problem” and Its Denial of Women’s Drug Problems The second factor has been American society’s biased definitions and values for what constitutes a substance abuse problem, which of such problems deserve attention, and the type of action merited. Unlike other health or disease issues, AOD issues in the United States have traditionally been complicated by society’s moral judgment of substance abuse, in that substance abuse attracts attention only if it involves violence and crime and threatens society’s order and safety. In comparison to men’s drug problems, women’s drug problems are more likely to be iatrogenic in nature and involve fewer violent acts, which are therefore less threatening to society. This pattern may have subsequently led society to perceive the drug problem as mainly a men’s problem and, consequently, to focus drug treatment and prevention only on men. In fact, during the nineteenth century, the majority of the opium and morphine addicts in the United States were women (Kandall ). Although both men and women suffered pain, physicians at the time were more likely to prescribe medications for women because they thought men were more able to handle pain than women and that therefore men were less in need of medications than women. Opiates and morphine were commonly prescribed for women as a means of dealing with “female complaints,” such as menstruation pain and other physical discomforts related to gynecological problems or childbirth. They were also prescribed to help women with neurasthenia (“nervous weakness” such as insomnia, headache, deficient mental control, nervous dyspepsia, and so on). Women were believed to have a higher rate of these dysfunctions than men (Kandall ). Women’s addiction to opiates and morphine and the subsequent agonies they had to sustain were not unnoticed at the time, but American society tolerated and neglected women’s addiction largely because it was mainly iatrogenic (so women were actually victims and not “aggressive drug abusers”). Such behavior usually did not provoke crime or result in an obvious violation of the prescribed Victorian norm for the female gender role, and generally it created no threats to society (Kandall ). The landscape of drug abuse in the United States changed dramatically at the turn of the twentieth century, when the majority of the drug-addicted population was no longer composed of morphine- or opium-addicted middle- or high-socialstatus white women residing in rural areas. Instead, more urban men with diverse ethnic backgrounds and lower socioeconomic status became involved with drug

8

Helping Substance-Abusing Women in General

abuse and addiction (Kandall ). The demographics of cocaine users and abusers, as well as those of opium addicts, had also gradually changed from groups of professional and upper-middle-class males to groups of males of the lower socioeconomic or criminal classes. Since cocaine was expensive, many drug abusers turned to violence to acquire the drugs. Drug addiction, therefore, had begun to be linked to poverty and crime (Kandall ). Unlike the women who were involved with morphine and opium addiction in the nineteenth century, this new epidemic of drug abusers had a much more “deviant” sociodemographic background, and thus a sense of fear and urgency arose. Society was particularly worried about the possibility of sexual victimization of white women by drug-abusing, “crazy” minority men—a concern that eventually led to passage of the Harrison Anti-Narcotic Act in  (Kandall ). Courtwright, Joseph, and Des Jarlais stated that “the sinister transmogrification of narcotic addiction was a critical precondition for the legal developments that followed. It would have made no sense—politically, culturally, morally, or in any other way—to repress addicts who were mainly sick old women” (quoted in Kandall :). Over time, American society demonstrated its values and priorities in defining what a drug problem is and whether it deserves attention: only when drug problems posed threats to society’s norms and order would they attract attention. Although the numbers of traditional morphine- and opium-addicted middleand high-class white women declined after the enactment of the Harrison Act, which criminalized drug possession, transportation, and use, including physicians’ prescribing narcotics, new groups of female drug abusers emerged. Some of the old group of addicted women might still have been able to get drugs from their “brave” or “greedy” physicians or through other means, but others switched their opiate of choice to heroin and Dilaudid, for example (Courtwright, Joseph, and Des Jarlais, cited in Kandall ), and still others sought treatment in private sanitariums or public facilities. Among a newer group of drug-abusing women, drug addiction was not iatrogenic in nature but rather was related to their curiosity about drugs, the motivation to join a gang, or the intention to get a “kick”; their drug of choice tended to be heroin instead of morphine (Kandall ). A large proportion of the women in this group were African Americans with a relatively poorer socioeconomic background (Kandall ). This group of female drug abusers has been sustained since the early to the mid-twentieth century and into the early twenty-first century. A study of  women from across the country admitted to the Lexington Treatment Center during the second half of  indicated that .% of the total female admissions to the center were African American. Williams and Bates () noted the overrepresentation of African American women in the admissions as population statistics from  show that only % of the female population in the country was African American. Further, in comparison to the overall number of women admitted to the center, the African American women were more likely to

Introduction

9

be younger and to come from selected metropolitan areas like Chicago, New York, and Washington, D.C. By , the percentage of African American women’s admissions had increased to %. (It is uncertain whether the disproportionately high admission rate among African American women represented a true rate of their addiction; possibly it was a result of racism and classism of related professional and criminal systems, or a disparity of admissions to private versus public treatment facilities between white and African American women.) (Cuskey, Moffett, and Clifford, cited in Kandall ). Women of this group relied mainly on male drug dealers, other addicts, and family members who abused drugs for their drug supplies. They might also engage in prostitution and commit other petty crimes to fulfill their drug needs. Kandall cited many examples demonstrating the suffering and despair of the women. The predicament of women in this group provoked less sympathy from society than that of women in the group of traditional drug abusers whose drug abuse was iatrogenic in nature. However, both groups were neglected by society because their drug problems were not involved with major crimes or violence and had not threatened society’s norm and order. Yet another group of women drug abusers consisted of those who became addicted to some of the new prescription drugs discovered during the post–World War II period. Although the advent of psychotropic drugs in the mid-twentieth century had a major impact on the treatment of many mental illnesses (Engstrom and Hong ), the pharmaceutical industry and physicians were criticized for overpromoting and overprescribing the medications to the general public, particularly women (Engstrom and Hong ; Kandall ). Kandall commented on the similarities between physicians’ overprescribing tranquilizers and stimulants for women during the mid-twentieth century and their overprescribing morphine and opium for women during the nineteenth century. Metzl () stated that “the pills became known as the treatments of choice for the . . . specific forms of essentialized womanhood” (). Women were prescribed drugs to relieve pressures related to motherhood or singlehood, to help them readjust to a housewife role from a career-woman role that gave them satisfaction but ended when the war ended; to be more able to handle demands of the postwar lifestyle such as long working hours and the dual responsibilities of job and family; or to suppress appetite and maintain slenderness (Kandall ; Metzl ). The prevalent use and abuse of prescription drugs among women at the time were well reflected in the s Rolling Stones song “Mother’s Little Helper,” which described how unhappy housewives sought prescription drugs to help them get through the day (Engstrom and Hong ; Metzl ). By the end of the s, women comprised twothirds of psychoactive drug users, with Valium as the most commonly prescribed drug from  to  (National Center on Addiction and Substance Abuse at Columbia University ; hereafter cited as CASA). According to CASA, the National Commission on Marihuana and Drug Abuse has acknowledged that a substantial number of women are having prescription drug abuse problems. The

10

Helping Substance-Abusing Women in General

organization also noted, however, that “self-medication by a housewife . . . with amphetamines or tranquilizers . . . is generally viewed as a personal judgment of little concern to the larger community” (quoted in CASA :–). In summary, although large numbers of women in the nineteenth and the early and mid-twentieth centuries did experience and suffer drug addictions, they did not receive adequate attention from society because, ironically, their drug addiction posed little threat to society. Among these women some were involved with iatrogenic addiction, which was viewed with “benign neglect” by society, while others engaged in self-medication, which was mostly viewed as “a personal judgment of little concern to the larger community” (National Center on Addiction and Substance Abuse [hereafter CASA] :). Other female drug abusers were more likely to commit crimes, but their offenses were generally prostitution and petty crimes, less violent and on a smaller scale than those of male drug abusers. The change in the drug abuse landscape at the turn of the twentieth century marked drug addiction as a “men’s disease,” relegating women’s drug problems to insignificance—if not invisibility—and failing to recognize their special treatment needs.

From Denial to Acknowledgment and Beyond Society’s denial did not begin to change until the last quarter of the twentieth century. In the post–World War II period, both American science and feminism made significant strides (Legato, cited in National Institutes of Health ), and female psychology and development theories have gained great momentum since the s and s (Gilligan ; Miller ). More women-specific AOD research and treatment began to emerge during the late s and s, and particularly since . Today, although more researchers and practitioners have gradually acknowledged women’s AOD problems and realized the possible physiological, psychological, social, and cultural differences between women and men and their implications for AOD etiology and the clinical course of the AOD disease, as well as the subsequent effective diagnosis, treatment, and prevention, much more effort is still needed to improve practice and research in this area. Women-specific health studies in general, and women-specific AOD research in particular, have reached some milestones since the s. The emergence of female psychology and development theories in the s and s has furthered an understanding of women’s unique treatment needs (Brown ). In  the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research Belmont Report emphasized the importance of women’s participation in clinical investigations. Women-specific AOD treatment and research began to emerge in the s, declined in the s, and reemerged in the s, a pattern that may be related to () inconsistency in federal and state efforts for

Introduction

11

funding such treatment and () the rise of crack cocaine babies. Finkelstein () summarized the public funding history of women’s substance abuse treatment, showing that the federal effort (P.L. –) on funding such treatment began in , but in  federal funding was shifted to block grants administered by the states, making women’s substance abuse treatment compete with other local interests. In  federal rules (R.L. –) required each state to set aside % of its block grant specifically for treating women, and that amount was increased to % in . The Center for Substance Abuse Treatment (CSAT) (a) stated that both the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism conducted research and distributed information on the special needs of substance-abusing women by ; however, surveys of treatment programs in the s showed that most programs were not treating women, and the crack baby epidemic in the mid-s “caught most States with too few residential slots for the many pregnant women and mothers in need of specialized care” (). The gender perspective continued to be emphasized during the late twentieth century, and gender-based studies have been growing. Government and private nonprofit organizations have advocated and set guidelines for the inclusion of women in clinical studies and research data analyses by gender. For example, in  the Institute of Medicine (IOM) published Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies. In  the National Institutes of Health Office of Research on Women’s Health published Agenda for Research on Women’s Health for the st Century: A Report of the Task Force on the NIH Women’s Health Research Agenda for the st Century. In  the IOM published Exploring the Biological Contributions to Human Health: Does Sex Matter? The growing number of gender-specific studies on diseases has been viewed as benefiting not only women but also men. By knowing more about how diseases may function differently for women and the differences between women and men, researchers and scientists have begun to better understand how diseases may function differently for men. Consistent with the overall ethos of an emphasis on gender-specific health studies, more women-specific AOD treatment and research have also appeared since . For example, CSAT has funded about  treatment programs for pregnant and parenting women since . The Center for Substance Abuse Prevention has supported more than  programs to enhance services for pregnant / postpartum women and their infants (CSAT a). A search of PsycINFO with the keywords “women,” “substance abuse,” “treatment,” and “gender-specific” indicated one article published before ; one from  through ; two from  through ;  from  through ; and  from  through . Similar results were obtained searching the PubMed database with the same keywords: one article was published before ; one,  through ; nine,  through ; ,

12

Helping Substance-Abusing Women in General

 through ; and ,  through  (Sun a). Although these numbers may not account for all studies conducted during the various periods, they nonetheless reflect a trend. Even though American society has moved from denial of women’s AOD problems in the nineteenth century to an acknowledgment of women’s AOD problems in the twentieth century, along with making other progress such as the emergence of gender-specific scientific studies at the turn of the twenty-first century, more efforts are still needed in at least three areas. First, the stigma attached to women’s AOD problems needs to be reduced or eliminated. The progress that society has made over the past two hundred years has not eliminated the stigma attached to women’s AOD problems. Brown () stated: “It is an ironic victory: women have gained the right to be acknowledged alcoholics and drug addicts, an attribution that still carries severe negative moral connotation and stigma for females. Women have paradoxically gained the right to acknowledge moral failure” (). Second, further scientific study should be directed toward understanding the nature of women’s AOD problems and their unique treatment needs and generating and evaluating effective treatment strategies. Although research in this area did increase during the late twentieth century and continues today, the efforts are still in their infancy, and knowledge about effective women-specific practice is still inadequate. For example, during the process of writing this book I found that many studies addressing AOD treatment topics in relation to adolescents, older adults, and homeless individuals included very few women or simply did not analyze results for women separately from those for men. Third, efforts should be made to encourage and assist treatment programs in providing gender-specific treatment. Although more treatment facilities have began to accept AOD-abusing women, women-specific treatment has not necessarily been offered. For example, only % of the , treatment facilities that participated in the  National Survey of Substance Abuse Treatment Services (N-SSATS) survey reported that they did not accept women clients, but more than half (%) of the facilities that did accept women clients did not offer special programs or groups for women (Substance Abuse and Mental Health Services Administration [SAMHSA] d). Examining the  N-SSATS data, Olmstead and Sindelar () found that less than half of the treatment facilities with special programs for women actually offered women-specific key services. Only % of them offered child care; %, transportation assistance; and %, housing assistance. The rates were even lower for facilities that accepted women but had no special programs for women: % provided child care; %, transportation assistance; and %, housing assistance. Not only should these facilities be encouraged to offer gender-specific programs or groups but also researchers should explore why they did not offer gender-specific treatment.

Introduction

13

The Epidemiology of Women’s AOD Problems Current AOD Use, Abuse, and Dependence: The Prevalence Overall, although men have a higher substance use prevalence rate than women in all three AOD areas (illicit drug use, alcohol use, and cigarette use), the prevalence gap between men and women appears to be narrower for illicit drug use than for alcohol use and cigarette use. The  National Survey on Drug Use and Health (NSDUH) data (SAMHSA a, b) showed that among people  or older: () about .% of men versus .% of women used illicit drugs (preceding year use); () about .% of men versus .% of women used alcohol (preceding year use). The gap was wider for binge alcohol use, .% for men and .% for women; and for heavy alcohol use, .% for men and .% for women (preceding year use); () for cigarette use, the rate was about .% for men and .% for women (preceding year use). With respect to AOD abuse and dependence, rates for men can also be compared to those for women. The AOD use inquiry asks only whether an individual has used the substance or not (in the preceding year or month), but the AODdependence or -abuse question explores whether the use of the substance has created a problem for the person or the person’s surroundings. The  NSDUH defined substance dependence or abuse using the DSM-IV criteria (American Psychiatric Association ). DSM-IV uses two different sets of criteria to evaluate substance dependence and substance abuse, with the more stringent criteria applied to dependence. “Substance Dependence implies physiological changes and loss of control; Substance Abuse refers to social and legal problems” (Morrison :). A new client usually would be assessed first for the possible diagnosis of “substance dependence”; only when the client did not meet dependence criteria would he or she then be assessed for a possible diagnosis of “substance abuse.” In other words, substance abuse is a residual category (Morrison ). The  NSDUH data (SAMHSA a) indicated that, overall, men are twice as likely as women to experience substance dependence or abuse. For example, .% of the male population aged  or older met the DSM-IV criteria for illicit drug dependence or abuse in the preceding year, whereas the rate was .% for women. For alcohol dependence or abuse, the rate difference is wider, with .% for men but .% for women. When illicit drug and alcohol dependence or abuse are combined, the rates are .% for men and .% for women.

The Factors of Age, Race / Ethnicity, and Family Income SAMHSA’s data (a, b) indicated that although women age  or older had a lower alcohol abuse / dependence rate, illicit drug abuse / dependence rate,

14

Helping Substance-Abusing Women in General

and cigarette use rate than their male counterparts, adolescent girls and boys (age –) had equivalent rates for all three substances. Among women of all age groups, those in the – group had the highest past year alcohol abuse / dependence rate, illicit drug abuse / dependence rate, and cigarette use rate. Among women of all race / ethnic groups, American Indian or Alaska Native women had the highest rates on all three measures. Among women with all levels of family income, women with a family income lower than $, had the highest rates on all three measures. All the trends in relation to age group, ethnicity, and family income reflected in women were also reflected in men (tables ., ., and .).

Primary Drug Used at Treatment Admission According to SAMHSA’s  Treatment Episode Data Set (TEDS; SAMHSA ), the total number of treatment admissions nationwide was ,,, .% of them men and .% women. The top three drugs used by women Table 1.1. Percentages of Past Year Alcohol Dependence or Abuse Among Persons Aged 12 or Older, by Gender and Demographic Characteristics, 2005–2006

Age Group 12–17 18–25 26–49 50 or older Race / Ethnicity White African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Asian Two or More Races Hispanic or Latino Family Income Less than $20,000 $20,000–$49,999 $50,000–$74,999 $75,000 or more

Male

Female

5.1% (SE = 0.18) 21.5% (SE = 0.38) 12.1% (SE = 0.34) 5.2% (SE = 0.35)

5.8% (SE = 0.20) 13.6% (SE = 0.31) 5.7% (SE = 0.21) 1.5% (SE = 0.17)

10.3% (SE = 0.22) 9.5% (SE = 0.58) 21.3% (SE = 3.78) 15.0% (SE = 3.20)

5.6% (SE = 0.16) 4.0% (SE = 0.32) 12.4% (SE = 2.05) 5.8% (SE = 1.81)

4.9% (SE = 0.63) 11.4% (SE = 2.43) 12.1% (SE = 0.59)

2.2% (SE = 0.38) 5.7% (SE = 0.80) 4.3% (SE = 0.29)

13.4% (SE = 0.48) 10.4% (SE = 0.33) 8.6% (SE = 0.40) 9.6% (SE = 0.36)

6.2% (SE = 0.27) 5.0% (SE = 0.20) 4.4% (SE = 0.27) 5.0% (SE = 0.24)

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2005 and 2006 (unpublished data supplied by SAMHSA).

Introduction

15

Table 1.2. Percentages of Past Year Illicit Drug Dependence or Abuse Among Persons Aged 12 or Older, by Gender and Demographic Characteristics, 2005–2006 Male Age Group 12–17 18–25 26–49 50 or older Race / Ethnicity White African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Asian Two or More Races Hispanic or Latino Family Income Less than $20,000 $20,000–$49,999 $50,000–$74,999 $75,000 or more

Female

4.7% (SE = 0.18) 10.1% (SE = 0.27) 3.4% (SE = 0.19) 0.9% (SE = 0.14)

4.6% (SE = 0.18) 6.1% (SE = 0.21) 1.8% (SE = 0.12) 0.3% (SE = 0.08)

3.3% (SE = 0.11) 5.8% (SE = 0.43) 6.7% (SE = 1.68)

2.0% (SE = 0.08) 2.4% (SE = 0.23) 6.9% (SE = 2.05)

4.2% (SE = 1.23) 1.8% (SE = 0.36) 3.6% (SE = 0.56) 4.0% (SE = 0.33)

0.9% (SE = 0.43) 0.9% (SE = 0.26) 6.0% (SE = 1.69) 2.0% (SE = 0.18)

6.5% (SE = 0.33) 3.8% (SE = 0.18) 2.4% (SE = 0.18) 2.6% (SE = 0.15)

3.3% (SE = 0.19) 2.0% (SE = 0.11) 1.7% (SE = 0.17) 1.4% (SE = 0.11)

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2005 and 2006 (unpublished data supplied by SAMHSA).

at treatment admission were alcohol (“alcohol only” or “alcohol with secondary drug”; .%), opiates (.%), and cocaine (.%), followed by marijuana / hashish (.%), stimulants (mainly methamphetamine / amphetamine; .%), and other (.%). The top three drugs used by men at treatment admission were alcohol (.%), marijuana / hashish (.%), and opiates (.%), followed by cocaine (.%), stimulants (.%), and other (.%).

The Impact and Consequences of Women’s AOD Problems The negative health (e.g., injury, disease, disability, death) and social (e.g., distressed interpersonal relationship, lower level of work performance, unemployment, violence, crime) consequences of drinking have been well documented (WHO ). Although men are more likely to be heavy and frequent drinkers and thus more likely to suffer the consequences, women may be more vulnerable to AOD consequences in many ways, physiologically, psychologically, and

16

Helping Substance-Abusing Women in General

Table 1.3. Percentages of Past Year Cigarette Use Among Persons Aged 12 or Older, by Gender and Demographic Characteristics, 2005–2006

Age Group 12–17 18–25 26–49 50 or older Race / Ethnicity White African American American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Asian Two or More Races Hispanic or Latino Family Income Less than $20,000 $20,000–$49,999 $50,000–$74,999 $75,000 or more

Male

Female

16.8% (SE = 0.35) 51.0% (SE = 0.45) 38.1% (SE = 0.52) 22.2% (SE = 0.66)

17.6% (SE = 0.35) 43.2% (SE = 0.46) 31.7% (SE = 0.48) 16.7% (SE = 0.55)

32.0% (SE = 0.39) 32.7% (SE = 1.14) 45.1% (SE = 4.84)

28.5% (SE = 0.38) 23.1% (SE = 0.80) 41.4% (SE = 3.76)

29.9% (SE = 4.68) 25.9% (SE = 1.75) 37.0% (SE = 2.82) 33.9% (SE = 0.98)

36.2% (SE = 7.00) 10.2% (SE = 1.09) 32.5% (SE = 2.63) 21.0% (SE = 0.74)

42.7% (SE = 0.87) 36.5% (SE = 0.57) 29.3% (SE = 0.74) 23.7% (SE = 0.58)

34.0% (SE = 0.67) 28.3% (SE = 0.52) 23.8% (SE = 0.64) 18.7% (SE = 0.52)

Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2005 and 2006 (unpublished data supplied by SAMHSA).

socially. One study (N =  substance-abusing women and  substance-abusing men) showed that the women perceived their quality of life to be significantly worse than did the men (Peters, Millward, and Foster ). Peters and colleagues found that although both sexes rated their quality of life poor, the women’s score was significantly lower than the men’s (mean = . ± . for women and . ± . for men; p = .; a score ≤  indicates a poor quality of life). “Quality of life” encompassed such dimensions as health, sleep, nutrition, work, self-esteem, autonomy, love, stress, mood / affect, security, social nurturance, public support, environment, outlook, and so on. The following sections discuss the negative impacts of AOD that are particularly pertinent to women, including both health consequences and some psychosocial consequences. Note that the negative consequences of AOD may become triggers or risk factors leading to further AOD misuse. On the other hand, some researchers (Hart and Fazaa ) argue that a “risk factor” believed to contribute to alcohol abuse may actually be a consequence of alcohol abuse. There may be a reciprocal relationship between negative consequences and risk factors, forming

Introduction

17

a vicious cycle, regardless of which occurs first. For example, a sexual assault initially related to a woman’s AOD misuse may prompt her to abuse AOD to selfmedicate the pain and shame invoked by the assault (Kaysen et al. ). A conflicting relationship between a woman and her spouse or other family members may trigger her relapse, further worsening the strained relationship (Sun ). It is therefore important to incorporate an understanding of AOD consequences and the reciprocal relationship between a consequence and a precipitating risk factor when planning prevention and treatment contents and strategies.

The Physiological / Health Consequences The Impact of Alcohol Abuse and Dependence on Women A Higher BAC and the “Telescoping Effect”

Many studies, although not all, have shown that, compared to men, women experience the adverse effects of alcoholism in a shorter period of time and / or with less alcohol consumption (Diehl et al. ; Piazza, Vrbka, and Yeager ; Randall et al. ). Women may also progress faster than men from their first use to development of alcohol-use disorder. These more rapid changes in women have been called the “telescoping” effect (Piazza, Vrbka, and Yeager ). This phenomenon occurs because of women’s higher blood alcohol concentration (BAC) than men’s when a comparable amount of alcohol is consumed (Ely et al. ). Women’s higher BAC can be attributable to the fact that they generally have a smaller body size and proportionately more body fat and less body water than men. Because alcohol is diffused in body water, women’s overall smaller amount of body water leads to their higher BAC (Mumenthaler et al. ). Another possible factor, although it awaits more research to confirm, is women’s lower level of the enzyme gastric alcohol dehydrogenase (ADH) in the gastrointestinal (GI) system (Graham et al. ; Walter et al. ). The liver plays a major role in metabolizing ethanol, but the GI tract also metabolizes ethanol to a lesser degree (Seitz and Pöschl ). Gastric ADH helps to retain and break down some alcohol in the stomach and intestines before the alcohol penetrates into other parts of the body—a process known as the “first pass metabolism” (Nolen-Hoeksema ). Frezza and colleagues () discovered that because of women’s lower level of gastric ADH, women tend to metabolize less ethanol than men during the “first pass metabolism,” resulting in greater bioavailability of alcohol in women. Thus, Frezza et al. concluded, the increased level of bioavailability of alcohol may lead to women’s vulnerability to various complications of alcoholism. This gastric ADH factor, however, applies mainly to younger adults in that younger women have a lower gastric ADH activity than their age-matched men. Gastric ADH tends to decrease with age. This is more applicable to men, as women maintain a stable lower level of gastric ADH during their lifetime (Seitz and Pöschl ).

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Helping Substance-Abusing Women in General

Consistent with the “telescoping effect” theory, extensive studies have shown that women develop adverse alcohol-related problems earlier than men during the course of their drinking career and that both sexes suffer alcohol-induced liver, heart, and brain problems despite the fact that women consume less alcohol than men. Women additionally may suffer breast cancer and reproductive system dysfunction, and pregnant women may deliver babies with complications. Alcohol-dependent women or women with heavy drinking also have a significantly higher mortality rate than their male counterparts (Nolen-Hoeksema ). Liver Diseases

Voluminous literature has consistently suggested that in women, the liver is more prone to the toxic effects of chronic alcohol use than in men, liver injury progresses more rapidly over a shorter period of time and with less alcohol consumed, and / or alcoholic liver cirrhosis is more likely to develop and more likely to cause death (Becker et al. ; Chen et al. ; Colantoni et al. ; Hall ; Mandayam, Jamal, and Morgan ; Müller ; Nolen-Hoeksema ; Tuyns and Pequignot ). For example, Becker et al. (:; Copenhagen City Heart Study, “population-based prospective cohort,” N = ,) indicated that, in comparison to men who consumed  to  drinks per week (relative risk of developing alcoholic cirrhosis or alcoholic liver disease = ), an intake of  to  drinks per week increases the risk for alcoholic liver cirrhosis or alcoholic liver disease in men, whereas it takes only  to  drinks per week to increase these risks in women. The relative risk for developing liver cirrhosis is  in male heavy drinkers ( to  drinks per week) but  in their female counterparts. Various reasons have been posited to explain women’s higher risk for alcoholic liver disease: () As mentioned earlier, women are more likely to have a higher BAC or bioavailability of alcohol in the body. () Some animal studies reported that females are more likely to have a higher level of hepatic tumor necrosis factor alpha (TNF alpha) after chronic exposure to alcohol, which promotes apoptosis. The much-elevated TNF alpha in females may be related to estrogen in the female subjects (Colantoni et al. ; Yin et al. ). Heart Problems

According to the literature review results, the impact of alcohol on the heart is not as straightforward as it is on the liver. While alcohol has been determined to have only an adverse impact on the human liver, particularly among women, it may have either a harmful or beneficial impact on the human heart, depending upon the amount consumed and the frequency of drinking, the person’s age, gender, levels of heart disease risk, and so on. Despite the various definitions for light, moderate, and heavy alcohol consumption, many empirical studies concurred with the “U-shaped curve” theory, which suggests that light or moderate drinkers tend to have a lower mortality rate than the abstainers or the heavy drinkers,

Introduction

19

primarily because of their relatively lower heart disease rate (White, Altmann, and Nanchahal ). For example, Fuchs et al.’s study (), a prospective study with , women aged –, reported that compared to nondrinkers, women consuming . to . grams of alcohol daily had a relative risk for death of ., women consuming . to . grams daily had a relative risk of ., but women consuming  grams or more daily (with other predictors of mortality adjusted) had a relative risk of .. Fuchs et al. explained the results by saying that women who were light-to-moderate drinkers (. to . grams per day) had a lower risk for death from heart disease compared to the abstainers, whereas women who were heavier drinkers encountered an increased risk for death from causes like liver cirrhosis and breast cancer. Researchers have posited several reasons for the protective role of alcohol, including the possibilities that moderate alcohol consumption (a) increases the level of high-density lipoprotein (HDL) cholesterol, the prostacyclin-to-thromboxane ratio, the level of “tissue-type plasminogen activator,” paraoxonase activity, and estrogen; (b) improves insulin sensitivity; and (c) decreases platelet aggregation, blood clotting, and stress (Kolovou et al. ; Rich-Edwards et al. :; Tolstrup et al. ). The protective role of alcohol is particularly linked to its ability to increase HDL cholesterol, which is negatively related to the development of coronary heart disease (CHD) (Kolovou et al. ). Citing Rimm et al., Kolovou et al. () said: “Consuming  g of alcohol per day increases HDL cholesterol levels by  mg / dl . . . which in turn is equivalent to an estimated % reduction in CHD risk” (). On the other hand, alcohol’s harmful effects have been well documented (Hanna, Chou, and Grant ; Nolen-Hoeksema and Hilt ; Rich-Edwards et al. ). For example, alcohol’s antithrombotic function (the prevention of the formation of clots in the bloodstream) may raise the risk for hemorrhagic stroke. Drinking at a moderate level may still raise the risk for hypertension and at an excessive level may add to the risk for dysrhythmia and cardiomyopathy, which often cause sudden death among young people. Alcohol consumption may also increase the risk for breast cancer and cirrhosis. In addition, alcohol is linked to many preventable injuries and fatalities. Although the U-shaped theory appears to receive some acceptance from the research community, there are at least three areas of concern that need to be addressed. Each is relevant to both sexes but especially salient with respect to women. First, many questions still await clarification through relevant studies, particularly in relation to the definitions of abstention versus light versus moderate versus heavy drinking and the threshold for dose and frequency to reach the beneficial but not harmful effect. For example, Tolstrup et al. (; N = , women and , men aged –) found that numbers of drinks per week, but not numbers of days a person drinks per week, were inversely related to CHD among women. Drinking alcohol at a minimum of one day per week lowered women’s risk for CHD compared to drinking alcohol for less than one day per week, but

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Helping Substance-Abusing Women in General

the results showed little difference for those who drink one day a week versus those who drink two to four days, five days, or seven days a week. (However, those authors found that for men, drinking frequency does make a difference and has an inverse relationship with CHD occurrence in that men who drank every day had the lowest risk for CHD, followed by men who drank five or six days per week, who drank two to four days per week, and so on. Men who never drank had the highest CHD rate). On the other hand, Hanna, Chou, and Grant (:; N = , men and women) found that among women, moderate drinkers (an average of .–. ounces of alcohol per day “during the respondent’s heaviest drinking period”) were % more likely to indicate having heart disease than infrequent drinkers (.–. ounces of alcohol per day). Second, the U-shaped findings may be more applicable to older women than to middle-aged and younger women despite the applicability to both middle-aged and older men. White, Altmann, and Nanchahal () found that for young and middle-aged women (aged –) as well as young men (aged –), there is a positive dose-response relationship between a person’s alcohol consumption and the person’s risk of death, meaning that abstention is associated with the least risk of death whereas heavy drinking has the most risk. Consistently, Fuchs et al. () found that the U-shaped findings emerged only among their older female subjects and women with risk factors for CHD. Fuchs et al. stated that light to moderate drinking does not decrease mortality rate for their younger female subjects or those without risk for CHD; on the contrary, it increases substantially the mortality rate in this population. The applicability of the beneficial effect of alcohol mainly to the older women, as well as middle-aged and older men, has very much to do with its function in reducing heart diseases among these populations. According to statistics from the Centers for Disease Control and Prevention (hereafter CDC), men have a higher mortality rate due to heart disease than women until the age of , at which point the rate is almost equal for both genders. For example, during , about .% of all deaths among men versus .% of all deaths among women in the – age group were caused by heart disease; the rates were .% and .%, respectively, for the age group –, but .% for men and .% for women in the age group  and older (CDC n.d.a, n.d.b). The literature suggests that women have been protected by estrogen and thus develop a lower rate of cardiovascular heart problems; however, such protection diminishes when women face menopause, which causes a sharp decline of estrogen. Third, although alcohol’s protective effects are limited to older people and people at risk for CHD, alcohol’s harmful effects may be applicable to all age groups and both sexes. Not surprisingly, it requires a smaller amount of alcohol for women than for men to experience these harmful effects rather than the beneficial effects. For example, Hanna, Chou, and Grant () found that among women, consumption of more than  drinks per day (during the period in the past year

Introduction

21

when they drank most) is related to a significant increase in heart disease risk, whereas among men, it takes more than  drinks per day to increase the risk. Similarly, Fuchs et al. () reported that the beneficial effect of alcohol is confined to women who had  or fewer drinks per day and that consumption of more than  drinks per day increases women’s mortality. As mentioned earlier, alcohol’s possible harmful effects have been well documented, and it is controversial as to whether professionals should recommend a moderate intake of alcohol to help their older clients reduce heart disease risk. Many professionals oppose such a recommendation, particularly for their old female patients, because of the heightened risks of all the possible negative consequences, including, for example, breast cancer, liver cirrhosis, and potential interaction effects between alcohol and prescription drugs (see chapter ). They suggest that our understanding of the mechanism of alcohol’s protective effect for the cardiovascular system should be used to create interventions that imitate the positive function of alcohol without alcohol’s harmful consequences (Rich-Edwards et al. ). Reproductive System Dysfunction and Fetal Alcohol Syndrome

Alcohol may induce sexual dysfunction in women (and men) in that women’s sexual arousal may be suppressed in a dose-responsive way (Blume and Zilberman ). Although the cultural belief is that alcohol might facilitate sexual arousal, and women may say they feel more aroused after consuming alcohol, their physical response actually tends to be depressed (Blume and Zilberman ; Nace ). Exposure to chronic heavy drinking may further put women at high risk for reproductive system dysfunction such as erratic menstruation, menstruation cessation, and early menopause (Blume and Zilberman ; Nolen-Hoeksema and Hilt ). Chronic heavy drinking may even bring about inhibition of ovulation and infertility in women (Blume and Zilberman ; Nace ). For example, Eggert et al.’s Swedish prospective study (cited in Nolen-Hoeksema and Hilt ) reported that infertility rates are % higher among women who are heavy drinkers than among women who are moderate drinkers. Nolen-Hoeksema and Hilt’s review, however, did show that not all studies confirm the connection between lower fertility and moderate to heavy drinking in women. Drinking during pregnancy may put women at risk for spontaneous abortions, prenatal death of the fetus, or giving birth to a baby with fetal alcohol syndrome (FAS) or fetal alcohol spectrum disorder (FASD) (Gemma, Vichi, and Testai ). The diagnosis for FAS includes three criteria: “characteristic facial dysmorphology,” “growth restriction,” and “central nervous system / neurodevelopmental abnormalities” (Sokol, Delaney-Black, and Nordstrom :). The diagnosis for individuals who do not meet the criteria of the classic FAS—i.e., those who are less affected and meet only partial FAS criteria—may be considered under the umbrella term FASD (Sokol, Delaney-Black, and Nordstrom ). The Institute

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Helping Substance-Abusing Women in General

of Medicine has developed a classification system encompassing five categories of diagnosis for prenatally alcohol-affected individuals, ranging from the classic FAS to four types of FASD. Prenatal AOD exposure may cause short- and long-term damage to the infant’s physical, cognitive, and behavioral development (Little and Yonkers ; Streissguth ). The review by Sokol, Delaney-Black, and Nordstrom () indicated that preschool children who were prenatally exposed to moderate maternal drinking may show hyperactivity and inattention problems, and school-aged children prenatally exposed to moderate maternal drinking may have learning problems, memory shortfall, impulsivity problems, and psychiatric problems such as mood disorders. The same review further showed that maternal binge drinking during pregnancy may exert an even more adverse impact on the fetus, with children who were so exposed having a higher likelihood of being diagnosed with developmental delay. They may also demonstrate a lack of persistence in preadolescence and multiple neurobehavioral problems in adolescence. The adverse impact may continue into adulthood, with issues like trouble with problem solving, difficulties with other everyday life-functioning tasks due to executive-functioning insufficiency, and increased levels of substance abuse and antisocial behavior. Nolen-Hoeksema and Hilt’s () review showed that heavy maternal drinking is related to FAS, whereas low to moderate maternal drinking is associated with alcohol-related birth defects. No clear threshold developed for the level of drinking during pregnancy that would cause FAS or FASD. Generally speaking, heavier drinking is more risky than light or moderate drinking, and binge drinking is more risky than non–binge drinking. Sokol, Delaney-Black, and Nordstrom () said that although an average of more than  drink per day during pregnancy is likely to cause risk, studies also found that an average of . drink per day can cause risk as well. Because of the uncertainty of the threshold for risky drinking during pregnancy and the role of the various susceptibility factors, the professional community has recommended abstinence for both pregnant and preconceptional women (Sokol, Delaney-Black, and Nordstrom ). On the other hand, not all alcohol-exposed infants show significant medical complications or developmental problems, and it is difficult to estimate outcomes for individual children because of the possibility of multiple factors other than exposure to alcohol. Statistics about the occurrence of FAS vary. Gemma, Vichi, and Testai () stated that less than % of women who drink heavily during pregnancy give birth to babies with FAS. The prevalence of FAS in the United States is estimated to be .–. per , births, and the prevalence of FAS or other FASD is about  per , births (National Association of State Alcohol and Drug Abuse Directors ). Depending on the type and combination of drugs used, the amount and frequency of use, the trimester in which the drug is used, the reactions of the mother using the drugs, and the fetus’s genetic susceptibility to

Introduction

23

AOD, a baby may show severe, mild, or no symptoms (Gemma, Vichi, and Testai ; Kropenske and Howard ; Little and Gilstrap ; Streissguth ). As mentioned earlier, heavy drinking is more risky than moderate / light drinking, and binge drinking more harmful than non-binge drinking. Smoking or involvement with other drugs in addition to alcohol may pose more damage risks. First-trimester alcohol exposure may cause congenital anomalies, while exposure during the second or third trimester may affect growth (Coles ). FASD (including FAS) is also likely to be related to mother’s age, health condition, and nutritional status (Gemma, Vichi, and Testai ). FASD may be related not only to environmental factors but also to genetic factors (Gemma, Vichi, and Testai ). The genetic factor here does not mean that FASD is hereditary; rather, it suggests that some individuals or some racial groups may be more vulnerable to the occurrence of FASD because, genetically, they might be subject to more severe neuronal or other damage when exposed to alcohol prenatally (Gemma, Vichi, and Testai ). The CDC’s – data indicated that populations of a lower socioeconomic status (SES) and some racial minorities had considerably higher rates of FAS. For example, American Indian / Alaskan Native children were  times, and African American children  times, more likely than their white counterparts to present FAS (Sokol, Delaney-Black, and Nordstrom ). It is not completely clear whether this disparity is related to SES, genetic predisposition, research bias, or a combination of factors. Breast Cancer

The relationship between alcohol consumption and breast cancer was first suggested in the late s, and although not all empirical studies since then have substantiated the relationship, most have. Most research findings confirmed the relationship as positive and dose-responsive, meaning that the greater the amount of alcohol consumed, the higher the risk of breast cancer (Singletary and Gapstur ). Most research also confirmed that although there are multiple risks other than alcohol that may be associated with breast cancer (genetics, lifestyle, etc.), the alcohol–breast cancer relationship is not confounded by other factors (for example, cigarette smoking) or other alternative explanations (McDonald et al. ; Singletary and Gapstur ). Various studies have shown the following characteristics regarding the alcohol-breast cancer relationship. 1. Excessive and moderate drinkers are more likely to have increased breast cancer risk than light drinkers or abstainers. For example, Mørch et al.’s () study showed that women who had  to  drinks per week are . times as likely to develop breast cancer as those who had only  to  drinks per week. Berstad et al. (; N = , women diagnosed with breast cancer and  control group subjects aged –) reported that those who consumed  or more drinks per day

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Helping Substance-Abusing Women in General

have an % increase of breast cancer risk compared to abstainers. Singletary and Gapstur () confirmed that data from several countries since  revealed consistent findings suggesting that excessive and moderate drinkers (more than  drinks per day) are at a higher risk for breast cancer than abstainers. 2. Even moderate drinking may increase the risk of breast cancer. For example, McDonald et al. () showed that  or more drinks per week may raise breast cancer risk, and Singletary and Gapstur () indicated that data from several countries since  suggest the dose-response relationship between alcohol intake and breast cancer can start with consumption as low as  to  drinks per day. 3. Many alcohol–breast cancer studies revealed that it is the alcohol consumed recently, rather than during a lifetime, that is related to the diagnosis of breast cancer (Berstad et al. ; McDonald et al. ; Tjønneland et al. ). For example, Berstad et al. showed that consumption of  or more drinks per day in the five-year period preceding the diagnosis of breast cancer is linked to an % increase in breast cancer risk compared with that of nondrinkers. Berstad et al. () found no breast cancer risk increase for lifetime alcohol consumption. Likewise, Tjønneland et al. found that breast cancer risk is linked mainly to recent alcohol consumption, not previous lifetime intake. McDonald et al. also found that alcohol intake of  or more drinks per week during the two years prior to the subjects’ reference age was linked to an increased risk of breast cancer. McDonald et al. thus suggest that alcohol exposure later in life may be more critical than exposure early in life in affecting breast cancer risk. 4. Both premenopausal and postmenopausal women may be affected. Although we understand that the alcohol–breast cancer relationship is related to alcohol’s facilitation of endogenous estrogen, how the process induces or promotes breast cancer is not completely clear. Research has shown that the alcohol–breast cancer relationship may be applicable to both young (premenopausal) and older (postmenopausal) women (Singletary and Gapstur ). Berstad et al.’s () study reported that alcohol consumption may be related to increased risk of breast cancer among young women. On the other hand, McDonald et al. () found that most of the alcohol–breast cancer relationship appeared in women who were – years old, although statistically the interaction effect between age and alcohol–breast cancer risk was not significant. Although it is not fully understood how alcohol consumption raises the risk for breast cancer occurrence, it is generally believed that alcohol intake appears to increase the endogenous estrogens, and estrogen-related elements are recognized risk factors associated with breast cancer (Mørch et al. ). More research is needed to understand the biological mechanisms explaining the alcohol–breast cancer relationship, as well as the effects of interactions of alcohol with other breast cancer risk factors (Singletary and Gapstur ).

Introduction

25

Brain Damage and Cognitive Function Impairment

The literature is consistent in finding that alcoholics of both sexes have a greater degree of brain damage than non-alcoholics, but the literature is inconclusive regarding whether alcoholic women are more prone to alcoholism-induced brain damage than alcoholic men are. Two major research groups have engaged in studying the topic, but they were not able to reach consensus on the research outcomes. On one hand, Hommer’s team has consistently found that both alcoholic men and alcoholic women develop greater CSF volume (brain shrinkage) than their control subjects and that the difference between the alcoholic women and the control women is greater than the difference between the alcoholic men and the control men (Hommer et al. ). Hommer’s group also reported that these differences took place despite the alcoholic women’s fewer years of exposure to heavy drinking. On the other hand, Pfefferbaum’s team has been unable to confirm that substance-abusing women are more vulnerable than their male counterparts with respect to brain damage (Hommer ). Hommer thus advocated that more scientists join the investigation. Mann et al.’s study (; N =  subjects,  women and  men) confirms that both alcoholic men and alcoholic women are more likely to have brain atrophy than the healthy control subjects, but alcoholic women developed an equivalent amount of brain reduction to alcoholic men following a significantly briefer period of alcohol dependence. Mann et al. stated that the more rapid development of brain atrophy in alcoholic women is consistent with the “telescoping effect” theory. Likewise, most research findings on alcoholic–cognitive dysfunction relationship indicated that () alcoholic women and men had poorer cognitive performance than their nonalcoholic counterparts; () alcoholic women had a poorer level of cognitive function than alcoholic men or there was no significant difference between the two, but in both cases the alcoholic women tended to have a shorter drinking history and a less severe drinking pattern. This means that cognitive dysfunction occurs sooner during women’s drinking careers, compared to men’s—a phenomenon that echoes the “telescoping effect” theory. For example, Nixon et al. (cited in Hommer ) showed that alcoholic women and alcoholic men had similar levels of cognitive dysfunction despite the fact that the men had more years of heavy drinking than the women. Flannery et al. (; N =  alcohol-dependent men,  alcohol-dependent women,  control men, and  control women in Russia) found that although both alcoholic men and alcoholic women experienced a higher level of cognitive and neuropsychological dysfunction than the healthy control subjects, alcoholic women experienced a higher level of such dysfunction than alcoholic men. Three weeks after detoxification the alcoholic women performed more poorly than alcoholic men in areas like “motor speed,” “visuoperceptual and visuospatial processing,” “working memory,” and “spatial planning and problem solving” (Flannery et al. :,

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Helping Substance-Abusing Women in General

). Flannery et al. additionally found that although their female alcoholic subjects performed more poorly, they actually were younger and had a shorter drinking history and duration of alcohol dependence than their male counterparts. Again, the telescoping effect among alcoholic women is observed. In accordance with these findings, Nolen-Hoeksema () showed that both alcoholic men and alcoholic women had a poorer level of cognitive function than nonalcoholic men and nonalcoholic women and that most research findings indicated poorer cognitive function in alcoholic women than in alcoholic men. Nolen-Hoeksema did come across studies that reported no significant difference on the neuropsychological functioning level between alcoholic men and alcoholic women, but she said this could be because the female alcoholics included in these studies usually had a shorter drinking history and a less severe drinking pattern than their male counterparts. Unlike the above-mentioned studies, which were based on alcohol-related clinical populations (that is, the participants came from AOD treatment programs and thus tended to be individuals with AOD disorder), many studies based on general populations (participants came from the community and thus were less likely to have AOD disorder) showed that mild or moderate drinking may have a beneficial effect on cognitive function for the older population (Bond et al. ; Ganguli et al. ; Ngandu et al. ) or for older women (Dufouil, Ducimetière, and Alpérovitch ; Elias et al. ; Stampfer et al. ; Yonker et al. ). For example, Bond et al.’s () population-based study (N = , Japanese Americans; , women and  men aged  and older) found that for both men and women, moderate drinking (less than  drink [. grams] per day) is linked to better cognitive test scores than abstinence or heavy drinking (more than  drink per day). Specifically, men showed U-shaped curve findings in both their Cognitive Abilities Screening Instrument (CASI) and reaction time (RT) scores; moderate drinkers performed better than abstainers or heavy drinkers ( p = < .). For women, RT findings followed the U-shaped curve, with a faster RT in women who were moderate drinkers compared to either abstainers or heavy drinkers. However, a linear relationship in CASI was found in that women in the heavy-drinking group (the mean number of daily drinks for the group was .) had a higher CASI score compared to light / moderate drinkers (. drink per day) or abstainers. Solfrizzi et al.’s Italian Longitudinal Study on Aging (; N = , non–cognitively impaired older individuals and  older patients with mild cognitive impairment, aged –) found that among the patients whose cognitive function was mildly impaired, those who drank moderately (less than  drink per day) showed a lower percentage of advance to dementia than those who abstained. Stampfer et al.’s () U.S. Nurses’ Health Study (N = , participants aged –) reported that for moderate drinkers (less than  drink [ grams of alcohol per day), compared to abstainers, the comparative risk of general cognition impairment was ..

Introduction

27

Various reasons for the beneficial effect of alcohol on cognitive function have been posited. One of the most credible theories is that moderate drinking lowers cardiovascular disease rates and thus may help maintain brain vasculature and inhibit subclinical strokes, all of which may bring about better cognitive functioning (Stampfer et al. ). Elias et al. () suggested that moderate drinking may decrease hypertension risk, a known factor in poor cognitive function. Of course, more studies are still needed to confirm alcohol’s beneficial effect on cognitive function among the general population, particularly in relation to gender and race, as well as the reasons for the relationships. It is also important to accentuate that alcohol’s beneficial effect on the cognitive function, assuming that it exists, is applicable mainly to the general population, not to individuals with AOD disorders.

The Impact of Drug Abuse and Dependence on Women HIV/ AIDS Risk

Although the differential impact of the alcohol pharmacology on the two sexes is well established (for example, women attain a higher level of BAC than men given an equal dose of alcohol and the “telescoping effect” among women), impact of the pharmacology of other drugs and the differential impact on the two sexes has been less well studied (Blume ). On the other hand, studies have shown that women may be more vulnerable than men to HIV / AIDS when drug abuse is involved, although both sexes are at high risk. According to the CDC (:), during , % of the “reported cases of HIV infection” among women versus % of such cases among men were the result of “injection drug use.” Further, the leading transmission category was “male-to-male sexual contact” (%) for men, whereas it was “high-risk heterosexual contact” for women (%), including % of the infected women being infected through “sex with injection drug user.” Only % of the infected men became infected via “high-risk heterosexual contact,” including % of the infected men being infected via “sex with injection drug user.” Two reasons are suggested to explain the possible gender disparity in drugrelated HIV / AIDS risk: () women’s practice of unsafe injection drug use and () women’s engagement in unsafe sex. Among substance-abusing women, socially marginalized and impoverished women—such as street prostitutes and homeless women—may be more at risk for HIV / AIDS than other women because of their higher rates of unsafe injection drug use and / or unsafe sex practice (Elifson, Sterk, and Theall ; Wenzel et al. ).

Unsafe Injection Drug Use The literature is inconsistent regarding whether women are more likely than men to be injection drug users (IDU), possibly because of the different research methods and sample sources involved. Some studies reported that women and girls may be more likely than men and boys to engage

28

Helping Substance-Abusing Women in General

in injection drug use (e.g., Darke et al. ; Otto-Salaj et al. ; Shillington and Clapp ); some reported that men and boys are more likely to engage in injection drug use (e.g., CDC ; Wright et al. ); and some suggested no difference between the two sexes (Pugatch et al. ). Shillington and Clapp’s () study (N = , adolescents attending publicly funded AOD treatment programs) found that .% of the girls versus .% of the boys “ever injected drugs” ( p < .), and .% of the girls versus .% of the boys “injected drugs [in the] past  months” ( p < .). In addition, girls may be more likely than boys to start injecting drugs at an early age. Miller et al. (), studying  young injection drug users in Vancouver, found that young women were more likely than young men to start injection drug use at the age of  or younger, and that those who started injecting drugs at age  or younger were also more likely to test positive for HIV or hepatitis C than their counterparts who started later than . The  Youth Risk Behavior Surveillance (YRBS) (CDC ), however, indicated that .% of the female high school students versus .% of their male counterparts used illegal injection drugs one or more times during their lifetime. Wright et al. (:; N =  rural stimulant users “currently neither in substance abuse treatment nor incarcerated”; women = .% of the sample) reported that the men were significantly more likely than the women to have ever injected drugs (adjusted odds ratio = .). This may be interpreted as meaning that although (young) women may have an equivalent / lower rate of injection drug use than (young) men (e.g., those in the CDC  YRBS sample and those in Wright et al.’s sample), (young) women with more-severe drug problems or those of the clinical population are more likely to use injection drugs than their male counterparts (e.g., those in the treatment programs in Shillington and Clapp’s study, the methadone-maintenance clients in Darke et al.’s study, and those who were incarcerated in Otto-Salaj et al.’s study). While women with drug problems may be as likely as men to engage in injection drug use, it is likely that they will share or borrow needles / injecting equipment more often than men with drug problems, as shown by various studies (e.g., Bennett et al. ; Cheng et al. ; Evans et al. ; Frajzyngier et al. ; Johnson et al. ). For example, Pugatch et al. () studied  substance abusers aged  to  who attended a drug detoxification center in Massachusetts. They found that the young women and the young men shared similar percentages regarding “injection drug use” (% and %, respectively, no significant difference), but the young women were more likely to share needles than the young men (% and %, respectively, p = .). Johnson et al. (;  men and  women, Alaska) reported that % of their female subjects, compared to % of their male subjects, had shared needles ( p < .). Evans et al.’s () study ( females and  males) reported that % of their female participants versus % of their male participants had borrowed needles from their sexual partner ( p < .).

Introduction

29

The only study found indicating that men were more likely to share needles than women was one conducted in Tanzania (Williams et al. ). However, the background characteristics of women versus men in that study were somewhat atypical of those in the other studies. For example, the women tended to have a higher average income than the men (mostly because of the women’s trading sex), and therefore the women were probably more likely than the men to be able to afford clean needles / drug paraphernalia (Williams et al. ). In addition, more women were single (% versus %) and more men were living with a spouse (% versus %). The lower rate of having a steady sex partner among the women in Williams et al.’s study () could also partially account for why the women did not have a higher rate of needle sharing than the men. One reason that women may be more likely than men to share needles is that women are more likely than men to have an IDU sexual partner (Booth et al. ; Evans et al. ) and that, for men or women, living with an IDU (family members, particularly sex partners) increases the odds of needle / other injecting equipment sharing (Darke et al. ; Fitzgerald, Lundgren, and Chassler ; Johnson et al. ; Shaw et al. ). Further, “primary sex partner being IDU” is a predictor for syringe sharing among women (Lum, Sears, and Guydish ) or a predictor for HIV risk behavior (including needle sharing) for women but not for men (Choi, Cheung, and Chen ). Davies et al. () showed that women are more likely than men to obtain used injecting equipment from a sex partner, whereas men are more likely than women to obtain used equipment from a close friend. Choi, Cheung, and Chen said that women may consider needle sharing a “much more private matter” and therefore confine their needle sharing “mostly within very intimate networks, such as with the main sex partner” more so than men (:). Women may be further subject to the risk of using the used needles / drug equipment because of gender role socialization and social norms such that a man tends to use the needle / paraphernalia first and then pass it on to his female partner (Bennett et al. ; Choi, Cheung, and Chen ; Davies et al. ; Evans et al. ; Lum, Sears, and Guydish ). More studies are needed to confirm gender disparity regarding the issue of unsafe injection drug use.

Unsafe Sex Substance-abusing or not, women may be in a more disadvantageous position to practice safe sex, including negotiating condom use. Studies have shown that women may be less likely than men to use condoms or to use condoms consistently during sex (Booth et al. ; Evans et al. ; Pugatch et al. ; Wright et al. ). Pugatch et al. revealed that % of the women versus % of the men reported “always having used condoms for vaginal sex” ( p = .), and % of the women versus % of the men reported “always having used condoms for anal sex” ( p = .) (:). This appears to be consistent with the CDC’s () YRBS findings that .% of the girls versus .% of the boys reported using a

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condom during their last intercourse. The only study found indicating women as more likely to use condoms than men was that of Williams et al. (). Several reasons may explain why women may be vulnerable to risky sex practice, among them women’s lack of resources and their financial reliance on men, the gender role socialization that puts them in a less powerful role in the relationship, childhood / adulthood sexual and other trauma and violence, AOD-using during sex, and / or multiple sex partners / trading sex for money or drugs. Despite different ages and ethnicities, women in Surratt and Inciardi’s focus groups consistently said that “the primary barrier they faced to safe sex was a lack of empowerment to negotiate condom use, due to expectations of negative reactions from male partners on whom they depended for financial support” (:iv). Such a risk is particularly applicable to substance-abusing impoverished women, such as street prostitutes and homeless women, who desperately need a fix for their drug urge and see sex as the only way for them to get money or drugs. Gender role expectation and socialization may be another factor. Otto-Salaj et al. () found that although girls are more likely than boys to engage in risky behavior, girls actually reported a higher level of HIV / AIDS- related knowledge ( p < .) and intention to practice safe behaviors than boys ( p < .). One interpretation of this could be that girls are cognitively and intellectually competent about refraining from risky behavior, but their competency may be attenuated or sabotaged, in a gender-inequity sexual relationship, by their male sexual partners. Roberts and Kennedy (N =  female college students) found that although the women reported “feeling confident in their ability to ask their partner to use a condom,” more than half of them did not decline the sex when the male partner chose not to use a condom (:). Roberts and Kennedy () said that a male partner’s refusal of condom use may be presented in a way of coercion unrecognized by the woman; also, a woman may accept unprotected sex with her “steady” male partner because of her erroneous belief that if she is monogamous, her male partner must be monogamous as well and, therefore, the sex is not risky. The “resource” and “gender role” factors may explain and reconcile the inconsistent findings from Williams et al.’s study (). As mentioned earlier, the background information of the women versus the men in Williams et al.’s study was somewhat different than that in many other studies: the women had a higher average income and a lower stable sexual partner rate than the men. Because this made them less likely to be subjected to gender inequality issues, they may have been more empowered to practice safe sex, including condom use. Females may be more likely than males to be subjected to childhood sexual abuse (Finkelhor ) and other life sexual violence and traumas, which may be directly or indirectly related to unsafe sex practice and HIV risk (Bensley et al. ; Paxton et al. ; Wyatt et al. ). For example, Kushel et al. () reported that both men and women in the homeless / marginally housed group experienced high rates of physical assault during the preceding year (.% for women

Introduction

31

and .% for men, no significant difference). However, homeless / marginally housed women experienced a significantly higher rate of sexual assault (preceding year) than their male counterparts (.% versus .%, p < .). Wyatt et al. () reported a severe trauma history to be one of the predictors of a woman’s HIV seropositivity status (odds ratio = ., p = .). Wyatt, Myers, and Loeb () suggest that a woman’s decision-making ability with regard to safe sex practice, such as negotiation of the use of a safe sex method, may be attenuated because of her experience of physical and sexual trauma. Further, women’s use of mind-altering drugs during sex also lowers inhibitions and puts them at greater risk of unsafe sex (CSAT ). Wechsberg et al. (; N =  African American crack-using women) found that a majority of the women engaged in sex while high. Eighty-eight percent of the non-homeless women and % of the homeless women in their study reported unprotected sex practice. More than half of the college female students in Roberts and Kennedy’s () study reported using AOD during sex despite being aware of the increased risk. Finally, substance-abusing women may be more likely than substance-abusing men to have multiple sex partners through trading sex for money or drugs and to engage in other HIV risk behaviors. Pugatch et al’s study () showed that young women were significantly more likely than young men to have traded sex for money or drugs ( p < .), to have had sex with a partner who is HIV-infected ( p < .) or who is an injection drug user ( p < .), and to have had a sexually transmitted disease (STD) diagnosis ( p < .). Otto-Salaj et al. (), who studied  incarcerated adolescents, found that girls were more likely than boys to report engaging in risky behavior related to HIV transmission (e.g., having a history of STD, trading sex for money, reporting various sex partners, and using injection drugs).

Race / Ethnicity Although “harm reduction” education and programs on safe injection drug use and safe sex practice are critical in AIDS prevention for all substance-abusing women, they should be especially emphasized when working with substance-abusing minority women. According to CDC  data (CDC ), all racial minority women, except Asian / Pacific Islander women, have a higher estimated AIDS rate than white women. The CDC data indicated that African American women had the highest estimated rate of AIDS (. per , population) among all women, followed by Hispanic women (.), American Indian / Alaska Native women (.), white women (.), and Asian / Pacific Islander women (.). (These distributions parallel those among their corresponding male counterparts, in that African American men had the highest rate [. per , population], followed by Hispanic men [.], American Indian / Alaska Native men [.], white men [.], and Asian / Pacific Islander men [.]). Although substance-abusing women may be exposed to AIDS risks through unsafe injection drug use or unsafe sex, or both, women of different racial / ethnic

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groups appear to experience different levels of risk with regard to each issue. Therefore, AOD treatment and prevention programs, particularly their “harm reduction” component, should incorporate such insights in designing and delivering their services. The CDC  data (CDC :) showed that % of white women who were “reported cases of HIV infection” became infected through injection drug use versus % of the infected African American women, % of the infected Hispanic women, % of the infected American Indian / Alaska Native women, and % of the infected Asian / Pacific Islander women. The higher statistics revealed that white women and American Indian / Alaska Native women had a higher proportion of infection through risky injection drug use than did other ethnic women. Therefore, safe drug use practice (clean needles and syringes) should be especially emphasized when working with these two groups of substance abusers. On the other hand, the data (CDC ) revealed that % of the HIVinfected white women, % of the African American women, % of the Hispanic women, % of the American Indian / Alaska Native women, and % of the Asian / Pacific Islander women became infected via “high-risk heterosexual contact.” Although safe sex practice should be stressed when working with all substance-abusing women, as “high-risk heterosexual contact” is the primary transmission category for all women, safe sex practice should be particularly stressed when working with substance-abusing Hispanic women, as Hispanic women overall have a higher percentage on this measure. Another complicating issue is that % of the HIV-infected Asian / Pacific Islander women and % of the African American women versus % of the white women, % of the Hispanic women, and % of the American Indian / Alaska Native women indicated “other / risk factor not reported or identified” as the transmission category (–). Therefore, more research is needed in order to better understand the specific HIV risk factors among African American and Asian / Pacific Islander women.

The Psychosocial Consequences Women Receive a Harsher Societal Sanction for Their AOD-Using Behavior Not only may women experience a more adverse health impact from AOD use than men, but they may also face harsher societal sanctions for their AOD-using behavior. A survey of college students (cited in Blume ) showed that a drunken woman who was raped gets less sympathy from the respondents, who perceived that the woman should have not consumed alcohol in the first place. On the other hand, the same respondents were more forgiving of a male perpetrator who consumed alcohol when victimizing a woman, since “it’s the alcohol, not the person” that caused the trouble. Even women themselves may pose a double standard in judging women’s AOD-using behavior. Blum, Nielsen, and Riggs () cited

Introduction

33

the results of a survey of a national sample of women, reporting that the survey respondents disapproved of women’s drinking more strongly than men’s. Finkelstein () stated that society’s negative attitudes toward women’s AODusing behavior stem from the issues of sexuality and mothering; substance-abusing pregnant women receive the most condemnation from society. She commented that society often views substance-abusing women as having a weak will, being sexually licentious, and being irresponsible in giving birth to and caring for their children. All these negative societal labels have imposed a tremendous stigma on women’s substance-abusing behavior, and women often experience rejection and isolation or develop depression, guilt, and lower self-esteem as a result of the stigma.

AOD Use Places Women at Higher Risk for Sexual / Nonsexual Victimization Women are more likely to be sexually / nonsexually victimized when AOD use is involved. Parks and Fals-Stewart’s () study (N =  college women) reported that the odds of the women encountering sexual aggression were seven times greater and the odds of the women encountering nonsexual aggression were about four times greater on days when they had any alcohol intake than on days when they had no alcohol intake. Likewise, Gross and Billingham’s survey of female college students (cited in National Institute on Alcohol Abuse and Alcoholism [NIAAA] ) showed a significant correlation between a woman’s reported amount of alcohol consumed weekly and the sexual victimization she experienced. Malik and colleagues (cited in NIAAA ) found that high school girls who used alcohol in the preceding year had a higher chance of being subjected to dating violence than their non-using counterparts. Leonard and Senchak’s study (cited in NIAAA ) shows that wives’ drinking problems are associated with husband-to-wife aggression apart from the degree of the husband’s drinking. Two factors explain the relationship between women’s AOD use and their higher risk for sexual or nonsexual victimization, although the relationship is not necessarily causal. First, research findings have shown that intoxication may impair cognitive function and motor ability, making a woman less competent to discern the cues that presage a would-be sexual assault, as well as less able to resist sexual coercion once it starts (see Testa and Parks ). Second, research findings show that society in general and men in particular may perceive intoxicated women as more acceptable objects for sexual assault. A rape is less likely to be considered “rape” when the victim has been drinking (Blume and Zilberman ; Testa and Parks ). Both society and men tend to attach a stigma to drinking women, as mentioned above, because the women defy gender role norms; they also tend to believe that alcohol stimulates women’s sexual desire (although, in fact, it decreases physiological sexual arousal in women) and, therefore, that “a woman under the influence who says ‘no’ really means ‘yes’” (Blume and Zilberman :; Testa

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and Parks ). The sexual and moral lewdness attached to intoxicated women provides rationalization, if not justification, for the men’s sexual / nonsexual aggression toward drinking women (Blume and Zilberman ).

Substance-Abusing Mothers May Be at Higher Risk of Child Abuse and Neglect Studies have shown a link between child maltreatment and parental substance abuse, and estimated rates of substance abuse among parents / caretakers in the child welfare system ranged from % or % to % (Dore, Doris, and Wright ; Grella, Hser, and Huang ; Young, Gardner, and Dennis ). Parents in the substance abuse–child maltreatment context tend to be mothers (Grella, Hser, and Huang ). Although both substance-abusing mothers and substance-abusing fathers could maltreat a child, Locke and Newcomb () found an association between mothers’ substance abuse and poor parenting but not between fathers’ substance abuse and poor parenting. Perhaps this result is related to the roles of a mother and a father, in that a mother tends to spend a great deal of time in taking care of a child, but a father may engage more with a child in activities related to play (Parke, cited in Locke and Newcomb ). More studies are needed to explore the issue. Substance-abusing mothers in the child welfare system are more likely to lose their child custody rights than non-substance-abusing mothers in the child welfare system (Grella, Hser, and Huang ). Parental function may be negatively affected by substance abuse in various ways. A substance-abusing mother may have financial difficulty because her money is being spent on AOD, and / or she may be physically and mentally incompetent because her judgment is impaired by AOD. These factors may impair her ability to provide shelter and stable care to a child, resulting in physical neglect of the child. Her mental and psychological impairment due to AOD may also directly or indirectly contribute to emotional neglect and abuse as well as to physical and sexual abuse of the child (Dore, Doris, and Wright ; Grella, Hser, and Huang ). Finally, even in the absence of overt child maltreatment, parental substance abuse may negatively affect a child’s general mental health and psychological development (Dore, Doris, and Wright ).

Chapter 

Etiologies and Risk Factors

S

cholars have proposed various theories to explain why people (both men and women) abuse or become addicted to substances. The moral model is based on the assumption that substance abuse is a personal choice and that an individual with addictions is simply an irresponsible person. This assumption leads to the belief that addictive behavior is immoral and, consequently, should be punished. The criminal justice system and some religious organizations adopt this model. Biological theory, on the other hand, assumes that addiction is hereditary and that people become addicts because they are predisposed to do so. Biological theory also assumes that addiction is a disease in and of itself. Psychological theory links addiction to a certain personality type and perceives substance abuse as a form of self-medication that helps an individual control depression and anxiety. Sociological theory blames society for drug abuse, citing in particular the limited legitimate opportunities that are available to certain underprivileged groups, resulting in their pursuit and condoning of drug abuse and drug dealing. Finally, the multivariate theory, also known as the biopsychosocial theory, is based on the premise that addiction stems from multiple factors, including biological predisposition, psychological stress, family and community environment, and social deprivation (Fishbein and Pease ; Fisher and Harrison ). Most professional alcohol and other drug (AOD) treatment programs subscribe to the biopsychosocial theory, with an emphasis on the disease concept. None of the above theories, however, differentiate between men and women, although they may be relevant to both sexes. Since the s, more gender-specific research has helped to identify risk factors that stand out because of their more frequent occurrence among women with AOD problems. This chapter presents those theories, perspectives, and risk factors. For the convenience of discussion, we arbitrarily categorize

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all risk factors as psychosocial, psychological, or biological. Such a division is arbitrary because these factors are often dynamic and fluid and they interact with each other. Likewise, any single risk factor should not be viewed in isolation. Each should be considered in a holistic context, for its impact on the eventual occurrence and persistence of a disorder must be evaluated with respect to its possible interaction with other risk factors as well as with protective factors that the individual possesses (Cooper, cited in Raeburn ). The following discussions of these risk factors are not necessarily exhaustive, as they cover only the currently available literature encountered by the author. Also, although the risk factors considered here are particularly salient to women, they are not necessarily totally irrelevant to men. The difference is a matter of degree. Most important, these theories, perspectives, and risk factors provide only a frame of reference for understanding women’s addiction in general. Practitioners should not sacrifice individualization when it comes to assessment and treatment of an individual client.

Psychosocial Risk Factors Two of the risk factors fall into the psychosocial category: () family AOD history and / or dysfunctional family history and () substance-abusing male partners.

Family AOD History and / or Dysfunctional Family History Substance-abusing women tend to have a higher rate of dysfunctional family history / family AOD history than their male counterparts. The variable “family AOD history” here refers more to an environmental factor than a genetic one, in that the background people in the person’s life could include not just AOD-abusing parents, siblings, and relatives but also frequent friends in the house while the person was growing up. The variable “dysfunctional family history” may mean a broken family with one or both parents missing or a family with member(s) who exhibit deviant or pathological behavior. All of the nine empirical studies reviewed showed a statistically significant link between substance-abusing women and a family AOD history / dysfunctional family history (Boyd ; Chatham et al. ; Chermack et al. ; Deng, Vaughn, and Lee ; Howell and Chasnoff ; Langan and Pelissier ; Toray et al. ; Zilberman, Hochgraf, and Andrade ; Zimmer-Höfler and Dobler-Mikola ). Only one of the studies reviewed (Green et al. ) found that the relationship between the two variables approached significance (instead of being significant). None of the other reviewed studies indicated results otherwise. A provider portrayed the cycle of abuse that was typical of the women in her program (Howell and Chasnoff :): “Picture an alcoholic grandmother who has a daughter who is a substance abuser, who gave birth to her daughter who is a substance abuser and alcoholic (our client), who also gave birth to a little girl.”

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Toray et al. () found that, compared to the male adolescents (n = ), the female adolescents (n = ) reported a higher percentage of mother’s drug use ( p < .), as well as a higher percentage of father’s drug use ( p < .). Langan and Pelissier () showed that % of the substance-abusing men (n = ,) reported drug use in the family of origin versus % of their female counterparts (n = ) ( p < .). Chermack et al.’s () study indicated that women had a more severe family alcoholism history than men ( p < .). Zilberman, Hochgraf, and Andrade () studied  Brazilian drug-dependent individuals ( women and  men) and found that % of the women versus % of the men ( p = .) reported that a first-degree relative had alcohol problems. Chatham et al. () showed that substance-abusing women had a higher rate of dysfunctional family history than their male counterparts. They reported a higher level of criminal participation by both parents, and a significantly greater proportion of them indicated the mother’s involvement in AOD treatment and the father / mother’s involvement in treatment for psychological problems. Two international studies reviewed showed similar results. Zimmer-Höfler and DoblerMikola’s () study of  Swiss-German heroin-addicted individuals (.% women) indicated that more female subjects came from a broken home and that both parents tended to be missing for the female subjects whereas only one parent tended to be missing for the male subjects. Their study also revealed that the women reported a much higher suicide rate (%) among members within their close social networks than the men did. Deng, Vaughn, and Lee () studied incarcerated drug offenders ( women and  men, Taiwan) and found that the female drug offenders were more likely than their male counterparts to have grown up in a family that did not have two parents. Green et al. () reported that substance-abusing women attending an HMO program were slightly more likely than their male counterparts to have a family AOD history (.% versus .%, p = .). Although voluminous studies suggest a higher rate of family AOD history among substance-abusing women than among substance-abusing men, few have explained why (Toray et al. ). One theory proposed by Toray et al. was that because women have a greater emotional involvement with their family of origin, they are therefore more likely to identify with or be affected by their family of origin, including its AOD problems. This view could find support in the nature of the socialization process for men versus that for women: men are encouraged to be in the public sphere and be independent, whereas women are encouraged to be in the domestic sphere and be interdependent. Toray et al. adopt Bandura’s social learning theory, suggesting that children who are exposed to parental substance abuse behaviors are likely to develop substance abuse behaviors themselves, which are further likely to be reinforced by their parents. Chermack et al. () proposed another theory, stating that the effect of a family history of alcoholism on an individual’s later development of AOD and

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violent behavior tends to be mediated by a family history of violence (violence from one parent to the other and violence from parent(s) to the participant). Chermack et al’s theory is consistent with the adverse childhood experience (ACE) theory, but it accentuates the negative impact of ACE on women. Studies have revealed a strong and proportionate relationship between the number of categories of ACE that one is exposed to and the risk of developing AOD problems later in life (Dube et al. ; Felitti and Anda ). Such a link exists regardless of whether the person has an alcoholic parent or not (Dube et al. ). The wave  ACE studies explored eight ACE categories: childhood verbal abuse, physical abuse, sexual abuse, domestic violence, substance abuse in the family, mental illness in the family, incarcerated family members, and parental divorce or separation (Hillis et al. ). The wave  ACE studies added two more categories: childhood physical neglect and emotional neglect. According to Dong et al. (), ACE does not occur alone or independently; % to % of their study respondents who had encountered one ACE reported at least one other ACE. Felitti and Anda () (N = a cohort of more than , Kaiser health plan patients; half were women) indicated that women were more likely than men to report having experienced five or more (out of ten) ACE categories. Consistent with the ACE theory, the “unequal footing” theory proposed by Sun (b) suggests, from a developmental perspective, that individuals born to families with multiple risks have an initial unequal footing. During their childhoods they don’t have equal opportunities to experience the basic trust, parental love and supervision, and other essential nature-or-nurture elements that are fundamental to an individual’s later normal development. Such a negative impact is particularly applicable to a woman growing up with a lower socioeconomic status (SES). Sun’s qualitative study of  AOD-using women revealed five factors explaining how early childhood experiences may, directly or indirectly, link women to AOD addiction. A woman may experience one or more than one of the following five risk factors: () being born with fetal alcohol syndrome; () turbulent and unstable family situations (constant moving, violent behavior, absence of biological father, multiple stepfathers, staying with relatives rather than parents); () growing up in an environment where grandmother, mother, father, aunts, siblings, and / or cousins all use AOD, creating easy access to and acceptance of a drug-using lifestyle; () physical / sexual abuse or other exploitation, resulting in a lack of basic trust of adults and rage toward others and self; and () AOD use at an early age, leading to dropping out of school before completing seventh grade and thereby being unprepared for making sound judgments, for problem solving, and for developing vocational skills. The fourth theory would suggest that both men and women are equally affected by the negative impact from their AOD-using family of origin, and both thus may develop AOD problems later on in life; in addition, men may be more likely than women to be affected by factors other than a substance-abusing or

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dysfunctional family history to develop AOD problems. For men, personal choice, involving curiosity, adventure, and pleasure seeking, as well as a quest for power and peer influence are among the possible factors, other than a dysfunctional family, that influence their substance abuse. Therefore, we see a higher rate of family AOD history among substance-abusing women than among men. The causes of substance abuse among women may be more homogeneous (e.g., a family AOD history / dysfunctional family history), whereas they may be more heterogeneous among men (e.g., personal choice other than a family AOD history / dysfunctional family history). Again, this may be related to society’s gender role expectations and its double standard in judging women versus men. Men are more free to pursue an AOD-using lifestyle than women are, regardless of whether a dysfunctional or substance-abusing family of origin is involved. In other words, although both men and women from families with AOD problems are likely to develop AOD problems themselves, probably fewer women from families without AOD problems are likely to develop AOD problems than men from families without AOD problems. More studies are needed to clarify this issue.

Treatment Implications The insight that substance-abusing women may have a high rate of family AOD history may contribute to more effective treatment for women, particularly adolescent girls. Toray et al. () said that it is counterproductive to treat a substanceabusing adolescent girl while her parent(s), sibling(s), or other members of the household are still using. They believe it is critical to treat other addicted family members at the same time as treating an addicted adolescent. Boyd () suggested that the treatment programs should assess a woman’s family background regarding AOD-using history and, wherever possible, provide her and the family members with family therapy. Boyd said a woman should be granted an opportunity to talk about the substance-abusing environment that she grew up with and that she may revisit. Effective strategies empowering her to deal with her substance-abusing family member(s) should also be included in the treatment. In addition, Dube et al. () advocated that ACE assessment be included in AOD treatment and prevention. Other strategies may include offering parenting classes so as to help women break the cycle and targeting “habilitation” (in addition to rehabilitation) by filling in whatever the woman has missed (e.g., education, employment skills, self-confidence, and other life skills) while growing up.

Substance-Abusing Male Partner Extensive studies have documented that substance-abusing women are more likely to be introduced to or maintain drug use and abuse by their male sexual partner than the other way around (Anglin et al. ; Brady and Randall ; Eldred and Washington ; Riehman, Hser, and Zeller ; Schneider et al. ;

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Wilsnack and Wilsnack ). For example, Riehman, Hser, and Zeller (N =  cohabiting / married recent drug users) showed that partner-related variables cannot predict much about men’s motivation to get treatment, but they can significantly predict women’s motivation, in that the odds of a woman’s desire and readiness for treatment decrease if she has a drug-using partner and increase if her partner has been under treatment. Wilsnack and Wilsnack found no strong link between husbands’ self-reported drinking problems and their perceptions of their wives’ drinking frequency, but they did find such a link between wives’ self-reported drinking problems and their perceptions of their husbands’ drinking frequency. Schneider et al. (N =  female and  male alcoholics) showed that being married decreased relapse risk for men but increased relapse risk for women in a short period (see chapter  for more information about the impact of substance-abusing male partners on women). The reason that both the factor of “family AOD history” and the factor of “substance-abusing sexual partner” affect women’s AOD-using behavior to a much greater extent than men’s may be related to traditional gender role expectation and the socialization process. Citing Haavio-Mannila, Wilsnack and Wilsnack () stated: “Women are more likely to imitate the drinking behavior of higher status males, whether in the family or in the workplace than men are to imitate female drinking behavior” (). Sun’s () qualitative study discovered that one of the four major factors contributing to women’s relapse was women’s judgment of their self-worth—or, more specifically, their lack of self-worth—and its connection to intimate relationships with men. Many women in that study appeared to build their self-worth and a sense of well-being and success on the existence of their relationship with the men. They might have felt that they would lose everything if they lost their men. That study revealed that a woman may use AOD to please her drug-using partner or to “keep him home,” may stop using AOD because he wants to stop using, and may relapse because he chooses to use again. A woman in that study stated: “My whole world revolved around him.”

Treatment Implications Numerous researchers (e.g., Laudet et al. ; Riehman, Hser, and Zeller ; Tuten and Jones ) have strongly recommended that treatment professionals must consider the drug-using status of a substance-abusing woman’s sexual partner when admitting the woman, and take the partner’s drug-using and treatment behavior into consideration as a major factor when treating the woman. Cavacuiti () addressed the issue of “concordant couples” (both partners are substance abusers) and stated that clinicians must provide effective family-couples therapy and be cognizant that both members of the dyad may not necessarily be moving at the same pace in terms of treatment. Behavioral couples therapy (BCT) may be applied if a woman’s male partner is a non-user (Winters et al. ; see chapter  for a more detailed discussion of BCT). Equally important, the practitioner

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should assess whether the woman’s partner is violent in addition to abusing substances and whether the woman should be placed in a safe and supportive environment to achieve maximum recovery (Schneider et al. ). Users or not, male partners of substance-abusing women are not all willing to be involved with the women’s treatment, nor are all male partners suitable to participate in the women’s treatment (Laudet et al. ). Nonetheless, practitioners must explore the role that drugs played in the relationship between substanceabusing women and their male partners. The power of women’s partners must not be ignored. Practitioners’ recognition of the role played by the women’s partners may better help the women surmount obstacles and increase the odds of a successful treatment outcome (Laudet et al. ).

Psychological Risk Factors Both men and women may be subjected to psychological risk factors for substance abuse. Five such factors are especially pertinent to women: () unpleasant affects and interpersonal problems, () life transition crises, () childhood abuse and traumas, () co-occurring mental disorders, and () an obsession and dissatisfaction with body image and appearance. There may be an overlap between or among the five areas; the categorization here is for the convenience of discussion. Women may abuse / misuse AOD to cope with negative emotions, psychological issues, or psychiatric symptoms; they may also abuse / misuse tobacco, illegal or legal drugs, or food in an attempt to control their weight and physical appearance. The theme of “self-medication” by women using AOD or other substances appears to cut across all five areas. As discussed in chapter , self-medication has not been uncommon among women historically, as illustrated by those nineteenth-century women who used morphine and opium and mid-twentieth-century women who used tranquilizers to reduce negative affects and pain. Many empirical studies today (e.g., Annis and Graham ; Back et al. ; Haseltine ; Hser, Anglin, and Booth ; Langan and Pelissier ; McKay et al. ; Pisinger and Jorgensen ; Thom ; Zimmer-Höfler and Dobler-Mikola ) have consistently suggested that women* are more likely than men to use or relapse to AOD to self-medicate negative emotion. *Note: The term “women” here (except for the Pisinger and Jorgensen study) refers primarily to women from clinical populations (clients receiving AOD treatment or meeting DSM AOD disorder criteria) rather than to women in the general population. Nolen-Hoeksema’s () review showed that in the general population men may be more likely than women to self-medicate emotional pain, whereas in the clinical population women are more likely than men to do so. Olenick and Chalmers (cited in Nolen-Hoeksema ) showed that % of the female clinical population (clients diagnosed with alcohol use disorder, or AUD) versus % of the female general population (social drinkers) reported drinking to alter a negative mood. On the other hand, % of the male clinical population versus % of the male general population reported doing so.

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Both to highlight the significance of the role of self-medication in contributing to women’s AOD abuse / misuse and to provide a more complete picture regarding other risk factors involved in women’s AOD abuse / misuse, we need to address the sensation- or pleasure-seeking factor and the control or power factor. Study findings are relatively more consistent regarding women’s (clinical population) using AOD for self-medication, but they are relatively less consistent about the impact of the pleasure-seeking factor on the two sexes. Although many studies (Annis and Graham ; Back et al. ; Haseltine ; Hser, Anglin, and Booth ; Langan and Pelissier ; Thom ) suggest that men are more likely than women to use AOD to seek pleasure, enhance positive feelings, or for social reasons, some others (McKay et al. ; Pisinger and Jorgensen ; ZimmerHöfler and Dobler-Mikola ) indicate no significant difference between the two sexes. Zimmer-Höfler and Dobler-Mikola’s () study showed that the same percentage of women and men heroin users (% each) gave “sensation-seeking curiosity” as the motivation to initiate the use. McKay et al. (;  male and  female patients) found that although women reported significantly higher “unpleasant affect” and “interpersonal problems” scores than men before their relapse and men reported a significantly higher “positive experience” score than women before relapse, there was no significant difference in the “sensation seeking” score between the two sexes before relapse. Pisinger and Jorgensen (; N = , daily smokers [gender distribution not presented] and N = , individuals in the general population in Copenhagen, Denmark [both smokers and nonsmokers included, equal number of women and men included]) reported that a similar proportion of women and men smokers relapsed because they “missed smoking at parties” (% and %, respectively), although a greater percentage of women than men smokers relapsed because they were nervous or depressed (% versus %, respectively) or because they experienced crises such as death, unemployment, illness, or other problems (% versus %, respectively). Scourfield, Stevens, and Merikangas’s study (; N =  probands,  women and  men) shed an interesting and important light on the impact of self-medication and sensation seeking on the two sexes. They divided participants of each gender into four groups (substance abuse only, substance abuse and comorbid anxiety, anxiety only, and control) and found that the “substance abuse only” women had a significantly higher thrill-seeking score than the “substance abuse and comorbid anxiety” women, whereas there was no significant difference in the thrill-seeking score among the “substance abuse and comorbid anxiety” group, the “anxiety only” group, and the control group. On the other hand, there was no significant difference in the sensation-seeking score between the “substance abuse only” men and the “substance abuse and comorbid anxiety” men. Scourfield, Stevens, and Merikangas () therefore suggested that their findings lend some support to the self-medication theory for women and the notion that the

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thrill-seeking factor may have a stronger impact on women’s pursuit of substance abuse when dual diagnosis or self-medication is irrelevant. In other words, Scourfield, Stevens, and Merikangas believe that because society holds a stricter standard for women’s AOD-related behavior and women are thus less likely to pursue an AOD-using lifestyle, a woman who does not have a dual diagnosis or a need to self-medicate pain but ends up still using AOD is probably more likely to be predisposed to a higher level of thrill-seeking personality trait, which propels her to actually engage in AOD use. Those authors also called for more prospective studies to examine this issue. Research findings about the impact of the power or control factor on the two sexes are not abundant but are consistent. Zimmer-Höfler and Dobler-Mikola’s () study showed that although both sexes shared the same percentage (% each) in the sensation-seeking factor; among the remaining % of the participants of each sex women were more likely to use because of feelings of sadness and men because of feelings of powerlessness. Some behavioral addiction (in contrast to AOD addiction) studies also point in the same direction. For example, Young’s () Internet addiction study revealed that women are more likely to pursue interpersonal support, relationship, and romance or to criticize their spouse by participating in chat rooms, whereas men seek power, status, dominance, and control by gravitating toward information glut, aggressive interactive computer games, and / or cyber-porn. Likewise, Brubaker and Cohen () suggest that women may gamble to avoid pain or to escape from reality, while men tend to gamble to compete or to seek control. Three other things may further help us better understand the theory of selfmedication in reference to women. First, some laboratory and other studies (Back et al. ; Frankenhaeuser et al. ; Steiner, Leslie, and Nyamathi ) have suggested that women tend to have a stronger subjective reaction to stress than men do despite men’s having a stronger physiological reaction to stress than women do—e.g., heart rate. However, these findings are preliminary, and more studies are needed, with larger sample sizes. Second, women are particularly prone to self-medicating using AOD when they do not possess functional coping skills (CASA ). Third, women are more likely to self-medicate using AOD when they have a high expectation of the function of AOD to take care of the issues (CASA ). For example, CASA’s  study showed that girls who believe that alcohol helps reduce sadness and boredom report more alcohol use than girls who do not believe that. As young as the sixth grade, girls are more likely than boys to perceive that alcohol has a positive function in decreasing negative moods and feelings (Johnson and Johnson, cited in CASA ).

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Unpleasant Affect and Interpersonal Conflicts Empirical studies on alcohol (Annis and Graham ; Donovan, cited in CASA ), cocaine (Back et al. ; McKay et al. ), heroin (Zimmer-Höfler and Dobler-Mikola ), or drugs in general (Langan and Pelissier ) have consistently shown that women are more likely than men to use substances to self-medicate negative emotions and / or other interpersonal problems. Annis and Graham (N =  clients, % female) found that subjects who fell into the “negative profile” group—i.e., those who were significantly more likely than other profile groups to report that their heavy drinking was triggered by conflict with other people and negative emotions—tended to be women. Donovan (cited in CASA ) found that girls who engaged in heavy drinking were more likely than their boy counterparts to do so in order to get away from their frustration, anger, or other problems. Back et al.’s () study (N =  women and  men, all cocaine-dependent) found that women may be more likely to use cocaine to cope with negative emotions, whereas men usually use cocaine in positive, pleasant emotion situations. McKay et al.’s study showed that female subjects had significantly higher scores of “unpleasant affect” ( p < .) and of “interpersonal problems” ( p < .) than their male counterparts prior to relapse. Their analyses further revealed that this difference is not merely a reflection of gender difference, since women may have been more likely than men to have a higher level of unpleasant affect and interpersonal problems, with or without relapse. They found that such gender difference appeared to be specific to the relapse occurrence and not existent during the period of abstinence. Zimmer-Höfler and Dobler-Mikola () found that women tend to perceive their initial heroin use to be attributable to their problems with their significant others, whereas men are more likely to attribute their initial heroin use to special situations. Langan and Pelissier’s study () (N = , men and  women) indicated that a higher proportion of men than women used drugs for hedonistic reasons (% versus %, p = .) and a higher proportion of women than men used drugs to reduce psychological or physical pain (% versus %, p = .). The relationship between interpersonal conflicts and negative emotion is often bilateral, and both were perceived by women as major triggers to relapse (Sun ). Grella, Scott, and Foss’s () study found that substance-abusing women are more likely to have serious interpersonal problems than men both at intake and at the - and -month post-intake follow-ups. According to Sun’s qualitative study, substance-abusing women’s interpersonal conflicts may arise because of () their ineffective communication skills in dealing with the various authoritative systems, such as the child protective service system, substance abuse counselors, or the criminal justice system; () their lack of resources and, thus, their involuntary continued connection or living with family members or relatives with whom they

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may have dysfunctional relationships and interpersonal problems; () their interpersonal conflicts with their male partner due to his infidelity and / or mental or physical abuse. (See appendix B for details.)

Life Crises and Transition The literature has shown that women may be more likely than men to attribute AOD abuse / misuse or relapse to a life crisis (Pisinger and Jorgensen ; Thom ). Life crises may include, for example, death of one’s own baby (or miscarriage), the spouse, a close relative, or a best friend; realization of infertility; divorce or separation; retirement; empty nest; loss of physical independence; persistent or unexpected illness in a parent or in self; financial crisis; employment problems; addition of a new baby, intensifying existing marital problems (Long and Mullen ; Pisinger and Jorgensen ; Sun ; Thom ). For example, Pisinger and Jorgensen’s study () reported that more female than male smokers relapsed because “something important happened” (death, unemployment, illness, and problems; % of the women versus % of the men, p < .). Thom (; N =  men and  women) found that men perceived how alcohol became a problem in their life differently than women did. Men attributed their drinking problems mainly to their occupation and the drinking social network they were in. Both gradually dragged them into a drinking lifestyle. Men didn’t usually recognize their drinking problems until their physical state or social relationship (for example, marriage) was impaired because of drinking. Significantly more men ( of the  men) than women ( of the  women) relayed this situation ( p < ., Fisher’s Exact Test). Women, on the other hand, tended to attribute their drinking problems primarily to “a response to a specific, distressful event, or as a response to problematic social situations where they had learned to use alcohol as a coping device” (). Seven of the  men versus  of the  women indicated this situation ( p = ., Fisher’s Exact Test; although the result did not reach statistical significance, it provided a direction).

Childhood Sexual / Physical Abuse Research findings have long established the link between childhood sexual / physical abuse and women’s later development of AOD problems. Many studies consistently show high rates of childhood sexual / physical abuse among AOD-using women or high rates of AOD abuse among women with a history of childhood sexual / physical abuse (McCauley et al. ; Wilsnack et al. ). However, the nature of the link between childhood maltreatment and women’s development of AOD problems is not completely clear. First, the link is not necessarily of a causal nature. Second, studies have shown that patients with a childhood sexual / physical abuse history do not necessarily have a worse AOD treatment outcome compared

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to their counterparts without childhood sexual / physical abuse. Third, alcoholdisordered patients with a childhood sexual / physical abuse history do not necessarily have a higher drinking frequency than alcohol-disordered patients without a childhood sexual / physical abuse history (Zlotnick et al. ). Finally, although many studies consistently showed a link between childhood sexual abuse and the later development of AOD problems, those studies were retrospective in design. The prospective studies yielded less consistent results, with some reporting no such link (e.g., Widom, Weiler, and Cottler ) and others showing a link (e.g., Bailey and McCloskey ). Therefore, more studies are needed to help us better understand this issue. Nonetheless, the literature does provide the following four explanations as to how childhood sexual abuse (CSA) may increase a woman’s risk of developing AOD problems later in life: () CSA may provoke shame, guilt, anger, poor selfconcept, damaged sense of self, depression, and self-blame in the victim, leading to self-medication with AOD or other avoidant or tension-reducing dysfunctional behavior such as suicidality (Briere and Elliott ). () Childhood abuse and other traumatic stressors may disrupt the victim’s brain chemistry (such as serotonin production) (Bremner ), resulting in a lower level of self-regulatory ability or a “behavioral under-control.” Bailey and McCloskey’s review () suggested that the elements of “behavioral under-control” include aggression, impulsivity, inattention, hyperactivity, and sensation seeking or risk seeking. The impulsivity and sensation-seeking attributes increase the individual’s risk for substance abuse (Bailey and McCloskey ; McGue et al. ). Bailey and McCloskey’s longitudinal study (; N =  sexually abused girls and  non-abused girls) found that CSA is prospectively related to a later development of substance abuse. It also found that the pathway from CSA to substance abuse is mediated by “behavioral under-control” but not “depressive self concept” (). () CSA may lead to posttraumatic stress disorder (PTSD), which then leads to women’s substance abuse through self-medicating. In other words, women’s substance abuse may relate to their response to a trauma (e.g., PTSD) rather than to the traumatic event per se (e.g., childhood abuse) (Epstein et al. ; Simpson ). () Childhood abuse does not occur in a vacuum and may be accompanied by multiple other family problems and adverse childhood experiences (ACE), leading to the development of substance problems later in life (Dong et al. ; Widom et al. ). As mentioned earlier, ACEs may include parental divorce or separation, household AOD abuse, family member with mental illness, and domestic violence, in addition to childhood abuse and neglect. Felitti and colleagues (; Felitti and Anda ) suggested that ACEs may disrupt a person’s neurodevelopment, which may then impair cognitive, emotional, social, and other functions; which further leads the person to adopt health-risk behavior and eventually results in disease, disability, and, ultimately, an early death.

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Dual Diagnosis / Co-occurring Disorders The term “comorbidity” means a co-occurrence of at least two psychiatric disorders, and the term “dual diagnosis” means, more specifically, a co-occurrence of substance use disorders and other psychiatric diagnoses (Stinson et al. ). However, “co-occurring disorders” (COD) has gradually replaced “dual diagnosis” because “dual diagnosis” could mean a combination of mental retardation and mental disorders, not necessarily substance abuse and mental disorders; it also implies the existence of only two diagnoses, but in fact it could include more than two (CSAT ). “Comorbidity” may further be classified as homotypic comorbidity in that all the co-occurring disorders are from similar diagnostic groupings (e.g., sedative dependence and alcohol dependence disorders) or heterotypic comorbidity in that the co-occurred disorders are from dissimilar diagnostic groupings (e.g., alcohol dependence disorder and PTSD) (Stinson et al. ). This section focuses on COD, which is defined as a combination of at least one independent substance use disorder and at least one independent mental disorder (CSAT ). Both epidemiological and clinical studies have found a high level of cooccurrence between AOD use disorders and other psychiatric disorders, particularly mood / anxiety disorders (Grant et al. ). Such a co-occurrence is especially salient between AOD dependence (versus AOD abuse) disorders and mood / anxiety disorders. For example, the – National Institute on Alcohol Abuse and Alcoholism’s National Epidemiologic Survey on Alcohol and Related Conditions data showed that () individuals with “any substance use disorder” were . times more likely than individuals without “any substance use disorder” to have “any mood disorder” and . times more likely to have “any anxiety disorder” and () individuals with “any substance dependence disorder” were . times more likely than individuals without “any substance dependence disorder” to have “any mood disorder” and . times more likely to have “any anxiety disorder” (Grant et al. ). The mood and anxiety disorders here refer to independent mood and anxiety disorders and not to AOD-induced symptoms or AOD withdrawal symptoms. The above example shows that a substance-abusing person is more likely to be afflicted with a psychiatric disorder. This next example demonstrates that a person diagnosed with a psychiatric disorder is more likely to be afflicted with a substance use disorder. The Epidemiologic Catchment Area Study data indicated that AUD occurred in .% of the individuals with bipolar I disorder; .%, bipolar II disorder; .%, schizophrenia; .%, panic disorder; and .%, unipolar depression. All of the rates just cited are higher than that of the general population, .% (cited in Frye et al. ). Further, Sacks et al.’s review (cited in CSAT ) showed that AOD treatment programs report that about % to  % of their clients are afflicted with co-occurring mental disorders, and mental

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health programs report that about % to % of their clients are afflicted with co-occurring AOD use disorders. Female problem drug users living with children under age  were four times more likely to report a major depressive episode occurring in the past year, and . times more likely to report depression, anxiety, agoraphobia, or panic attack, compared with females who were not problem drug users (U.S. Department of Health and Human Services ). Compared to male addicts, female addicts again show a higher rate of comorbid psychiatric disorder, particularly depression and anxiety (Blume ). According to Blume and Zilberman (), the more commonly found comorbid psychiatric disorders among addicted men are “antisocial personality disorder,” “pathological gambling,” and “residual attention deficit disorder”; among addicted women, they are depression, anxiety (e.g., PTSD, social phobia), eating disorders, and so on. Levander et al’s study (; N =  bipolar women and  bipolar men) indicated that bipolar women with alcohol use disorder (AUD) had a significantly higher PTSD rate than bipolar women without AUD (.% versus .%, p = .; odds ratio = .). However, the PTSD rate was not significantly different between the AUD and non-AUD groups among bipolar men (.% versus .%, NS). Mangrum, Spence, and Steinley-Bumgarner () studied dual-diagnosed clients ( women and  men with AOD use disorders and severe / non-severe psychiatric disorders) and found that a significantly higher percentage of women were having PTSD compared to men (% versus %, respectively, p = .) and the two sexes were not different on all other psychiatric diagnoses such as depression, bipolar, dysthymia, panic disorder, generalized anxiety, obsessive compulsive disorder, or psychotic disorder. One key issue about the co-occurrence of AOD use disorder and other psychiatric disorders that is still not completely clear is whether there is a causal relationship and, if there is, which variable is the cause. Although Vaillant () suggested that depression or anxiety is more the resulting behavior than the predisposing factor for alcoholism, his sample included only men; such a connection is unclear among women because of the lack of studies (Blume ). Blume summarized various studies, showing that about % of dual-diagnosed women had depression as their major disorder (depression occurs before alcoholism), compared with % to % of men. Similarly, Zilberman, Tavares, Blume, and el-Guebaly’s  review of empirical studies showed that women with depression are more likely to later develop an alcohol use disorder than are both women without depression and men with depression. This depression-drinking sequence may support the self-medication theory for women. Frye et al.’s study () findings also lead to the self-medication theory for women. Frye et al.’s logistic regression revealed that the characteristics of “polysubstance use” and “social phobia” were more prevalent among bipolar women with a lifetime alcoholism history compared to bipolar women without alcoholism, but

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that the characteristics of “family history of alcoholism,” “family history of bipolar disorder,” and “history of physical abuse” were more prevalent among bipolar men with a lifetime alcoholism history compared to bipolar men without alcoholism. Those authors thus suggest that the “genetic loading” factor may play a more important role in men’s bipolar-AUD, whereas it is possible that bipolar-AUD in women is more about an attempt to self-medicate social phobia and depressive episodes. The self-medication theory, however, may not be the only mechanism linking AOD use disorder and other psychiatric disorders. More studies are still needed to confirm what we have found so far. Multiple other theories could explain the association between AOD use disorder and other psychiatric disorders. To take PTSD as an example, in addition to the self-medication theory, which suggests that alcohol is used to numb traumatic memories, Reynolds et al.’s review (:) suggested three other alternative theories: () The “PTSD symptoms” are not really symptoms produced by an independent PTSD disorder but are the withdrawal symptoms of AOD use disorder or symptoms related to active AOD use. () An AOD-using lifestyle may predispose an individual to traumas and subsequently PTSD—i.e., AOD use disorders occur prior to PTSD; or AOD use post trauma may further expose the individual to other traumas. () The PTSD-AOD or AOD-PTSD link is not really a causal relationship; instead, both may occur due to a third cause, such as a “history of conduct problems,” “genetic or neuropsychological factors,” and so on. The COD issue is important both to AOD treatment and to mental health treatment programs. The medical compliance of a patient in a mental health program may be compromised if the patient has an unaddressed AOD use problem. Likewise, although a secondary psychiatric disorder (a disorder occurring after AOD use disorder) will decrease or disappear when AOD use disorder is treated, an unaddressed primary psychiatric disorder (a disorder occurring before AOD use disorder) may sabotage AOD treatment outcomes and may trigger AOD relapses (Reynolds et al. ). For example, Green et al.’s () logistic regression analyses ( women and  men) revealed that a woman presenting higher Addiction Severity Index psychiatric scores at baseline was less likely to maintain abstinence at follow-up compared to a woman with lower psychiatric scores. Likewise, Najavits et al.’s study (;  cocaine-dependent outpatients with PTSD [.% female] and  cocaine-dependent outpatients without PTSD [.% female] indicated significant improvement from baseline to months  and  in areas of alcohol, legal, employment, and psychiatric only for their cocaine-dependent outpatients without PTSD, not for their cocaine-dependent outpatients with PTSD.

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Dissatisfaction with Body Image and Appearance Studies have suggested an association between women’s consciousness about— or even obsession with—body image and appearance and their various substance abuse problems, such as smoking, methamphetamine use, or disordered eating. The issue of dissatisfaction with body image and appearance is particularly relevant to young white women, although more-recent studies suggest that adolescent girls of other ethnic groups may be equally likely to be affected (Erickson and Gerstle ). Nolen-Hoeksema’s () review suggested that although both girls and boys undergo puberty and display secondary sex characteristics (body appearance change), girls appear to view their body appearance change more negatively than boys do and they dislike the weight they gain. Further, girls tend to place more emphasis on their appearance and base their self-esteem and emotional well-being on how they look. Young’s () Internet addiction study revealed gender difference in that men sought power, whereas not only did women seek interpersonal support when online but they “also enjoyed the comforting realization that no one they encountered on-line could know what they looked like” (–). Despite more opportunities for women today, women still face enormous pressure from prevailing cultural messages to be thin and beautiful, among many other demands, to please others.

Smoking Women may smoke for various purposes, one of which is to lose weight. Studies have directly or indirectly shown a link between women’s smoking and their concern about weight. For example, Austin and Gortmaker’s () prospective study (N = , middle school girls and boys) indicated that girls who dieted once a week at baseline were two times more likely to become smokers two years later than girls who reported no dieting. Girls who dieted more than once a week were four times more likely to have become smokers two years later than girls who reported no dieting. Voorhees et al.’s () ten-year cohort study (N = , African American girls and , white girls) showed that an African American girl was . times, and a white girl was . times, as likely to be a daily smoker at ages – if they reported “trying to lose weight now” at ages – (). The literature has suggested that women are less likely than men to quit smoking. One possible reason is that women smokers worry about post-quitting weight gain. Pisinger and Jorgensen’s () study indicated that % of the women versus % of the men ( p < .) reported “weight gain” as one of the reasons for smoking relapse. Younger or overweight women smokers may be particularly at risk for relapse if they gain weight after quitting. One study indicated that, compared to men, younger women are much more likely to report a smoking relapse that is attributed to weight gain (Pisinger and Jorgensen ;

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Pomerleau and Saules ). The studies by Pisinger and Jorgensen and by Pomerleau and Saules revealed that overweight women smokers, compared to their normal-weight counterparts, may be more at risk for relapse due to concerns about weight gain after quitting; they may also have a lower self-efficacy in relation to avoiding relapse when facing weight gain.

Methamphetamine Women may also abuse methamphetamine (meth) for various reasons (to get high or avoid stress, to be more energetic and productive). Also, like nicotine, meth suppresses appetite, and women may count losing weight as one of the reasons they use it. Empirical studies on the association between women’s meth use and their intention to lose weight are less systematic and prevalent than those on the link between women’s smoking and their motives to lose weight or relapse for fear of weight gain. Some ethnographic and qualitative studies (Joe ; Sun ) and several quantitative studies (Brecht et al. ; Cretzmeyer et al ) did reveal the association between women’s meth use and their intention to lose weight. Brecht et al.’s () study (N = ; % female) found that % of the women versus only % of the men initiated meth use to lose weight, along with other purposes. The Iowa Case Management Project study (N = ) of meth use among rural residents discovered that women were significantly more likely than men to use meth to lose weight ( p = .), along with motives like a desire to escape, to handle emotional problems, and so on (Cretzmeyer et al. ). Joe’s () ethnographic study of  women (mean age = ) showed that weight loss motivated many women to continue meth use. Joe stated: “Several females described a dramatic and severe loss of weight over a short time span. . . . In some instances, the desire to keep their weight down becomes obsessive” (). One woman said, “It wasn’t being stoned, it made me lose weight. I liked getting skinny!” and others said “staying slim and trim” and “looking good” “builds one’s self confidence” (Joe :–). Women’s (particularly young white women) concern about their weight and appearance may partially explain their high rate of meth use. According to Cretzmeyer et al.’s () analyses of SAMHSA’s TEDS data, the group aged – accounted for only % of the total treatment admissions (all drugs) in , but they accounted for % of the total meth admissions that year. Although whites constituted % of the total treatment admissions nationwide, they constituted more than % of the total meth admissions. Also, although women made up less than % of the total treatment admissions nationwide, they represented % of the total meth admissions. Likewise, Shillington and Clapp’s () data analysis of , adolescents (% females) who attended AOD treatment programs revealed that a significantly higher percentage of girls than boys

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reported meth / crystal as their primary drug choice (.% versus .%, respectively, p < .).

Eating Disorders (ED) and Disordered Eating (DE) Eating disorders basically include anorexia nervosa (AN) and bulimia nervosa (BN). In , DSM-IV added binge eating disorder (BED) as a possible new category of diagnosis that awaits further study. Disordered eating is defined as problematic eating behavior or subclinical symptoms of AN, BN, or BED fulfilling partial criteria of AN, BN, or BED. Eating disorders have increased in the past fifty years, and more than % of the individuals afflicted with AN and BN are women (American Psychiatric Association ; Striegel-Moore and Cachelin ). The prevalence rates for those who meet full criteria for AN or BN are low, but the rates for those who exhibit subclinical AN or BN symptoms are much higher (Striegel-Moore and Cachelin ). The following discussion mainly highlights a possible connection between the theory of women’s concern about their weight and appearance and their development of ED / DE. The etiology of ED / DE is not well understood and may include multiple risk factors, including the sociocultural context factor (beauty ideal, gender roles), the family and interpersonal context factor (family dynamics and peer influences), the personal factor (genetic and personality traits), and the trauma factor (physical and / or sexual abuse) (Striegel-Moore and Cachelin ). One risk factor that is often part of the equation is a woman’s weight concern, dissatisfaction with her body and shape, and her dieting behavior, all of which may result from her internalization of the sociocultural messages that thin is beautiful and physical appearance is important. Although today’s women enjoy more equal rights and opportunity in relation to men, and sometimes some anti-tradition gender role ideology may emerge, society’s double standard in relation to the importance of appearance and certain eating behaviors have been subjected to change only slowly and may still be powerful influences on women. Some gender role biases include considering women’s appearance to be more important than men’s in dating and believing that women who eat small meals are perceived to be more feminine (see Striegel-Moore, Silberstein, and Rodin’s  review). Such views may still be prevalent and have a direct or indirect impact on women’s development of ED / DE. Many prospective studies consistently indicated that the development of DE / ED is associated with a girl’s weight concern, body image dissatisfaction, and dieting behavior (Striegel-Moore and Cachelin ). Graber et al. (N =  adolescent girls; cited in Striegel-Moore and Cachelin) found that an ED / DE occurrence has more to do with a girl’s personal vulnerabilities (such as negative body image, being overweight, depression) than to her relationship with her family. Both of Killen et al.’s prospective studies (N =  adolescent girls and N =  high school adolescent girls, respectively) revealed that of the variables

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investigated (weight concerns, dietary restraint, pubertal development, body mass index, behavioral or psychological characteristics related to eating disorders), only the variable of weight concerns was significantly associated with the onset of “partial syndrome BN” (cited in Striegel-Moore and Cachelin ). Citing Stice and Cameron et al.’s prospective study (N =  adolescent girls), which showed that dieting and binge eating were predictors of greater weight gain, Striegel-Moore and Cachelin () discussed the possibility that BN and BED are the result of an individual’s initial intention to achieve thinness. Such intention leads to DE behavior and the subsequent weight gain, which in turn intensifies the person’s urge to get thin and thereafter starts the whole vicious cycle until a full syndrome of BN or BED is eventually reached. However, Striegel-Moore and Cachelin () pointed out that weight concern is actually part of the core symptoms and diagnostic criteria of ED and therefore future research should explore what leads to an individual’s concern about weight gain. Recently, Corning, Krumm, and Smitham’s () social comparison study (N =  undergraduate women aged –) provided a perspective on who becomes more vulnerable to the occurrence of ED or subclinical ED. They found that ED-symptomatic women were more likely than ED-asymptomatic women to compare self with others in everyday life. In addition, ED-symptomatic women tended to rate themselves in a more defeating way than asymptomatic women when they compared themselves with the images of other women. (See chapter  for more discussion on ED.)

Treatment Implications Various scholars have suggested gender-specific treatment based on the research findings that female substance-abusing clients are more likely to initiate or relapse to AOD use and abuse because of negative emotion and conflicting interpersonal relationships, whereas male clients do so because of positive emotion or a desire to control and compete. Those scholars (Annis and Graham ; Brady, cited in Haseltine ; Langan and Pelissier ; McKay et al. ) suggested that treatment and relapse prevention for women should focus on increasing women’s feelings of well-being, as well as helping them learn to anticipate, recognize, and effectively cope with conflict situations and negative emotions without resorting to AOD use. All of these are in contrast to the recommended treatment for men, which has emphasized self-control and different methods of coping with triggers related to pleasant situations or peer enticement. For women who are “pure substance abusers” (i.e., those who are not comorbid with affective disorders) and predisposed with a higher level of sensation- or thrill-seeking personality traits, treatment programs may devise and provide safe substitutes to meet their needs for risky activities (Scourfield et al. ). The issue of women’s possibly stronger subjective reaction to stress, if confirmed by future studies, may also be incorporated

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into treatment strategies for helping them better deal with various stress-loaded conflict situations (Back et al. ). Screening for a history of childhood abuse and / or COD and following with timely treatment or referral are also critical, since women, compared to men, tend to have higher rates of childhood sexual abuse and the affective disorders-substance abuse comorbidity. An emphasis on providing COD-specific treatment to CODafflicted clients, whether in an AOD treatment setting or a mental health setting, has gained momentum in the last two decades (CSAT ). Interested readers can refer to TIP  for detailed information about COD treatment (CSAT ). The understanding of the link between women’s dissatisfaction with body image and their substance abuse / ED problems further enables treatment programs to devise more women-specific assessment and treatment strategies. The programs can incorporate functional and healthy methods of weight control into their treatment contents and curriculum, equip the women with effective coping skills, and provide them with resources at the medical, school, home, and community levels (Perkins ; Voorhees et al. ). In addition, smokers who are young or overweight women are at a higher risk and should be given extra attention.

Biological Risk Factors Multiple biological factors are related to AOD risk (such as race, age of initial use, FAS exposure status, genetic heredity); among them, genetic heredity is probably one of the most well-known factors. McLellan et al.’s () review showed that genetic contributions play a similar role in affecting addiction problems as they do in affecting other chronic illnesses such as hypertension, type  diabetes mellitus, and asthma. However, it is unclear whether the genetics factor affects women the same way it affects men. Before we discuss the genetic influence, let us examine the familial factor, since genetic influence comes from the familial factor. The familial factor on the transmission of substance dependence and particularly alcohol dependence, long documented in the literature, clearly suggests that first-degree relatives (parents, siblings, offspring) of an individual with substance dependence problems are at a higher risk than the general population to eventually develop substance dependence (Cotton ; Zuckerman ). What is not totally clear is how the familial factor operates. Is it through a genetic or an environmental pathway, or both, and to what extent? Other factors that further compound the issue include gender, age of onset of AOD problems, ethnicity, types of substance, psychiatric comorbidity, and degree of severity of the AOD problem (McGue and Pickens ). Although the AOD heredity research findings have been consistent regarding the genetic influence for men, these findings have been inconsistent for women (Wasilow-Mueller and Erickson ). Whether the genetic factor has a stronger impact on men’s AOD problems than women’s has been one of the most

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controversial topics in the research area of gender and substance abuse (Heath, Slutske, and Madden ). One line of AOD heredity research findings has demonstrated that, indeed, men are more likely than women to be affected genetically. For example, both Han, McGue, and Iacono’s () study and Prescott et al.’s () study revealed that their male substance abusers were overall more likely to be affected genetically than their female substance abusers. Han, McGue, and Iacono reported that the genetic factor explains a larger proportion of the variance in accountability to alcohol, tobacco, and drug use in men than in women (about %, %, and %, respectively, for men versus %, %, and %, respectively, for women). Multiple approaches can be used to detect levels of genetic influence. One common method is to compare monozygotic twins (shared % genes) with dizygotic twins (shared an average of % genes); if the concordant rate among the monozygotic twins is higher than that among the dizygotic twins, it can then be inferred that there is a high genetic influence (McLellan et al. ). Blume and Zilberman () suggested that the genetic factor related to drug-use-disorder heritability is stronger for men than women, whereas the environment factor is stronger for women than men. AOD heredity studies by Jang, Livesley, and Vernon (), by King et al. (), and by McGue, Pickens, and Svikis () also pointed out that men tend to be subjected to the genetic influence more so than women, and / or women tend to be affected by the shared-environment factor more so than men. The “shared-environment” usually involves an environment that “distinguishes the general environment of one family from another, and influences all children within a family to the same degree” (Jang, Livesley, and Vernon :). This is consistent with the comments earlier in this chapter stressing the impact of family AOD history / dysfunctional family of origin on women’s development of AOD problems. Another line of AOD heredity research findings, however, pointed out that women are as likely as men to be affected genetically. For example, Kendler and colleagues () studied , female-female twin pairs and found that the concordant rate (both twins afflicted with alcoholism) was consistently higher in the monozygotic twins than in the dizygotic twins, and the heritability estimates were between % and %. Studies by Heath et al. (), Prescott, Aggen, and Kendler , Prescott and Kendler (), and Kendler et al. () all showed that women are as likely as men to be affected genetically when it comes to AOD problems. Heath () reviewed the relevant adoption and twin studies and suggested that “evidence indicates an important genetic influence on alcoholism risk; this influence appears as strong in women as in men” and that “many studies that followed children of alcoholics prospectively to identify precursors of alcoholism risk have focused on sons of alcoholics, assuming a stronger genetic influence in men than in women.” In addition, although both the Prescott et al. () and the Han, McGue, and Iacono () studies suggested that the genetic factor appears to show a stronger influence on men than women, the differences between

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the two sexes in both studies were not statistically different (that is, the results cannot be generalized from the sample to the population). Further, Heath et al. (cited in Prescott et al. ) said that although AOD female twin studies showed inconsistent results regarding the genetic factor, a reanalysis of the findings from these studies actually suggested no significant difference between or among the values. Half of the twin and adoption studies reviewed by Svikis and Velez () revealed no genetic effects on women, but the other half did report genetic effects. Our review of the above-mentioned ten studies showed that all ten indicated genetic influence for men and that five indicated an overall low or no genetic influence for women, while five suggested an overall equal genetic influence for the two sexes. Scholars have come up with possible explanations as to why research findings are inconsistent regarding the genetic influence on women’s developing AOD problems. For example, Prescott et al.’s () review pointed out that many AOD heredity studies focused on men and only a few included women. Even when a large number of female participants were recruited from the general population, the number of substance-abusing female participants is still low, due to the overall lower AOD prevalence rate in the general population. The lower number of AODabusing female participants in AOD heredity studies may result in an inadequate statistical power, making it difficult to obtain a more precise estimation regarding the impact of the genetic factor on women. Another explanation for the disagreement among the AOD hereditary research findings about women is that different studies may have adopted different diagnostic definitions or criteria. For example, Prescott et al. () found that although Pickens and colleagues investigated a subset of the sample used by McGue and colleagues, the two studies yielded very different results in that Pickens et al. reported an alcohol dependence heritability rate of . in women and McGue et al. reported an alcohol abuse / dependence heritability rate of . in women. The third explanation could be “ascertainment differences” and / or “etiologic heterogeneity” (Prescott et al. ). Different studies may have recruited participants from different sources, resulting in a systematic difference in clients’ characteristics, which in turn affected the study outcomes. In addition, participants with different subtypes of alcoholism may be subjected to different degrees of genetic etiology. For example, Prescott et al. () and Prescott and Kendler () suggested that female twins studies that recruited participants from treatment programs were less likely to show the genetic influence than those that recruited participants from the general population. Our review of the above-mentioned ten studies indicated that within the group that reported low or no genetic influence on women (N = ), two studied treatment populations (McGue, Pickens, and Svikis ; Prescott et al. ) and three studied the general population (Han, McGue, and Iacono ; Jang, Livesley, and Vernon ; King et al. ), whereas within the group that reported a similar impact of genetic influence on both sexes (N = ), all five studies

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investigated the general population (Heath et al. ; Kendler et al. ; Kendler et al. ; Prescott, Aggen, and Kendler ; Prescott and Kendler ). Overall, the research findings so far suggest that the genetic factor has a strong bearing on men, but it is still uncertain whether it is applicable to women in the same way. Further genetic studies will be required to clarify the sex factor on AOD-related heritability (McLellan ), and such studies should involve a large number of women subjects (Svikis and Velez ). In addition, the majority of the above-mentioned ten studies investigated only the difference in the genetic impact of alcoholism on men and women; future studies should target other licit and illicit drugs in this regard.

Treatment Implications If women are as likely as men to be affected by the genetic factor, it would be important to address this issue in dealing with female clients; an emphasis on the genetic component may reduce their feelings of guilt and shame through the insight that the AOD problem is not their fault but is an illness transmitted from previous generations. Regardless of the impact of the genetic factor on women, the “sharedenvironment” component of the familial factor (AOD family history / dysfunctional family of origin) may be emphasized to reduce women’s feelings of shame and guilt about their AOD problem by understanding that it is not their fault but something that they acquired as an result of their early childhood, negative, immediate environment. Of course, this does not mean that personal responsibility should be ignored; rather, it is intended to de-stigmatize AOD-using behavior. The genetic factor knowledge may also be integrated into AOD prevention programs so that women and adolescent girls may be empowered with the knowledge and thus avoid getting involved with AOD in the first place.

Chapter 

Factors in Successful Treatment Programs for Women

W

hat kind of AOD treatment program will best suit women’s needs and produce more-successful treatment outcomes or retention rates for female clients? (Retention is included as an outcome variable because numerous empirical studies suggest its association with positive post-treatment outcomes for men and women [e.g., Messina, Wish, and Nemes ; Stevens and Arbiter ; Wexler, Cuadrado, and Stevens ]). Traditionally, the available data have not been of much help in answering this question, since most early studies selected only male subjects or included a disproportionately small percentage of women (Vannicelli ). More-recent studies, however, have investigated treatment success factors specifically related to women. An examination of these studies has identified five pertinent factors: () single- versus mixed-sex programs, () residential treatment versus intensive outpatient / day treatment versus traditional outpatient treatment, () provision for child care versus no provision for child care, () case management and / or a “one-stop shopping” model, and () supportive staff and provision for individual counseling.

Single- Versus Mixed-Sex Programs Nine studies suggested that women-only programs produce positive treatment outcomes / retention. The studies of Grosenick and Hatmaker (a) and Nelson-Zlupko et al. () were qualitative studies with

This chapter is adapted from the author’s  article “Program Factors Related to Women’s Substance Abuse Treatment Retention and Other Outcomes: A Review and Critique,“ Journal of Substance Abuse Treatment  (): –. Interested readers may refer to the original article for a more detailed discussion.

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results suggesting that women perceived a women-only program to be more beneficial than a mixed-sex program because it was easier for them to discuss issues such as children, sexuality, prostitution, and sexual / physical abuse. These studies also suggested that a women-only program reduced sexual harassment. Ravndal and Vaglum () found in their qualitative study that some women in their mixed-sex program were likely to develop a sexual relationship with male clients in the same setting, resulting in early dropout when the male partner dropped out. All three qualitative studies provided some theoretical background for the association between single-sex programs and positive treatment outcome. Six quantitative studies (Dahlgren and Willander ; Grella ; Gutierres and Todd ; Roberts and Nishimoto ; Zankowski ; Zilberman, Tavares, Andrade, and el-Guebaly ) also suggested that women-only programs produce better treatment outcomes or retention than mixed-sex programs. However, three studies suggested no outcome differences between single- and mixed-sex programs. (The non-randomized  three-group study of Dodge and Potocky-Tripodi also indicated no treatment-outcome difference between women-only and mixed-sex groups but is not included in this review because the authors concluded that all three treatments were ineffective.) Bride () found no significant difference in length of stay (LOS) between single- and mixed-sex programs. Copeland et al. () found that although the women-only group had greater improvement than the mixed-sex group on depression and self-esteem at discharge, the two groups were not different in any of the treatment outcomes at the six-month follow-up. Neither study used random assignment of participants to the groups; therefore, the “no difference” outcomes could be attributable to selection bias or idiosyncratic differences between groups. This is further supported by Copeland et al’s suggestion that lesbians, women with young children, and women with a history of childhood sexual abuse tended to participate in the women-only group and that therefore “the expected differential treatment outcome for the [women-only] group was attenuated by these comparatively more ‘difficult’ clients” (). Finally, Kaskutas et al. (), in a four-group randomized study, also found no treatment outcome difference between single- and mixed-sex programs. However, the short LOS of participants at all four sites calls into question whether the programs actually affected the participants regardless of which group they attended. Specifically, the planned LOS was six weeks for the women-only group and the first mixed-sex community group and three weeks for the second mixed-sex community group and the mixed-sex hospital group. However, the participants’ actual mean LOS figures were ., ., ., and . days, respectively. Although all nine studies contribute to the knowledge base, they also all suffer some design weaknesses. Grosenick and Hatmaker (a) and Nelson-Zlupko et al. () surveyed women’s perceptions instead of actually measuring the targeted behaviors. Ravndal and Vaglum () included only six women in their mixed-sex group and four in the women-only group, making generalization

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difficult. The women-only and mixed-sex samples in the study of Zilberman et al. () were collected in different periods (the former sample in –, the latter sample in –), as were those in Zankowski’s study (; women-only in , mixed-sex in ); thus, the impact of selection bias (e.g., change of subject profiles over time) cannot be ruled out. The remaining four quantitative studies did not control for multiple factors associated with treatment outcome that were operating within their studies. Therefore, it is difficult to assess which factor(s) contributed most, or even at all, to the outcomes. For example, the single-sex program in Gutierres and Todd’s study () not only involved a single sex but also provided child care and culturally sensitive practices, which were unavailable for women in the coed program. In Roberts and Nishimoto’s study (), the single-sex program provided day treatment, whereas the mixed-sex program provided a traditional outpatient program. Although Dahlgren and Willander () used a randomized, controlled trial, their women-only group lasted for eight months, whereas their control group lasted only five months. Because LOS proved to be significantly related to outcome for both groups, the longer treatment for the women-only group makes it difficult to determine the pure effect of the single-sex factor (Hodgins, el-Guebaly, and Addington ). The hypothesis that a single-gender program may have more-positive treatment outcomes for women does seem to be supported by the research findings, with a ratio of nine versus three studies. However, a critical review suggests significant methodological problems with most of these studies. Further empirical studies, with better methods, are needed before we can confidently claim such a relationship. In addition, four other design and procedure issues are worthy of attention. The first issue involves controlling “substance abuse choice” in evaluating treatment program effectiveness. Zilberman, Tavares, Andrade, and el-Guebaly () found that only alcohol-dependent women, not drug-dependent women, in the women-only program had significantly higher retention than women in the mixed-sex group. Their findings may reconcile the inconsistent results between the study of Dahlgren and Willander () and that of Bride (). The Dahlgren and Willander study (findings suggested better outcome / retention in the women-only group) included only “women in early phases of alcohol dependence” (), whereas in the Bride study (which found no outcome / retention difference between the women-only and mixed-sex groups) % of the sample identified cocaine as their primary drug. Drug-dependent women may be distinctly different from alcohol-dependent women (Zilberman, Tavares, and Andrade ) and therefore require different treatment strategies. The second issue concerns standardizing outcome variables and time intervals for follow-up measurements. McLellan et al. () suggested three outcome

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domains: “reduction of alcohol and drug use,” “improvement in personal and social function,” and “reduction in public health and safety threats” (). The outcome variables and the times that they were measured varied considerably in the studies reviewed. Some studies included LOS only; others included abstinence and relapses at the one- and two-year follow-ups, depression and self-esteem at the six-month follow-up, and so forth. For alcohol treatment effectiveness, Kadden and Litt () suggested drinking frequency, intensity, and consequences as universal treatment outcome indicators but not psychosocial or biological measurements. From the perspective of study replication and cross-study comparison, an overlap of outcome variables across various studies would be both necessary and feasible. A third issue is whether the single-sex element should be applied to both clients and staff or just to clients. Although .% of the women in the Grosenick and Hatmaker (b) study perceived it important to have female staff, % believed that having male staff as male figures for their children was also important, to show that “not all men are bad” and to offer male perspectives on issues such as anger and healthy relationships. Finally, Blume and Zilberman () suggested that single- or mixed-sex group choice should be based on an individual client’s needs, that the combination of women-only group therapy and mixed-sex group therapy may be suggested, and that a client’s needs may change throughout a treatment process and, thus, the treatment strategies may need to be reassessed.

Treatment Intensity Residential Treatment and Retention / Other Outcomes Five studies (one qualitative and four quantitative) were included in this category, and all those reviewed showed that residential treatment had a more positive impact on women’s treatment outcome than the alternative (usually outpatient care). One qualitative study (Grosenick and Hatmaker a) offered a theoretical basis for this conclusion. It found that clients consistently reported that the residential nature of treatment would help them decrease substance abuse and prepare them for independent living after discharge. Most of these clients had received outpatient treatment previously and had relapsed. Perhaps because women are more likely than men to lack resources and to experience stress and burdens from their families (Yaffe, Jenson, and Howard ), a residential program might be more necessary for them, to provide a more stable structure and necessary support to help them concentrate on recovery (Grosenick and Hatmaker a). Two quantitative studies found that residential treatment had a more positive impact on women’s treatment outcomes than did less-intensive forms of

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care. Messina, Wish, and Nemes () compared clients randomly assigned to a longer-term inpatient program (ten months of inpatient plus two months of outpatient) with those assigned to an abbreviated inpatient program (six months of inpatient plus six months of outpatient treatment). They found that at the nineteen-month post-discharge follow-up, women in the longer-term program had lower criminal activity and higher employment rates than women in the abbreviated program. Sowers et al. () compared women attending a women’s residential program with women attending a day treatment program and found that the residential clients had better outcomes in abstinence, criminal activity, and employment at the “posttest and follow-up” (the specific period was not reported, possibly at the end of treatment or shortly after program completion). Two other quantitative studies suggested the greater impact of residential treatment on women’s successful completion of continuing treatment. Scott-Lennox et al. () found that women who had received prior residential care from the same agency as their outpatient treatment were more likely to complete the outpatient treatment. Coughey et al. () found that clients who had received residential treatment were more likely to complete the aftercare program than those who had not received residential treatment. The aftercare program case managers stated that women with unstable conditions or inadequate prior drug treatment were most likely to drop out and that these women should receive “first care” prior to aftercare. Although the five studies cited contribute to the knowledge base, they must be viewed in light of their limitations. For example, Grosenick and Hatmaker (a) surveyed women’s perceptions rather than their actual behaviors in residential care. Sowers et al. () did not disentangle multiple treatment conditions in their design. The programs were different not only in treatment types (residential versus day treatment) but also in many other aspects (e.g., the residential clients received many on-site services plus on-site child care, whereas the day treatment clients did not have such services, the residential program had more voluntarily admitted clients than the day treatment center, and so on). Thus it is difficult to assess which factor(s) may have affected the outcomes.

Treatment Intensity, Retention, and Other Outcomes The review findings indicate that treatment intensity increases retention (four studies) but has only limited impact on treatment outcomes (one study). This means, for example, that a woman may be more likely to complete a treatment if she attends treatment more than once a week, but this may not make much difference in her treatment outcomes (AOD use, employment, and criminal behavior), assuming that she completes the treatment. It may be that the more intensively a person attends a program, the more likely it is that she will identify with the

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program, its staff, and other members, develop a sense of belonging, and therefore be less likely to drop out of the program. However, once the program is completed, personal and environmental relapse factors may operate in much the same way, regardless of the intensity of the treatment experience. Three of the four studies (Comfort and Kaltenbach ; Roberts and Nishimoto ; and Strantz and Welch ) indicate that the dropout rate may not differ much between regular and intensive outpatient programs or among regular, intensive, and residential programs for the first three months after admission but that both the intensive outpatient and the residential programs have significantly better retention than the regular outpatient program after three months. One of the four studies (Wald ) found that clients who received intensive outpatient treatment (six or more hours of counseling per week) were more likely to complete treatment than those who received less-intensive treatment (% versus %, p < .). Once again, the studies of Strantz and Welch () and Roberts and Nishimoto () did not disentangle coexisting multiple conditions (that is, the day treatment [intensive] and regular outpatient programs were different not only in terms of the required number of sessions per week but also in terms of single-sex versus mixed-sex treatment and treatment approach. Thus, it is uncertain as to what degree the retention difference was attributable to treatment intensity, other factors, or an interaction among all the factors. One problem with the Wald retention study () was that one of the agencies studied provided both intensive and non-intensive therapies with % self-referred subjects and the rest mandated and the second agency provided only non-intensive therapy but with % selfreferred subjects. Wald’s analysis also indicated that self-referred women were less likely to complete the treatment than mandated women. Could the association between treatment intensity and retention, in fact, be the association between referral source and retention? Although the above-mentioned four studies suggest that treatment intensity increases retention, Gerstein and Johnson () found that treatment intensity does not have a strong impact on treatment outcomes. They found that for women, the treatment type (modality / intensity) had an inconsistent impact on treatment outcomes. Although all three types (non-methadone outpatient, short-term residential, and long-term residential) produced change, the amount of change in crack use seen at post-treatment follow-up was similar across all treatment types, although the outpatient group showed almost twice the amount of change in employment as the long-term residential group for level of employment rate. No data were reported on methadone programs. Those authors also found only modest and inconsistent differences in post-treatment outcome associated with different levels of treatment intensity (“more than once a week” versus “up to once a week”).

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In conclusion, all but one study suggested that women were more likely to complete treatment and do well following residential treatment than following other types of treatment. More studies of outcomes other than retention are needed to verify this conclusion.

Provision for Child Care Six studies examined the role of child care in addiction treatment; all six (two qualitative and four quantitative) indicated that providing child care had a positive impact on women’s treatment outcomes. Two qualitative studies (Grosenick and Hatmaker a; Nelson-Zlupko et al. ) measured mothers’ perceptions of how child care service affects treatment outcomes and provided a theoretical background for such an association: mothers perceived that they would be less likely to enter treatment without child care; on-site child care services freed them from juggling between treatment and arranging for child care, thus allowing them to concentrate on treatment; and seeing their child daily made them feel good about themselves. Four quantitative studies—the randomized two-group design studies of Hughes et al. () and Stevens and Patton (), the non-randomized three-group design study of Metsch et al. (), and the non-randomized two-group design study of Wobbie et al. ()—found that the mothers whose child stayed with them during residential treatment had a significantly longer LOS or were more likely to complete the treatment than the mothers whose child was not with them during treatment. Only two of the four studies (Metsch et al. ; Stevens and Patton ) investigated follow-up outcomes in addition to LOS. Stevens and Patton measured AOD use, employment, child custody, incidence of arrest, and aftercare involvement. Metsch et al. measured AOD use. Both follow-ups were done at six months after discharge; however, Stevens and Patton did not provide p values and it is uncertain if the differences are statistically significant. Furthermore, the data provided by Hughes et al. () indicated that although women in the with-child-care program had a significantly higher LOS (M = . days) than those in the no-childcare program (M = . days; p < .), the standard deviation was much greater for the former program (SD = . days) than for the latter program (SD = . days). This may mean that the with-child-care program did not benefit all mothers and thus may enhance retention for only certain groups of mothers. In this regard, a Center for Substance Abuse Treatment (CSAT)-sponsored focus group of women (CSAT a) revealed that not all women preferred to have their children join them in residential treatment. Some women felt that being a consistent parent was too demanding and thus wanted to initiate their recovery alone to build a foundation and then gradually involve their children in their recovery program. Unfortunately, these possibilities could not be verified through examination of the

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other three studies in our review (Metsch et al. ; Stevens and Patton ; Wobbie et al. ); none of them provided SD for their mean LOS. In summary, these studies offer consistent findings on this issue: the state of knowledge regarding child care and treatment outcomes can still be improved. Future studies should provide complete statistical analyses, investigate whether certain types of mothers are more likely to benefit from residential programs, and analyze multiple factors and interaction effects in assessing the effect of the child care service. Second, studies should measure not only LOS but also other outcomes, such as AOD use, employment, child custody, and criminal behavior. Third, studies should use the same time intervals for follow-up measurements. One double-edged methodological sword is the issue of random assignment of mothers to with-child-care groups versus no-child-care groups. On the one hand, random assignment can ensure that the two groups share equivalent characteristics and would thus avoid selection bias (as in the statement of Wobbie et al. [] that the longer LOS for the child-with-the-mother group could be attributable to the possibility that only the less-problematic mothers were allowed to have their child stay with them and that the less-problematic clients normally tend to comply with treatment, resulting in a longer LOS and a higher likelihood of completing the treatment). On the other hand, researchers may need to pay attention to the possible negative impact of the random assignment on women. A woman assigned to a no-child-care group may feel disempowered because of her inability to choose to have her child stay with her during treatment, which in turn may negatively affect her recovery. The less-positive outcomes of the no-child-care group may not be related to the lack of child care per se but to a mother’s feelings of being disempowered by her lack of options (Stevens and Patton ).

Case Management Seven studies examined the role of case management in addiction treatment. Five of these (Evenson et al. ; Jansson, Svikis, and Beilenson ; Laken and Ager ; Lanehart et al. ; McLellan et al. ) found that case management enhanced retention or treatment outcomes. Two other studies (Howell and Chasnoff ; Marsh, D’Aunno, and Smith ) found inconclusive or paradoxical findings regarding the effect of case management. Two additional studies (McMurtrie et al. ; Volpicelli et al. ) examined the one-stop-shopping model of onsite access to health and social services. Both found these services to be positively related to retention and / or treatment outcomes.

Provision for Case Management The qualitative study of Howell and Chasnoff () revealed that treatment providers perceived intensive case management to be critical in helping women

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recover, particularly after discharge from residential care. Clients, however, perceived case management as both positive and negative. Some appreciated the support, and others believed that such support could be misused by clients (i.e., “enabling”). Although this study measured staff and client perceptions regarding the relationship between case management and treatment outcome instead of the actual behaviors, it nevertheless provides some theoretical foundation for the complexity of this relationship. Five studies suggested that case management enhances retention or treatment outcomes. The one-group study of pregnant and postpartum substance-abusing women of Lanehart et al. () indicated that intensive case management and aftercare support produced good post-treatment outcomes in the areas of substance abuse, employment, incarceration, and children’s birth weight. Evenson et al. () evaluated programs that offered wraparound and intensive case management for women with children. They found that women performed better during the treatment than prior to admission in the areas of substance abuse (e.g., % to % abstinent), parenting, functional level, and employment. The path analysis results of Laken and Ager () showed a significant association between case management service and treatment retention for pregnant women. McLellan et al. () showed that welfare-recipient women who participated in the CASAWORKS for Families program made significant improvements in the areas of substance abuse and social / family functioning at six-month follow-up and employment at twelve-month follow-up. The CASAWORKS for Families emphasized interorganizational coordination so that women could receive comprehensive and concurrent services. Jansson, Svikis, and Beilenson () found that, as compared with mothers of drug-exposed infants who received a low-intervention (four or fewer visits within two years) case management, mothers who received a high-intervention (five or more outreach service visits) case management were more likely to use postpartum substance treatment, less likely to report recent drug use at two-year follow-up, and more likely to have child custody rights. Four of the five positive studies reviewed were of a one-group design and one was of a non-randomized two-group design. All of them may have threats to internal validity, making it difficult to infer a causal relationship. Another weakness with the study of Evenson et al. () is that it was a retrospective study and did not describe how the retrospective study was conducted. If we assumed that clients were asked to recall data for then versus now (e.g., blackouts occurrence at admission versus current period), the reliability of the data may be questionable. Also, the five studies did not share consistent dependent variables. For example, Lanehart et al. () evaluated AOD use, employment, incarceration, and birth weight; Jansson, Svikis, and Beilenson () focused on AOD use, AOD treatment service use, and child custody right; and Laken and Ager () targeted retention. Furthermore, only two of the five studies (Laken and Ager ; McLellan et al. ) provided a detailed description regarding case management content.

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With regard to the negative studies, the quantitative study of Marsh, D’Aunno, and Smith () suggested that case management does not necessarily improve treatment outcomes directly but rather may improve outcomes indirectly through linking clients to the appropriate health and social services they need. Marsh, D’Aunno, and Smith compared participants who attended an initiative program (enhanced services on transportation, outreach, and so on) with those who attended a regular program. Their path analysis showed paradoxical findings. Women in the initiative program were more likely to abstain from drugs than those in the regular program; use of the access services (transportation and outreach) was positively related to use of social services; and use of social services was negatively related to drug use. However, women who used transportation and outreach the most were significantly less likely to abstain from drugs. These authors explained the paradox in two ways. First, possibly clients who used transportation and outreach services the most were also clients who had the most severe psychiatric, family, and drug problems. “Even though these clients are gaining access to programs, social services provided apparently are not effectively addressing their problems so that they can reduce their drug use” (). Second, “there is clearly something else besides the access services that makes the enhanced service program more effective” (). In summary, although five of the seven case management studies showed an indication of a positive relationship between case management or service use and retention / treatment outcomes, all were complicated studies with some design weaknesses. Future studies in this area should consider a randomized two-group pretest and post-test design and disentangle multiple coexisting treatment conditions from the treatment intervention. Outcome variables should also be standardized to include not only LOS but also other widely measured treatment outcomes. In addition, case management services may encompass different levels of intensity and types of services. Future research should also identify and measure the core ingredients of a case management package that are thought to contribute to a positive outcome (Jansson, Svikis, and Beilenson ; Marsh, D’Aunno, and Smith ).

One-Stop-Shopping Model McMurtrie et al. () stated that comprehensive services provided on-site help women build a trusting relationship with the treatment team, encourage them to use a wide range of services, and prevent dropout. On-site services also may promote mutual understanding and coordination among various professionals who often have different treatment philosophies and approaches. Both McMurtrie et al.’s () non-randomized three-group design and Volpicelli et al.’s () randomized two-group design suggest a positive impact of the one-stop-shopping model on treatment outcomes. McMurtrie et al. found that mothers who participated

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in the one-stop-shopping treatment had a significantly lower percentage of lowbirth-weight babies than mothers who attended two other local special prenatal clinics (% versus % and %). Volpicelli et al. () compared outcomes between a case management outpatient program and a psychosocially enhanced treatment program. Both programs provided group therapy and on-site child care, but the psychosocially enhanced treatment program offered on-site individual counseling and other services, whereas the case management outpatient program referred clients off-site to other community sources for such services. The authors found that although clients in both groups made progress, those who attended the one-stop-shopping program had higher retention and lower cocaine use at the twelve-month follow-up. To summarize, because only two studies were reviewed for this issue, more studies with a randomized controlled design are needed in the future to enhance our confidence in these conclusions. It might also be interesting to compare four groups on a continuum: no case management, regular case management, case management that specifically emphasizes interagency coordination, and case management that provides on-site comprehensive services (e.g., McLellan et al. ). In addition, the outcomes variables need to be standardized and include not only AOD use but also measures of parenting, depression / anxiety, criminal behavior, and employment.

Supportive Staff and Individual Counseling Five studies examined the role of supportive and / or individual counseling in women’s addiction treatment. All five found that staff supportiveness and / or the availability of individual counseling were positively associated with better treatment outcomes. The elements of supportive / non-confrontational quality and individual counseling are grouped together because both are designed to help women deal with personal issues of shame, stigma, and low self-esteem. Three of the five studies were qualitative (Grosenick and Hatmaker b; Nelson-Zlupko et al. ; Sun ) and suggested the importance of a counselor’s genuine concern, respect for and trust in the client, and supportive, nonjudgmental attitude. These three qualitative studies measured women’s perceptions but provided some theoretical framework for the importance of supportive individual counseling for women. Although group treatment may be a standard part of treatment for both men and women (Luthar and Walsh ), the additional individual counseling offered by a nonjudgmental counselor appears to add special benefit for women. This may be because women in treatment often experience more emotional stress, depression, childhood sexual / physical abuse, and other psychological disturbance than men (Wechsberg, Craddock, and Hubbard ). In addition, women experience a higher level of stigma and condemnation from society for their substance abuse than do men (Finklestein ).

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In this regard, Sterk and colleagues studied HIV risk prevention programs for women; they found that women “wanted to start with one-on-one sessions” because it was easier for them to talk about their experiences concerning previous abuse and their behavior to support drug habits with one person instead of a group (cited in National Institute on Drug Abuse ). A supportive and confidential individual counseling approach may more effectively handle women’s feelings of shame, guilt, and inadequacy than a group counseling session. Two quantitative studies found that the addition of individual counseling to group treatment particularly benefits women. Volpicelli et al. () showed that mothers receiving on-site individual counseling and other services had better retention and lower cocaine use at the twelve-month follow-up than those receiving group counseling with referral out for individual counseling and other services. Wald (), in a non-randomized two-group comparison study, also indicated that women attending an agency that provided both individual counseling and group treatment had a better retention rate than those attending an agency providing only group treatment. More large-scale studies should be conducted to investigate directly the relationship between a counselor’s degree of genuine concern / supportive attitude and client treatment outcomes, and more randomized two-group studies are needed to verify the function of individual counseling for women. Future studies are also needed to evaluate different types of counseling (individual versus group) with different styles (supportive versus confrontational), exploring whether a supportive group approach can achieve the same effect as a supportive individual approach does or has a better effect than a confrontational individual approach. Finally, the outcome variables should also be extended to include depression, anxiety, criminal behavior, and employment, in addition to AOD use and retention.

•

•

•

This systematic review focused on program factors related to women’s AOD treatment success. Although  empirical studies were identified and five types of care and services were reviewed, our review criteria excluded many related studies and omitted several emerging factors that have not yet been studied. One limitation of this review is a potential bias owing to its being based only on published studies from peer-reviewed journals. Often a positive (hypothesis was confirmed) study is more likely to be accepted for publication in such journals (Shields ). The findings from this review indicate that empirical research on female AOD treatment efficacy is still in its infancy (Dodge and Potocky-Tripodi ). Many of the studies reviewed had various degrees of research design weaknesses, including a lack of randomization and appropriate control groups, which makes causal inference difficult. For example, most case management efficacy studies were of a one-group design, with the lack of a control group possibly caused by an

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unwillingness to deprive clients of case management services that were thought to be helpful to them. In addition, cost-effectiveness analysis was not included in many of the existing studies (Ashley, Marsden, and Brady ). Despite their limitations, the  studies still provide some direction regarding future research, as well as suggestions for potentially effective program planning and practices with substance-abusing women. The following are some of the direct implications of our review: 1. Women-only programs are still scarce and policymakers must make such programs more available to women. 2. Agency administrators and practitioners should make women-only groups available as an option if a program is unable to take only women. 3. When referring a woman, particularly one with few resources and heightened environmental stress, practitioners should keep in mind that a residential program is likely to have a more solid and long-lasting effect on her recovery. Thus, the current American Society of Addiction Medicine’s least-restriction patient placement criteria and managed-care rules must be tempered by the philosophies that many women may need first care instead of aftercare and habilitation instead of rehabilitation and that treatment intensity enhances treatment retention. 4. Policymakers and administrators should consider child care and other services on-site as being an optimal treatment for women. Case management with the availability of community services is a potentially viable alternative. 5. Administrators and practitioners must emphasize a nonjudgmental and nonconfrontational approach in working with women and provide women with individual counseling in addition to group counseling.

Although these suggestions are supportable from the review, it must be emphasized that all findings need to be further verified, expanded, or modified by more and better research. There are many important questions remaining from this review that should be addressed by future research. For example, a single-sex treatment may show better outcomes / retention than a mixed-sex treatment, but what are the specific ingredients of the treatment and therapeutic issues during women-only treatment that actually produce the better outcomes? Case management service may be generally seen as beneficial from this review, but case management encompasses a wide range of services and intensities. Which of its particular features / processes actually contribute to outcome change? Does the counselor’s supportiveness and the quality of client-counselor interaction matter more than the treatment contents or services provided? Finally, to what degree does aftercare or continuing care affect the post-discharge outcomes? In conclusion, although more studies have been conducted regarding womenspecific substance abuse treatment since the s, more empirical studies with sound research designs are still needed to advance our understanding on this topic.

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The  articles reviewed offered rather strong suggestions for important components (i.e., women-only group, residential treatment, child care, case management, and supportive individual counseling) required for effective treatment of substance-abusing women. However, these suggestions need to be confirmed and expanded by additional scientific research with better designs (e.g., randomized two-group design). At the same time, it is recognized that this type of research may face many challenges, among them compliance with the ethical guidelines, obtaining agency cooperation, recruiting representative samples of participants, and tracking those participants.

Chapter 

Treatment Methods

T

his chapter introduces seven commonly known AOD psychosocial treatment methods / approaches: motivational interviewing / motivational enhancement therapy (MI / MET), cognitive-behavioral therapy (CBT), professional -step facilitation intervention (TSF), brief intervention (BI), contingency management (CM), behavioral couples therapy (BCT), and community reinforcement approach (CRA). These seven methods do not include pharmaceutical treatment methods, and they are not the only psychosocial treatment methods used in the field. Interested readers are encouraged to explore other methods as well. Also, the material presented only summarizes the key components of each method. Readers may refer to the specific manuals noted to acquire more detailed information about each method (Web site addresses for available manuals are included at the end of each method section). Although all seven methods are applicable to both men and women, research findings, if any, on gender-specific issues relevant to each method are also addressed. All the methods are compatible with each other and can complement one another. For example, MI may be necessary to increase a client’s motivation for treatment and abstinence but not sufficient to help the client develop adequate skills to achieve abstinence. Likewise, CBT may be necessary to increase a client’s competency to deal with relapse triggers but not sufficient to make the client want to stop AOD use. In such a case, a five-session treatment designed to help adolescents (for example) may include two MI / MET sessions and three CBT sessions to achieve the best treatment results. As long as the method is appropriate, the format of delivery, whether through individual or group sessions, can be flexible. In the above example, the CBT may be provided in group session and the MI in an individual session. Another example is

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the addition of CM to BCT to help dually addicted couples, a treatment method that is currently under evaluation. Some methods may be more appropriately used in conjunction with another method—for example, CM as mainly an adjunct to other AOD treatment. Some others may be used as stand-alones or integrated into other AOD treatment—for example, BCT. All the treatment methods, however, should be supplemented with case management wherever possible and feasible. Finally, effective treatment relies on accurate screening and assessment (see appendix A for relevant screening and assessment tools).

Motivational Interviewing (MI) / Motivational Enhancement Therapy (MET) MI or MET emphasizes mobilizing a client’s inner resources (i.e., motivation) to change his or her substance abuse or other behavioral problems. The approach respects a client’s dignity and self-determination and follows the client’s own pace in helping the client change. The empirical data have overwhelmingly illustrated the positive impact of MI or MET on the treatment of substance-abusing clients (Burke, Arkowitz, and Menchola ; Dunn, Deroo, and Rivara ). In contrast with the traditional confrontation-of-denial approach, which originated from the predominantly male substance-abusing client population, MET, an approach in the style of the Rogerian client-centered model, is thought by many experts to be more appropriate for work with substance-abusing women. Empirical evidence shows that MI / MET is particularly effective in “enhancing [clients’] entry to and engagement in more intensive substance abuse treatment” (Dunn, Deroo, and Rivara :). Carroll et al. () compared the outcomes of two groups of substance-abusing parents who were referred by child welfare for an AOD evaluation. They found that those who received the “enhanced evaluation” (i.e., the standard evaluation plus motivational interviewing) were more likely to attend the initial treatment session after evaluation than those who received only the standard evaluation (% versus %, p = .). Carroll et al. thus recommended that the practitioner integrate the “comparatively inexpensive” MI element into the regular AOD evaluation session. The MI / MET is a relatively user-friendly therapy approach. The literature has indicated that social workers or clinicians who do not have an AOD treatment background or who are not specialists in the AOD field can successfully use this approach (Dunn, Deroo, and Rivara ; Hohman ). Carroll et al. () stated: “Motivational Interviewing techniques can be taught to and used by ‘real world’ clinicians” (). Hohman () thus suggested that child welfare workers use MI to work with their substance-abusing parent clients, on the basis that () a high percentage of clients in the child welfare system are AOD users and their parental functions are impaired by their AOD-using behavior and () most child welfare workers are not equipped with AOD treatment background or training.

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Stages of Change MET is based on a well and widely cited “stages of change” theory (Prochaska and DiClemente ; Prochaska, DiClemente, and Norcross ), which proposes that a person may go through six stages, with or without the intervention of professional treatment, in changing addictive behaviors. A person may not consider that she or he has a problem or may not consider a change (precontemplation); the person may start wondering if she or he has a problem and if she or he wants or can afford a change (contemplation); after contemplation, a decision may be made to take action to change (determination); next, the person actually takes action to change (action) and sustains the change (maintenance), but may relapse after having achieved and maintained the change (relapse) and then may start the cycle again. A practitioner’s role in this method is () to observe and assess which stage of change the client is currently in and () to effectively facilitate the client’s moving toward the direction of change (e.g., from precontemplation to contemplation, or from contemplation to determination to action, and so forth). To achieve this end, a practitioner has access to five principles and two strategies (Miller et al. ).

The Five Principles In the process of facilitating clients’ movement from one stage to the next in favor of change, a practitioner should keep in mind five principles: () expressing empathy, () developing discrepancy, () avoiding argumentation, () rolling with resistance, and () supporting the client’s self-efficacy (Miller and Rollnick ). The first, third, and fourth principles all appear to point in the direction of respecting the client’s self-determination and dignity and aiming to build rapport with the client. The second principle refers to facilitating the client’s awareness of a discrepancy between where the client wants to be (goals for life) and where the client is now. Burke, Arkowitz, and Menchola (:) said this is where MI “begins to depart from classic client-centered therapy.” An appropriate heightening of such a discrepancy could plant a seed of change in the client. The fifth principle emphasizes the importance of the practitioner’s faith in the client and the conveyance of hope to the client in his or her effort to change. The client needs to be assured that it is possible to achieve a non-AOD-using lifestyle.

The Two Strategies The First Strategy The first strategy is to help clients by “building motivation for change,” which corresponds to shifting the stage from precontemplation to contemplation and determination. Miller and Rollnick () suggested that workers explore the areas of “importance” and “confidence,” both of which constitute the client’s intrinsic motivation. To what degree (for example, on a scale from  to ) does the client

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think it is important for him or her to change the targeted behavior (e.g., AOD use)? To what degree does the client feel confident that he or she is able to make such a change? The practitioner may thus focus on, accordingly, importance work, confidence work, or both to enhance the client’s motivation to change. Practitioners may use the following methods to achieve the goal: 1. Elicit self-motivational statements from the client by asking open-ended questions (e.g., “I assume, from the fact that you are here, that you have been having some concerns or difficulties related to your drinking [using drugs]. Tell me about those” [Miller et al. :]). The client should do most of the talking during the beginning phase (Miller and Rollnick )—this helps build rapport between the client and the worker; it also helps the worker understand more accurately the key issues involved before giving out opinions. Open-ended questions encourage the client’s expression and elaboration. 2. Listen with empathy. Practitioners may follow each open-ended question with two or three “reflections” instead of with another question (Miller and Rollnick ). Listening with empathy or reflecting back to the client to confirm what the client means can enhance the rapport and the elaboration of the client’s expression 3. Share with the client your feedback about his or her pre-treatment AOD assessment. A practitioner can show the client a copy of the “personal feedback report,” which compares the client’s assessment results with normative standards. 4. Affirm the client’s attitude of self-responsibility and reinforce his or her selfmotivational statements (e.g., “I think it’s great that you’re strong enough to recognize the risk here and that you want to do something before it gets more serious” [Miller et al. :]). 5. Avoid evoking clients’ resistance and deflect such resistance if it occurs (e.g., a client said, “But I don’t think I’m an alcoholic or anything.” A practitioner may deflect the resistance by using a simple reflection or a “double-sided reflection”— i.e., “You don’t think you’re that bad off, but you do wonder if maybe you’re overdoing it and damaging yourself in the process” [Miller et al. :]).

The Second Strategy The second strategy will kick in once the client shows sufficient motivation to change. A therapist helps clients by “strengthening commitment to change,” which targets shifting from determination to action (Miller et al. :). The following are some of the “how-to” tools: 1. Recognize the client’s readiness to change. 2. Remind the client that the freedom of choice and responsibility rests with

him or her. 3. Discuss with the client the pros and cons of action (change) and inaction

(no change).

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make sure that the client’s own ideas and knowledge about the issue have been elicited and that the advice to be given is helpful to enhance the client’s safety and motivation to change (Miller and Rollnick ). The practitioner should provide a cluster of strategies for the client’s choice rather than just one. It is also important that the practitioner request permission to give advice, for example, by saying, “I don’t know if this will matter to you, or even make sense, but I am a little worried about your plan. Would you mind if I explained why?” (Miller and Rollinick :). 5. Help the client develop a plan for change. A change plan worksheet may cover the following items (Miller et al. :): a. The changes I want to make are: ________________________________ ___________________________________________________________ b. The most important reasons why I want to make these changes are: ____ ___________________________________________________________ c. The steps I plan to take in changing are: _________________________ ___________________________________________________________ d. The ways other people can help me are: Person ___________________________________________________ Possible ways to help _________________________________________ e. I will know that my plan is working if: ___________________________ ___________________________________________________________ f. Some things that could interfere with my plan are: _________________ ___________________________________________________________ For a detailed manual and step-by-step procedures in implementing MI / MET treatment, readers can refer to: () Miller et al., Motivational Enhancement Therapy Manual, Project MATCH Monograph Series, Volume  (reprinted ) and () Miller and Rollnick, Motivational Interviewing ().

Cognitive-Behavioral Therapy (CBT) Voluminous literature has suggested that substance-abusing women are more likely than substance-abusing men to have deficiencies in life skills and other coping skills. For many women, more so than men, simply having the motivation to change is not sufficient; they must also learn coping skills regarding how to maintain sobriety and prevent relapses. (Likewise, we cannot assume that clients who are receiving CBT are already sufficiently motivated to change; incorporating MI / MET would enhance the effectiveness of CBT [Longabaugh and Morgenstern ]). CBT empowers a person with the knowledge and techniques to deal with specific at-risk situations without resorting to AOD use. The primary goal of CBT, according to Longabaugh and Morgenstern, is to “design techniques through which maladaptive responses can be ‘unlearned’ and replaced

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with adaptive responses” (). Fuller and Hiller-Sturmhöfel () stated that “variations of CBT are widely used in alcoholism treatment under the label of ‘relapse prevention.’ In formal CBT, patients practice behavioral or cognitive skills to cope with high-risk situations through rehearsal, role playing, and homework” (). Carroll () stated several reasons why a drug addict may lack coping and problem-solving skills: () many drug addicts may have never had the opportunity to learn how to cope with adult life challenges because they started their drug-using career during early adolescence; () they may have acquired the coping skills at one time, but their chronic drug use may have weakened their skills; and () they may have coexisting psychiatric problems that negatively affect their coping skills. Substance-abusing women are more vulnerable in this regard than substance-abusing men because the women are more likely to come from a family with an AOD-using history (see chapter ) and achieve a lower level of education; therefore, they are more likely to have been deprived of the opportunity to learn problem-solving and other life skills during early childhood or adolescence. On the basis of qualitative, in-depth interviews of  substance-abusing women, Sun (; appendix B) identified four major themes representing factors that contribute to the women’s relapse: () low self-worth and its connection to intimate relationships with men (e.g., dependence on men, abandonment by men, and poor self-identity); () interpersonal conflicts (e.g., with the authoritative systems such as child protective workers or significant others) and / or negative emotion (e.g., the feeling of loss, depression, and other dual diagnosis); () less ability to sever the tie with the (old) using network (due to the “built-in” feminine characteristics and virtues that emphasize loyalty, friendship, love and caring, and sympathy) and to establish a tie with the (new) non-using network (due to shame, a lack of opportunities through job placement because of a lower rate of employment, and obstacles to attending AA because of a lack of transportation and child care, etc.); and () a lack of AOD-related knowledge and relapse-prevention coping skills. Many of the factors appeared to be related to women’s socialization and the gender-role formation process, as well as to their disadvantageous social reality. More studies with larger sample sizes are needed to confirm this finding. To effectively help women build relapse-prevention skills, the framework of the CBT method must be filled out with gender-sensitive specifics. The following is a brief introduction to generic CBT. Readers are encouraged to refer to a detailed, step-by-step manual, Carroll, A Cognitive-Behavioral Approach: Treating Cocaine Addiction (; available at http: // www.drugabuse.gov / TXManuals / CBT / CBT.html) or Kadden et al., Cognitive-Behavioral Coping Skills Therapy Manual, Project MATCH Monograph Series, Volume  (reprinted ; also available at http: // pubs.niaaa.nih.gov / publications / MATCHSeries / Project%MATCH%Vol_.pdf ). Carroll () suggested two major components in CBT: functional analysis and skills training.

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Functional Analysis (FA) According to FA, “for each instance of [drug use] . . . the therapist and patient . . . identify the patient’s thoughts, feelings, and circumstances before and after [the drug use]” (Carroll :). The purpose of doing FA is to help both the clinician and the client assess high-risk situations that may lead to relapse. Through understanding the antecedents and the consequences of the behavior (i.e., the client’s relapse), individualized strategies can be devised to reduce the occurrence of such a behavior. The informal assessment may include the following questions (Kadden et al. :): 1. “In what kinds of situations do you drink [use drugs]? What are your trig2. 3. 4. 5.

gers for drinking [using drugs]?” “Can you give a specific example (e.g., a relapse story)?” “Can you remember your thoughts and feelings at the time?” “What were the positive consequences of drinking [using drugs]?” “What were the negative consequences of drinking [using drugs]?”

Skills Training The CBT therapist works with the client in determining the treatment goals and the types of skills to be acquired (Carroll ). Various tools are used to train the clients in the coping skills, including instruction, homework, modeling, role playing, and behavioral rehearsal (Longabaugh and Morgenstern ). Kadden et al. () suggested that clients be equipped with the following general coping skills to deal with cravings or triggers (–): 1. Recognize “triggers” and reduce the exposure to them. One strategy to

deal with a trigger is to avoid it in the first place. Clients are encouraged to get away from things, places, and people related to AOD use. 2. Cope with the craving or trigger when unable to avoid it. a. “Get involved in some distracting activity.” Clients are encouraged to engage in various hobbies or activities, such as reading or jogging, when experiencing a trigger. b. “Talk it through.” A client can share his or her urge with a friend, a family member, or a sponsor. “Talking it through” can help identify the source of the trigger and allow the client to relieve feelings. One item in a CBT client’s “Personal Emergency Plan: High-Risk Situation” is “I will call my list of emergency numbers” (Kadden et al. :). c. “Urge surf.” Kadden et al. () suggested that urge is time-limited. Clients can “experience” the urge and “surf ” on top of the urge until it diminishes and vanishes.

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d. “Challenge and change your thoughts.” When undergoing a trigger,

an addict tends to remember just the positive consequences of AOD use but not the negative ones. CBT asks clients, each time they experience cravings or triggers, to focus on the negative consequences of AOD use or the benefits of not using AOD instead of the positive consequences.

Professional 12-Step Facilitation (TSF) Intervention The goal of TSF is to facilitate clients’ “active participation in the fellowship of AA” (Nowinski, Baker, and Carroll :) and to encourage them to rely on the “fellowship of AA, and not the individual therapist . . . as the major agent of change” (). TSF incorporates the AA -Step philosophies, particularly the first steps (“accept” and “surrender”), into its sessions. The practitioner discusses these steps with clients and helps them employ the steps to better deal with the alcoholism problem. Clients will not only attend AA meetings and participate in AA social activities but also read AA literature. To help clients achieve this, the TSF practitioner needs to be knowledgeable regarding the AA texts and community AA / self-help-group resources. To cope with urges, TSF recommends strategies that are consistent with the -Step philosophy. Among them are “Calling an AA friend,” “Going to a meeting,” “Going to an AA social,” “Calling your sponsor,” “Calling the AA Hotline,” “Changing a habit pattern,” “Distracting yourself,” and “Praying” (Nowinski, Baker, and Carroll :). For a detailed manual and stepby-step procedures in implementing TSF, readers can refer to Nowinski, Baker, and Carroll, Twelve Step Facilitation Therapy Manual, Project MATCH Monograph Series, Volume  (reprinted ). The difference between TSF and the simple referral of clients to AA and other self-help groups in a comprehensive treatment plan, which has been done traditionally by many practitioners, is that TSF is designed explicitly to encourage clients to participate in the AA or other self-help groups. As a result, TSF clients had a higher level of AA involvement than those who received other treatment methods (e.g., MET or CBT) that may also have included referrals to AA. The TSF clients attended AA meetings more frequently and were more likely to have or to serve as an AA sponsor (Tonigan, Connors, and Miller, cited in Humphreys ). The value of TSF rests not only in its AA philosophy but also in its fellowship, which presents the opportunity to establish a non-using social network. The research results of Project MATCH indicated that “TSF and the resulting AA involvement was particularly effective for outpatients whose social networks (e.g., family members and friends) supported drinking. At the -year follow-up, those patients had better outcomes with TSF than with MET . . . outpatients in the upper median for a supportive drinking network who received TSF had % of abstinent days, compared with % of abstinent days among similar patients receiving

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MET” (Fuller and Hiller-Sturmhöfel :). Women in general emphasize interpersonal relationships and social networks more than men do (Straussner ). Pregnant women and women with young children may particularly rely on their social network for practical reasons. Unfortunately, the social network of many of the women also supports an AOD-using lifestyle. The TSF method offers an opportunity for the women to establish a new non-using social network. Moos, Moos, and Timko (; N =  women and  men with alcohol use disorders) found that “women who participated in AA for an annual average of  weeks or longer in years  to  were more likely to achieve stable remission than were women who did not participate in AA,” whereas the difference between the two groups was not significant among men (). Moos, Moos, and Timko suggested that women may be more able to elicit and benefit from support that involves social bonds and supportive peers. Although substance-abusing women may be in dire need of (re)building nonusing social networks in general and of participating in AA or another self-help group in particular, obstacles exist for some women to achieve either or both goals (Sun ; appendix B). Society’s double standard and bias in judging a woman, particularly a mother, in terms of her AOD-using behavior intensifies the woman’s guilt, shame, and low self-esteem, which may make her hesitant to interact with non-using people, worrying that they may look down on her because of her using behavior (Sun ; appendix B). The relatively lower employment rate of women compared to men further reduces a woman’s opportunity to establish a new nonusing social network. A woman may be apprehensive about the safety of attending an AA group that consists mostly of strangers. It’s uncertain if everyone is truly there for recovery or just to fulfill the legal system’s demand. Second, AA is not available on every corner of the neighborhood, and a lack of transportation often prevents a woman from attending the meetings. The lack of a babysitting service or resource is another barrier. The practitioner should connect the woman with the appropriate (all-women) AA or other self-help group and with “a sponsor” with whom the practitioner has established a certain degree of trust. When necessary, transportation (e.g., carpool or van service) and day care or other child care services should be offered to allow the woman to participate in AA. Treatment programs should also help women organize an “alumnae” AA, where the woman may feel more comfortable and secure because of its connection with her old agency and peers. Further, some women may perceive AA to be male-centered and past-oriented and feel that its philosophy of “powerlessness” and “surrender” exacerbates their already-existing poor self-concept, low self-esteem, and feelings of shame and guilt. The Women for Sobriety self-help groups, founded by Jean Kirkpatrick, may serve as an alternative to AA (Kaskutas ). Women for Sobriety emphasizes women’s strengths and promotes women’s self-development, competency, self-worth, and autonomy.

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Brief Interventions Brief interventions (BI) are interventions that help to identify a potential or real substance abuse problem in a person and motivate the person to decrease risky, substance-abusing behavior (Babor and Higgins-Biddle ; CSAT c). Many empirical studies have shown BI to be effective in alcohol consumption reduction (see meta-analyses done by Kaner et al. [] and Ballesteros, Duffy, et al. []). Although BI has been found to be effective for helping at-risk drinkers, fewer studies are found on its effectiveness in helping at-risk drug users or abusers (Babor and Kadden ). The impact of gender on the effectiveness of BI has been unclear, inconsistent, and controversial. Fleming et al. () have suggested that women may be more receptive than men to BI because women are more likely to react favorably to alcohol assessment or its related problem assessment, whereas Ballesteros, González-Pinto, et al.’s () meta-analyses of clinical trials reported that men and women achieved a similar level of BI treatment outcomes for alcohol consumption. On the other hand, Kaner et al.’s () meta-analyses of clinical trials showed that BI decreased alcohol consumption per week only among men, not among women. SAMHSA TIP  (CSAT c) identified several groups of professionals who can implement BI, including both AOD treatment providers and non-AOD treatment providers such as physicians or nurses, social workers, mental health professionals, EAP or student counselors, health educators, clergy, and lawyers. Three reasons are given to justify BI involvement by the non-AOD treatment providers: () most substance-abusing clients, particularly women and older people, may be reluctant to attend AOD treatment programs because of the stigma attached, but they may often seek help or treatment from primary care, mental health systems, or other non-AOD-specialized treatment programs (CSAT c); () many excessive drinkers are not necessarily alcohol dependent and can be helped in nonAOD-specialized treatment programs (Ashley et al. and Caetano et al., cited in Babor et al. ); and () BI is a relatively easy-to-learn and easy-to-deliver AOD treatment method that treatment providers who are not AOD specialists can acquire (Babor and Higgins-Biddle ).

The Four Levels / Types of BI BI is a structured and manualized treatment method with four different approaches designed for four different client groups as differentiated on the basis of their AUDIT screening (available in appendix A) scores or their degrees of severity of AOD problems (see table .).

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Table 4.1. Four Risk Levels and Their Corresponding AUDIT Scores and Intervention Methods Risk Level Zone I Zone II Zone III Zone IV

Intervention Alcohol Education Simple Advice Simple Advice plus Brief Counseling and Continued Monitoring Referral to Specialist for Diagnostic Evaluation and Treatment

AUDIT Score 0–7 8–15 16–19 20–40

Source: T. F. Babor and J. C. Higgins-Biddle, Brief Intervention—For Hazardous and Harmful Drinking: A Manual for Use in Primary Care (World Health Organization, Department of Mental Health and Substance Dependence, 2001), 12.

Alcohol Education For individuals in the low-risk group or those who receive a low AUDIT score (– points), AOD education is provided. Not only is the person praised for his or her low-risk AOD-using behavior but he or she is also given information about what constitutes “a standard drink” and the recommended number of standard drinks per week, as well as the possible negative consequences of excessive drinking. The main goal of this level of treatment is prevention.

Simple Advice For clients who fall into the low high-risk group (an AUDIT score of – points) or those who are at high risk for, but are not yet experiencing, negative consequences of alcohol consumption, “simple advice” intervention may be provided (using a “patient education brochure”). Simple advice intervention includes the following four steps (Babor and Higgins-Biddle :): 1. “Giving feedback”: The worker presents objective statistics and informs the client that his or her drinking level falls into the high-risk category. 2. “Providing information”: The worker provides the client with information about negative consequences of excessive drinking or drinking above the recommended level. The worker advises the client to immediately reduce the current level of drinking. 3. “Establishing a goal”: This is the most important component of the simple advice method. The worker helps the client to choose either the goal of total abstinence or the goal of low-risk drinking. The worker should inform the client that certain conditions permit only total abstinence, including being pregnant, being afflicted with a mental disorder, having a physical problem (e.g., liver damage) or a medical condition that requires abstinence, or an AOD dependence disorder history.

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4. “Giving advice on limits” and “explaining a ‘standard drink’”: The worker should inform the client regarding what constitutes “low-risk” drinking and what defines a “standard drink” should the client choose low-risk drinking (instead of abstinence) as the goal.

All of the above components should be implemented in a context that is encouraging, nonjudgmental, clear and objective, and authoritative but not confrontational (Babor and Higgins-Biddle ).

Brief Counseling This intervention is appropriate for clients who fall into the high high-risk group (AUDIT score of – points) or those who are already experiencing harmful consequences because of their drinking, although the drinking may not yet have become a dependence disorder. Brief counseling is one stage beyond simple advice. In addition to all the elements covered in simple advice, brief counseling further helps clients with strategies and tools to change their harmful drinking behavior and / or other related problems. Four steps are involved in brief counseling (Babor and Higgins-Biddle : ): 1. “Giving brief advice”: The worker provides simple advice (discussed above) 2. “Assessing and tailoring advice to stage of change”: The worker can tailor

his or her advice and counseling according to the client’s “stage of change” (see motivational interviewing above for a detailed description of “stage of change”). Feedback to the client about his or her drinking behavior’s being excessive and risky and the possible negative consequences of risky drinking may be emphasized if the client is in the “precontemplation” stage. The purpose is to raise the client’s awareness of his or her drinking problem. If the client is in the “contemplation” stage, the worker may emphasize to the client the benefits of changing the risky drinking behavior and the detriment of not changing. A goal of total abstinence or low-risk drinking and the beginning of the first step can also be discussed. If the client is already in a later stage of change such as the “preparation,” “action,” or “maintenance” stage, the worker can continue to provide advice and encouragement to help the client sustain the change. 3. “Providing skills training via the self-help booklet”: The worker can provide the client with a “self-help booklet,” which includes information teaching clients to identify high-risk situations and ways to cope with the high-risk situation without resorting to drinking or drinking too much. (A detailed description is available at http: // whqlibdoc.who.int / hq /  /WHO_MSD_MSB_.b.pdf.) 4. Follow-up: The worker should continue to monitor the client periodically and offer support and feedback with an emphasis on identification of relapse triggers and coping strategies.

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Referral for AOD Specialized Treatment The highest level of BI is referring a client for AOD specialized treatment. This is appropriate for clients who have an AUDIT score of – points or who are considered “probably alcohol dependent.” Although clients with alcohol dependence may require more-specialized treatment than what BI can offer, BI practitioners can facilitate the referral process more effectively and better motivate clients who normally may be resistant to AOD specialized treatment by applying the method of simple advice.

Contingency Management Voluminous empirical studies have verified the (initial) treatment efficacy of contingency management (CM) for substance-abusing clients (see reviews by Higgins, Alessi, and Dantona ; Petry ; Prendergast et al. ). CM may be effective in helping not only regular but special populations, including pregnant or postpartum women and adolescents (Higgins, Alessi, and Dantona ). CM may be effective with treatment for various drug addictions (e.g., alcohol, cocaine, methamphetamine, heroin, marijuana, and nicotine) (Higgins, Alessi, and Dantona ; Roll et al. ). CM views AOD-using behavior as an operant behavior that can be altered by manipulating the consequences of the behavior— that is, a desirable behavior (for example, AOD abstinence) can be reinforced and maintained through positive reward, while an undesirable behavior (AOD relapse) can be discouraged through withholding the reward or imposing a punishment (Higgins and Petry ).

Four Essential Components The CM method involves at least the following four components (Higgins and Petry ; Moos ): 1. Monitoring a client’s AOD use or other targeted behaviors to ensure both that the client’s violation of the rules (e.g., using AOD) is detected and that his or her merits (e.g., AOD abstinence or achievement of other targeted goals) are observed. One way to monitor a client’s AOD use is through routine and frequent urine testing. 2. Providing the client with agreed-upon tangible rewards when he or she achieves AOD abstinence and / or other targeted goals. 3. Withholding the incentives from the client when he or she fails to achieve the agreed-upon goals (e.g., fails to attend treatment, receives a positive urine test, and so on). 4. Helping the client develop a long-term AOD-free lifestyle by expanding his or her repertoire of healthier activities that can compete with, and therefore replace, the rewards derived from AOD using. Healthier and AOD-free activities

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may include better family relations, a satisfying job, enjoyable recreation, and / or social relations.

Five Principles / Strategies The following principles and strategies can facilitate effective implementation of the CM approach:

A Compatible Philosophy It is important to make sure that practitioners’ values and perspectives on human behavior are consistent with the philosophy of CM. For example, when a homeless client relapses, not all practitioners feel comfortable removing the client’s reinforcer by transferring him or her from a private, furnished apartment to a homeless shelter (Schumacher et al. ). Likewise, not all practitioners view providing clients with tangible rewards as appropriate. Some believe that such “rewards” function as bribes.

Accuracy and Consistency It is also important to assure that the monitoring and rewarding procedures are executed carefully, accurately, and consistently. CM studies that show poor treatment outcomes could be attributable to “inconsistent monitoring and application of consequences” (Higgins and Petry :). Prendergast et al.’s () metaanalysis of CM studies suggested that researcher-involved CM studies produced more-effective treatment outcomes than researcher-not-involved CM studies. They observed that “researcher involvement in design or delivery of treatment is related to the issue of attention to fidelity of program implementation” and that researcher-involved CM treatments “tend to follow standard protocols, involve specially trained staff, and provide close monitoring of treatment delivery—all of which are likely to improve treatment implementation and to be associated with better treatment effects” (). Thus, training is critical in helping agencies and practitioners to effectively implement the CM approach.

Written Contract Another important factor is to establish a “written” contract with the client. The contract can include detailed descriptions of (a) the desired behavioral change; (b) tools, schedules, and frequency of monitoring; (c) treatment / intervention duration; and (d) consequences of achieving / failing to achieve the agreed-upon goals (Higgins and Petry ; Petry ).

Choices of Target Behaviors and Types of Reinforcement Researchers and practitioners have suggested that CM can target not only behaviors directly related to AOD treatment (such as AOD abstinence) but also those

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indirectly related to AOD treatment (such as keeping appointments, attending vocational training, complying with medication instructions, participating in -step self-help groups) (Higgins, Alessi, and Dantona ; Moos ). Petry et al.’s () review showed that about % of clients would be unsuccessful in earning reinforcement if abstinence was the only criterion; reinforcement of completion of the goal-related activities (such as keeping appointments) increases the opportunities for clients to gain reinforcers. Types of reinforcement or rewards for CM can be monetary (cash, vouchers, or prizes) or non-monetary. Two issues are involved with monetary reinforcement: (a) the magnitude of the reward: high versus low value and (b) the format of the reward: cash versus voucher versus prize. Although some studies (such as Carroll et al. ) found no relationship between the magnitude of reward and the degree of effective treatment outcome, many other studies substantiated the link between a higher magnitude of reward and a more effective treatment outcome (such as Higgins et al. ; Petry et al. ; Silverman et al. ). For example, Petry et al. reported that clients in their $ CM condition (the average predictable utmost earnings were $) had a significantly higher rate of drug-free specimen submittals than their standard-care clients (control group) (.% versus .%, p < .) and their clients in the $ CM condition (.% versus .%, p < .), whereas there was no significant difference between the $ CM group and the standard-care group. Sindelar, Elbel, and Petry (:) further reported that it is less costly to attain an “incremental week of consecutive abstinence” via adding the $ CM, instead of the $ CM, to the standard-care condition. More studies are needed to determine the amount of monetary value that is most cost-effective. Researchers have compared the CM treatment outcomes of using cash versus voucher versus prize as a reinforcer. Traditionally, practitioners hesitate to reward clients with cash for fear of clients’ purchasing AOD with the cash. However, some evidence shows that cash is a stronger reinforcer than a voucher (see Vandrey, Bigelow, and Stitzer’s review ). Vandrey, Bigelow, and Stitzer’s own study () revealed that high-magnitude cash-based incentives appeared to generate a higher rate of cocaine abstinence than their high-magnitude voucher-based incentives. Further, research has shown that a cash reward is not necessarily more dangerous than voucher reward in tempting clients to use AOD (Vandrey, Bigelow, and Stitzer ). Those authors, however, cautioned that their sample size was small (N = ) and that more studies regarding this issue are needed. The major difference between a voucher-based and a prize-based CM is that each time clients submit a negative AOD test result or achieve an agreed-upon goal, a voucher-based CM would provide them with a voucher, whereas a prize-based CM would give them an opportunity to draw a “card” from an urn to possibly earn a prize. The “card,” for example, can be simple praise such as “good job, try again” but no prize, an item that is worth $ to $, or a $ jumbo prize (Petry et al. :). The prize-

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based CM was initially created because it is believed that it is less costly than the voucher-based CM. Both voucher-based and prize-based CM methods have proven efficacious compared to standard care (Petry et al. ; Petry et al. ). One major criticism of CM is the costs involved because it necessitates a provision for tangible rewards to clients. Researchers have suggested at least three strategies in this regard. First, treatment programs can work with community resources, asking commercial companies for goods donation or organizations that care about the issues for funds donations (Donatelle et al. ; Schumacher et al. ). Second, not all clients need CM, and it may be more beneficial and thus saved for helping more severely impaired clients. For example, Petry et al. () found that clients who tested cocaine-negative at intake tended to submit cocaine-negative specimens during treatment regardless of the treatment condition (i.e., high- versus low-magnitude CM versus standard care), whereas clients who tested cocainepositive at intake tended to do better when assigned to the high-magnitude CM group, compared to the low-magnitude CM and standard-care condition. More studies are needed to confirm this finding. Third, a variety of non-monetary rewards can be made available to clients. For example, take-home methadone, GED classes, vocational training and employment placement, housing, child care provision, transportation services to and from an agency, treatment fee refunds / rebates, and / or ceremonies that recognize a client’s treatment progress and completion could all be potentially effective reinforcers (Petry ; Roll, Chudzynski, and Richardson ). “Informing” is another strategy that can be used: the specified consequence of an undesirable behavior (such as AOD relapse or noncompliance with treatment plan) is to inform the client’s employer or the relevant legal authority (Petry ). Petry acknowledged that it may be difficult to get clients to commit to such an agreement voluntarily. Overall, the efficacy of the various reinforcers (other than vouchers) still awaits further verification (Petry ).

Combining CM with CBT and CRA It is unknown whether CM can stand alone as a treatment for AOD-using clients. Often CM is considered as an adjunct to standard treatment (Prendergast et al. ). Although CM is effective in producing initial positive treatment outcomes, such outcomes can be maintained by clients for only a limited time after the incentives are terminated (Moos ; Prendergast et al. ). Researchers have suggested combining CM with cognitive behavioral therapy (discussed earlier) and / or community reinforcement approach (discussed later) to reach longer-term treatment benefits (Epstein et al. ; Moos ). Petry et al. () suggested that more studies are needed in this regard. For a detailed description of CM, see A. J. Budney and S. T. Higgins, A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction, NIDA  Manual  (available at http: // www.nida.nih.gov / pdf / CRA.pdf ).

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Behavioral Couples Therapy Behavioral couples therapy (BCT) assumes that the AOD-use disorder of a married / cohabited individual may significantly affect his / her relationship with his or her non-using spouse and vice versa. BCT, therefore, aims both to employ the non-using spouse’s support for AOD abstinence and to convert the negative interaction between the partners into positive interaction, both of which promote abstinence in the client. Although traditionally BCT was more for substance-abusing men with a non-using female spouse (like many other AOD treatment methods and approaches), studies have begun to verify the effectiveness of applying BCT to help an AOD-using female partner with a non-using male spouse (Winters et al. ). Generally speaking, the BCT approach is not suitable for () ”dually addicted” couples (i.e., both partners are using); () couples who have a considerably damaging relationship (e.g., domestic violence that called for medical attention) that might harm both or one of them; () couples in which one or both of the partners are afflicted with a psychiatric condition (e.g., schizophrenia) that disturbs their BCT participation (Fals-Stewart, O’Farrell, and Birchler ; Klostermann et al. ). To help couples who have a harmful relationship, Fals-Stewart, O’Farrell, and Birchler suggested referring the perpetrator to a domestic violence treatment program and having the substance-abusing partner receive AOD counseling. For dually addicted couples, BCT usually does not work, since it involves helping a substance-abusing client move toward abstinence primarily through the support of a non-using partner. When both are using, not only is there no support for abstinence from a spouse but also the couple’s shared AOD-using activities further reward and reinforce their AOD-using behavior (Klostermann et al. ). As mentioned earlier, studies are beginning to show that using the BCT method for treatment of a substance-abusing woman with a non-using male spouse is as effective as it is for substance-abusing men with a non-using female spouse. However, the ineffectiveness of BCT with dually addicted couples has posed a big challenge to helping substance-abusing women, as they are usually more likely than substance-abusing men to be in a dually addicted couple relationship. For example, in the process of recruiting subjects for their BCT study, Winters et al. () found that about % of the married (or cohabiting) substance-abusing women were living with their substance-abusing male spouse, and thus they had to exclude those women from the study. If couple-oriented therapy (like BCT) is critical but also impractical for a substance-abusing woman with a substance-abusing male spouse, how can these women be helped? The usual practice would be to separate the woman from the man if the woman is seeking treatment but the man is not. The usual result is either that the woman successfully completes the treatment, moving toward recovery, and terminates her relationship with the substance-abusing man or that

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the woman fails the treatment and returns to the man. A majority fall into the latter category. Recent research has targeted the method of combining BCT and contingency management for helping dually addicted couples. Material incentives such as vouchers or other non-AOD-related prizes are offered to couples who attend BCT treatment together and / or both submit negative urine tests. The preliminary findings of the effect of using BCT plus CM with dually addicted couples appear promising, but such research is still in its infancy, and more studies are needed to evaluate the long-term effectiveness of treatment outcomes (FalsStewart, O’Farrell, and Birchler ; Klostermann et al. ).

The Four Components and Steps BCT is a structured method that assigns many tasks or “homework” to clients. Most couples receiving BCT appeared to appreciate the change that the very structured therapy sessions and the “homework” brought to their disorganized lives (Fals-Stewart, O’Farrell, and Birchler ). BCT usually requires fifteen to twenty outpatient couple therapy sessions (couple seen together) over a period of five to six months. Recently a shorter BCT format comprising only six sessions has been developed and has undergone evaluation (Fals-Stewart, Birchler, and O’Farrell ). BCT can be applied as an independent treatment or as an adjunct to a regular AOD treatment (Klostermann et al. ). In general, BCT involves four major components or steps.

Step : Helping the Couple Shift Focus from Mutually Negative Feelings to Positive Interaction Often the partners may have developed negative feelings toward each other because of one partner’s AOD using and the multiple related issues. The practitioner should first help the couple resolve or decrease such negative feelings while moving along into the core of the therapy, which involves completion of tasks that require a positive interaction between the two partners (Klostermann et al. ). To avoid AOD-related conflicts and relapse, the couple is encouraged to address past AOD using or fears of future using in the setting of therapy sessions rather than bringing them up in the home (O’Farrell and Fals-Stewart ).

Step : Helping the Couple Design and Implement a Daily Sobriety Contract One major part of BCT is to help the couple develop a daily sobriety contract, which lays out the responsibilities of the two partners regarding helping the using partner to achieve abstinence. For example, following the “one day at a time” philosophy, the using partner should express to the non-using spouse his or her goal for the day to achieve abstinence, comply with medical strategies such as taking Antabuse or Naltraxone, and / or attend self-help groups. In turn, the non-using

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spouse should show support to the using partner for his / her efforts (O’Farrell and Fals-Stewart ). The practitioner gives the couple a calendar, and the non-using spouse logs the outcomes of the daily sobriety contract on the calendar every day. The couple and the practitioner review and discuss each partner’s contract outcome performance at the beginning of each therapy session; the practitioner also verbally praises the couple for their performance whenever appropriate (O’Farrell and Fals-Stewart ).

Step : Enhancing the Couple’s Communication and Problem-Solving Skills Another important task of BCT is to enhance the couple’s communication skills and problem-solving abilities, since both may promote abstinence (FalsStewart, O’Farrell, and Birchler ). This step may be particularly important for substance-abusing women. Winters et al. () said that BCT providers reported that when they were working with male clients with non-using female partners, more BCT sessions were spent on AOD abuse and misuse issues and issues related to abstinence contract compliance, whereas when they were working with female clients with non-using male partners, more BCT sessions were devoted to relationship issues, communication skills teaching, and positive-interaction enhancement. Although further systemic studies are needed to confirm this finding, it is nonetheless consistent with the themes presented in chapter . Practitioners can help the couple implement at least five activities or assignments to enhance their communication and problem-solving skills (Fals-Stewart, O’Farrell, and Birchler ): 1. “Catch(ing) your partner doing something nice”: This assignment asks both partners to observe and recognize one nice thing that the other partner does each day (). 2. Surprising the partner with a “Caring Day”: This assignment encourages each partner to show caring by surprising the other with something special done in a day. 3. Doing non-AOD-related fun activities together: Fals-Stewart et al. () noted that many families have abandoned the tradition of engaging in pleasing activities together. Regaining such family rituals or activities helps to promote positive experiences and recovery. 4. Learning effective communication skills: Training can increase the skills of both partners with respect to empathizing, paraphrasing, and other types of communication, all of which may facilitate more competency in dealing with life stressors in general and relationship stressors in particular and in reducing the risk of relapse.

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5. Working effectively with not only the BCT therapist but also other relevant providers to maximize the overall treatment effectiveness: BCT usually is offered in conjunction with individual (and group) treatment; a BCT therapist can coordinate with an individual treatment provider to better serve the client. For example, a couple may reveal the client’s vocational training need in a BCT session, but such training may be better included in the client’s individual AOD treatment plan and more effectively fulfilled by the client’s individual treatment provider.

Step : Helping the Couple Develop and Implement a Post-treatment Relapse-Prevention Plan Like the outcomes of many other AOD treatment methods, the outcomes of BCT tend to be positive mainly for the early post-treatment and decline thereafter. For example, Winters et al (; N =  drug-abusing women who were married or cohabiting) reported that the women made progress regarding “percentage of days abstinent,” but the progress seemed to be active mainly during the early stage of post-treatment and to decline in the later stage of post-treatment, in that the “percentage of days abstinent” was .% at pre-treatment, .% at post-treatment, .% at three-month follow-up, .% at six-month follow-up, .% at nine-month follow-up, and .% at twelve-month follow-up. Although both the post-test and all the follow-up tests were significantly higher than the pretest, there was a declining trend from post-test to the twelve-month follow-up test. In terms of the “dyadic adjustment” score (relationship satisfaction), the pretest score of the women was . versus . for the post-test, . for the three-month follow-up, . for the six-month follow-up, . for the nine-month follow-up, and . for the twelve-month follow-up. Only the post-test, three- and six-month follow-ups were significantly better than the pretest; the nine- and twelve-month follow-ups were not better (Winters et al. ). Winters et al. therefore suggested that attention should be given to strategies to sustain the treatment gains after treatment ends. Three elements may be emphasized: 1. Practitioners can help the couple develop a “continuing recovery plan,” focusing on activities the couple can engage in to continuously promote sobriety. The plan may include a continuing “daily trust discussion,” a “relapse contingency plan” that lays out what to do when relapse occurs, including speaking to sponsor, recontacting the BCT practitioner, etc., and a continuing commitment to engage in shared activities that reward and enhance the couple’s relationship (Fals-Stewart, O’Farrell, and Birchler ). 2. Practitioners should also help the couple to deal with and negotiate the issue regarding tapering the frequency of the agreed-to post-treatment activities. For example, during the first month after treatment, the daily “abstinence trust

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discussion” in relation to AA attendance and medical compliance can be done seven times a week, but reduced to three times a week when moving to the second month of post-treatment, once a week during the third month, and so on (Klostermann et al. ). 3. Practitioners may also emphasize the notion that relapse is not uncommon during the recovery process and that the couple should not view relapse as treatment failure and / or give up hope on the using partner’s recovery (this may be particularly crucial for the non-using spouse, who might feel betrayed when relapse occurs) (Fals-Stewart, O’Farrell, and Birchler ).

Community Reinforcement Approach (CRA) CRA suggests that an individual’s substance abuse behavior may be either reinforced or discouraged by the environment, including family relationships, recreational / social activities, and vocation (Meyers, Smith, and Lash ; Meyers and Squires n.d.). CRA aims to help a client replace pleasure obtained from AOD use with pleasure derived from rewarding, non-AOD-involved family relationships, recreational / social activities, and vocations. To achieve this goal, the client may need a rearrangement of the three areas, which requires skills training on the client’s part as well as the involvement of the client’s significant others. CRA was originally designed to treat alcohol-dependent clients but later was also applied to cocaine- or opioid-dependent clients (Abbott et al. ; Higgins and Abbott ; Moos ). Despite its empirically proven efficacy (Higgins et al. ; Meyers and Squires n.d.; Miller and Wilbourne ), CRA traditionally has not been widely used by treatment programs (Kadden ; Meyers and Miller ). This could be because the field has long adopted the disease model, which views the cause of AOD use disorder as being within an individual rather than in the environment (Meyers and Miller ). Another reason could be that CRA implementation is believed to be high cost and labor-intensive (Barber ; Kadden ). However, CRA appears to be consistent with the social work cardinal value that stresses human behavior as being the product of interactions between the individual and the environment. Researchers and practitioners have advocated for more involvement of social workers in the AOD treatment field (Sun ), and CRA could perhaps be more effectively implemented by a social worker in an AOD treatment program or by a collaboration between a counselor in an AOD treatment program and a social worker in a community agency. Following are the components of CRA and strategies for its implementation.

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Four Components Help the Client Develop Rewarding Life Areas Daily life and environment encompass multiple areas, and different clients may need help in different areas. CRA uses the “Happiness Scale” (HS) and “Goals of Counseling Form” (GC) to devise a treatment plan for a client. The HS assesses a client’s needs in ten areas: drinking, job / education progress, money management, social life, personal habits, marriage / family relationships, legal issues, emotional life, communication, and general happiness (Meyers and Smith ). The client ranks each area from  through  ( being “completely unhappy” and  being “completely happy”). Given the HS results, the practitioner and the client work on GC to devise a treatment plan, which includes goals and strategies to achieve the goals (Meyers and Smith ). Among the multiple areas in life, the three most emphasized are vocation, social and recreational activities, and marital and family relationships. Vocation

Vocation provides a client with multiple sources of pleasure: self-esteem, positive social interaction with coworkers, praise from supervisors, and financial reward (Meyers and Squires n.d.; Smith and Meyers ). A steady job also provides structure in the client’s daily life and thus deters drinking activities (Smith and Meyers ). CRA practitioners can help a client find a job, maintain the job, and improve job satisfaction (Meyers and Squires n.d.). Smith and Meyers () believe that, for many clients, it may be easier to obtain a job than to maintain one. Therefore, efforts should be made to explore factors contributing to the client’s previous job losses. Practitioners should help clients more effectively deal with those factors (which may include anger management or other emotional issues), whether they are AOD-related or not (Smith and Meyers ). Most CRA studies appear to include only a small percentage of women and do not analyze men and women separately. Sun’s (n.d.) qualitative study shows that obtaining a job could be as difficult as keeping a job for many women. Women in that study faced multiple barriers in getting a job: less education, a lack of job skills and work history, drug-affected brain, AOD-use background, criminal history, older age, and a lack of basic tools such as a car, appropriate clothing for job interviews, and child care. Habilitation (in addition to rehabilitation) and case management are critical to help women with such issues. Social and Recreational Activities

Substance-abusing individuals are usually caught in the “substance-abusing culture.” Their recreational life may revolve around AOD activities, and their social network overlaps with their AOD-using social circles (Meyers and Squires n.d.;

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Smith and Meyers ). The CRA practitioner should help a client to: (a) recognize the need to sever ties with the old AOD-using social circles and to avoid AOD-involved recreational activities, (b) identify sources and opportunities for non-AOD-involved enjoyable activities, and (c) overcome obstacles to engaging in non-AOD-involved enjoyable activities (Meyers and Squires n.d.; Smith and Meyers ). Smith and Meyers remind practitioners not to assume that clients automatically know how to arrange their recreational and social activities once they quit AOD using; they stress the importance of devoting considerable time and employing “functional analysis” as well as “problem solving” to help clients in this life area. Practitioners may need to be sensitive about the stigma perceived by substanceabusing women when helping those clients to build (or rebuild) non-using social networks and recreational activities. Perhaps because of society’s double standard and harsh judgment, substance-abusing women may feel ashamed and inadequate when interacting with non-users (Sun ). In addition to functional analyses and problem-solving skills training to enhance women’s new sources of non-AODinvolved social and recreational activities, practitioners should help the women overcome the stigma barrier by stressing that it is the AOD, not the person, that is vicious, and that society in general respects people who pursue recovery. Marital / Family Relationships

The spouse and other family members—especially if they live with the client— may play a critical role in facilitating or sabotaging the client’s recovery. A conflicting relationship is often common between the client and the spouse / family members; regardless of whether the conflicting relationship is the cause, the consequence, or both, of a client’s AOD use, practitioners should help both parties turn a conflicting relationship into a rewarding one (Meyers and Smith ). Meyers and Smith specified the marital counseling method (:–), which they suggest can also be applied to other relationships, such as that of a parent to an adult child. CRA marital counseling does not emphasize expanded marital therapy but focuses on improving basic relationship skills for all parties by enhancing their ability to set realistic expectations and practice effective communication and problem-solving skills (Meyers and Smith ; Miller, Meyers, and HillerSturmhöfel ). Improving marital and family relationships could be more critical and challenging for substance-abusing women than for men. As mentioned in previous chapters, more substance-abusing women than substance-aubusing men are growing up in a family with AOD problems and / or having a spouse with AOD problems. CRA relationship counseling (and the behavioral couples therapy discussed above) has a better chance of success if the spouse and / or other family members are non-users. Regardless of whether or not the spouse and family members are users,

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Weaver, Turner, and O’Dell () found, the women (N = ) perceived “family” and “marital / intimate relationships” to be two of their major sources of psychosocial stress during both prerecovery (.% and .%, respectively) and recovery (.% versus .%, respectively). Sun (n.d.) also found that many women, because of the long waiting list for transitional housing or for other reasons, returned to their old family members or spouse with whom they had a dysfunctional relationship. If the spouse and other family members are non-users, it may be beneficial to involve all parties and enhance their communication and problem-solving skills. Practitioners may additionally provide family members insights into the woman’s co-occurring disorders and functional ways to recognize and deal with her relapse triggers. The involvement of family members may facilitate “a more consistent and realistic kind of support” (Orlin, O’Neill, and Davis :).

Two Types of Functional Analyses (FA) Similar to CBT, CRA functional analysis explores the antecedents that trigger a client’s substance abuse and the consequences that follow substance abuse. Antecedents may include both external and internal triggers. Assessment of external triggers focuses on with whom, where, and when the client uses AOD. Assessment of internal triggers targets the client’s thinking and physical and emotional feelings before using AOD. For “consequences,” both the short-term positive consequences that reinforce the client’s substance abuse and the long-term negative consequences should be explored. The idea is to first help the client recognize the triggers of substance abuse and understand that the positive consequences are short-lived and, in the long run, will be replaced with many negative consequences. A second goal is to equip the client with the skills to effectively deal with the triggers and to develop alternative, non-AOD-involved activities that can compete with AOD and bring about both short- and long-term pleasurable consequences (Meyers and Miller ; Meyers and Smith ). CRA conducts FA not only for drinking behavior but also for non-drinking behavior that brings pleasure to a client (Meyers and Miller ; Meyers and Smith ). Antecedents preceding a non-drinking behavior are identified. For example, with whom, when, and where does the client engage in this non-drinking behavior? What is the client’s thinking and feeling (physical and emotional) before the non-drinking behavior takes place? The “consequences” are also analyzed, exploring the short-term negative consequences and the long-term positive consequences. The purpose is to understand and enhance the magnitude of the existing non-AOD-using behavior that can compete with the AOD-using behavior.

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Communication, Problem Solving, and AOD-Refusal Skills Training Many substance-abusing clients do not have effective communication and / or problem-solving skills because they grew up in a substance-abusing family with no role models or because they experienced chronic exposure to AOD, leading to impaired cognitive capacities and dysfunctional interactions with others. Sun (n.d.) found that because of ineffective communication and a lack of problemsolving skills, some substance-abusing women have dysfunctional interactions not only with spouses and other family members but also with their CPS workers, AOD treatment counselors, and parole / probation officers. Although those authority figures, theoretically, are responsible for helping the women, they ironically may serve as relapse triggers. Communication and problem-solving skills training together with FA will empower the women to achieve a rewarding, non-AODinvolved lifestyle. Smith and Meyers (:) summarize four guidelines for effective communication: “label your feelings,” “make an understanding statement,” “accept partial responsibility,” and “offer to help.” They give an example to demonstrate how a wife who wants to go out for dinner more frequently could communicate more effectively with her husband: “I would like you to go out to dinner with me every Friday or Saturday night. I know that you’re really tired by the end of the week and you’d rather stay home [understanding statement], and it probably doesn’t help to have me pressuring you to take me out [partial responsibility]. I do feel bad though, when you seem to prefer to watch TV instead of talking to me over dinner [feelings]. Maybe it would help if I made a point of either making or ordering us a nice dinner at home for the weekend night that we don’t go out [offer to help]” (). For problem-solving skills, Meyers and Smith (:) emphasized four steps: “defining the problem”; “generating potential solutions”; “deciding on a solution,” assessing possible obstacles in executing the solution, and supplementing with a backup plan; and “evaluating the outcome” of the solution and modifying it if necessary. For AOD-refusal skills, Meyers and Smith suggest using FA to help a client identify triggers, seeking and linking the client with non-using social support and network, and role playing to practice skills such as saying “no” to strangers who invite them for drinks, preparing for alternatives when family members or close friends invite them for drinks, changing conversation topics from AOD to something else, and reconstructing one’s own negative thoughts that are likely to lead to relapses.

The Practitioner as Case Manager To fully implement CRA and help a client obtain pleasure from a non-AODinvolved lifestyle requires a practitioner to not only target the client’s AOD problems but also focus on many other areas of the client’s life. CRA workers should be cognizant of and actively address clients’ non-AOD-related or everyday needs in

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addition to their AOD-related treatment needs, be knowledgeable about community resources, and effectively link clients with those resources (Meyers and Squires n.d.; Miller, Meyers, and Hiller-Sturmhöfel ).

Three Strategies Sobriety Sampling Instead of a lifelong abstinence requirement, CRA suggests a “sobriety sampling” approach when first meeting a client who is not ready for total abstinence. The goal could be  days of sobriety, which could be negotiated down to  days, two weeks, or even one day, depending on the client’s “readiness.” The philosophy of sobriety sampling is that many clients may not be ready to completely give up their habits and may be scared away if they are required to never drink. According to Meyers and Smith (), “sobriety sampling” approaches abstinence in a “gentler” way and helps the client: (a) build a bond with the practitioner, as on one hand the client is helped to understand the severity of his or her drinking problem and on the other hand comes to realize that the goal is not overwhelming but attainable; (b) feel success more easily, since the goal is a short-term one and, thus, establish self-efficacy; (c) experience an opportunity of improvement of symptoms related to the cognitive, physical, and / or emotional areas because of the “timeout” from drinking; and (d) earn the trust of significant others (family members, probation officers, CPS workers, and so on) and restore broken relationships more quickly. Further, should the client relapse during the sobriety-sampling period, the practitioner and the client may gain critical information about the additional help the client needs to maintain sobriety. A practitioner should motivate a client to try sobriety sampling and help the client devise a plan to reach the goal once a time period is mutually agreed upon. Meyers and Smith () suggest several strategies, including scheduling the next meeting in only a few days, conducting FA to explore possible triggers during the period, and developing new coping skills with a backup plan.

Incorporating a Medication Component One reason pharmacotherapy may have a more successful outcome when it is combined with psychosocial treatment is that a client’s daily intake of medications can be better monitored by significant others, resulting in the client’s better compliance with medications. CRA has suggested that a supportive spouse, close friend, employer, or probation officer can be trained to effectively monitor a client’s daily intake of disulfiram (Antabuse) (Meyers and Squires, n.d.; Meyers and Smith ). Meyers and Smith wrote a chapter about “disulfiram use within CRA” (:–). A physician must be involved to assess the client’s medical status for appropriateness of disulfiram intake. Both the client and the significant other should be informed of the purpose and advantages of taking disulfiram

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and the possible reactions—such as sweating, breathing difficulty, dizziness, and vomiting—should the client drink after taking disulfiram. Further, both the client and the significant other need to understand that the monitor role is supportive, not punitive or “watchdog.” In addition to disulfiram, recent studies have also investigated the efficacy of combining naltrexone use with CRA in helping opiate addicts (e.g., Roozen, Kerkhof, and van den Brink ; Rothenberg et al. ). One rationale of this approach was to involve a significant other in monitoring a client’s naltrexone ingestion and compliance. More randomized trials are needed to assess the efficacy of combining naltrexone use and CRA.

High Treatment Intensity at the Start The initial period may determine whether or not a client drops out of treatment. Two strategies to improve treatment retention have been suggested: () if a client is ready, the appointment should be scheduled the following day or as soon as possible (a waiting list is not recommended) (Miller, Meyers, and Hiller-Sturmhöfel ), and () a client should be seen more frequently initially (e.g., more than once a week) and less frequently only after abstinence becomes steady (Miller, Meyers, and Hiller-Sturmhöfel ). In addition, CRA may be combined with CM. Budney and Higgins () found that a vouchers program was effective in retaining clients and that clients receiving CRA and vouchers stayed longer than those receiving only CRA. Secades-Villa et al. () found that cocaine-abusing clients receiving CRA plus vouchers had higher treatment retention than their counterparts receiving standard care (% versus % completed six months of treatment). They also had a higher rate of continuous abstinence for  weeks than their standard-care counterparts (% versus %). For a detailed description of CRA, see A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction, NIDA Manual  (available at http: // www. nida.nih.gov / pdf / CRA.pdf ); Meyers and Smith, Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach (); and Meyers and Miller’s edited volume, A Community Reinforcement Approach to Addiction Treatment ().

PART TW O

Helping the Six Specific Vulnerable Populations

Chapter 

Pregnant Women

T

he negative consequences of substance abuse by pregnant women have been doubly emphasized because of the involvement of an innocent fetus. However, the individual rights of these women and their lack of specific resources further compound the issue (Jos, Marshall, and Perlmutter ). Helping this population thus becomes an imperative, as well as challenging, mission. During pregnancy a woman may be highly motivated to stop unhealthy or risky behavior, including AOD use/abuse, because of a natural maternal instinct to protect her unborn child. (In fact, during pregnancy, about % to % of female smokers spontaneously stop smoking and about % of female drinkers quit drinking [Flick et al. ; Ockene et al. ].) But why do some pregnant women continue to use AOD? People who believe in free will and personal choice but underestimate the negative impact of an “unequal footing” and a detrimental environment on an individual’s behavior may ascribe such risky behavior to lack of a moral conscience or sense of responsibility. This moral model has been adopted by certain policymakers who suggest a punitive approach to handling AOD use/ abuse during pregnancy. The punitive approach, however, has proved to be ineffective in dealing with the issue (Finfgeld ; Jessup et al. ). As mentioned in chapter , AOD treatment programs traditionally are designed for men and are not readily available to women. Such a service deficiency is particularly evident for pregnant women (Finkelstein ). Although more programs have expanded their doors in the s

A part of this chapter is a variation of the author’s  article “Principles for Practice with Substance-Abusing Pregnant Women: A Framework Based on the Five Social Work Intervention Roles,” Social Work  ().

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to substance-abusing pregnant women (SAPW) due to federal funding policies, many do not provide pregnancy-specific treatment (Breitbart, Chavkin, and Wise ). While those programs do accept pregnant clients, they are limited in that they serve only middle-class or non-Medicaid clients, provide no child care or referrals, and do not emphasize prenatal care or make such referrals (Breitbart, Chavkin, and Wise ). This chapter includes three components: () prevalence and types of AOD use and abuse among pregnant women in the United States, () risk factors for substance use and abuse during pregnancy, and () six treatment guidelines and strategies for helping SAPW.

Characteristics and Nature of AOD Use and Abuse Among Pregnant Women Prevalence The – data from the National Survey on Drug Use and Health (NSDUH) conducted by SAMHSA (OAS a) showed that .% of U.S. pregnant women aged  to  years used alcohol in the preceding month, .% were binge drinkers, .% were heavy users of alcohol, .% used tobacco products, and .% used illicit drugs.

Type of AOD Used/Abused SAMHSA’s (OAS a)  Treatment Episode Data Set (TEDS) indicated that among pregnant women – years old, cocaine/crack was the primary substance for % of the total treatment admissions and methamphetamine (MA)/ amphetamine (A) was responsible for % of the total admissions, followed by alcohol (%), marijuana (%), and heroin (%). On the other hand, alcohol was responsible for % of the total admissions among nonpregnant women, followed by cocaine/crack (%), heroin (%), MA/A (%), and marijuana (%). It appears that pregnant women are more prone to stimulant use (cocaine/crack, MA/A) than are nonpregnant women. MA/A use or abuse is even more prevalent among SAPW in the Southwest region of the United States. A Nevada study indicated that MA/A accounted for % of the total treatment admissions ( of  admissions) among SAPW (Towle, Bailey, and Gibbs ).

Risk Factors for AOD Use and Abuse During Pregnancy Although empirical studies did not directly explain the causality, they revealed at least four areas of insight that help us understand the background of these women and the possible risk factors for their AOD use and abuse during pregnancy: () the

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intimate partner, () psychiatric disorders and dual diagnosis, () a disadvantageous socioeconomic background, and () AOD-related risk factors (e.g., a more severe AOD problem prior to pregnancy).

Intimate Partner An intimate partner plays a critical role when a woman is pregnant, since at that time she is much more vulnerable and in need of emotional and concrete support, especially from her partner. Three issues in particular can significantly affect a pregnant woman’s AOD-using behavior: () the absence of an intimate partner, () AOD-using behavior of an intimate partner, and () domestic violence.

The Absence of an Intimate Partner Empirical studies have consistently shown that married women (pregnant or nonpregnant) are less likely than nonmarried women to have any alcohol use, to engage in binge drinking, to use illicit drugs, and/or to smoke (CDC ; Tsai, Floyd, and Bertrand ). Multiple factors may contribute to a married woman’s lower rate of AOD use and abuse, among them family responsibility and intimate partner companionship and support. A nonmarried woman, on the other hand, may have more freedom to engage in various behaviors (functional or dysfunctional) or may feel more boredom or emotional emptiness and thus be more likely to engage in AOD-using or -abusing behaviors. Marital status may have an even greater impact on a woman’s AOD-using behaviors during pregnancy. Although the relationship between being single and using AOD among pregnant women is not necessarily unidirectional, the absence of an intimate partner for a pregnant woman could be an indicator of lack of social support or absence of a stable home environment (Leonardson and Loudenburg ), both of which may exacerbate the already stress-laden pregnancy stage and in turn increase a woman’s risk for AOD use/abuse. Empirical studies have consistently suggested that AOD-using pregnant women are more likely to be single than are non-AOD-using pregnant women and/or that single pregnant women are more likely to engage in AOD-using or -abusing behaviors than are married pregnant women (Burd et al. ; CDC ; Grangé et al. ; Huang and Reid ; Leonardson and Loudenburg ; Meschke, Holl, and Messelt ; Noble et al. ; Perry et al. ). For example, the CDC’s – Behavioral Risk Factor Surveillance System (BRFSS) study (N = , women aged –, with , pregnant women) reported that compared to a married pregnant woman, a nonmarried pregnant woman is . times as likely to engage in “any alcohol use,” . times as likely to engage in “binge drinking,” and . times as likely to engage in “frequent drinking” (CDC ). CDC’s analysis also showed that a nonmarried nonpregnant woman tends to be more likely than a married nonpregnant woman to engage in

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drinking behaviors, but the gaps appear to be narrower (. times, . times, and . times, respectively). This finding may indicate that marital status has a more significant impact on pregnant women’s AOD-using behavior than on nonpregnant women’s AOD-using behavior. Leonardson and Loudenburg’s () largescale study (N = , pregnant women) found being single to be one of the risk factors for AOD use among pregnant women, while being married and being “a full-time housewife” were protective factors. Burd et al. (; N = , pregnant women) reported that .% of their nonmarried participants scored  points or greater on TWEAK (indicating a high drinking risk; see appendix A for TWEAK screener), as compared to .% of their married participants. Perry et al. () found that drug-using pregnant women (n = ) had a significantly higher rate of being single than their non-AOD-using counterparts (n = ) (%–% versus %, p < .). Noble et al. () (N = , pregnant women) reported that when compared to nonmarried pregnant women, married pregnant women had a lower rate of alcohol use (.% versus .%), illicit drugs use (.% versus .%), and tobacco use (.% versus .%). Grangé and colleagues (; N =  pregnant women, France) found that a significantly higher proportion of pregnant women who smoked until delivery were single compared to nonsmoking women (.% versus .%, p < .). Grangé et al. stated: “It is more difficult for a pregnant woman who lives alone to stop smoking than for a woman who has company. Women who live alone appear to be more dependent because, on average, they smoke their first cigarette earlier in the day than women who have company” ().

AOD-Using Behavior of an Intimate Partner Pregnant women’s AOD-using behaviors are heavily affected by the AOD-using behavior of their intimate partners (Bresnahan, Zuckerman, and Cabral ; Hutchins and Dipietro,; Leonardson and Loudenburg ; Ockene et al., ; Perreira and Cortes ). Bresnahan, Zuckerman, and Cabral reported that pregnant women whose partners are substance abusers were five times more likely to be substance abusers than pregnant women who had no such partners. Tuten and Jones () reported that a substance-abusing pregnant woman with a non-AOD-using male sexual partner stayed in treatment significantly longer than did her counterpart with an AOD-using sexual partner ( days versus  days, p < .). The non-AOD-using male partner had more formal education and was more likely to be employed, more functional (less in need of legal, health, dental, and transportation services), more supportive of the pregnant woman’s AOD treatment (% versus %, p < .), and less likely to give the woman money to buy drugs (% versus %, p < .) than the AOD-using male partner. Ockene et al. (; N =  pregnant women who quit smoking during pregnancy and  pregnant women who did not quit smoking during pregnancy, Boston) showed that pregnant women who had a husband or partner who smoked were

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less likely to quit smoking than their counterparts whose husband or partner did not smoke.

Domestic Violence (DV) Velez et al.’s () review showed that “violence against women involves a continuum of behaviors including intense criticisms and demeaning remarks, restraint of normal activities and freedoms, jealous control, denial of access to other persons or resources, threats and intimidation, sexual coercion and assault, rape, physical attacks, and even homicide” (). Velez et al. further suggested that emotional abuse may be more harmful for some women, but most DV studies focused only on physical and/or sexual abuse. Velez et al.’s own study (N =  substanceabusing pregnant women) reported that .% of the pregnant women in the study were exposed to emotional abuse during their present pregnancy; .%, physical abuse; and .%, sexual abuse. Substance-abusing pregnant women exposed to intimate partner violence are more likely to have more-severe AOD problems and/or other psychiatric problems than substance-abusing pregnant women exposed to no intimate partner violence (Martin, Beaumont, and Kupper ; Perreira and Cortes ; Tuten et al. ). Leonardson and Loudenburg () revealed that the factors of “physical abuse in last year” and “physical abuse this pregnancy” significantly predicted pregnant women’s drinking (). McFarlane, Parker, and Soeken (:; N = , pregnant women “from public prenatal clinics in Houston and Baltimore”) indicated that African American pregnant women who were exposed to a partner’s physical abuse were significantly more likely to smoke (.% versus .%, p < .) and to engage in alcohol/illicit drug use (.% versus .%, p < .) than their counterparts who were not exposed to partner physical abuse. Among white pregnant women, those who were exposed to physical abuse were more likely to smoke than those who were not exposed to physical abuse (.% versus .%, p < .). White pregnant women exposed to partner physical abuse also showed a higher rate of alcohol/illicit drug use than their counterparts who were not exposed to partner physical abuse (.% versus .%), although the difference is not statistically significant. Although the relationship between DV and AOD using among pregnant women is not necessarily unidirectional, DV is likely a risk factor for women’s ATOD (alcohol, tobacco, and other drugs) use and abuse.

Psychiatric Disorders and Dual Diagnosis, Particularly Depression Depression and Other Psychiatric Disorders During Pregnancy Women are more vulnerable to depression than men are. Women at childbearing age are at the highest risk for depression. Marcus et al.’s review () showed that “women who experience depressive symptoms associated with childbearing are at greatly increased risk for future depressions over a -year period” (). Although

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postnatal maternal depression has traditionally received more attention than antenatal depression, antenatal depression has recently been considered as important as postnatal depression (Pajulo et al. ). Not only does maternal depression directly affect a child’s emotional and cognitive development, but it may also increase the risks for substance abuse during and after pregnancy, possibly resulting in AOD-exposed fetuses and postnatal child neglect (Pajulo et al. ). Empirical studies indicated a link between a woman’s depression during pregnancy and her use of alcohol and/or cigarettes during pregnancy (Marcus et al. ; Pajulo et al. ). Meschke, Holl, and Messelt’s  study (N = , pregnant women, Minnesota) reported that pregnant women who drink had a significantly higher level of depressed mood than those who abstain (p < .). As mentioned in chapter , although the relationship between depression and AOD use can be bidirectional (i.e., depression occurs first or AOD use occurs first), research has shown that depression is more likely to occur first among women, while AOD use is more likely to occur first among men (Blume ; Vaillant ). Flick et al. () found that a pregnant woman’s psychiatric disorders may impede her attempts to quit smoking. Flick et al. found that “persistent tobacco users” (women who continued using tobacco after knowing about their pregnancy) were . times as likely to be diagnosed with a psychiatric disorder than nonusers and “nonpersistent users” (women who stopped using tobacco after knowing about their pregnancy) were  times as likely. Also, % of the persistent users were diagnosed with at least one of the following disorders: “generalized anxiety disorder,” “bipolar I disorder,” “oppositional disorder,” “drug abuse or dependence,” and “attention deficit-hyperactivity disorder” (:). Flick et al. suggested that clinicians who hope to be successful in helping pregnant women quit smoking may also have to address the women’s underlying psychiatric disorders.

Impact of Childhood Maltreatment Trauma (CMT) Not much empirical research has been done regarding the impact of CMT on a pregnant woman, but the literature has suggested that CMT relates to psychopathology during pregnancy (Lang, Rodgers, and Lebeck ). In their review, Lang, Rodgers, and Lebeck noted that pregnancy and the postpartum period bring about tremendous stress in a woman’s body and immediate environment, as she adapts to the overwhelming physical changes of pregnancy, the addition of a new family member, shifting family dynamics, and a new balance between resources and demands. Citing the literature, Lang, Rodgers, and Lebeck said that changes due to pregnancy may be especially challenging for trauma survivors, since trauma weakens an individual’s feeling of security and ability to trust others. Trauma may also enhance an individual’s “tendency to feel out of control or to experience as intrusive pregnancy-related changes or the fetus’s presence.” Further, the pain related

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to childbirth or intimate contact with a young child may activate “memories of childhood traumas” (:). As mentioned in chapter , numerous studies have illustrated the link between childhood sexual/physical abuse and women’s later development of AOD problems. A substance-abusing woman is at high risk for having had a childhood maltreatment history, which in turn may intensify the woman’s psychiatric symptoms when she becomes pregnant, assuming that Lang, Rodgers, and Lebeck’s () theory is true. Eiden, Foote, and Schuetze () compared cocaine-using mothers who retained child custody with foster-care mothers and found that the former had experienced a significantly higher level of childhood trauma than the latter. Lang, Rodgers, and Lebeck’s study of  pregnant women confirmed the relationship between a history of childhood maltreatment trauma and increased risk for depression, anxiety, relational aggression, and illicit drug use during pregnancy. However, Lang, Rodgers, and Lebeck () suggested that more research needs to be done on whether or not the association between childhood maltreatment and psychopathology during pregnancy and the postpartum period is due to the fact that childhood maltreatment raises the psychopathology risk overall or to the fact that childhood maltreatment causes the pregnancy period to be particularly difficult.

A More Disadvantageous Social and Economic Background The relationship between AOD using during pregnancy and a woman’s socioeconomic status (SES)/racial background is an important but complicated issue. It is important because risk factors related to SES/racial background, if identified, can be targeted for effective prevention of the occurrence of fetal alcohol syndrome (FAS), fetal alcohol spectrum disorder (FASD), or other fetal problems related to in utero drug exposure. It is complicated because different researchers may have used different methodologies and operational definitions (for example, self-reporting versus actual AOD testing; no differentiation versus differentiation between levels of alcohol use—i.e., any use, binge drinking, or frequent drinking; no differentiation versus differentiation between alcohol and illicit drug use; the use of a sample limited to “Medicaid eligible pregnant women” versus general pregnant women, or women of “child-bearing age” versus pregnant women, or “currently pregnant” women versus women pregnant within the past  months) to study this issue, resulting in seemingly inconsistent or contradictory findings. Despite these difficulties, a close look at the various empirical studies still allows us, to a certain degree, to organize patterns of similarities and reconcile the disparity among findings. A review of fifteen studies shows that, overall, although women of a higher SES may be more, or equally, likely to have “any alcohol use” during pregnancy than women of a lower SES, women of a lower SES may be

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more likely to engage in a more severe form of drinking (binge drinking, frequent drinking, heavy drinking, etc.) during pregnancy. Women of a lower SES may also be more likely to engage in tobacco use and/or illegal drug use during pregnancy than their higher SES counterparts. In general, studies also suggest that white women may be more likely to have “any alcohol use” during pregnancy than African American or Native American women, but African American or Native American women may be more likely to engage in a “more severe form” of drinking during pregnancy. African American pregnant women may also be more likely than white pregnant women to engage in illicit drug use. The theory is that “women with higher SES are likely to be better informed about potential health risks and hence may perceive prenatal alcohol consumption to be more risky” (Testa and Reifman :). CDC () pointed out that “potential disparities in health knowledge of pregnant women might be a contributing factor to sustained levels of binge and frequent drinking” (). In addition, women of lower SES or racial minorities may have fewer resources, and that lack may in turn exacerbate the already stressful pregnancy period, intensifying the women’s dysfunctional coping mechanisms such as risky drinking behavior. The implication is that pregnant women with a disadvantageous social and economic background or a racial minority background may be at higher risk for FAS/FASD because, although no amount of drinking is safe during pregnancy and the threshold for FAS/FASD occurrence is unknown, the general consensus is that moreintensive drinking or a greater amount of alcohol leads to a higher level of blood alcohol concentration, which, in turn, increases the risk that the fetus may develop FAS or FASD (see chapter ). Four SES factors—education, employment, income, and racial background—merit further discussion here.

Education Study findings on the relationship between education level and drinking during pregnancy are not completely consistent. As mentioned earlier, the inconsistency could be a result of the different methods used by researchers. Overall, three findings emerged: () AOD using (or high-risk AOD using) during pregnancy is associated with a lower educational level: pregnant women who engaged in “high-risk drinking” tended to have less education (less than high school) than pregnant women who did not engage in high-risk drinking did (Leonardson and Loudenburg ). Among women (– years old) who “might become pregnant,” those without a college degree appeared to be slightly more likely than those with a college degree to engage in binge drinking or to have a higher number of episodes of binge drinking per year (. versus .) (CDC a). Women with a higher educational/occupational status (SES) were less likely to drink during pregnancy than women with a lower educational/occupational status (SES was defined using the Hollingshead Index; Testa and Reifman ). Women with “more than high school” education were less likely to smoke during pregnancy than women

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with less than high school education (Ebrahim et al. ; Ockene et al. ; Perreira and Cortes ). Palma et al. (:) found that “high maternal education” and “smoking cessation” were the two most important factors associated with alcohol cessation during pregnancy. () “Any alcohol use” during pregnancy is linked to a higher educational level: The – BRFSS data (CDC ) showed that pregnant women with high school or greater than high school education were more likely to have “any alcohol use” than pregnant women with less than high school education (the distribution was similar among nonpregnant women) (CDC ). The  U.S. National Maternal and Infant Health Survey (NMIHS; self-reported data, CDC ) found that pregnant women with  or more years of education were more likely to engage in “any alcohol use” than their counterparts with fewer years of education. Perham-Hester and Gessner () found that women with more than a high school education were more likely to engage in “any third-trimester drinking” than women with high school or less. However, maternal education did not independently predict whether or not a woman would engage in “regular third-trimester drinking.” () “Prenatal alcohol use” was associated with both “the least [less than high school] and most educated [some college or college] women” among African Americans, and it was associated with more-educated women among whites (Perreira and Cortes ). However, Perreira and Cortes did not differentiate between “any alcohol use” and “high-risk drinking” or “heavy drinking.” Risk drinking involves more than just “any alcohol use”; it entails alcohol tolerance, heavy drinking, binge drinking, and/or frequent drinking. The empirical data overall seem to suggest that women with a higher level of education are less likely to engage in “risk drinking” and less likely to engage in smoking during pregnancy than their counterparts with a lower level of education, whereas they may be more likely to engage in “any alcohol use” during pregnancy (or outside pregnancy) than their less educated counterparts. The implications of these findings are that practitioners should emphasize prevention and intervention (drinking and/or smoking) with pregnant women with lower educational levels but not ignore pregnant women with higher educational levels, because although binge drinking, frequent or regular drinking, or other high-risk drinking is detrimental to a fetus, “any alcohol use” during pregnancy could still be risky (i.e., no drinking during pregnancy is safe). Again, more studies are needed, as the studies reviewed adopted differing operational definitions for terms such as “alcohol use,” “risk drinking,” “pregnancy,” and so on.

Employment Status Study findings on the relationship between employment status and drinking during pregnancy are not completely consistent. Again, this result could be attributable to the different research methods and operational definitions used. Overall, two major findings emerged.

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First, SAPW appeared to have a higher unemployment rate than their non-user counterparts (Leonardson and Loudenburg ; Perry et al. ). Perry et al. reported that % of their AOD treatment-seeking pregnant women and % of their non-treatment-seeking SAPW were unemployed, versus % of their nonuser pregnant women. It is likely that the SAPW in Perry et al.’s study were a clinical population and therefore had a more severe AOD problem than women in other studies that used a general population (studies described in the next category). Caetano et al.’s () study, despite not showing a negative relationship between a woman’s educational level and heavy drinking during pregnancy, did indicate (although the finding was not statistically significant) that unemployed women were more likely to engage in heavy drinking than employed women. Second, employed women were more likely to have “any alcohol use” or to engage in risk drinking. For example, the – BRFSS data (CDC ) showed that employed women, pregnant or nonpregnant, consistently were more likely to engage in a broad range of drinking behavior (any use, binge drinking, or frequent drinking) than their unemployed counterparts. Although Tsai, Floyd, and Bertrand’s () study (child-bearing-age women –; –; n = ,) suggested that employed women had a higher percentage of binge drinking than unemployed women (.% versus .% in ), participants in their study were “childbearing-age women” rather than “pregnant women.” In addition, Tsai, Floyd, and Bertrand (n = ,) further reported that unemployed women had a higher number of episodes of binge drinking per month than employed women (. versus .).

Income With respect to income, six studies produced two major findings. First, pregnant women with a lower income may be more likely to use alcohol, illicit drugs, and/or tobacco than pregnant women with a higher income. Noble and colleagues (; N = , pregnant women) found that pregnant women receiving “public assistance” appeared to have higher alcohol use, illicit drug use, and tobacco use than their “insured/self pay” counterparts (.% versus .%, .% versus .%, and .% versus .%, respectively). AOD use outcomes in the study were collected by urine testing. Tobacco use outcomes were obtained through participants’ self-reporting. Perreira and Cortes’s study () also revealed that among both African American and white pregnant women, poorer and less-educated women had a higher rate of tobacco use. Second, pregnant women with a higher income may be more likely to have “any alcohol use” (CDC ; Tough et al. ), but pregnant women with a lower income may be more likely to engage in binge or problem drinking (Burd et al. ; CDC ; Leonardson and Loudenburg ; Tough et al. ). Tough et al.’s study showed that pregnant women with a higher annual family income were more likely than their lower-income counterparts to consume alcohol

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during the period between conception and pregnancy recognition) (N = ,), whereas pregnant women with a lower income appeared to be more likely to engage in binge drinking than their higher-income counterparts (n = ; significant at bivariate level although not at the multivariate level). The  U.S. NMIHS (CDC ) found that higher-income pregnant women appeared to be more likely to engage in “any alcohol use” (i.e., .% of the < $, group versus .% of the $,–$, group versus .% of the $,–$, group versus .% of the $, group), whereas pregnant women with family income equal to or lower than $, were more likely to engage in “frequent drinking” (i.e., .% of the < $, versus .% of the $,–$, versus .% of the $,–$, versus .% of the $,). Frequent drinking was defined in that study as “consuming six or more drinks per week during pregnancy” (CDC :). Burd et al.’s findings revealed that .% of the pregnant women whose income fell in the $–$, range received a TWEAK score ≥ ,versus .% of those in the $,–$, category, and .% of those in the $, or more category (p < ., significant at the bivariate level although not at the multivariate level). A TWEAK score ≥  is an indicator of risk drinking or a more severe drinking problem than just “any alcohol use.” Leonardson and Loudenburg () reported that .% of the pregnant women with an income of $–$, were at high risk for alcohol use versus .% of those whose income was $,–$,. The relationship between family income and drinking during pregnancy seems similar to the relationship between maternal education and drinking during pregnancy; a higher level of education or family income tends to associate with “any alcohol use” during pregnancy, whereas a lower level of education or family income tends to associate with “problem drinking” during pregnancy. Further, the link between a lower family income and problem drinking among pregnant women appears to be consistent with the link between a lower family income and problem drinking (alcohol abuse and/or dependence) in the overall (female) population (see chapter ). It appears that pregnant women with less education and a lower family income are more likely to engage in illicit drug use and smoking compared to their counterparts who have higher educational and family income levels.

Racial Background Empirical findings related to SAPW racial background can be summarized as follows: 1. Five studies suggested that white pregnant women may have a higher rate of “any alcohol use” than African American or other ethnic groups of pregnant women (CDC ; Huang and Reid, ; Meschke, Holl, and Messelt ; Perreira and Cortes, ; Tough et al. ). For example, Perreira and Cortes (; N = ,) indicated that .% of white versus .% of African American

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and .% of Hispanic women engaged in “any alcohol use” during pregnancy (p < . between white and African American and between white and Hispanic). Huang and Reid (; N = about ,) found that white women were % more likely than African American women to engage in “any alcohol use” during pregnancy. Although many studies showed that white women tend to have a higher rate of any alcohol use during pregnancy, some studies showed that white women may be more likely to quit drinking after becoming pregnant than African American or other nonwhite women. For example, SAMHSA NSDUH data (OAS d) showed that .% of nonpregnant white women versus .% of nonpregnant African American women used alcohol “in the past month” (a bigger gap), whereas .% of pregnant white women versus .% of African American pregnant women used alcohol “in the past month” (a smaller gap). The BRFSS data (CDC ) showed that although more white nonpregnant women used alcohol than nonwhite nonpregnant women did (.% versus .%), it appeared that more nonwhite pregnant women used alcohol than white pregnant women (.% versus .%). Noble et al. () showed that African American pregnant women had a higher rate of “alcohol use” than their counterparts of white or other racial groups. (However, Noble et al. did not differentiate between “any use” and “frequent use,” as they used urine specimens at admission to determine alcohol use status.) 2. Six studies suggested that Native American/African American/other nonwhite pregnant women may be more likely than, or equally likely as, white pregnant women to have a “higher level” of drinking or to engage in “binge” or “frequent” drinking (Burd et al. ; CDC , ; Huang and Reid ; Leonardson and Loudenburg ; Perreira and Cortes ). For example, the  NMIHS (CDC ) revealed that white pregnant women had a lower race/ ethnicity-specific proportion of frequent prenatal drinking than all other racial/ ethnic groups. SAMHSA NSDUH data (OAS d) showed that although more white nonpregnant women than African American nonpregnant women engaged in binge drinking during – (.% versus .%), it appears that more African American pregnant women than white pregnant women engaged in binge drinking (.% versus .%). The same data further showed that .% of white nonpregnant women versus .% of African American nonpregnant women engaged in heavy drinking, whereas .% of white pregnant women versus .% of African American pregnant women engaged in heavy drinking. Burd et al. () found that, compared to the risk for pregnant women of other racial/ethnic groups, the risk for Native American pregnant women to get a high TWEAK score (an indication of problem drinking) was raised by %. This trend is partially consistent with the trend in the general female population, in that the “past year alcohol dependence or abuse” rates were .% for American

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Indian/Alaska Native women, .% for Native Hawaiian/other Pacific Islander, .% for white women, .% for Latina women, .% for African American women, and .% for Asian women (see table . in chapter ). 3. African American women were more likely than white or Latina women to engage in illicit drug use during pregnancy (Noble et al. ; OAS d; Perreira and Cortes ), whereas white women were more likely than women of African American/Latina/other ethnic groups to smoke cigarettes during pregnancy (Ebrahim et al. ; Huang and Reid ). For example, .% of African American versus .% of white versus .% of Hispanic women engaged in illicit drug use during pregnancy (Perreira and Cortes ; p < . between African Americans and whites and between African Americans and Hispanics). The NSDUH data (OAS d) also showed that both white and Hispanic pregnant women had a lower rate of “past month any illicit drug use” than their nonpregnant counterparts, whereas there was no significant difference between pregnant and nonpregnant African American women (the rates were .%, .%, and .% for nonpregnant white, African American, and Hispanic women, respectively; and .%, .%, and .% for pregnant white, African American, and Hispanic women, respectively). The same data further indicated that .% of the white women, .% of the African American women, and .% of Hispanic women smoked cigarettes (past month use) during pregnancy.

Association Between FAS Incidence and Low SES Background Regardless of whether pregnant women of lower SES are at a higher risk than their counterparts of higher SES for substance abuse, a disadvantageous social and economic environment may intensify the negative consequences of substance abuse during pregnancy, increasing the risk for FAS/FASD occurrence. (Of course, the occurrence of FAS/FASD also depends on the amount of alcohol consumed, the mother’s and the fetus’s response to alcohol, and the trimester when the exposure takes place [see chapter ]). Various researchers suggest that alcohol exposure during pregnancy is a necessary but perhaps not sufficient cause of FAS/FASD; multiple other factors that exacerbate the negative consequences of drinking may also be implicated in causing FAS/FASD, for example, lack of prenatal care during early trimesters, negative feelings about self, stress, erroneous belief about effects of various alcoholic beverages, binge or heavy drinking, poor nutrition and health, smoking, drug use, or exposure to violence (Abel ; Burd et al. ; citations in Caetano et al. ). Although knowledge of FAS/FASD incidence is limited (Sokol, Delaney-Black, and Nordstrom ), available statistics do indicate that the FAS incidence rate is substantially higher among lower SES or racial minority populations; American Indian/Alaskan Native children were  times more likely and African American children  times more likely than their white counterparts to develop FAS (Sokol,

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Delaney-Black, and Nordstrom :, citing CDC data). Abel (:) pointed out that the incidence of FAS at sites where the population has low SES and/or African American/Native American background is about  times higher (. cases per ,) than at study locations characterized by middle/upper SES and white racial background (. per ,). Abel further suggested that the major factor associated with FAS is SES rather than race. These data must, however, be viewed with caution, for Chasnoff, Landress, and Barrett () found that a racial or social class bias might have contaminated the statistical rate of AOD use during pregnancy. Their study (N =  pregnant women in Pinellas, Florida) found that African American and/or poorer pregnant women shared a similar rate of positive AOD urine test results with their white counterparts (.% of African American pregnant women versus .% of their white counterparts; .% of pregnant women attending public clinics versus .% of their counterparts seeing private obstetricians), but the Pinellas County statistics showed that African American women were significantly more likely to be reported to the authorities for AOD use during pregnancy than their white counterparts were (.% of African American women versus .% of white women were reported), as were poor women than other women. It is unclear whether and how the racial/social class bias may have affected the various statistical outcomes, and more scientifically sound studies should be conducted.

AOD-Related Risk Factors Inadequate AOD knowledge, smoking, and a history of chronic drinking may increase a woman’s risk for drinking or using drugs during pregnancy.

Inadequate Knowledge of AOD and the Negative Impact of AOD on Fetuses Various studies pointed out that women’s AOD use/abuse may be related to their lack of knowledge about the addictive nature and harmful effects of AOD in general (Eliason and Skinstad ; Sun ) and about the detrimental effects of AOD on fetuses and children in particular (Branco and Kaskutas ; Grangé et al. ; Kaskutas ; Leonardson and Loudenburg ; Ockene et al. ; Perry et al. ). Perry et al. found that the non-treatment-seeking SAPW in their study were less likely to recognize such negative consequences of AOD use as low-birth-weight babies and higher risk of caesarean section than were their counterparts who were treatment-seekers or nonusers. They were also more likely to believe that a lower amount of drug use would not harm the fetus. Grangé et al. reported that % of the women who did not stop smoking during pregnancy perceived that “smoking can lead to a lower birth weight” versus % of the women who did stop smoking (p < .) (:). Also, % of those who

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failed to stop smoking during pregnancy perceived that “smoking can increase the risk of premature birth” versus % of those who did stop (p < .). Branco and Kaskutas () found that some urban African American/Native American pregnant/postpartum women believed that an alcoholic beverage can be detrimental to a fetus only “if it burns going down” (); Kaskutas () found that some wine, beer, and wine cooler drinkers considered those drinks to be safer than other alcoholic beverages.

Tobacco Use Most studies consistently point out that tobacco use predicts alcohol consumption and/or binge drinking during pregnancy. For example, Tough et al. () found that pregnant women who smoked were three times more likely to consume alcohol or engage in binge drinking than non-smoking pregnant women, during the period from conception to pregnancy recognition, and . times (%) more likely, after learning about being pregnant. CDC () data showed that .% of women who smoked more than ten cigarettes per day reported prenatal drinking, while .% of non-smoking women reported it. McFarlane, Parker, and Soeken’s () study (N =  white,  African American, and  Hispanic pregnant women) indicated a strong significant relationship between smoking and AOD use (X  = .; df = ; p < .): .% of the smoking women also used AOD, whereas .% of the non-smoking women used AOD, and % of the AOD-using women smoked, whereas .% of the non-AOD-using women smoked. This significant relationship applied to all ethnic groups.

Degree of AOD Severity Women who have a higher level of AOD dependency prior to pregnancy may be at high risk for AOD using/abusing during pregnancy. Leonardson and Loudenburg () found that pregnant women who reported being able to hold four or more drinks were at high risk for drinking during pregnancy. Smith et al. (; N =  women receiving prenatal care) reported that length of drinking history, reported tolerance to alcohol, a history of alcohol-related illness, and drinking by siblings best predicted a woman’s drinking during pregnancy (). Smith et al. () suggested that women with a chronic drinking history and/or severe alcohol-related problems should be identified and targeted for intensive prevention. Likewise, both Ockene et al. () and Grangé et al. () found that pregnant women who failed to quit smoking tended to have a higher level of tobacco dependency prior to pregnancy than their counterparts who successfully quit smoking. Ockene et al. () showed that the average number of cigarettes per day “before learned of pregnancy” was . (SD = .) for those who spontaneously quit smoking during pregnancy, but . (SD = .) for those who continued to smoke during pregnancy (p < .).

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Intervention and Treatment Principles and Strategies . AOD Screening for Pregnant Women Early Identification Early identification of AOD use during pregnancy is critical not only because it maximizes the time available for the woman to receive counseling and treatment (Leonardson and Loudenburg ), but also because of the structural changes that can occur in a fetus’s brain because of alcohol exposure early in development (Chasnoff et al. ). However, many prenatal health care and other service systems do not implement AOD screening procedures with their pregnant clients (Kennedy et al. ), for a variety of reasons, among them lack of training, inaccurate beliefs about AOD among the professionals, clients’ resistance, uneasiness of practitioners in asking clients about AOD use, a deficiency of expertise in helping a client whose screening outcome is positive, lack of time, and costs (Kennedy et al. ; Saitz et al. ).

AOD Screening Tools for Pregnant Women Self-Report Screeners Versus Urine Toxicology Tests

Some professionals rely on urine toxicology tests and thus de-emphasize the regular AOD screening procedures (Chasnoff et al. ). However, Chasnoff et al. noted that urine toxicology tests usually do not detect alcohol use and usually can identify only illicit drug use that occurred within forty-eight hours before testing. Another limitation of a urine test is the cost, which makes the self-report screeners more feasible for universal AOD screening. Indirect Versus Direct Approach

Should the professional ask specific questions regarding the amount and frequency of AOD use and abuse or ask questions that are indirectly related to AOD issues? Russell et al. () preferred an indirect approach, believing that a direct approach could trigger a woman’s denial of AOD use altogether. They cited the results of a study in which “the sensitivity of a screen for alcoholism fell from % to % when questions on the quantity and frequency of drinking were asked prior to screening” (). However, Clark, Dawson, and Martin () found that a detailed screening that includes direct questions about the specific quantity and frequency of AOD use yielded more reports of prenatal AOD use than screening that included only “yes” or “no” boxes to be checked.

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Screening Tools

Several AOD screening tools for pregnant women have been developed, among them T-ACE (Sokol, Martier, and Ager ), TWEAK for Pregnant Women (Russell ), the Brief MAST, the Modified Alcohol CAGE for Pregnant Women (Midanik, Zahnd, and Klein ), Modified Drug CAGE for Pregnant Women (Midanik et al.), and the -P (Burke and Caldwell, cited in Russell ), P Plus© (Chasnoff et al. ), and the  P Plus Smoking (Kennedy et al. ) (see appendix A). Most of them possess acceptable sensitivity and specificity. If a positive screen is found, appropriate (specialized) AOD treatment or referrals for such treatment must be pursued.

. Enhancing Pregnant Women’s Understanding of the Impact of AOD on Pregnancy and Fetus As mentioned earlier in this chapter, many (pregnant) women have misconceptions about the nature of various types of AOD. Although specificity of perinatal substance abuse knowledge varies with different audiences, all practitioners should understand the effects of drugs on fetuses so that they are equipped to effectively explain non-use during pregnancy to their clients (Farkas ). Sharing information with SAPW is critical in prevention and rehabilitation and may help reduce their guilt and anxiety, thus increasing rapport and cooperation (Little and Gilstrap ). As mentioned earlier, many SAPW lack knowledge of the negative impact of AOD on their fetuses and children (Grangé et al. ; Kaskutas ; Leonardson and Loudenburg ; Perry et al. ). Information should be explained nonjudgmentally (Siney ) and in a way suitable to the woman’s comprehension (Little and Gilstrap ). At least five points should be made: (a) effect of substance abuse on nutrition, (b) effect of substance abuse on medical conditions, (c) contraception and prevention of unwanted pregnancy, (d) effects of substance abuse and sexually transmitted diseases, and (e) environment and early intervention for drug-exposed children.

Effect of Substance Abuse on Nutrition Nutrition is important for any pregnant woman, but it is a particular concern for SAPW. Substance abuse can affect a pregnant woman’s nutrition directly and indirectly. Directly, habitual alcohol and other drug (AOD) use may depress appetite, impair metabolism, and change nutrient activation, thereby affecting both maternal and fetal nutrition (CSAT ). Indirectly, the often chaotic lifestyle of the substance-using woman may lead to self-neglect, including poor diet (Sparey and Walkinshaw ).

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Effect of Substance Abuse on Medical Conditions Drug Impact on Fetus

A fetus is extremely vulnerable to drug effects because fetal tissue is very sensitive to drugs and the fetus has not developed enzyme systems to metabolize drugs (Geller ). Prenatal AOD exposure may cause short- and long-term damage to the infant’s physical, cognitive, and behavioral development (Little and Yonkers ; Streissguth ; Van Beveren, Little, and Spence ). However, not all drug-exposed infants show significant medical complications or developmental problems, and it is difficult to predict outcomes for individual children. Depending on the type and combination of drugs used, the reactions of the mother using the drugs, the amount and frequency of use, the trimester in which the drug is used, and the fetus’s genetic susceptibility to AOD, a baby may show severe, mild, or no symptoms (Little and Gilstrap ; Streissguth ). The concept of “critical periods” suggests that first-trimester drug exposure may cause congenital anomalies, whereas exposure during the second or third trimester may affect growth (Coles ; Little and Gilstrap ). The brain may be particularly susceptible because its development occurs throughout pregnancy (personal communication with Colleen Morris, M.D., University of Nevada School of Medicine, October , ). Neonatal Abstinence Syndrome (NAS)

AOD-exposed fetuses, particularly those exposed to alcohol or heroin, may develop withdrawal symptoms at birth when the maternal drug supply stops. NAS usually appears within  hours of birth; the infant may die if the withdrawal is severe and untreated. Although the effects of NAS depend on type of drug exposure and obstetric factors, it may involve the central nervous system (seizures, tremors, irritability, abnormal suck or poor feeding), the autonomic nervous system (sneezing or yawning), the gastrointestinal system (diarrhea and vomiting), and the pulmonary system (increased apnea) (CSAT ; Walkinshaw, Shaw, and Siney ). Teaching the mother about the effects of drugs may help her redefine her baby’s behaviors. For example, the baby’s nonresponsiveness or irritability would be symptoms of medical withdrawal and not a sign of rejecting the mother (Sameroff and Fiese, cited in Schutter and Brinker ). Maternal Detoxification

Although drug use clearly negatively affects both mother and fetus, maternal detoxification must be considered with caution, since it may be harmful, “causing placental vasoconstriction with increased rates of abruption or placental insufficiency leading to death or poor growth of the fetus” (Hepburn :). Although opioid withdrawal symptoms are less likely to be life-threatening to the mother, for the fetus they may cause spontaneous abortion or intrauterine death. While

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acute withdrawal from alcohol and other sedative or hypnotic drugs may harm mother and fetus, withdrawal from cocaine or other stimulants is less severe and medication is usually not required (CSAT ; Siney ). An inpatient setting for detox allows the mother and fetus to be monitored by a medical team, including an obstetrician (CSAT), and tapering off the dependent sedative/hypnotic drugs helps mother and fetus reach a drug-free state slowly, thereby experiencing no uncontrollable withdrawal (CSAT; Siney ). For heroin addiction, treatment includes methadone maintenance or detox, and pregnant women are usually advised to choose methadone maintenance because of the possible lethal impact of detox on the fetus (Blume ; CSAT ; Hepburn ). However, total abstinence and long-term maintenance should not be the only options; a pragmatic approach tailored to help each client achieve overall drug use reduction and a stable lifestyle is a feasible goal (Hepburn ).

Contraception and Prevention of Unwanted Pregnancy Carten () studied twenty AOD-using postpartum women, only two of whom had planned pregnancies. AOD-using women might be more likely than nonusing women to have unwanted pregnancies because of irregular menstruations resulting from drug use (Boyd ). Pregnancy among these women is often detected only after the first trimester, when the mother feels fetal movement or experiences other physical changes and abortion often is no longer a choice (Boyd ; Siney ).

Substance Abuse and Sexually Transmitted Diseases AOD-using women may put themselves at risk for HIV/AIDS and other sexually transmitted diseases (STDs) in three ways: injecting drugs or having sexual partners who inject drugs; engaging in prostitution for drugs, thereby increasing unsafe sex; and using mind-altering drugs, which may lower inhibitions and put them at greater risk of unsafe sex (CSAT ). STDs may lead to spontaneous abortion, premature birth, or intrapartum infections such as purulent conjunctivitis in the baby’s eyes (Carey ). A baby can contract HIV from the mother while in utero, during childbirth, or through breast feeding; women diagnosed with HIV must seek help from experts specializing in HIV and perinatal transmission (Cohen ).

Environment and Early Intervention for Drug-Exposed Children Environment

Developmental outcomes for drug-exposed infants may be related not only to drug exposure in utero but also to the quality of their postnatal environment. Parker, Greer, and Zuckerman () called it “double jeopardy” when prenatally impaired children postnatally live in a poor environment. Postnatal environmental

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factors include family context (for example, parent–child interaction, parental mental stability, parental AOD use, and domestic violence) and the context of poverty (for example, nutrition, stable housing, access to health care, and community violence) (Carta et al ; Harden ). Although methodological difficulties exist in comparing the effects of neonatal drug exposure with those of the postnatal environment, most such studies emphasize the importance of both factors, if not just the environment (Carta et al. ; Harden ). For example, Howard () found that toddlers who were exposed to drugs in utero and who lived in caring environments performed better than those without caring environments, although the former did not perform as well as preterm toddlers who were not exposed to drugs in utero. She inferred that both biological and environmental factors were important. Comparing children of untreated mothers using heroin, mothers receiving methadone, and a non-using group, Lifschitz et al. () found that maternal narcotic use did not predict a child’s intellectual performance; rather, the “amount of prenatal care,” “prenatal risk score,” and “home environment” did. Regardless of the nature-versus-nurture debate, most people would agree that a child’s developmental outcome is affected by the number of risk factors and their degree of persistence, be they biological, environmental, or mixed (Bernstein and Hans ; U.S. Department of Health and Human Services [DHHS] ). Early Intervention

Human brain complexity relies on neurons and their interconnections, and a baby has more neurons available for molding networks at birth than at any other life stage. The brain at birth is not fully configured, tending to be formed by external stimuli, particularly during the first two years (Resnak, cited in Stump ). Spinelli (cited in Stump) called this capacity “plastic” and “adaptive.” Another capacity is “canalization,” including the brain’s self-correcting ability following deflections caused by external insults. Both the plastic and the canalization capacities, however, may be bounded by “critical periods.” Wilson’s definition of critical periods, as cited in Stump, is this: “Development includes coordinated pathways of change over time. Many of these pathways appear to depend upon the activity of timed gene-action systems that switch off and on according to a predetermined plan” (Stump :). The brain’s plastic and canalization capacities offer an opportunity to mediate prenatal damage, but the limitations imposed by critical periods suggest that timely intervention must be provided. Early identification and intervention are critical in order to optimize the development of drug-exposed children (Kropenske and Howard ).

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. Connecting Pregnant Women with Community Resources Just as important as explaining the significance of a healthy environment to a mother is helping her to build one. AOD-using women are particularly in need of case management because of lower education, inadequate vocational training, lack of life skills and other resources, and child care needs (Yaffe, Jenson, and Howard ). The negative effects of psychosocial risks are far-reaching for SAPW, and their meager pregnancy outcomes may be more the consequences of underlying socioeconomic deficiency than of drugs (Hepburn ). As discussed earlier, one of the risk factors for AOD use during pregnancy is a disadvantageous social and economic background. Unhealthy and impoverished environments further worsen the development of drug-exposed children, who desperately need a functional postnatal environment for a second chance.

Contents of Case Management Case management for SAPW may be extensive, including access to prenatal care; prevention of unwanted pregnancy; housing, nutrition, transportation, child care, and financial assistance; education and vocational training; emotional coping skills training; parenting education; AOD and psychiatric treatment; general health care; legal services for child abuse or other criminal behavior; and screening, assessment, and intervention services of early childhood development. Weisdorf, Parran et al. () compared a pregnancy-specific program (that is, required obstetric care; parenting classes; content on pregnancy, nutrition, and AOD use; and child care services) with a traditional program and found that the former had significantly lower inpatient dropout rates and higher outpatient completion rates.

Case Management: Prevention Compared with Crisis Intervention “Up-front” Case Management

Up-front case management is necessary to enhance women’s treatment motivation and prolong treatment retention, because they may not enter treatment unless their basic needs (for example, child care, transportation, and housing) are met (Coletti ; Howell and Chasnoff ; Poland Laken, and Ager ). Hughes and colleagues () found that the average length of stay of women admitted to a child live-in demonstration program (. days) was significantly higher than the average length of stay of those admitted to a standard program (. days). Prevention and Outreach

Case management should not be limited to up-front services or crisis intervention, however. It should also be oriented toward prevention and rehabilitation. Emphasis should be on early involvement of community resources and long-term follow-up, focusing on establishment of a healthy and stable family environment

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(Hepburn ). Risks for SAPW are not necessarily reduced after delivery, and they do not disappear after the initial residential or outpatient treatment; aftercare is critical to help the mother change her lifestyle (Finkelstein ; Howell and Chasnoff ; Sparey and Walkinshaw ). Outreach is another key to prevention. Many SAPW, hesitant to reveal their AOD use, are reluctant to volunteer for treatment. Fearing prosecution and the loss of the child, many avoid prenatal care until a very late stage. Women often are referred because of positive urine toxicology or drug-positive birth outcome. How to identify and reach SAPW early has been considered one of the most difficult challenges (Finkelstein ; Howell and Chasnoff ; Howell, Heiser, and Harrington ). Howell and Chasnoff indicated four outreach routes: clinicbased (prenatal programs), indigenous outreach in nontraditional settings, enlistment of aid from family members, and word of mouth from clients who have completed the program. Coletti () suggested that information on how state regulations may affect child custody should be shared with women to help overcome their fears. Hennessey () implemented an outreach program in Illinois to help AOD-using mothers in the child welfare system. They identified and made daily contact with the at-risk families; engaged and accompanied families, removing barriers to services; motivated, nurtured, and advocated for the families; and served as role models or surrogate family members and friends.

The “Five Clocks” and Turf Issues Case management often involves multiple agencies with conflicting treatment philosophies and timetables, resulting in service fragmentation for clients. Young and colleagues () delineated the “four clocks” issue: child welfare systems require parents to be assessed at six months, a permanency plan at twelve months; AOD treatment expects client relapse and subscribes to “one day at a time, for the rest of your life”; Temporary Assistance for Needy Families (TANF) obliges clients to find employment within twenty-four months; and the developmental timetable of the first eighteen months is critical for the infant and mother to establish bonding. Young () recently advocated for a “fifth clock,” urging workers from different fields to collaborate to provide the most effective services. Poland Laken and Hutchins () indicated that interdisciplinary teams better meet women’s complex needs; the challenge was interagency turf issues related to different values and policies. Feig () offered directions at the program planning and administration levels for bridging service systems: “joint training for social services and substance abuse treatment staff,” “team staffing” (for example, social services hires a part-time AOD counselor to conduct AOD assessment, and the AOD program has on-site CPS staff working with parents and children), “joint funding for services,” and “joint goal-setting for programs” (for example, systematic discussion of various treatment philosophies, not case by case) (–).

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At the individual level, workers should involve all agencies early and deal with turf issues when developing a team, making conflicts secondary to collaboration (Poland Laken and Hutchins ). “One-stop shopping” may also reduce service fragmentation by locating various professionals (for example, obstetrics professionals, AOD counselors, child development specialists, and social service workers) at a single site so that clients can obtain services in one place, rather than being sent to different locations. McMurtrie and colleagues () found that babies of the one-stop shopping program had a significantly higher mean birth weight than control group babies. They concluded that not only did this model allow professionals to better coordinate services, but it enhanced client motivation to consume a broader range of services.

Assuming the Role of Mediator A mediator helps parties negotiate conflicts by coaching them to handle conflict constructively (Barsky ). Mediation in child protection emphasizes “facilitation,” “problem solving,” “developing a mediation alliance,” and “maintaining fair neutrality” (Barsky and Trocme :). Barsky () suggested two types of mediation: emergent, in which the practitioner maintains a primary professional position (for example, as a social worker) but applies mediation techniques to help the client; and contractual, in which a formal mediator is hired, thereby eliminating the possibility of real or perceived conflict of interest that could arise when one person fills dual roles. Emergent Mediation

Emergent mediation can be applied to improve interorganizational communication in connecting clients with community resources. Child protective services (CPS) workers, who also often encounter SAPW, may apply emergent mediation techniques as well (Barsky and Trocme ). Although disputes between families and CPS are common, many CPS workers have not been trained in conflict resolution techniques (Savoury, Beals, and Parks ). Mediation skills may help CPS workers and clients to avoid an adversarial relationship and achieve more mutually beneficial and productive communications (Barsky and Trocme ). Contractual Mediation

Mediation should receive greater attention in CPS because of its family empowerment and problem-solving orientation (Wilhelmus ). A SAPW or family with an earlier negative experience with the CPS may perceive any CPS worker as biased against them, regardless of repeated good intentions. In such cases, a contractual mediator—a neutral third party with mediation skills—may better earn the trust of the woman or family and achieve more productive communication (Barsky and Trocme ; Savoury, Beals, and Parks ). Certain criteria

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should be met before using mediation with CPS clients—for example, the child should not be in immediate danger, and the parties involved should not be severely impaired (Savoury, Beals, and Parks ).

. Enhancing Pregnant Women’s Inner Strengths and Other Resources To enhance the inner strengths and resources of SAPW, practitioners can provide them with counseling and other clinical treatment to address four areas of concern: (a) dealing with shame and guilt, (b) treating the dual diagnosis, (c) enhancing self-efficacy, and (d) strengthening non-using social networks.

Dealing with Shame and Guilt Sexuality and mothering underlie punitive attitudes toward AOD-using women, and SAPW receive the most severe societal condemnation, resulting in low selfesteem, isolation, and guilt (Finkelstein ). Finkelstein and colleagues () provided strategies to help the mother deal with guilt. Among the strategies are accentuating that both she and her child suffer from AOD and that her AODusing behavior is not intentional; helping her express and disperse guilt feelings by listening to what she has to say about mistakes she feels she has made; stating that parenting choices are often hampered when engaging in AOD use; and conveying hope that she can regain control over her life if she stays sober.

Screening for and Treating the Co-occurring Disorders (COD) Treatment of dual diagnosis is important for substance-abusing women but more so for SAPW. The issues here may include psychiatric disorders, a history of childhood sexual/physical abuse, and domestic violence. As mentioned in chapter , substance-abusing women are more likely than non-substance-abusing women or substance-abusing men to be afflicted with psychiatric disorders (depression, anxiety, etc.), and for these women the psychiatric disorders usually occur prior to the AOD problems. Such a COD diagnosis is particularly relevant for SAPW, as pregnant women normally would be motivated to stop using for the sake of protecting their unborn children, and one reason why they fail to do so is because of the need to self-medicate their preexistent psychiatric disorders by AOD using. Therefore, it is important to screen, assess, and treat/refer SAPW for possible psychiatric disorders. As discussed earlier, a strong link exists between childhood sexual/physical abuse and the development of substance abuse, despite the uncertainty of the link’s causal nature. Horrigan, Schroeder, and Schaffer () found a triad relationship among AOD use, violence, and depression during pregnancy, and suggested that identification of one symptom was indicative of the others. Root () said that women may use AOD to cope with psychiatric symptoms resulting from

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childhood sexual/physical abuse and that those issues, if left untreated, may trigger relapse. Further, pregnant women exposed to domestic violence (DV), whether physical/sexual abuse or mental abuse, are more likely to have more severe AOD and/or other psychiatric problems than their counterparts who are not exposed to DV. Although AOD use and DV can relate in either direction, many AOD programs fail to screen for DV; likewise, shelters usually do not screen for AOD problems and may even remove the woman if she has AOD problems (Miller ). It is important to screen, evaluate, and treat/refer women for these issues, particularly when treatment plan noncompliance is frequent (Jessup ). AOD treatment without simultaneous attention to the dual diagnosis may diminish the chances of success (DHHS ).

Enhancing Self-efficacy The literature suggests that traditional confrontational counseling is more effective with male AOD clients than with female clients who suffer from low self-esteem or psychological trauma (Yaffe, Jenson, and Howard ). Sherman () advocated the use of empowerment and self-efficacy to help SAPW. He defined selfefficacy as “an individual’s beliefs about her capability to mobilize the motivation, cognitive resources, and action needed to exercise control over task demands” (). Miller and Rollnick () suggested that even when clients know they have problems, if they do not believe they can change, they can only deny the problems. It is extremely important to instill hope in these clients regarding their capacity to change. Three strategies for making progress in this area may be emphasized. Staff’s Encouragement and Empowerment

A positive attitude among the staff toward women is critical in enhancing their self-efficacy. Carten () found that the three responses most frequently given by clients as the most helpful aspect of their treatment program were “care and respect of staff,” “the staff won’t give up on you,” and “individual relationships with staff ” (). Sun () quoted one interviewee as saying, “My social worker has faith in me . . . which, in turn, gives me confidence in myself ”(). Involving the mother in developing a case plan also empowers her (Carten). Peer Counseling and Culturally Sensitive Practice

Peer counseling increases client self-efficacy (Grant et al. ; Sherman ). Paraprofessionals with life experiences similar to those of clients can be trained to help. These peer counselors can serve as inspirational models and convey hope to clients that recovery is possible (Grant et al. ; Sherman ). Uziel-Miller and Lyons () indicated that only a few of the programs studied offered “culturally informed programming,” even though clients in those programs were mainly African American women (). AOD-using white and African American women may have different needs (Carroll et al. ). Jackson

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() suggested an “Afrocentric treatment perspective” emphasizing community involvement. She believed that by learning one’s heritage and being part of the community, a woman is more likely to develop productive roles other than that of substance abuser. Vocational Training

Female AOD clients have lower education and fewer marketable job skills and work experiences than their male counterparts (Nelson-Zlupko, Kauffman, and Dore ). Fiorentine and colleagues () found that men had a higher employment rate at post-treatment than women did (. percent compared with . percent; p < .). Kissin and colleagues () indicated that more than  percent of SAPW were unskilled, and  percent had been unemployed in the past three years. Unemployment may impede women’s long-term recovery because of many negative implications, especially for single mothers, such as a lack of financial resources, reliance on male AOD-using partners, no meaningful life goals, and low self-esteem (Yaffe, Jenson, and Howard ). Gregoire and Snively () showed a link between economic self-sufficiency and improvement in areas of AOD use, family, social function, and so forth. Marsh and Miller () showed that “a strong work history” was associated with positive treatment outcomes and suggested that job training and counseling be included in women’s AOD treatment plans.

Strengthening a Non-using Social Network Amaro and Hardy-Fanta’s () interviews with SAPW found “relationships” to be the key theme. Women’s self-esteem was heavily and negatively affected by “disconnected relationships” and by “the absence of positive, growth-enhancing relationships” (–). Relationships also may have a practical function—they are women’s resources for emergency child care and other assistance (Tracy ). Substance-Abusing Partners

AOD use by male partners predicted pregnant women’s AOD use (Bresnahan, Zuckerman, and Carbel ; Hutchins and Dipietro ). Bresnahan, Zuckerman, and Carbel said that these women, when counseled to stop using AOD, may face “the double loss” of a major coping device (AOD) and a major love relationship. Laudet and colleagues () identified five reasons why male partners might not support women’s treatment: their own AOD-using behavior may send a powerful message to the women; they want to maintain the status quo, which might change if women recover; they might be working on their own recovery, unable to be bothered; they may have different views on treatment goals (for example, believing that AOD using is acceptable if the woman fulfills household responsibilities); and they might want to disassociate themselves from an AODusing woman because of the stigma attached to her. Laudet and colleagues ()

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suggested that workers need to understand each client’s partner situation, and that not all men should be engaged. Cavacuiti () addressed the issue of “concordant couples” (both partners are substance abusers) and stated that clinicians must provide effective family-couples therapy and be cognizant that “both members of the dyad” may not necessarily “be equally ready to engage in treatment” and that “there is also the difficulty of both giving and receiving support from the partner while trying to curb one’s own ‘substance abuse’” (). Facilitating Non-using Support Systems

Studies consistently indicate that AOD-using women get less social support than other women. They may have a broken relationship with their original non-using support systems because of drug abuse (Merseyside Drugs Council ; Sun ). Dodge and Potocky-Tripodi’s () study indicated that AOD-using women, compared with non-users, are less likely to seek help from relatives and friends. Marcenko, Spence, and Rohweder () found that pregnant women with AOD history received less family support than pregnant women without such history (for example, % compared with %, respectively, did not know how their families felt about their pregnancy). Merseyside Drugs Council () suggested that pregnancy is an opportunity to reconnect and may result in a “rallying round ‘for the baby’s sake.’” However, intervention of family support groups may be necessary because of bitter, mistrustful relationships between the two parties. Practitioners can adopt the emergent mediator role; for example, mediating between a woman and her non-using original family to improve their fragile or conflict-laden interaction. The role of mediator thereby enhances the role of facilitator or clinician in strengthening non-using social networks. To strengthen the new non-using support system, practitioners can help women join the workforce or connect them with community resources (for example, churches, women’s self-help groups or sponsors, schools, and neighborhood councils (Kissin et al. ; Pape ). Alcoholics Anonymous may provide a second home for some AOD-using women, in that they seek and maintain non-using friends and social support to replace their former using social circles (Kaskutas ).

. Advocating for Substance-Abusing Pregnant Women Advocacy for Effective Policies and Laws on Substance Abuse During Pregnancy Controversy about policies on AOD use during pregnancy stems from different philosophical beliefs. Pandya () described three issues: () harm reduction versus use reduction: whether reducing the harm to the fetus or reducing the mother’s AOD use should guide the practice; () supply control versus impulse control: whether drug dealers or the woman should be punished; and () criminal versus

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victim: whether the mother is guilty of harming the fetus or is a victim of a poor socioeconomic environment. It is difficult to argue whether the philosophical positions are right or wrong, but most people would agree it is important to establish policies that effectively target the problem. Research strongly suggests that criminalizing AOD-using behavior does not deter women’s drug use; instead, it prevents them from seeking prenatal care and AOD treatment for fear of being detected or prosecuted (Finfgeld ; Jessup et al. ). It is imperative for social workers to educate society and policymakers about the implications of criminalizing SAPW and to advocate for policies that promote more rehabilitation, more harm reduction (Finfgeld ), and less of a punishment orientation.

Advocacy for Pregnancy-Specific Treatment Programs Although SAPW represent a top priority for federal funding, establishing a pregnancy-specific program is a challenge. The trend of fee for service based on the number served makes it tough on a new program, which may not quickly bring in sufficient clients. As noted earlier, it is not easy to recruit SAPW for treatment. Obtaining a program license and hiring qualified staff are two more difficult, funding-related tasks. In light of constraints resulting from the issue of fee-for-service policies, program administrators may request staffing grants (personal communication with Larry Ashley, addiction specialist, University of Nevada, Las Vegas, March , ). Multiple funds should be sought—the federal block fund (managed by SAMHSA) considers SAPW a top priority and is a major funding source; TANF pays for AOD treatment if a pregnancy is more than six months along; the state or county can play an important role in funding; a sliding scale fee from clients, although minimal, may help; and other community funds may be available. In some cases it can take up to thirty grants to run a program (personal communication with Diane Thorkildson, acting director, Light House Sierra, April , ). Although Medicaid is supposed to serve poor AOD-using women with children, states and providers are daunted by multifarious federal regulations (Darnell ). In some states AOD treatment is not paid by Medicaid unless it is offered in a hospital. Creative recruitment of funding and coordination of suitable plans are critical strategies for program survival.

Advocacy for Nonjudgmental Attitudes in the Obstetric and Other Communities Double standards and stigma regarding AOD-abusing women are well documented (Blume ), and the stigma is more severe when the drug abuser is pregnant (Finkelstein ). The obstetric community may be biased against these women, holding them responsible for birth outcomes (Boyd ). Service providers often hold negative views of women clients, and sexism and sex role stereotyping are commonplace in drug treatment programs. Nelson-Zlupko, Kauffman,

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and Dore () found that women’s distrust of service systems presented a major obstacle to their treatment. For humanistic and practical reasons, social workers must advocate for a nonjudgmental attitude toward SAPW at all levels, particularly in the obstetric, substance abuse treatment, and child welfare communities.

. Applying Treatment Methods Brief Intervention (BI) As described in chapter , BI can be conducted by various professionals in various settings. Although more studies are needed to verify the effectiveness of employing BI to help certain client populations, including pregnant women (Saitz et al. ), some emerging research shows that BI may be effective in helping pregnant women. For example, O’Connor and Whaley’s () study (N =  alcoholusing pregnant women) showed that women assigned to the BI group were five times more likely to maintain abstinence than women assigned to the assessmentonly group. In addition, their newborns had greater birth lengths and weights. The BI was manual-guided and included ten- to fifteen-minute counseling sessions conducted by a nutritionist. Floyd et al. () conducted a randomized trial (N =  women aged – who were at risk for alcohol-exposed pregnancies [AEP]) evaluating the effectiveness of BI on reducing the hazard of AEP among preconceptional women. They focused on both women’s drinking and contraception. The results showed that women who were given information plus a brief motivational interview (n = ) were two times more likely to decrease AEP risk during follow-up compared to women who received only information (n = ). The brief motivational intervention covered one contraception consultation visit and four counseling sessions. Kennedy et al. () developed a  P (parents, peers, partner, past, and present) screening tool (see appendix A) and a user-friendly protocol of a decisionmaking tree for the  P. According to Kennedy et al., a professional reviews the filled-out self-administered questionnaire (screener) with the woman, and then may take eight alternative steps: () If a pregnant woman gives a negative response to all  items plus the tobacco-use (+) question, she receives educational materials and no follow-up is needed. () If she gives a positive response to one or more of the + items, she is further assessed for the possibility of use, abuse, or dependence. () If the assessment determines that the positive response is associated with only her parents, partners, and/or peers, she receives education and materials and no follow-up is needed. () If the assessment indicates the woman’s past use but not present use, she receives advice from the staff, who promote abstention and provide education and materials. The woman is followed up regarding her AODusing status and other questions. () If the assessment shows a positive response to the woman’s present use, she is further assessed for the possibility of (i) no AOD

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abuse problem, (ii) an AOD abuse problem, or (iii) an AOD dependence problem. () If no AOD abuse evidence is indicated, the woman receives advice from a staff member, who promotes abstention and provides education and materials. She is also followed up for her AOD-using status and other questions. () If evidence of AOD abuse is indicated, the staff refer the woman for AOD specialist assessment and AOD treatment program. () If evidence of AOD dependence is indicated, the staff connect the woman with detoxification treatment. In both cases, the staff follow up on the referral outcomes (e.g., whether or not the woman kept the appointments with the referred agency) and her AOD use status (Kennedy et al. ).

Motivational Interviewing/Motivational Enhancement Therapy (MI/MET) Several studies investigated the effectiveness of MI/MET in helping pregnant women to quit smoking or to reduce AOD consumption. Their results were inconclusive, although most of them indicated only marginal effectiveness (see Stotts et al.’s review ). Two studies are examined here. Stotts et al.’s study (N =  pregnant women reporting smoking in the preceding seven days) randomly assigned the women to an MI group and a control group (usual care). The MI treatment, provided by master-level counselors over an eight-week course, included one face-to-face MI interview, three telephone MI sessions, and one letter with personalized feedback about assessment results. The results showed no difference in smoking-cessation rates between the two treatment groups, although the MI group both significantly decreased their depression and increased their self-confidence to quit smoking from before to after treatment, compared to the control group of women. Haug, Svikis, and DiClemente () randomly assigned  pregnant women who were dependent on opioids and were smoking to a MET group and a control group (standard care with practitioner advice). A foursession MET treatment based on the Project MATCH MET manual and provided by master-level counselors was offered to the MET group women. The results at ten-week follow-up indicated no significant difference in the smoking-reduction/ cessation or illicit drug use rates at post-treatment between the MET group and the control group. However, the women in the MET group were more likely to progress (e.g., from the precontemplation to contemplation stage) and less likely to regress (e.g., from the contemplation to precontemplation stage) along the continuum of motivation-change stages. To improve the effectiveness of MI/MET with respect to SAPW (particularly those with a disadvantageous socioeconomic background), experts recommended (a) more-intensive MI/MET and CBT sessions, separate from the regular prenatal visits; (b) treatment that combines pharmacological and behavioral approaches if a woman has a severe AOD or smoking dependency and/or multiple psychosocial problems; (c) MET as an adjunctive intervention in addition to other critical

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treatment, such as stress management, harm reduction, and enhancement of behaviors that are conducive to health protection (Haug, Sivikis, and DiClemente ; Stotts et al. ).

Cognitive Behavioral Therapy Reynolds et al. () randomly assigned pregnant women who were drinkers to a “self-help” group (n = ) and a control group (usual care; n = ). The results showed that the women in the self-help group appeared to be more likely to quit drinking than the women in the control group (% versus %, p < .). This self-help approach tended to be more effective with women who were “light” drinkers. The self-help group women received a cognitive-behavioral-oriented treatment that included a short educational session (ten minutes) and a manual of nine-step self-help strategies to be implemented in nine days by the women at home. The educational session shared with the women the information regarding the negative effects of alcohol on fetuses and taught them ways to use the nine-step manual. Each of the nine steps in the manual focuses on one behavior/cognition facilitating a woman’s alcohol cessation. The following are the nine-steps: () targeting fetal alcohol syndrome information to increase the woman’s motivation to quit alcohol, () building her self-confidence that she has the ability to quit drinking, () helping her to keep a diary to identify any drinking pattern, () eliminating alcohol and shunning drinking locations, () connecting with a non-drinking buddy and social network, () self-monitoring and self-rewarding for alcohol consumption cessation, () resisting peer, media, and other pressures that contribute to drinking, () managing stress without resorting to drinking, and () sustaining abstinence.

Contingency Management (CM) Experts pointed out that CBT and CM are two treatment approaches demonstrating the most empirical effectiveness for stimulant (e.g., cocaine, MA/A) users (Rawson, Gonzales, and Brethren ). As mentioned in the beginning of this chapter, SAPW are at high risk for stimulant use and abuse, including cocaine and/ or MA/A (OAS a; Rawson, Gonzales, and Brethren ; Towle, Bailey, and Gibbs ), and thus CM and CBT may be effective treatment approaches for some SAPW. Two CM empirical studies on substance-abusing pregnant women are discussed here. Escalating Voucher Incentive Approach

Jones et al. () implemented a -day “escalating voucher incentive schedule” program, in which  substance-abusing pregnant women were randomly assigned to the incentive group while  women were assigned to the control group (receiving no incentives). The results showed that the women in the incentive group had

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significantly longer treatment retention than those in the control group (mean = . days [SD .] versus . days [SD .], p < .). The incentive group were also “more likely to display perfect or near perfect attendance,” while the control group were “more likely to display poor attendance” (i.e.,  or  out of the  days) (:–). In addition, the incentive group had a significantly lower rate of opiate and cocaine positive urine toxicologies than the control group during the second half of the study (days –). The Jones et al. schedule required the women to attend the treatment for the initial days – (residential). For days – (outpatient), the women were required to attend the treatment plus achieve a negative cocaine urine toxicology. The women received vouchers, which could be exchanged for service or goods each time they achieved the target behavior. They received $ for the first day, and the value increased $ per day thereafter. In other words, if the target behavior was achieved each day, a woman received $ for the second day, $ for the third day, and so on. Thus, a woman could earn up to $ in vouchers if she achieved the target behaviors for all  days. Jones et al. () noted three issues in implementing such a CM with pregnant women. First, although the CM is costly, it may be well worth it, considering the cost-benefit ratio, since not only the pregnant women but also the fetuses are involved. The medical and social costs for AOD-exposed fetuses are a great deal higher than the costs involved in the CM. Second, citing Amass, Jones et al. said that the agencies may solicit donations from baby merchandise stores or toy stores in the community to reduce the agencies’ financial burden. Third, although the escalating voucher schedule may be unfamiliar to staff in non-research agencies and may appear to be complex to implement, staff can be trained, with “a minimal amount of training and motivation,” to perform such a treatment approach (). Therapeutic Workplace Approach

The second example is a three-year Therapeutic Workplace (TW) approach conducted by Silverman et al. (), who randomly assigned young mothers who had originally failed a comprehensive and intensive treatment program designed for pregnant and postpartum women to a TW (n = ) or usual-care control group (n = ). Women of the TW group gained entrance each day to a three-hour work shift at the therapeutic workplace if they tested negative for cocaine and opiates that day. The women received basic academic education and job skills training at the therapeutic workplace. They earned “base pay vouchers” for their workplace attendance and abstinence, and vouchers for other targeted behaviors such as “professional demeanor.” The results showed that “relative to controls, Therapeutic Workplace participants increased cocaine (% vs. % negative; p = .) and opiate (% vs. % negative, p = .) abstinence on the basis of monthly urine samples collected until  years after intake” (). Silverman et al. said that the

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control group women made no progress to reduce their opiates or cocaine use and that % of the urine specimens gathered from the control group women in the second half period of the three-year study tested positive, which is virtually the same as their rate of use in the first six months of the three-year study.

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SAPW is a client population that deserves great attention because of the unborn fetuses involved. Pregnancy would normally motivate a woman to stop using AOD or to stop smoking because of her concern for her baby. However, several risk factors may propel a woman to continue using AOD during pregnancy. One key risk factor is related to her male partner. A pregnant woman is more likely to continue to use AOD or smoke if she is single or her male partner is absent, if her male partner is using, and/or if domestic violence is present. A history of dual diagnosis and/or childhood maltreatment may also impede a pregnant woman’s recovery because she needs to self-medicate underlying psychiatric disorders or trauma related to childhood abuse, which may become more salient during pregnancy. A woman may also fail to stop using during pregnancy because of her chronic or more severe AOD-using history prior to pregnancy or her lack of accurate knowledge about AOD and its impact on pregnancy and the fetus. Finally, higher-income pregnant women generally may be more or equally likely to have “any alcohol use,” whereas lower-income pregnant women generally may be more likely to have binge drinking or frequent drinking, use illicit drugs, and/or smoke. Although “any alcohol use” by a pregnant woman may result in FAS or FASD, maternal heavy drinking or binge drinking puts the fetus at high risk for FAS or FASD. Risk for the occurrence of FAS or FASD is further increased by a pregnant woman’s poor socioeconomic environment. Although African Americans and Native Americans have a higher FAS rate than whites, scholars suggest that socioeconomic status rather than race increases the risk. To help SAPW, practitioners may emphasize screening, early detection, and timely referral for appropriate AOD treatment; increase the client’s knowledge of AOD’s impact on pregnancy and fetus development; connect her with community resources; enhance her inner strengths and other resources, for example, by helping her deal with shame and guilt, as well as dual diagnosis; advocate for effective policies and treatment strategies, as well as cultivate a nonjudgmental attitude. BI may be applied by practitioners in general health care or social service programs. CBT or CBT plus CM have also been shown to be effective. Behavioral couple therapy may be an option for treatment if the male spouse is a non-user.

Chapter 

Adolescent Girls

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dolescence is one of the most important developmental stages in a person’s life. The extensive biological, psychological, and social development that takes place creates both promise and worry in adolescents. Making the transition from being infertile to fertile and from being a vulnerable child to an independent adult is an extremely demanding process. Adolescents are given more autonomy to explore the world and have new experiences, but they are also expected to become independent and functional members of family, community, and society. Although they mature in primary and secondary sex characteristics and become stronger physically and cognitively, they may not necessarily be equipped with solid coping skills and sound decision-making abilities. Waylen and Wolke () stated: “Adolescence can be considered as an opportunity to develop greater freedom and self-reliance or it can be considered as a threat” (). Substance abuse is one of the risky behaviors that an adolescent may experiment with. Adolescents may be motivated to drink or use drugs for a variety of reasons. They may be emulating the AOD-using lifestyle of adults in their immediate environment (e.g., family) or self-medicating in search of relief from the issues that they face during adolescence. They may be seeking to fit in with their peer group or to challenge authority figures. They may perceive AOD using as a way of entering adulthood or simply be influenced by the powerful media, which oftentimes glamorize AOD-using behavior (Greydanus and Patel ). The consequences of AOD use or abuse can be more damaging for an adolescent than for an adult, primarily because of the adolescent’s developmental stage. AOD-using adolescents are at risk for motor vehicle crashes, emergency room visits, suicide, violence or other delinquent behaviors, rape, truancy, and dropout. National Highway Traffic Administration

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() statistics showed that in  about % of -to--year-old drivers who died in car crashes had been drinking. SAMHSA (OAS a:) noted that in , “an estimated , alcohol-related emergency department visits were made by patients aged  to .” According to SAMHSA’s combined data for , , and  (OAS b), .% of youths who used illegal drugs were involved in a violent behavior during the preceding year, as compared to .% of youths who did not use illegal drugs. Also, during , .% of youth who drank heavily engaged in delinquent behaviors (e.g., group-againstgroup fights, attacking someone with the intention to harm the person, theft, selling illegal drugs, carrying a handgun) during the preceding year, as compared to .% of nondrinking youths (OAS b). Although AOD-using behaviors for some adolescents represent a short-lived or transitional period, research has suggested that early onset of AOD abuse during adolescence has a long-lasting impact on the later development of AOD addiction in adulthood (Andersen et al. ; Hingson, Heeren, and Winter ). For example, Hingson, Heeren, and Winter (N = ,) found that % of the participants who began drinking when they were younger than  encountered lifetime dependence, as compared to only % of those who began drinking at the age  or older. One explanation of the link between age of onset and later development of addiction could be that AOD affect the brain of an adolescent differently than they do that of an adult (Lubman, Yücel, and Hall ; Monti et al. ). Adolescents may be more sensitive to the effects of drugs than adults are and thus may move from simple use or abuse to the stage of dependence or addiction at a lower threshold than adults (Kandel ). (Some studies, however, suggest that the higher AOD risk among the using adolescents already exists before the onset of drinking owing to a premobid vulnerability [Prescott and Kendler ].) Among adolescents, girls may be more vulnerable to AOD problems than boys because of various risk factors and more-negative consequences. Although current statistics show that the AOD-using rate for girls is equivalent to that of boys, the research on girls lags behind the research on boys. The implications of society’s misperception that antisocial problems, including substance abuse, belong to boys and not girls can result in girls’ being less likely to be identified, accessed, and recruited for AOD prevention or treatment. Further, currently available youth AOD treatment facilities, already few in number, do not necessarily provide genderspecific treatment. This chapter focuses on helping substance-abusing female adolescents, incorporating their unique developmental and gender-specific needs. The terms “girls,” “adolescent girls,” “teenage girls,” and “female adolescents” may be used interchangeably. The first part of the chapter addresses the theories and characteristics of AOD problems among adolescent girls, providing an overall background. The second part discusses empirically based treatment guidelines, principles, and strategies for effectively working with this population.

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Theories and Characteristics of AOD Problems Among Adolescent Girls Summarizing various studies, Waylen and Wolke () stated that throughout childhood boys appear to have more mental or behavioral problems than girls, including attention-deficit/hyperactivity disorder and learning difficulties. However, after the onset of puberty, girls for the first time begin to show more mental and other behavioral problems than boys, among them depression, anxiety, smoking, eating disorders, and teen pregnancy (Waylen and Wolke ). In the following sections, we first discuss four important factors that contribute to or are related to substance abuse among adolescent girls. Next, we present factual data and statistics regarding the AOD problem and its related risks among girls. Finally, we discuss four important comorbidities that may be present along with AOD problems in girls.

Four Important Factors Related to Substance Abuse Among Adolescent Girls Multiple factors may contribute or relate to an adolescent’s substance abuse. The following discusses four factors that are particularly salient to substance abuse among girls: () the developmental factor, which consists of the biological / hormonal sphere, the psychosocial sphere, and the interaction between the two; () childhood sexual abuse and other adverse childhood experiences; () family dynamics, communications, and the parent-child relationship; and () the racial / ethnic factor. A girl’s AOD problem could be the result of one or more of the four factors in combination with other circumstances and characteristics specific to the individual.

The Developmental Factor The Biological / Hormonal Sphere

One of the most important disorders among female adolescents (and adults) is depression, and it is essential to address depression when discussing substance abuse among women. Statistics have shown that substance-abusing women not only have a higher rate of depression than their male counterparts but also have a higher rate of depression than their non-using female counterparts. According to Noble (), depression is “the leading cause of disease-related disability in women” (). The onset of depression in women parallels the onset of puberty (Steiner, Dunn, and Born ). The overall female-to-male ratio of depression is two to one, and that ratio stays true for women through their child-bearing years. Generally speaking, there is no significant difference in depression rates between girls and boys younger than  years old or between women and men after midlife

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(Kessler et al., cited in Noble ). On the basis of this observation, many experts have concentrated on the biological / hormonal sphere and the psychosocial sphere, as well as the synergy of the interaction between the two spheres, in explaining women’s depression. Since the depression prevalence gap between men and women begins in adolescence, many researchers theorize that the higher rate of depression among girls may be related to the onset of the dramatic changes in their hormonal systems. Female adolescents’ and adults’ experience of depression may be affected by their reproductive system, including the intake of oral contraceptives, the menstruation cycle, pregnancy and delivery, and menopause (Parry ). Depression associated with these changes in the reproductive system is believed to be at least partially attributable to fluctuations of female sex steroids or hormones, such as a decrease in estrogen during the beginning phase of menstrual cycle (premenstrual syndrome), an increase in estrogen during pregnancy with a dramatic decrease after delivery (postpartum depression), and the elimination of estrogen during menopause (menopausal depression). Although more studies are needed to understand the complexity of the relationship between ovarian hormones and brain functions, researchers suggest that the fluctuation of the hormones may unduly affect brain neurotransmitters (e.g., serotonin) and brain functions that mediate an individual’s affect and mood, and in turn result in depression (Deecher et al. ; Noble ). On the other hand, researchers proposed the genetic predisposing factor in addition to the factor of hormonal fluctuation. Since all women experience hormonal fluctuation but not all women experience depression, it is posited that only women who are genetically predisposed are vulnerable to the perpetuating effect of hormonal fluctuation on the brain (Noble ; Steiner, Dunn, and Born ). It is the genetic predisposing factor combining with the woman’s fluctuating gonadal hormones that determines how she responds to multiple environmental stresses and if depression takes place (Steiner, Dunn, and Born ). The Psychosocial Sphere

The onset of puberty not only dramatically promotes the primary (physical and hormonal growth) and the secondary sex characteristics (the external appearance) but also activates and intensifies the gender-specific socialization practice and role expectations of adolescents. Research review shows that society in general, and parents and teachers in particular, apply and reinforce stereotyped gender role expectations to adolescents. Adolescents, in turn, appraise themselves using the cultural norms of masculinity and femininity (Rosenfield ). According to Rosenfield, “The differences in socialization by gender appear to achieve their full expression in adolescence” (). Stereotyped gender socialization practices and role expectations may help explain why adolescent boys are more likely to develop externalizing disorders, while

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adolescent girls are more likely to develop internalizing disorders. Stereotypical gender role expectations may socialize adolescent girls into three areas of feminine traits. The girls may be encouraged or positively reinforced to exhibit feminine virtues such as selflessness, self-sacrifice, putting others’ needs before one’s own, and caring. They may be socialized to assume dependent, deferential, helpless, submissive, and relationship-oriented roles. Finally, the girls may perceive, correctly or incorrectly, from the traditional stereotyped gender role socialization process that feminine qualities include compliance in interpersonal relationships, avoiding conflict or confrontation, and deferring the expression of one’s own thoughts, wishes, or opinions (Zahn-Waxler, Race, and Duggal’s review ). On the other hand, adolescent boys are socialized to become masculine-oriented by exhibiting selfassertiveness, self-reliance, forcefulness, and a strong personality. Literature reviews suggest that the feminine traits that suppress adolescent girls’ self-assertiveness and self-expression contribute to the internalization of their negative feelings, resulting in a higher risk of depression. Depression plays a critical role in women’s development of AOD problems. The masculine characteristics that promote assertiveness and competence contribute to adolescent boys’ externalization of their negative feelings, resulting in a higher risk of conduct disorder and a lower risk of depression (Rosenfield ; Zahn-Waxler, Race, and Duggal ). The Interaction Between the Biological / Hormonal Sphere and the Psychosocial Sphere

Although the biological / hormonal theory does help us to understand depression among female adolescents and adults, researchers have not totally discounted the importance of the psychosocial factor, particularly the interaction between the biological / hormonal and psychosocial factors and its synergy. For example, in addition to detailing genetic predisposing and hormonal fluctuation factors, Noble’s () review of literature shows that other predisposing factors (e.g., marital status, educational status, nutrition, social economic status) may also influence a woman’s vulnerability to the occurrence of depression during menopause. Likewise, although postpartum depression may be attributable to both the hormonal fluctuation (a dramatic decline of estrogen in women after delivery) and the predisposed genetic factor, researchers found that it may also be affected by several psychosocial factors, such as whether the woman is isolated and has no social network support (Nolen-Hoeksema’s review ). Nolen-Hoeksema’s () review suggested two important notions in understanding the effect of the interaction between the biological / hormonal factor and the psychosocial factor on depression in girls. First, although both girls and boys undergo puberty and display secondary sex characteristics (body appearance change), girls appear to view their body appearance change more negatively than boys do. Girls are conscious about and dislike the fat and weight they gain during this stage, while boys seem to enjoy the muscle mass and other development

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that they undergo. Second, not only do adolescent girls view their secondary sex characteristics more negatively, but they tend to place more emphasis on their appearance and base their self-esteem and emotional well-being on how they look. Subsequently, this double setback makes adolescent girls more vulnerable to depression than their male counterparts are. Girls, in general, are one year ahead of boys in reaching puberty. Further, some girls mature earlier than average. Research has shown that girls who mature early may be more likely than their on-time or later-maturing peers to have emotional problems, to be involved with delinquency, to abuse alcohol or smoke marijuana, to be truant or drop out of school, and / or to become a parent earlier (Magnusson, Stattin, and Allen ; Mendle, Turkheimer, and Emery ; Stattin and Magnusson ). There are several reasons why early maturation leads to problems for girls. One of the most often cited is that girls who mature early tend to associate with older friends, both male and female, who may approve of or introduce the girls to a wide range of deviant behaviors, such as substance use, that are more normative for older adolescents or adults but inappropriate or illegal for the girls (Stattin and Magnusson ). Zahn-Waxler, Race, and Duggal’s review of the literature () shows that girls who mature early are more likely than their average-maturing counterparts to have depressive symptoms. The early-maturing girls may be under a great deal of stress simply because they are not ready for, or do not know how to cope with, the physical maturation and the stresses that accompany it (Zahn-Waxler, Race, and Duggal ). The depression could be related to girls’ hormonal changes (Mendle, Turkheimer, and Emery ) or their being conscious about and dissatisfied with their body image and dieting (Stice, Presnell, and Bearman ). Problems may occur when parents or other people treat the early-puberty girl as a more mature person than she actually is (Andrews ). Waylen and Wolke () said that early-maturing girls may have access to bars and adult movies before they reach legal age, which could create problems— particularly when there is a lack of effective parental monitoring and family rules or a de-emphasis on education.

Childhood Sexual Abuse (CSA) and / or Other Adverse Childhood Experiences (ACE) Numerous studies have documented the connection between CSA / ACE and the later development of physical, psychological, emotional, and / or behavioral problems. One such problem is substance abuse. Although boys and girls share similar rates of childhood physical abuse, more girls than boys experience childhood sexual abuse. Nolen-Hoeksema’s review () indicated that sexual abuse rates among girls increase considerably during early adolescent years and such abuse may continue throughout adolescence. Finkelhor et al. (cited in Nolen-Hoeksema ) found that prior to age , about % of the women had suffered sexual

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abuse by a perpetrator outside the family and about % of the women had suffered sexual abuse by a family member. In addition, girls between  and  are at the highest risk for sexual abuse. The average age when sexual / physical abuse occurred was . years (Kilpatrick et al. ). For a detailed discussion of the link between CSA / ACE and the later development of AOD problems, see chapter .

The Family Environmental Factor The family factor may include both genetic and environmental components (see chapter ). This section focuses on the family environmental component. The literature has suggested that the family environmental factor may exert a stronger effect on women than on men, with numerous studies indicating that more substance-abusing women than their male counterparts come from a dysfunctional family or a family with an AOD-using background. Theories explaining the phenomenon point to sex role socialization of females in that girls are taught to emphasize interpersonal relationships, particularly within the family context, while boys are encouraged to be independent and thus are more likely to be influenced by the outside world. Subsequently, women are more emotionally involved with their family and tend to identify with their family more than men do (Hsieh and Hollister ). Thus women are more likely to be affected by family stress and other dysfunctions. The family factor is doubly accentuated for adolescent girls, both because it is important developmentally for both girls and boys and because it is particularly salient for females. The following discusses how adolescent girls’ AOD use is related to the family’s dysfunction, including () the family’s AOD-using background, and () the negative parent-child relationship. Parental and Other Family Members’ AOD Use

Numerous studies have pointed out that substance-abusing women or adolescent girls are more likely than their male counterparts to come from families with an AOD-using background (see chapter ). Parental and / or other family members’ AOD use may directly or indirectly affect the adolescents’ AOD use, particularly girls. Directly, substance-abusing parents or other family members may function as negative role models and could normalize a drug-using lifestyle for the adolescents. As mentioned in chapter , Bandura’s social learning theory explains the generational transmission of many behaviors, including substance abuse in children who may model their parents’ substance-abusing behavior, which may be reinforced and therefore repeated (cited in Toray et al. ). In addition, AOD use by parents or other family members directly increases the adolescents’ access to AOD, which in turn increases the risk that they will use AOD as well. Indirectly, the AOD problems of parents or other family members may contribute to or intensify the risk of child neglect, physical abuse, and / or sexual abuse,

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which, in turn, may lead to an adolescent’s later development of AOD problems (Galaif et al. ; Kilpatrick et al. ). This “indirect impact” theory parallels the adverse childhood experience (ACE) theory discussed in chapter . Parental AOD use is one of the ten risk factors described by the ACE theory, which views all the risk factors as highly interrelated and as tending to co-occur to create an adverse childhood environment. Henry, Robinson, and Wilson’s () study also showed that an adolescent who reports his or her parents as currently using AOD tends to perceive the parents as less able to provide emotional and other support, which, in turn, increases the risk of the adolescent’s AOD use. Another indirect impact is that adolescents who live with an AOD-using family member are more likely to associate with friends who use AOD, which increases the risk of the adolescents’ using AOD (Bahr, Marcos, and Maughan ). Some studies (Bahr, Marcos, and Maughan and Galaif et al.) suggest that parental and / or other family members’ AOD use exerts only an indirect, not a direct, impact on adolescents’ AOD use. In other words, those studies showed that adolescents’ AOD use is associated more with their suffering child maltreatment or their connecting with AOD-using peers as a result of their parents’ AOD use. Those studies revealed no direct link between adolescents’ AOD use and their learning such behavior from AOD-using parents or other family members. Parent-Child Relationship

The parent-child relationship may affect an adolescent girl’s AOD-using behavior in three ways. First, the higher the level of parental supportiveness, family bond, and / or family hardiness the girl perceives, the less likely she will be to engage in AOD-using behaviors. Second, the more involved the parents are with their daughter’s life and / or the more open their communications about drug use, the less likely she will be to engage in AOD use. Third, the impact of the family bond on a girl’s AOD use could be connected to its impact on whether she associates with AOD-using peers and her educational commitment. The following elaborates these three explanations. Adolescents who perceive their parents as being supportive tend to report a lower level of AOD use. Henry, Robinson, and Wilson’s () empirical study (N = ; % girls and % boys) showed: () the higher the degree of “family hardiness” an adolescent perceives her or his family to possess, the higher the degree of parental supportiveness she or he would perceive, and, in turn, the less likely she or he would be to use AOD. “Family hardiness” was defined as “families’ strength, durability over time, sense of control, and ability to actively respond to stress” (). () the higher the degree of the “family coping coherence” an adolescent perceives the family to possess, the higher the degree of parental supportiveness he or she would perceive, and therefore, the less likely the adolescent would be to use AOD. “Family coping coherence” was defined as a family’s ability to “work together as a unit during challenging or stressful situations” ().

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CASA’s Formative Survey results showed that adolescent girls who communicate with their parents about substance abuse issues and the danger involved are less likely to use AOD, and that .% of the girls who had such conversations with parents stated that the conversations helped them refrain from smoking or other AOD use (cited in CASA ). CASA’s analysis of the National Household Survey on Drug Abuse data (NHSDA) (the name of the survey has now been changed to the National Survey on Drug Use and Health) also showed that girls who perceive that they can communicate with their parents and do not have frequent arguments with their parents are at lower risk for smoking and AOD use (cited in CASA ). Another factor is the parental involvement with the girls’ life. CASA analysis of the NHSDA found that adolescent girls whose parents are highly involved in their life (such as checking their homework, setting curfews, and monitoring their friendships) and give positive feedback (such as telling their daughters that “they’re proud of them”) are at lower risk for smoking or AOD use (). Although many studies have indicated that the closer and more intimate an adolescent feels about her or his family, the less likely she or he would be to use AOD frequently or in a large amount, many did not look into the process as to exactly how the family bond contributes to a lower risk of adolescent AOD use. One large-scale study (Bahr, Marcos, and Maughan ), which included , randomly selected adolescents in the seventh through the twelfth grades, did explore the issue and overall found that the direct impact of family bond on adolescents’ AOD use is only minimal; rather, the primary function of family bond on reducing adolescents’ AOD risk is achieved indirectly through two other factors—association with AOD-using peers and educational commitment. Their study results showed a sequential path: a stronger family bond leads to a lower risk of associating with AOD-using peers; in turn, a lower risk of associating with AOD-using peers leads to a lower risk of AOD use. Bahr, Marcos, and Maughan () said the negative relationship between the family bond and an association with AOD-using peers is particularly robust for female adolescents. Another sequential path found was that a stronger family bond leads to a higher educational commitment by the adolescent, which, in turn, leads to a lower risk of AOD use. The family bond / educational commitment / AOD use connection, according to the study’s findings, is stronger for adolescent boys.

The Racial / Ethnic Factor Although statistics show that minority youth, with the exception of Native Americans, do not necessarily have a higher AOD use / abuse rate than white youth, practitioners still need to address the racial / ethnic factor because studies suggest that racial identity may play an important role in minority adolescents’ overall identity development. Such development may directly and indirectly affect their psychological well-being and other behaviors, including AOD use. In addition,

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while numerous studies have suggested an association between treatment retention / completion and treatment outcomes (a high retention / completion rate associates with a better treatment outcome), non-white substance-abusing clients (youth and adults) have shown a lower treatment completion rate than their white counterparts (Austin and Wagner ; Campbell, Weisner, and Sterling ; SAMHSA b). For example, according to the  TEDS data (SAMHSA b:), whites were % more likely to “complete [AOD] treatment or transfer to further treatment” than their non-white counterparts. Austin and Wagner’s study showed that white adolescents completed an average of % of the required sessions compared to % for U.S.-born Hispanic adolescents, % for foreignborn Hispanic adolescents, and % for African American adolescents. Campbell, Weisner, and Sterling (N =  adolescents) found that Native American youth were less likely to return for treatment after intake than white youth, and African American youth had a lower treatment retention than whites. However, the above TEDS data analysis did not differentiate between males and females, and Austin and Wagner’s study included only .% females. Thus, more gender-specific data are needed to confirm the issue with respect to minority adolescent girls. Further, non-whites (youth and / or adults) often experience a greater degree of negative consequences of alcohol use (physically, mentally, and socially) than their white counterparts, despite their comparable or lower levels of use (Wallace ). Racial Identity

One definition of racial identity is “an individual’s attitudes, thoughts, feelings, and behaviors toward oneself and others with respect to racial group membership” (Helms, cited in Buckley and Carter :). The following four statuses of racial identity are generally recognized in relation to African Americans: (a) the pre-encounter status, in which an individual relies on white society to define him / herself and shows negative attitudes toward his / her own race, (b) the encounter status, in which the individual challenges his or her existing pre-encounter status about his / her race and experiences confusion and emotional turmoil, (c) the immersion-emersion status, in which the individual attempts to realize his / her African American heritage by idealizing African American culture while degrading white culture, and (d) the internalization status, in which the individual develops positive attitudes toward both the African American race and other racial groups (Buckley and Carter ). Perhaps because of the different definitions, sampling methods, and research designs used, study findings about the relationship between racial identity of youth of color and their substance abuse behavior are inconsistent. Some researchers suggest that high racial identity (e.g., ethnic orientation, ethnic pride) is related to low substance abuse (Gil, Wagner, and Tubman ), whereas others suggest that high racial identity is linked to high substance abuse (James, Kim, and Armijo ), and some studies suggest that there is no association between the

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two (Valdez, Mikow, and Cepeda ). However, many studies that specifically focus on African American youth and young adults appear to consistently suggest that African American youth with a higher level of racial identity or a positive viewpoint about being an African American tend to have a better overall psychosocial adjustment, including a higher domain-specific self-esteem, higher academic achievement, a lower level of delinquent behavior, stronger anti-drug attitudes, and / or a lower level of substance abuse behavior (Brook and Pahl ; Buckley and Carter ; Szapocznik et al. ; Townsend and Belgrave ). Resnicow et al. () showed that an “anti-white” attitude of African American youth may be related to an increase in their substance-abuse behavior, whereas their “problack” attitudes may be associated with their attitudes against substance abuse. Acculturation and Acculturative Stress

Acculturation is a complex concept that encompasses multiple dimensions and issues. Berry () stated that acculturation is “a process of cultural and psychological changes” and involves “changes in a person’s behavioral repertoire,” which may include “learning . . . languages, sharing . . . food preferences, and adopting forms of dress and social interactions” (–). Berry further suggested that different groups and individuals may adopt different “acculturation strategies,” resulting in different levels of satisfactory adaptations as well as stress. Further, members in the same family may choose different acculturation strategies and experience different acculturation rates, adding more difficulty and conflict to its acculturation process (Berry ). Study findings on the impact of acculturation on substance abuse behavior of minority adolescents are mixed (see De La Rosa’s review ). Many suggest that a higher acculturation is associated with a higher level of AOD use / abuse, while others suggest the opposite. More studies are needed to understand and reconcile the seemingly contradictory research findings. Many studies have shown that a higher level of acculturation is linked with a higher level of AOD use / abuse (Epstein, Botvin, and Diaz ; Gfroerer and Tan ; Marín and Posner ). For example, the  and  NHSDA estimates data (Gfroerer and Tan ; N = , youths representing the youths in the United States) showed that .% of the U.S.-born adolescent girls (aged –) versus .% of the foreign-born adolescent girls ( p < .) reported cigarette use in the past month (a similar trend was found among boys: .% versus. .%, respectively, p < .). The same tendency applied to “alcohol use” (.% versus .%, p < . for girls; .% versus .%, p = . for boys), “binge alcohol use” (.% versus .%, p < . for girls; .% versus .%, p = . for boys), “heavy alcohol use” (.% versus .%, p < . for girls; .% versus .%, p < . for boys). Gfroerer and Tan’s analyses additionally showed that for the past-month use of substance, the foreign-born youth with a less-than-five-yearU.S. residency had a significantly lower prevalence estimate than their U.S.-born

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counterparts (p < .) in all categories of substances. However, the prevalence estimates were not significantly different (except for “heavy alcohol use”) between foreign-born adolescents who had resided in the United States for ten years or more and the U.S.-born adolescents. Some studies further indicated that the relationship between acculturation and AOD use / abuse is more pronounced among women or younger women (Markides et al. ; Turner, Lloyd, and Taylor ; Vega et al. ). For example, Turner et al.’s study (N =  females and  males with Cuban or other Hispanic backgrounds, most between  and  years old when interviewed) reported that the U.S.-born females had a significantly higher rate of “lifetime drug dependence” than their foreign-born counterparts (.% versus .%, p < .), whereas no significant difference was found between U.S.-born males and their foreign-born counterparts (.% versus .%). Vega et al.’s study (N = , subjects of Mexican origin, aged –, in Fresno County, California) found that the impact of the joint effect of acculturation and U.S. nativity on drug use was stronger among women (adjusted odds ratio = .) than among men (adjusted odds ratio = .). One theory explaining the linkage between a lower acculturation and a lower AOD use / abuse rate among Hispanics is that Latino culture traditionally discourages illicit drug use (De La Rosa ) and that a higher acculturation makes it easier for Latinos to access AOD. Researchers also attempted to understand why the impact of acculturation on AOD use / abuse appears to be greater for Hispanic women than men. They believe that the traditional Hispanic culture has a stricter gender role expectation for women than men, in that women are highly discouraged from using / abusing AOD whereas men are relatively freer to engage in such behavior. A higher acculturation may set Hispanic women free from the traditional gender role constraints and they thus engage in more substance-abusing behavior. Conversely, Hispanic men are already freer than women to engage in AOD use / abuse, with or without the impact of acculturation. Although many studies show a positive association between levels of acculturation and levels of AOD use / abuse (i.e., high acculturation corresponds with high AOD use / abuse), there are studies that point to an inverse association between the two (i.e., low acculturation corresponds to high AOD use / abuse). For example, Vega et al.’s study (cited in De La Rosa ) reported that the U.S.-born Latino adolescent participants who experienced lower degrees of acculturation tended to engage in higher levels of substance use experimentation than their highly acculturated or bicultural counterparts. Vega et al. (cited in De La Rosa ) believe this is because the U.S.-born Latino adolescents with lower levels of acculturation are more likely to face “double jeopardy.” On the one hand, they suffer the same language problems and have the same narrower life opportunities that their foreign-born counterparts may experience. On the other hand, they endure the same “perceived discrimination” and other acculturation conflicts that

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their U.S.-born Latino peers may experience. In addition, Katims et al.’s study (cited in De La Rosa ) indicated that foreign-born Mexican American adolescents who have a lower level of acculturation are more likely to engage in AOD experimentation than their more acculturated counterparts. Katims et al. suggest that this is attributable to the psychological stress experienced by the foreign-born Mexican American adolescent during the process of adjusting to American life. Likewise, Gil, Wagner, and Tubman’s study (; N =  juvenile offenders, .% females) reported that foreign-born Latino adolescents tend to have a higher level of substance abuse than their U.S.-born counterparts. Gil, Wagner, and Tubman said that drug-using foreign-born Latino adolescents may come from families that suffer high levels of distress in adjusting to the new lifestyle and may be an “especially marginalized group” ().

Substance Abuse Statistics indicate that although men in general exceed women in AOD use / abuse, adolescent girls have shown an AOD use / abuse rate equivalent to that of adolescent boys (CDC ; SAMHSA a, b). As mentioned in chapter , SAMHSA’s data (a, b) indicated that .% of the females aged – versus .% of their male counterparts reported “past year alcohol dependence / abuse”; .% of the girls versus .% of the boys reported “past year illicit drug dependence / abuse”; and .% of the girls versus .% of the boys reported “past year cigarette use.” Similarly, the  YRBS (CDC ) revealed that .% of female ninth to twelfth graders versus .% of their male counterparts reported ever having one or more alcoholic drinks, .% of the girls versus .% of the boys reported current alcohol use, and .% of the girls versus .% of the boys reported episodic heavy drinking. Also, .% of the girls versus .% of the boys reported “current cigarette use,” and .% of the girls versus .% of the boys reported “current frequent cigarette use” (). This section presents () the types of drugs that girls are more likely to abuse, () ethnicity and AOD prevalence rates, () age factor and AOD prevalence rates, and () the direct and indirect risks involved in girls’ AOD use.

Types of Drugs According to the  TEDS data (SAMHSA c), marijuana was the primary substance of abuse at admission for % of the adolescent girls (– years old), followed by alcohol (%), stimulants (%), cocaine (%), opiates (%), and other (%). The rates for adolescent boys were %, %, %, %, %, and %, respectively. These national data showed that for both girls and boys admitted to treatment, marijuana was the primary substance abused and that a higher proportion of boys than girls (% versus %) had marijuana as their primary

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substance. On the other hand, a higher proportion of girls than boys had alcohol (% versus %), as well as stimulants (% versus %), as their primary substance abused at treatment admission. The factors of geographical region (e.g., methamphetamine abuse may be more widespread on the West Coast than in other areas in the United States), source of subjects (e.g., jail population versus community population), and methods (e.g., counting the frequency based on admissions [an individual may have multiple admissions during the year] instead of number of individuals) may affect rates for the various types of drugs. For example, Shillington and Clapp’s () data analysis of , adolescents who attended publicly funded AOD treatment programs during – in San Diego County, California, revealed that the girls’ primary drug choice was methamphetamine / crystal while marijuana was the boys’ primary drug choice. For their first drug choice, .% of the girls reported methamphetamine / crystal; .%, marijuana; and .%, alcohol. On the other hand, .% of the boys reported marijuana; .%, methamphetamine / crystal; and .%, alcohol. In addition, NIDA Notes () pointed out that girls are more likely to be diagnosed with single drug abuse or dependence whereas boys are more likely to be diagnosed with simultaneous poly-drug abuse or dependence.

Ethnicity and AOD Prevalence Rates The  NSDUH (SAMHSA n.d.d) data revealed a few notable themes: (a) American Indians / Alaska Native youth (aged –, girls and boys) exceeded youth of all other ethnic groups in rates of illicit drug use and cigarette use; (b) American Indians / Alaska Native youth and white youth (aged –) exceeded youth of all other ethnic groups in rates of alcohol use and binge alcohol use; (c) African American youth and Asian youth appeared to have lower rates of alcohol use and binge alcohol use than youths of other ethnic groups, and the rates for Hispanic youth appeared to be between those for white / American Indians / Alaska Native youth and those for African American / Asian youth; and (d) although Asian youth appeared to have the lowest rate of illicit drug use among all ethnic groups in  and , they were the only group whose  rate significantly surpassed its  rate. Their  binge-alcohol-use rate was also significantly higher than their  rate. The  NSDUH data (SAMHSA n.d.d) reported that American Indians / Alaska Native youth (aged –; girls and boys not separated) had the highest rate of “past month” illicit drug use (.%), followed by youth “with two or more races” (.%), African American youth (.%), white youth (.%), Hispanic youth (.%), and Asian youth (.%). American Indians / Alaska Native youth also had the highest rate of “past month” cigarette use (.%), followed by youth with two or more races (.%), white (.%), Hispanic (.%), African American (.%), and Asian (.%). Further, white and American Indian / Alaska Native

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youth shared similar rates of alcohol use (.% and .%, respectively), followed by youth with two or more races (.%), Hispanic (.%), Asian (.%), and African American (.%). For binge drinking, again, American Indian / Alaska Native and white youth lead other ethnic groups (.% and .%, respectively), followed by youth with two or more races (.%), Hispanic (.%), Asian (.%), and African American (.%). Although the YRBS survey is limited to school settings (and thus excludes youth who dropped out of the school) and reports mainly about three ethnic groups (African American, Hispanic, and white), it does provide detailed statistics regarding AOD and tobacco use rates among female high school students (grades –) of the three major ethnic groups in the United States. The following sections are based on the  YRBS data (CDC ; for methamphetamines, ecstasy, and heroin, only “lifetime use” information was available, not “current use” information). Cigarette Use

White adolescent girls have more smoking problems than Hispanic or African American girls. For “current cigarette use” (i.e., “smoked cigarettes on ≥  of the  days preceding the survey”), white girls had a higher rate than Hispanic and African American girls (.%, .%, and .%, respectively). This is consistent with the overall distribution of prevalence rates among adolescents (both boys and girls) in that white adolescents have a higher rate than Hispanic and African American adolescents (.%, .%, and .%, respectively) (CDC ). CDC data (CDC :) further showed that white girls had a higher rate of “current frequent cigarette use” (“smoked cigarettes on ≥  of the  days preceding the survey”) than those for African American girls and Hispanic girls (.%, .%, and .%, respectively). Alcohol Use

Both white and Hispanic girls seem to have more alcohol problems than African American girls. For “current alcohol use” (“had had at least one drink of alcohol on ≥  of the  days preceding the survey”), white and Hispanic girls had higher rates than African American girls (.%, .%, and .%, respectively). This is consistent with the prevalence rates for all adolescents of various ethnicities, in that white and Hispanic adolescents had higher rates than African American adolescents (.%, .%, and .%, respectively) (CDC :). For “episodic heavy drinking” (“had had ≥  drinks of alcohol in a row on ≥  of the  days preceding the survey”), again white and Hispanic girls exceeded African American girls (.%, .%, and .%, respectively). This distribution is consistent with the distribution among all adolescents, in that white and Hispanic adolescents had a higher rate than African American adolescents (.%, .%, and .%, respectively) (CDC :).

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Stimulant Use

Regarding current cocaine use rate (powder / crack / freebase), both Hispanic and white girls again exceeded African American girls (.%, .%, and .%, respectively). For lifetime cocaine use (“had used any form of cocaine one or more times during their life”), Hispanic and white girls had higher prevalence rates than African American girls (.%, .%, and .%, respectively). The distribution of all adolescents showed that Hispanic adolescents had the highest rate of lifetime cocaine use (.%), followed by white (.%) and African American (.%) (CDC :). For lifetime methamphetamine use, Hispanic and white girls again had a higher rate than African American girls (.%, .%, and .%, respectively). This trend applies to adolescents overall: Hispanic and white adolescents had a higher rate than African American adolescents (.%, .%, and .%, respectively) (CDC :). Heroin Use and Ecstasy Use

For lifetime heroin use (“used heroin one or more times during their life”), white girls had a higher rate than African American girls. The rates for white, Hispanic, and African American girls were .%, .%, and .%, respectively (CDC :). The rates for all adolescents (boys and girls) were .% for Hispanic youth, .% for white, and .% for African American (CDC ). For lifetime ecstasy use, Hispanic girls and white girls surpassed African American girls (.%, .%, and .%, respectively). The rates for all adolescents were .% for Hispanic youth, followed by .% for white and .% for African American (CDC ). Marijuana Use

The three ethnic groups of adolescent girls appeared to share a similar rate of “current marijuana use” (“used marijuana one or more times during the  days preceding the survey”): .% for whites, .% for African Americans, and .% for Hispanics) (CDC :). The rates for all adolescents (boys and girls) were .% for whites, .% for African Americans, and .% for Hispanics (CDC ).

Age and AOD Prevalence Rates The  YRBS (CDC ) indicated that both female and male adolescents showed an increase in cigarette use, drinking, and marijuana use from ninth grade to twelfth grade. For example, the current and lifetime marijuana use rates for girls increased from .% and .% among ninth graders to .% and .% among twelfth graders; for boys the rates were .% and .% to .% and .%. CASA’s () Formative Years survey results showed that the transition from high school to college is the period in which the greatest increase occurred among adolescents in drinking, smoking, and marijuana.

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Risk Behaviors Related to Substance Abuse Risk behaviors related to substance abuse among adolescent girls are multiple, among them use of injection drugs, sharing of needles and other paraphernalia, sex with IV-drug users, no use of condoms, sex trading for drugs or money, and so on. All of these behaviors increase the risk for HIV / AIDS, other sexually transmitted diseases, and unwanted pregnancies. See chapter  for a detailed discussion.

Psychiatric Disorders That Co-occur with Substance Abuse Four important comorbidities may co-occur with the AOD problems in adolescent girls: depression, ADHD and / or conduct disorders, eating disorders, and suicide. Depression, eating disorders, and suicide are addressed here because girls have a higher prevalence of all three pathologies than boys do, and there is a close relationship between the three pathologies and substance abuse. Although ADD / ADHD and conduct disorders are not as prevalent among girls, the co-occurrence of AOD use and ADD / ADHD among girls should not be ignored. Etiologies of or risk factors for the four pathologies are also summarized. Substance abuse problems usually co-occur and interact with other pathologies or behavioral problems, and it is important for practitioners to both assess those comorbidities and intervene (treatment or referral) when working with substanceabusing adolescents. Certain psychiatric symptoms that occur as a result of AOD use may disappear after AOD treatment. The AOD abuse or dependence, in this case, is considered to be the “primary diagnosis.” However, some co-occurring psychiatric symptoms may precede the occurrence of AOD use and require specialized psychiatric treatment in addition to the regular AOD treatment. Such AOD abuse or dependence is considered as the “secondary diagnosis.”

Depression and Other Internalizing Behaviors Internal Versus External Psychiatric Disorders

Research has shown that substance-abusing adolescent girls are more likely to manifest internalizing co-occurring psychiatric disorders or dysfunctional behaviors while their male counterparts are more likely to show externalizing disorders or behaviors (NIDA ). The internalizing behaviors listed in the NIDA Note are “depression,” “feelings of worthless,” “auditory or visual hallucinations,” “constant repetition of certain thoughts, ideas, or situations,” “repetitive and useless actions,” “frequent crying or atypical affect,” “severe headaches or other somatic problems,” “talk of suicide,” “decreased interest in activities,” “restricted activity levels,” and “withdrawal, avoidance of interactions, and lack of personal care.” The externalizing behaviors, on the other hand, include “recurring patterns of aggression,” “excessive arguing,” “use of physical or verbal coercion,” “noncompliance with reasonable request,” “persistent pattern of tantrums,” “persistent pattern of

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lying or stealing,” “lack of self-control or acting-out behavior,” and “behaviors that prevent development or maintenance of relationships.” Shrier et al.’s () study (N =  girls and  boys) showed that significantly more girls with substance use disorders reported depression than non-using girls (.% versus .%, p < .), while there was no significant difference between using and non-using boys. They also found that significantly more girls with “substance use problems” or “substance use disorders” reported mania than the non-using girls (.% versus .% versus .%, p < .), whereas there was no significant difference among the three groups of boys. Latimer et al.’s () study found that substance-abusing adolescent girls had a significantly higher rate of major depression than their male counterparts (.% versus .%; odds ratio = .; p < .), although the two did not differ significantly in their rates of double depression (major depression and dysthymia) or bipolar disorder. CASA’s () review indicated that mood disorders and eating disorders tend to coexist with substance abuse problems among females more often than males, but conduct or antisocial personality disorders tend to co-occur with substance abuse problems among males more than females. Etiologies of Depression / Internalizing Behaviors in Girls

Multiple factors contribute to depression, but three are particularly pertinent to the high prevalence of depression among adolescent girls: () biological / hormonal development, () the psychosocial factor, and () the interaction between the biological / hormonal development and the psychosocial factor. Briefly, depression among girls can be attributed to the dramatic hormonal fluctuation during puberty, as well as the gender role expectation / socialization that society imposes upon them that accentuates femininity (relationship-oriented, identifying with others’ well-being, caring, gentle, helplessness, etc.) rather than masculinity (independent, autonomous, emotionally detached, self-salient and self-contained, etc.). Rosenfield () stated that feminine qualities lead to girls’ tendency to develop internalizing behaviors and masculine qualities lead to boys’ externalizing behaviors.

ADHD and Conduct Disorders or Other Disruptive Behaviors Attention-deficit disorder (ADD) / attention-deficit hyperactivity disorder (ADHD) and conduct disorders (CD) are also possible comorbidities among substanceabusing adolescent girls. Although traditionally most research on ADHD and CD has focused on adolescent boys, more studies have emerged on adolescent girls during the last decade. Although boys still lead girls in ADHD and CD rates, the girls’ rates are not far behind and should not be ignored.

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ADHD Among Girls

Latimer et al.’s study () of adolescents with a “psychoactive substance use disorders” diagnosis showed that approximately one in every two boys had a comorbid ADHD diagnosis (.%) and about one in every four girls had such an ADHD diagnosis (.%). Shrier et al. () showed that their girl subjects with the diagnosis of “substance-using disorder” or “substance-using problems” had a significantly higher percentage of ADD comorbid distribution than their counterparts without substance use problems (.%, .%, and .%, respectively, p < .). Among boys, the ADD comorbid rates were .% for those with the “substance-use disorder” diagnosis, .% for those with “substance-use problems,” and .% for those without substance use problems ( p < .). ADHD is a type of neurobiological disorder classified by DSM-IV as three subtypes: () ADHD, Combined Type, () ADHD, Predominantly Inattentive Type, and () ADHD, Predominantly Hyperactive-Impulsive Type (). ADHD is frequently a concealed disorder in women and girls because its symptoms in females tend to be less overt than those in males. Females may manifest the Inattentive Type of ADHD (ADD) with symptoms characterized by forgetfulness and disorganization rather than the disruptive behaviors often witnessed in males (Quinn ). Quinn stated that even for the hyperactivity component, females may display hypertalkativeness and / or emotional reactivity rather than the excessive motor activity commonly seen in males with ADHD. Unfortunately, many parents and teachers have a stereotypical and inadequate definition of ADHD, focusing only on the hyperactive and disruptive behaviors, an emphasis that results in under-detection and a low referral rate of girls with ADHD (Hinshaw and Blachman ; Quinn ). Quinn () suggested that ADHD in women is often complicated by women’s hormonal fluctuations and coexisting disorders such as anxiety, depression, and learning disabilities. Quinn stated that ADHD may contribute to substance abuse and / or sexual acting out as girls enter puberty. In addition, girls and women with ADHD may experience feelings of inadequacy because of their often unsuccessful struggle to fulfill society’s prescribed appropriate gender role (Quinn ). All of these issues create not only difficulties in detecting and screening ADHD among women but also challenges in assessing and treating ADHD in women. Etiologies of ADHD

So far, empirical studies have indicated three risk factors related to the genesis of ADHD: () heritability, () low birth weight, and () prenatal exposure to alcohol, tobacco, and illicit drugs. Hinshaw and Blachman’s () review shows that heritability plays either an equal or a more important role in the origin of ADHD for women than for men. Two recent studies by Mick, Biederman, Prince, et al. (cited in Hinshaw and Blachman) and Mick, Biederman, Faraone et al. (cited in

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Hinshaw and Blachman) also indicated that the risk factors of low birth weight and maternal use of AOD and tobacco are equally important for boys and girls. Conduct Disorder (CD) and Other Disruptive Behaviors Among Girls

Regarding the comorbid CD rate, again, although boys lead girls overall, the girls’ rate should not be overlooked. According to Latimer et al. (), the comorbid CD rate among girls was .% versus .% for boys. Their study further showed that the comorbid oppositional defiant disorder (ODD) rate was .% among girls and .% for boys. When the authors collapsed all the “disruptive behavior disorders” (ADHD, CD, and ODD), they found soaring comorbidity rates displayed by both girls (.%) and boys (.%). Shrier et al. () indicated that girls with substance use disorder or substance use problems are more likely to exhibit CD than their counterparts without substance use problems (the rates were .%, .%, and .%, respectively). The rates for the three groups among boys were .%, .%, and .%, respectively. The literature has established the association among substance abuse, ADHD, and CD. Recent studies have further challenged the myth that ADHD and / or CD applies mainly to boys. Some researchers have said that the risk is high for both boys and girls who have substance use or abuse problems to have comorbid disruptive behaviors such as ADHD or CD. Shrier et al. () stated that substance-abusing girls “engaged in externalizing behaviors as extensively as their male counterparts but were distinguished by higher levels of internalizing symptoms” (e). Etiologies of CD and Other Disruptive Behaviors

Foster’s review () of empirical studies found the family to be one of the factors related to the genesis of CD in adolescent girls. Family affects CD development in two ways: () parental criminality, depression, and / or other psychiatric disorders or history of AOD use and / or criminality in a girl’s immediate family may be positively related to CD occurrence among girls (Fergusson and Horwood ; Moffitt et al. ; and Webster-Stratton , all cited in Foster ), and () genetic factors may also have an impact; researchers have found that the concordant CD rate is higher among monozygotic twins than dizygotic twins, even after controlling for the important environmental variables (Cronk et al.  and Jacobson, Prescott, and Kendler , both cited in Foster ). Foster’s review () further revealed that social factors may play an important role in CD occurrence among girls in two ways: () poor social background and () association with deviant (male) peers. Researchers found that a disproportionately high percentage of girls who are at risk for CD come from a disadvantaged environment. Compared to nonaggressive girls, girls at risk for CD were more likely to be born to a mother who was young, single, poor, and with limited education (Moffitt et al. ; Woodward and Fergusson ; both cited in Foster

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). Research has also shown a strong link between an adolescent’s development of delinquent behaviors and his / her association with deviant peers (Giordino  and Caspi et al. , both cited in Foster ). Girls’ association with boys particularly increases their risk for delinquent behaviors. Studies have shown that girls engaging in delinquent behaviors associate with more opposite-sex friends than girls who do not engage in delinquent behaviors (Claes and Simard  and Giordino , both cited in Foster). Foster’s review () also showed that hormonal factors could play a role in increasing the propensity for aggressive behaviors, but the study results are inconsistent. Another possible factor may be a girl’s exposure to sexual and / or other abuse, in that the abuse may cause the girl to run away, and in turn force her to engage in illegal activities to survive street life (Cauce et al.  and Hoyt and Scherer , both cited in Foster ).

Eating Disorders Anorexia Nervosa and Bulimia Nervosa

Eating disorders or disturbances often co-occur with depression and substance abuse among adolescents, particularly female adolescents. For example, Shrier et al. () showed that significantly more girls with substance use disorders reported eating disorders than did non-using girls (.% versus .%, p < .). No such analysis was performed for boys in their study because of the small percentages. Eating disorders are defined as “severe disturbances in eating behavior”; there are two categories: anorexia nervosa (AN) and bulimia nervosa (BN) (DSM-IV :). AN is characterized by “a refusal to maintain a minimally normal body weight” (), and BN is characterized by “binge eating and inappropriate compensatory methods to prevent weight gain” (). (AN behavior may also involve binge eating and purging.) The similar feature of both diagnoses is a troubled perception of body weight and body shape. The major difference between the two diagnoses is that individuals with an AN diagnosis are unable to maintain at least a minimally normal body weight based on age and height (body weight at least % of the expected normal weight), while individuals with a BN diagnosis are able to maintain this standard (DSM-IV ). The prevalence of BN is higher than the prevalence of AN. The DSM-IV statistics () showed that about .%–.% of adolescent girls and young women meet the full criteria for AN versus about %–% who meet the full criteria for BN. DSM-IV stated that the eating disorder rate has been increasing. Citing the literature, Stock et al. () indicated that the eating disorder rate among adolescents was .% for AN and % for BN. The prevalence rates are much higher for adolescent girls and young women who meet the subthreshold or subclinical criteria for eating disorders. Also, some research showed that girls or women with a BN diagnosis (binge eating with compensatory behavior) are more likely than

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their counterparts with an AN diagnosis (particularly the restrictive type) to engage in substance abuse (Stock et al. ). Higher Prevalence of Eating Disorders Among Girls

Girls have a higher eating disorder rate than boys. The rate for AN among men is unknown, but the rate of BN for men is only about  /  of the women’s. Field et al. () (N = , adolescents aged –) found that more girls than boys (.% versus .%) started bulimic behavior during a one-year period in a prospective study. The  YRBS data (CDC ) reported that .% of high school girls versus .% of high school boys “went without eating for ≥  hours to lose weight or to keep from gaining weight,” .% of the girls versus .% of the boys “took diet pills, powders, or liquids to lose weight or to keep from gaining weight,” and .% of the girls versus .% of the boys “vomited or took laxatives to lose weight or to keep from gaining weight” (). Prospective Sequence Among Eating Disorders (Bulimia Nervosa), Depression, and Substance Abuse

Although studies have been consistent regarding the comorbidity among depression, substance abuse, and eating disorders (bulimia nervosa), they have been inconsistent regarding the prospective sequence or causal relationships among the three pathologies (Stice, Burton, and Shaw ). Also, the comorbidity between eating disorders and substance abuse is more pertinent to BN than to AN. Stock et al.’s review () showed that BN tends to co-occur with substance abuse, but individuals with AN rarely abuse AOD. Stice, Burton, and Shaw () showed a bilateral relationship between BN and depression. The results suggested that depression may lead to girls’ bulimic pathology. Binge eating provides comfort and distraction to the girls, thus soothing their negative emotions. On the other hand, the study indicated that BN contributes to girls’ depression. The girls’ binge-eating and purging behaviors often provoke feelings of dysphoria, shame, and guilt, which may eventually lead to depression. Various theories explain the co-occurrence of eating disorders and substance abuse. Girls may use AOD to self-medicate the depression resulting from or associated with their eating disturbances or disorders, or they may use AOD to further enhance their unhealthy dieting behavior to control their body image (CASA ). Stice, Burton, and Shaw (), on the other hand, suggested that BN does not increase the risk of substance abuse, nor does substance abuse increase the risk of BN; the reason they coexist is because they have shared risk factors. Etiologies of Eating Disorders (ED)

Research on ED is not as sophisticated as research on many other psychiatric disorders such as depression. No complete multi-path models—other than single individual variables—have been tested in explaining the risk and protective factors

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for ED (Striegel-Moore and Cachelin ). Striegel-Moore and Cachelin consider that ED involves the interplay of multiple risk factors, including biological, personal, familial, and social factors. They propose two paths to explain the etiologies of ED. The “restraint pathway” suggests that an adolescent internalizes society’s definition of an ideal body size and shape and pursues such a standard by restricting her diet. In response to her restricted food intake, the adolescent may further develop various disordered eating behaviors, including binge eating. Researchers have suggested that an adolescent girl’s dissatisfaction with and concern for her weight could lead to various dysfunctional behaviors, including disordered eating, substance abuse, and smoking, all of which may be manifestations of the girl’s attempts to control her weight (CASA ; Field et al. ). Field et al. found that “smoking,” “getting drunk,” and “engaging in bulimic behaviors” can predict one another in a prospective way. CASA’s study showed that tobacco and other AOD may be used by adolescent girls with disordered eating problems to selfmedicate their aversive emotions or to help them lose weight. The second path, proposed by Striegel-Moore and Cachelin (), is the “interpersonal vulnerability pathway,” which suggests that disordered eating behavior could be the result of inadequate or dysfunctional interpersonal relationships. A child who experiences hostile or neglectful early interpersonal relationships may adapt by becoming sensitive and distrustful of interacting with others and develop a negative self-image of helplessness and of being “unworthy of care.” She may later resort to various strategies to meet her relational needs. Since the socialization process and gender-role expectations discourage a girl from “acting out” or externalizing her distress in an aggressive way, she may find that eating or various dieting behaviors soothe or distract her negative emotions and provide a sense of control (Striegel-Moore and Cachelin ).

Suicide Suicide is the third leading cause of death among adolescents, preceded by automobile crashes and homicides. Depression and substance abuse have a close relationship with suicide or suicide attempts among adolescents. There was a threefold increase in suicide among U.S. adolescents between the s and the s, which was ascribed to the increased substance abuse rate among adolescents during this time (Institute of Medicine, cited in Erinoff, Compton, and Volkow ). Adolescents in general, and adolescent girls in particular, are vulnerable to suicide. According to the  YRBS (CDC ), girls had a higher prevalence rate than boys in the following areas: (a) overall feelings of sadness and hopelessness “almost every day for ≥  weeks in a row so that they stopped doing some usual activities” (.% versus .%); (b) having “seriously considered attempting suicide” during the preceding twelve months (.% versus .%) (); (c) having “actually attempted suicide” during the preceding twelve months (.% versus

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.%); and (d) having made “suicide attempt treated by a doctor or nurse” (.% versus .%) (). The Factors of Ethnicity and Age

The factors of ethnicity and age in relation to suicide are also worth attention. Generally speaking, Hispanic girls and white girls are at a higher risk than African American girls, with the rates of having “seriously considered attempting suicide” being .%, .%, and .%, respectively. As for the indicator of having “attempted suicide,” the rate for Hispanic girls was .%, followed by African American girls (.%) and white girls (.%). For the indicator of having made a “suicide attempt treated by a doctor or nurse,” again, the  YRBS (CDC ) indicated that the rate for Latina girls (.%) exceeded the rates for white girls (.%) and African American girls (.%). Overall, younger adolescent girls appeared to be at a higher risk for suicide than older adolescent girls (CDC ). For the indicator of having “seriously considered attempting suicide,” the rates were .% for the ninth graders and .% for the tenth graders, but .% for the eleventh graders and .% for the twelfth graders. For the indicator of having “attempted suicide,” the rate for the ninth-grade girls was .%, followed by .% for the tenth-grade girls, .% for the eleventh-grade girls, and .% for the twelfth-grade girls. Risk Factors for Suicide

Although suicide is closely related to substance use disorders, studies on suicidal alcoholics and / or treatment of this population are rare, possibly because of the vast clinical labors required to help suicidal patients and the ethical concerns involved in the research designs (Cornelius et al. ). We know very little about predictors of imminent suicide (Cornelius et al. ). We do have empirical data indicating the risk factors for suicide (attempts) among substance-abusing clients. The reviews of Erinoff, Compton, and Volkow () and Cornelius et al. () point out the following risk factors: () a family history of suicide or a paternal alcohol abuse history; () severe lifetime comorbidity or “trimorbidity” with depression plus various AOD use disorders (e.g., major depression, cocaine abuse, and alcoholism); () a history of abuse or neglect during childhood; () a higher degree of introversion and neuroticism; () early onset of AOD use (e.g., clients who started AOD use during their adolescent years are four times as likely to attempt suicide than those who started AOD use later in life); and () improper and inadequate use of antidepressant medication. Why AOD Use Disorders Associate with Suicide

There are two current theories to explain how and why substance use and abuse are associated with suicide. First, excessive alcohol or drugs or acute AOD intoxication may serve as a “proximal risk factor” precipitating a substance abuser’s

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suicidal crisis and propelling him / her from the idea of suicide to an actual suicide attempt or a completed suicide (Esposito-Smythers and Spirito ). Hufford’s () and Esposito-Smythers and Spirito’s literature reviews (:) showed that concurrent AOD use and abuse while a person contemplates suicide may enhance “suicide-specific alcohol expectancies (e.g., ‘alcohol will give me the courage to make a suicide attempt’),” restrict the ability to generate and utilize adaptive coping strategies, and / or intensify aggressiveness toward self and / or others. Erinoff, Compton, and Volkow () also suggested that AOD use and abuse may increase suicidal risk through its escalation of impulsivity in a person with suicidal thoughts. The second theory posits that AOD use disorders serve as a “distal risks factor” for suicide. Esposito-Smythers and Spirito’s () and Hufford’s () literature reviews showed that substance use disorders heighten an adolescent’s comorbidities (e.g., depression) and increase stress in many of his or her life areas (e.g., academic performance, interpersonal conflicts, legal problems), all of which may contribute to suicidal behavior.

Intervention and Treatment Guidelines and Strategies This section includes three levels of guidelines for practitioners who work with adolescent girls. Some of the guidelines are equally relevant to both boys and girls; others are more relevant to girls; and some are specifically for girls.

Effectively Identifying and Recruiting Female Adolescents for Treatment / Prevention Programs One of the first steps to help substance-abusing girls is to effectively identify and recruit them for treatment. Girls are less likely than boys to be identified and, therefore, less likely to be recruited for treatment because of the general public’s gender bias. Girls are perceived as less antisocial and less likely to commit crimes, and therefore they are less likely to engage in substance abuse than boys. Also, girls tend to manifest “internalizing” disorders, which are more covert in nature and call less attention to themselves, while boys manifest “externalizing” disorders, which often are more overt in nature and may easily catch people’s attention. The implications are that although girls today are equal to boys with respect to substance abuse prevalence and the rate of antisocial behaviors among girls is rising, girls who are at risk are less likely to be identified and given opportunities to be treated than their male counterparts. Empirical examples demonstrating such a bias in the general public, as well as among professionals, are numerous. According to CASA’s () analysis, more girls than boys who purchased cigarettes at a store or gas station in the preceding month were not being asked for identification (.% versus %). Of course,

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while this could be the result of society’s bias, it could also be attributable to the fact that adolescent girls usually appear to be more mature physically than boys. CASA () in another survey showed that when presented with a fictional teenage female patient who has symptoms of drug abuse—such as runny nose, red eyes, chronic fatigue, loss of appetite, loss of interest in school, worse relationship with parents, etc.—pediatricians (who were given five options of diagnosis to check) were more likely to render a diagnosis of depression (.%) than one of illegal drug use (.%). However, when a fictional teenage male patient with the same symptoms was presented to the pediatricians, they were more likely to choose illegal drug use (.%) than depression (.%) as the diagnosis. Guthrie and Flinchbaugh () stated that many AOD treatment and prevention programs acknowledged that they were not as effective in recruiting girls as in recruiting boys. The interventionists of the programs believed that the difference may have a lot to do with the fact that “program recruitment methods were oriented more toward boys at high risk, as compared with girls who were at high risk, because they focused more on the types of visible negative behaviors in which boys tend to engage” ().

AOD Screening Tools for Adolescents No gender-specific AOD screening tools for adolescents have been developed so far (CASA ). Although AOD screening tools for adolescents in general have been developed, many of them have been criticized for being too lengthy and not feasible for use in certain settings, such as a pediatrician’s or physician’s office. Some well-established AOD screening tools, although short (CAGE, for example), have been considered inappropriate for application to adolescents because of the lack of developmental relevance. CRAFFT

Knight et al. () developed “CRAFFT,” based on the tool “RAFFT.” RAFFT, developed by the Brown University Project ADEPT, has been considered the most equivalent tool to CAGE for adolescents. According to Knight et al., the CRAFFT model possesses “a sensitivity of .% ( / ) and specificity of .% ( / ) for long-term treatment need” (). It also has reliability and strong evidence for criterion validity and can be used for AOD screening for adolescents by pediatricians and other primary-care providers (Knight et al. ). See appendix A for the CRAFFT scale. Adolescent Health Review

Harrison, Beebe, and Park () developed a computerized multidimensional screening tool called Adolescent Health Review, which can be completed in a very short time (about three minutes). It contains twenty-seven items such as “take

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diet pills to lose weight?” “had thoughts about killing / would like to kill myself,” “adult in your household . . . hit you so hard or so often?” “adult or older person . . . touched you sexually?” “have you had alcoholic beverage?” “have you used marijuana?” “missed work or school because of . . . use?” “hit anyone or become violent while using?” Gender-specific (girls versus boys) and age-specific (early versus middle versus late adolescence) normative data are also available to help the physicians or other health care providers discuss with the adolescent his or her specific results within a context. The tool provides automatic scorings and generates a one-page summary for outcomes. The summary page includes fourteen areas. The first six areas are “lack of exercise,” “poor nutrition,” “unhealthy weight control,” “family interaction problems,” “problems at school,” and “emotional distress.” Each area has two options for “reported risk level”: “none” or “moderate.” The other eight areas are “suicidal behavior,” “violent behavior,” “sexual activity,” “cigarette smoking,” “alcohol use,” “marijuana use,” “substance abuse / dependence,” and “physical or sexual abuse.” Each area has three choices for “reported risk level”: “none,” “moderate,” or “high.” Other Screeners

Finally, SAMHSA’s TIP  () included information on the nature and availability of seven AOD screening instruments for adolescents. 1. Adolescent Drinking Index (ADI):  items, with a completion

2. 3. 4.

5.

6.

7.

time of five minutes; available from Psychological Assessment Resources, Inc. Adolescent Drug Involvement Scale (ADIS):  items, with a completion time of four to five minutes; available in the public domain Drug and Alcohol Problem (DAP) Quick Screen: available in Clinical Pediatrics  (): – Drug Use Screening Inventory-Revised (DUSI-R):  items, with a completion time of twenty to forty minutes; available from the Gordian Group, telephone -- Personal Experience Screening Questionnaire (PESQ):  items, with a completion time of ten minutes; copyrighted and can be ordered from Western Psychological Services, telephone -- Problem Oriented Screening Instrument for Teenagers (POSIT):  “yes / no” items, with a completion time of twenty to thirty minutes; available from Dr. Elizabeth Rahdert, National Institute on Drug Abuse, telephone -- Rutgers Alcohol Problem Index (RAPI):  items, with a completion time of ten minutes or less; available from Dr. Helene Raskin White, telephone --

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Early Identification and Provision for Prevention and Treatment As mentioned previously, early identification and intervention of AOD problems among adolescents are critical in efforts to prevent the health risk behaviors associated with AOD abuse during adolescence, as well as the later development of AOD dependence in adulthood. Hallfors and van Dorn () suggested two major points of entry where adolescent substance abuse can be identified and early intervention can take place. One is the primary health care system and the other is the school system. Since both institutions serve adolescents regularly, they offer good opportunities for AOD screening, assessment, treatment, or referral. The prevention and treatment service emphasized here is not the “universal” prevention service, such as media or a commercial campaign targeting the general public or the AOD prevention contents integrated into the regular curriculum targeting all adolescents. Rather, the focus is the “selective” and / or “indicated” prevention services that identify, treat, or refer highrisk adolescents (Hallfors and van Dorn ). The SAMHSA TEDS data have suggested that although the criminal justice system is a major referral source for adolescent substance abuse treatment admissions, the schools have historically been a referral source particularly for adolescent girls and adolescents who have no previous treatment episodes (Terry-McElrath et al. ). Unfortunately, the TEDS data showed a significant decrease in school referrals—from accounting for % of the total admissions in  to % in ; this decline may mean that fewer adolescent girls are getting the treatment they need (Terry-McElrath et al. ). Hallfors and van Dorn’s () literature review revealed three detectable characteristics that are closely related to youth substance abuse problems: mental health and behavior problems, poor academic performance, and truancy. Hallfors et al.’s school survey (cited in Hallfors and van Dorn ) indicated that “students who reported being truant or getting grades of mostly C’s or lower were as much as  times more likely to report marijuana use and were also much more likely to use tobacco and other drugs. . . . Truancy, in particular, is a strong predictor of substance use” (). Hallfors and van Dorn offered professionals in the two systems the following steps to identify the highest-risk adolescents: (a) systematically ask children about their AOD use behavior, as well as risk factors related to AOD use; (b) assess parenting skills when families attend for pediatric care; and (c) frequently analyze relevant data to identify students who have a poor academic achievement and / or repeated truancy. Hallfors and van Dorn also suggested that physicians screen not only older but also young adolescents, since more and more adolescents start using AOD at a young age today. Referrals to AOD specialists and other followup guidance must also be implemented once a positive AOD screening is indicated. A face-to-face interview does not necessarily yield reliable or valid screening

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outcomes; rather, an approach that uses a computer may elicit more AOD-related information about the person.

Starting Primary Prevention Efforts During Early Adolescence Experts have suggested providing AOD prevention education and services during early, instead of middle or late, adolescence, particularly for girls (Sarigiani, Ryan, and Petersen ). Their reasoning is based on three factors: () Children today are beginning to experiment with AOD or other risky behaviors during their early adolescent years. Sarigiani, Ryan, and Petersen () reported that some fifth through eighth graders are already engaging in substance abuse. If prevention education is delayed until the later stages of adolescence, critical opportunities to intervene before those risky behaviors become worse and habitual or cause harm will be missed. () The early onset of puberty for some girls also highlights the need for early prevention education. Prevention education offered in the eighth grade “may be too late for the adolescent women who went through puberty at age  years” (Sarigiani, Ryan, and Petersen :). () Early prevention education and services may benefit victims of childhood sexual abuse, who are often at a higher risk for AOD problems. The average age of onset of substance abuse for victims of childhood abuse (physical or sexual) is about twelve years of age. Early AOD prevention education and services can identify and benefit those victims whose situation has not already been identified (Brems and Namyniuk ).

Developing Female-Adolescent-Specific AOD Treatment / Prevention Programs Keeping in Mind That Adolescents Are Not “Little Adults” This principle applies to all adolescents, girls or boys. The key is to integrate adolescents’ developmental needs and characteristics when working with adolescents. CSAT (b) (TIP ) suggested that adolescent clients should not be treated as “little adults.” SAMHSA and other authors (e.g., Guthrie and Flinchbaugh ; Morehouse ) recommended the following strategies: 1. Adolescents may be fearful of residential treatment. When residential treatment is indicated, practitioners should explain to the adolescent what the residential program is about and what can be expected, as well as his or her legal rights to terminate the treatment once admitted to the program. Relaying such information to the adolescent can reduce the fear of entering residential treatment. 2. The initial stage of treatment (i.e., the orientation stage) could be critical in engaging an adolescent. She or he may feel apprehension when entering a treatment program. All the new activities and requirements may intensify that apprehension.

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3. Treatment should be conducted in a manner that is “personal,” “respectful,” and “hopeful,” and practitioners should have an optimistic attitude. 4. Practitioners should be sensitive yet firm when counseling adolescent clients, “exercising authority without seeming authoritarian.” 5. The program should have explicit standards for behavior and administer those standards impartially. 6. Practitioners may help adolescents to fulfill their responsibilities in a way that the practitioners normally wouldn’t do or that is inappropriate to do for adults. One example is that the practitioner calls an adolescent client immediately to remind her about attending when she fails to show up for an outpatient treatment. 7. The program should emphasize interactive dialogues / activities. Empirical research has shown that adolescents in general, and girls in particular (Guthrie and Flinchbaugh ), prefer interactive (e.g., role playing) rather than unidirectional (e.g., one-way knowledge distribution) programs, and interactive AOD prevention programs are more effective than non-interactive AOD prevention programs (Tobler et al. ).

Screening for Childhood Maltreatment and / or Dysfunctional Family Background This step is relevant to working with both substance-abusing adolescent girls and boys but may be more important for girls because of the higher percentage of childhood (sexual) abuse among girls. Substance-abusing adolescent girls also are more likely than their male counterparts to come from a dysfunctional family. It is critical for AOD treatment practitioners to include a valid and reliable screener for childhood (sexual) abuse in the regular assessment of these adolescents. Staff who conduct intake / assessment must equip themselves with appropriate interviewing skills in exploring possible childhood maltreatment. Funk et al. (:) described six dimensions to be included in the screening and assessment: (a) the type of abuse: emotional, physical, and / or sexual; (b) the location of abuse: home, school, and / or neighborhood; (c) severity of abuse; (d) who is / are the perpetrators: family, peer, and / or stranger; (e) the frequency of abuse; and (f ) the time frame in which the abuse occurred. Funk et al. () suggested that although the issue awaits further study, it is most likely beneficial to the adolescent to place her in residential treatment when current severe childhood maltreatment and imminent danger are indicated. Adolescent victims of sexual abuse will also benefit from individual counseling provided by specialists who are skilled at treating sexual abuse cases. Gender-specific groups of sexual abuse victims are more appropriate than mixed-gender groups because the members share commonalities and the environment is supportive and safe, allowing discussion of victimization (Funk et al. ). The treatment program must also help the adolescent who is at risk for continued abuse to develop

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a safety plan that lays out specific steps she should take in case of crisis. When appropriate, the treatment plan should include parents, and strategies should be discussed and education provided to help the parents help their child and to help the family cope with the issue. Ongoing assessment of the condition of the victim and revision of the treatment plan as appropriate must be conducted, examining the appropriateness of the level of care, the need for family therapy, and / or the need for a psychiatric evaluation and treatment referral (Funk et al. ).

Screening for Co-occurring Disorders and Suicide Although substance-abusing adolescent girls often have co-occurring psychiatric disorders (e.g., depression, ADHD, conduct disorder, eating disorder), these comorbid disorders rarely are addressed or addressed in a systematic manner in AOD treatment programs (CASA ; Latimer et al. ). Latimer et al. said that about one in two adolescents relapse within ninety days of treatment because the treatment programs fail to address the adolescents’ comorbid psychiatric disorders. Although girls in general have a higher rate of internalizing disorders and a lower rate of externalizing disorders than boys, substance-abusing girls have a high rate of both internalizing (e.g., depression and / or eating disorder) and externalizing (e.g., ADHD and / or conduct disorder) disorders. Treatment programs must be thorough in screening, assessment, and treatment in both areas. In addition, given the relatively high suicide risk among substance-abusing adolescents in general and substance-abusing adolescent girls in particular, treatment programs should establish protocol concerning the care of clients with suicidal risk, including guidelines for screening, intervention, treatment, and referral. The relationship between substance abuse and these comorbid psychiatric disorders may be bilateral, with each intensified by the other. Particularly when the co-occurring disorder is the primary diagnosis (occurs first), a careful screening must be conducted and appropriate treatment or referral provided in order for girls to achieve long-term AOD recovery. CSAT (b) (TIP ) has recommended that AOD treatment providers work together with mental health providers to help co-occurring disordered AOD clients. If possible, the two treatments should be provided at one location. Staff involved should also be cross-trained. For a detailed discussion, readers can refer to TIP  (CSAT ).

Harm Reduction Empowering a Girl for a Safe Relationship with a Boy

Although it is important to offer girls general education about safe sex and less risky drug-using behaviors (such as avoiding injection drugs), it is critical to instill in the girls self-esteem and assertiveness in dealing with situations when practice

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of safe sex and less risky drug-using behaviors are issues because of the boys in their relationships. As mentioned earlier, Otto-Salaj et al. () indicated that although girls are more likely than boys to engage in risky behavior, girls actually reported a higher level of HIV / AIDS-related knowledge and a higher level of intention to practice safe behavior than boys. Girls may be cognitively and intellectually competent regarding refraining from risk behavior, but that competency may be attenuated or sabotaged in a gender-inequity sexual relationship by their male sexual partners who do not wish to engage in safe behavior. Banister, Jakubec, and Stein’s () review showed that the socialization process and role expectations may disempower girls, hindering or preventing them from having an egalitarian relationship with boys. Girls may perceive that “boys are everything” and think that a relationship with boys will give them status. Girls may also adopt society’s stereotypical definition of an ideal female, considering a woman a “bitch” if she sticks to her own thoughts, feelings, and wishes in a conflicting situation. Both of these attitudes will jeopardize a girl’s ability to practice safe sex and / or safer AOD-using behavior when her boyfriend prefers otherwise. Thus, in addition to the mere provision for HIV / AIDS-related knowledge and facts, gender-specific prevention programs need to emphasize and enhance girls’ self-assertiveness and self-esteem with respect to their lives in general and their relationships with boys in particular. Enhancing Self-esteem

Self-esteem also plays an important role in delaying AOD use and other risky behaviors among early adolescent girls. Khoury’s longitudinal research (cited in Guthrie and Flinchbaugh ) investigated change of gender role, depression, and self-esteem among girls and boys as they develop from early to middle adolescence. Khoury found that across four ethnic groups, girls who had higher selfesteem delayed AOD use significantly longer than their counterparts who had lower self-esteem. Enhancing girls’ self-esteem promotes the protective factors that help delay risky behaviors among girls. Conveying the Message of “Lifelong Consequences”

It is also important to relay the information to girls that the negative consequences of AOD use / abuse, sex without a condom, and other risky behaviors could be farreaching and long-lasting. Sarigiani, Ryan, and Petersen () pointed out that evidence has suggested that risky behaviors may have a lifelong impact on adolescent girls in the areas of reproductive health, other physical health, emotional well-being, and educational and / or vocational development. Sarigiani, Ryan, and Petersen stated: “The young adolescent girl needs to be informed that the behaviors she engages in today may have reverberations that will follow her through the rest of her life” (:).

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Individual Counseling and Its Combination with Group Counseling Motivational Interviewing (MI) / Motivational Enhancement Therapy (MET)

Very few AOD-using adolescents voluntarily seek treatment. Most are referred by their parents, teachers, the criminal justice system, or other authorities. Adolescents’ low motivation in getting treatment may be related to their relatively shorter period of AOD-using history than adults, which generally has not allowed them yet to experience the severe negative consequences of AOD use / abuse. How to increase the adolescents’ motivation for treatment has caught practitioners’ attention. Experts have suggested the application of the MI / MET as part of the treatment packet for substance-abusing adolescents, and empirical studies have begun to show some positive outcomes or limited promise (McCambridge and Strang ; Monti et al. ). However, no literature found so far has discussed gender-specific issues in relation to MI / MET application to adolescents. What follows is a summary of MI / MET for substance-abusing adolescents. One key point of MI / MET is to help adolescents recognize that the “changing” (i.e., changing their AOD use behavior) is for their own self-interest and benefit, not that of their parents, teachers, judges, or others. Therefore, it is important for the practitioner to reiterate to the adolescent that the counseling is intended to help achieve what the adolescent wants to achieve (Morehouse ). This concept promotes the growth of intrinsic motivation and also reduces the power struggle between the adolescents and the other parties, which typically can occur as they strive to become more autonomous and independent (Lambie ). Next, as mentioned in chapter , MI / MET considers that an individual may go through five stages to reach behavior change: precontemplation; contemplation; determination / preparation; action; and maintenance (Prochaska, DiClemente, and Norcross ). It is important for the practitioner who adopts a client-centered approach and builds rapport with the adolescent to assess which of the five stages the adolescent is in. The goal is to facilitate the client’s movement from the early stages (precontemplation, contemplation) to the later stages (preparation, action, and maintenance) To help facilitate change in clients, Miller and Rollnick () suggested the following techniques: () be client-centered and empathetic; () emphasize the discrepancies between what the client wants to be and what she or he currently is (e.g., failing grades and poor appearance because of AOD use); () avoid argumentation with the client; () ”roll with resistance” by using empathy instead of confrontation; and () boost the client’s self-efficacy by showing confidence in the client’s ability to cut or stop AOD use (see chapter  for a more detailed discussion). The five techniques can be adapted to be more adolescent-friendly by being sensitive to age-appropriate goals and issues. More relevant issues for adolescents may be parents (rather than spouse), school (rather than work), and peer pressure (rather than ambition). Adolescents may also be more receptive

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to the current or short-term concrete negative costs and consequences of AOD use than to something abstract or related to their quality of life in the long run (Diamond et al. ). Combining MI / MET and Cognitive-Behavioral Therapy (CBT)

Experts have also suggested combining the individual format of MI / MET with the group format of CBT to help substance-abusing adolescents. Two approaches, similar in format and content but different in dose, were proposed by the Cannabis Youth Study, funded by the Center for Substance Abuse Treatment: () MET / CBT , and () MET / CBT  (Diamond et al. ). MET / CBT  includes two individual MET sessions plus three group CBT sessions, while MET / CBT  covers two individual MET sessions plus ten group CBT sessions. These two approaches are still undergoing evaluation regarding their effectiveness. CBT is normally offered in an individual session but was modified to group format in the above-mentioned two approaches. Diamond et al. () explained the rationale to adjust CBT from individual to group format in working with adolescents. First, most adolescent substance abuse treatment programs offer primarily group-oriented treatment, and the group-format CBT may thus be more appealing to the programs. Second, a group-oriented approach may be more powerful in influencing adolescents to reach treatment goals because of their strong identification with peers during this developmental stage. To more effectively apply MET and CBT to adolescents, experts made the following changes: () the handouts (both the wording and the appearance), case vignettes, and exercises were modified to be more “adolescent friendly”; () more visual materials were added to increase the adolescents’ attention for CBT sessions; and () rewards were offered to adolescents who completed the exercise (Diamond et al. ).

Group Counseling Value of Group Counseling

Professional group counseling and / or the group-format intervention (e.g., the -step self-help groups) have played an important role in helping adult substanceabusing clients. Groups help the participants feel less guilty and less alone (“I’m not the only one who has the AOD problem”); help them exchange information regarding problem solving and other resources; provide honest feedback about negative and positive behaviors and other daily life issues; provide role models for, and therefore instill hope in, the participants (“if she can do it, so can I”); and offer opportunities to experience more-functional social and interpersonal interaction. Although group counseling appears to benefit substance-abusing clients in general, many adult female clients prefer (supportive) individual counseling, at least in the initial stage of treatment (Nelson-Zlupko, Dore, Kauffman, and Kaltenbach

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; Sterk et al., cited in National Institute on Drug Abuse ). This preference may be related to women’s low self-esteem, high level of emotional stress, depression, history of childhood sexual and / or other abuse. Society’s double standard (judging women’s AOD-using behaviors harsher than men’s) may further intensify women’s feelings of shame and guilt. A supportive and confidential individual counseling approach may more effectively handle women’s feelings of shame, guilt, and inadequacy than a group counseling setting. No systematic studies were found regarding whether female adolescents prefer individual counseling rather than group counseling. But one study (Grella and Joshi ) did show that physically and / or sexually abused girls were significantly less likely to participate in the -step self-help groups than abused boys, non-abused girls, and non-abused boys (the rates were .%, .%, .%, and .%, respectively). In addition, the abused girls had a higher level of rapport with their counselors than did the non-abused girls. Grella and Joshi thus suggested that abused girls may be more receptive to treatment with an individual counselor than to treatment geared to group process. Application of group counseling to adolescents (boys and girls not differentiated) has been highly valued because of adolescents’ peer-oriented developmental needs and characteristics. Similar to the group values to adults, group settings have been considered beneficial to help reduce adolescents’ feelings of isolation, offer honest feedback to their denial or other irrational thoughts and behaviors, provide them with alternatives to AOD use and coping strategies, and help them develop more functional and nonexploitative social relationships with peers. Counselors can arrange role playing or other exercises to help adolescents practice or rehearse AOD refusal skills in groups. Counselors can also provide AOD psychoeducation efficiently in groups. A group approach also offers the following benefits: () adolescents may perceive participation in a group as less stigmatizing or “illness”-like than one-on-one counseling, and () an adolescent who distrusts adults may also feel safer or more comfortable working with a counselor in the context of a group than in a one-on-one session (Morehouse ). Despite all the advantages recognized in the group treatment, recent research findings cautioned possible iatrogenic effects when group treatment is applied to adolescents. Iatrogenic Effects of Attending Groups Among Adolescents

In addition to the findings that (adolescent) females, particularly those with a childhood physical / sexual abuse history, may prefer individual counseling to group counseling, recent literature has cautioned that there may be other possible iatrogenic effects in the application of group counseling to adolescents (boys and girls not differentiated). Arnold and Hughes (:) stated: Homogeneous group treatment of delinquent or at-risk youth opens up the possibilities for reinforcement of deviant values, affiliation with peers who

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model antisocial behavior and values, increased opportunities for criminal activity, stronger identification with a delinquent subculture, as well as enhanced self-efficacy for, increased acceptance of, and skewed beliefs about the prevalence of delinquent behaviors. Group treatment may inadvertently do harm to the adolescents who have lesssevere behavioral problems when they are mixed with adolescents who have moresevere behavioral problems. The low-risk adolescents may be subtly influenced by the high-risk adolescents and change to become more deviant during or after the peer-based treatment or process. This may happen particularly if the group consists of a majority of high-risk adolescents (Latimer et al. ). Buehler, Patterson, and Furniss (cited in Dishion, McCord, and Poulin ) found that the peer-to-adult staff reinforcement rate ratio was nine to one in institutional settings, suggesting that the reinforcement magnitude from peers is so powerful that it may weaken adult guidance. Another example was the Cambridge-Somerville Youth Study (cited in Dishion, McCord, and Poulin ), which suggested an association between repeated exposure to summer camps during early adolescence and pervasive, long-term, negative effects on adolescents’ later development of problem behavior. The Guidelines

Not all group-oriented treatment will produce iatrogenic effects in adolescents. Why and how such negative effects occur still await further research. It is also uncertain whether such negative effects are equally applicable to girls’ and boys’ groups. Researchers and practitioners, however, emphasize caution and an open mind as to the possibility of unintended harm to adolescents when using group therapy with adolescents (Arnold and Hughes ; Dishion, McCord, and Poulin ). They also suggest the following guidelines: () do not simply rely on a group approach with adolescents; combining individual counseling and family treatment with group counseling is more beneficial for this age group; () mix the pro-social adolescents with the antisocial adolescents in the group in a balanced manner, so that the group dynamics and interaction are not dominated by antisocial themes or talks but are reinforced by pro-social themes and talks; and () handle the issues of “the forced nature of youth attendance,” “the composition of the group,” “the content or process within the group,” “the process of engagement,” or a combination of all these factors carefully because all of these considerations may affect the group’s and peers’ functioning. Positive peer influence can definitely benefit an adolescent’s recovery from AOD using (Dishion, McCord, and Poulin ; O’Leary et al. :).

Involving Family in the Treatment Family is the most critical factor in influencing children’s or adolescents’ development and forming their behavior. Thus practitioners must involve the family in

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treatment, if possible, when helping their adolescent clients. Particularly for adolescent girls, family involvement in treatment is significant because of girls’ strong identity with and close affiliation with their family. Unfortunately, there has been a myth that adolescents are more likely to be influenced by the media and peers than parents, resulting in many parents’ relinquishing parenting (Kumpfer and Alvarado ). Recent empirical (longitudinal) data (cited in Kumpfer and Alvarado) have shown, however, that family exerts a greater impact on adolescents’ health behavior than previously thought and that the most important factor contributing to adolescents’ not using AOD is their concern about parents’ disapproval of AOD use. Today, more and more practitioners begin to realize the importance of involving family in treating substance-abusing adolescents, and family therapy has become the most positively evaluated outpatient treatment method for adolescents diagnosed with AOD use disorders (Diamond et al. ). So far, the literature has not differentiated girls from boys in researching the impact of family-based treatment on substance-abusing adolescents. However, evidence-based family treatments for substance-abusing adolescents, in general, have been developed over the past decade. Three such treatments are () multisystemic therapy (MST), () multidimensional family therapy (MDFT), and () multifamily therapy group (MFTG). Multisystemic Therapy (MST)

By collaborating with the family / caregiver, MST targets five systems, as well as the interface of the five systems, in addressing an adolescent’s substance abuse or other deviant behavior: the individual, the family, peers, school, and the social network (Henggeler et al. , ). Because of the intensive nature of the work involved, MST usually requires a clinician equipped with at least a master’s degree and supervised by a child / adolescent psychiatrist. MST also allows only a small caseload of four to six families at a time per clinician. The treatment usually requires an average total of  hours over about  days, with the clinician being available  hours a day and days a week. To help the substance-abusing adolescents, the MST clinician integrates various strategies (such as strategic family therapy, structural family therapy, behavioral parent training, cognitive-behavioral therapy, psychopharmacological treatment) to increase the capacities of the caregiver (family) in implementing the following tasks (Henggeler et al. , ): 1. monitoring the adolescent’s overall behavior, giving positive reinforcement

(e.g., praise and privilege) to his / her desired behavior and sanctions to his / her negative or irresponsible behavior; 2. encouraging the adolescent’s participation in pro-social peer groups or activities and discouraging and sanctioning his / her affiliation with antisocial peer groups;

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3. monitoring and upgrading the adolescent’s school or academic performance /

vocational functioning, using various strategies such as communicating and collaborating with school teachers and other personnel, as well as taking advantage of after-school hours to promote academic progress. Multidimensional Family Therapy (MDFT)

MDFT focuses on three domains in addressing adolescents’ AOD problems: the adolescent, the parents (and other family members), and the interaction between the adolescent and the parents. MDFT has individual sessions with the adolescents, individual sessions with the parents (and other family members), and joint family sessions with the adolescent and the parents together. According to Liddle et al. (), the MDFT can include sixteen weekly sessions, spreading over four or five months. Each treatment episode can begin with the individual session with the adolescent and the individual session with the parents, followed by the joint family session. The individual sessions with the adolescent focus on helping him / her build overall competency, equipping him / her with cognitive understanding of the detrimental aspect of drugs, strengthening coping skills and problem-solving capacities in regulating negative emotions, increasing association with pro-social peers and decreasing connection to antisocial peers. The goals for the individual sessions for parents (and other family members) include decreasing parent(s)’ own AOD-using behavior and psychiatric distress, lessening their economic stress, enhancing the social support available to them, and improving their parenting practices. Finally, the family sessions (the adolescent and the parents joined together in the session) aim at promoting and rekindling the parental commitment to the adolescent, the adolescent’s attachment to the parents, the connection between the parents and the adolescent, and ultimately, a functional and healthy family organization that facilitates a context appropriate for the adolescent’s development and growth (Diamond et al. ; Liddle et al. ). The Multifamily Therapy Group (MFTG)

The essential feature of MFTG is to have three or four families meet regularly to “facilitate a supportive interfamily group process. Families were encouraged to help each other and to use themselves as examples for mutual problem solving” (Liddle et al. :). There are various multifamily group treatments. Springer and Orsbon () proposed one approach that includes three major components: solution-focused therapy, structural family therapy, and interpersonal and mutual aid approaches. Solution-focused and structural family approaches help identify issues and themes for discussion and improvement regarding the interaction between the parents and the adolescents, as well as the adolescents’ substance-abusing and other deviant behaviors. The mutual aid approach helps separate families mutually

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support each other’s efforts to reach a more functional and healthy family system and lifestyle. By exchanging feedback and sharing solutions to problems or other coping skills, the families can help each other with their identified struggles. Springer and Orsbon () gave two examples to demonstrate the solutionfocused therapy component. The “scaling question” asked participants (parents or adolescents) to rate the issue at hand on a scale from  to . Following is a concrete case example from Springer and Orsbon (): Johnny’s primary goal was to get along better with his parents. . . . The group leaders asked Johnny to rate . . . how well he got along with his parents during the preceding week, with  indicating that he did not get along with them at all and  indicating that he got along with them great. Suppose Johnny gave a rating of . The leaders would then ask Johnny what he and his parents could do over the next week to make it from a  to a . The emphasis on the one-point-increments strategy is to encourage clients to implement new and functional coping skills gradually (Springer and Orsbon ). The second method is to help clients set goals by asking the “miracle question.” Springer and Orsbon stated (): The leaders may have asked Johnny, “Pretend that you went home tonight and went to bed, and while you were sleeping a miracle happened so that when you woke up in the morning you and your parents got along great. When you woke up tomorrow, how would you know that this miracle happened? What would be the first thing that you would notice?” The structural family therapy component focuses on the clinician’s building a trust relationship with the family and “joining” in the family to influence the family’s structure and boundaries so that a more functional and healthy family can be achieved. To integrate the mutual aid approach component, each family is allowed to “act out” its problems or communication patterns in front of the multifamily group, and other families are encouraged to give feedback or share perceptions with the family right then and there regarding the specific issue(s) displayed. Springer and Orsbon () reported that the impact of the various other families’ feedback on the family is much greater than that of a single family therapist.

Incorporating the Factor of Ethnicity When working with adolescent girls, practitioners should integrate the ethnicity factor into the prevention curricula and / or treatment programs when appropriate. They should target the type and nature of the various risk and protective factors that a specific ethnic group of adolescent girls is likely to come into contact with. In particular, practitioners should be sensitive to the needs of adolescents of color,

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as they tend to have a lower AOD treatment completion rate, as well as more severe AOD consequences (e.g., involvement with the criminal justice system, HIV / AIDS infection, fetal alcohol syndrome). In addition, many “mainstream” AOD prevention / treatment models for adolescents are designed for white adolescents. Resnicow et al. () suggested that a mainstream AOD intervention model may be adapted to better fit the needs of adolescents of color by focusing on two dimensions: the “surface structure” and the “deep structure.” The Surface Structure Dimension

The surface structure aims to match “intervention materials and messages to observable, ‘superficial’ characteristics of a target population” (Resnicow et al. :) or to “give programs the ‘appearance’ of relevance to a particular culture by packaging them in a manner designed to increase their appeal, familiarity, and accessibility to the populations targeted” (Kreuter et al., cited in Ringwalt and Bliss :). For example, studies have shown that although racial minorities attend group treatment, they may prefer individual treatment more than their white counterparts do. Therefore one relevant strategy is to have individual intervention available when helping individuals of color. In helping African American adolescent girls, practitioners may use African American women / female role models to lead the treatment / prevention program or infuse stories of African American female role models into curriculum / treatment content. In addition, the generic name of an intervention model could be changed to a more Africentric name, such as changing “Strengthening Families” model to “Harambee” (Szapocznik et al. ). To better help Latina adolescents and their families, particularly those who are recent immigrants, practitioners may use a bilingual counselor or social worker (Szapocznik et al. ). In helping Native American adolescents, practitioners may change Anglo names in the materials, such as “Jill” and “Frank,” to names that are more familiar to Native American children, such as “Cheyenne” and “Takota” (Ringwalt and Bliss ). Or, “an image of a string tied around a finger (designed to serve as a reminder)” can be changed to “a picture of an Indian girl with a cloud over her head that contained the word ‘thinking’” (Ringwalt and Bliss :). The Deep Structure Dimension

The deep structure dimension focuses on “incorporating the cultural, social, historical, environmental, and psychologic forces that influence the target health behavior in the proposed target population” (Resnicow et al. :). This dimension also emphasizes an understanding and incorporation into the AOD intervention models the specific stressors experienced by adolescents of color, as well as specific coping strategies preferred (Resnicow et al. , cited in Ringwalt and Bliss ). At least four strategies have been developed under this dimension:

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1. Adapting the generic worldview / value to be more racially and ethnically relevant. For example, Ringwalt and Bliss (:) stated how the “positive values,” such as “fairness, following the rules, and being a good friend,” listed in the original curriculum were changed to the values of “generosity, courage, respect, and honesty” to better fit Native American culture. 2. Emphasizing the role of families and parent-child relationship. The family is important in working with most adolescents due to their developmental stage, but it is especially salient for working with racial minority adolescents. Hispanic, African American, and Asian populations historically emphasize family more than whites do (Szapocznik et al. ). Szapocznik et al.’s review revealed that nine of the twelve most efficacious AOD prevention / treatment models for helping African American and Latino adolescents involved the parents or families of the adolescents. Unfortunately, the girls and boys in the twelve studies were not analyzed separately or compared and, in addition, too few girls were included in the treatment models researched (Szapocznik et al. ). The role of family and parents / mother could be even more significant for minority adolescent girls. Valdez, Mikow, and Cepeda’s study (, N =  Mexican American adolescent girls aged – who had “a boyfriend, a close friend, or a family member in a street gang” []) reported that a lower-quality motherdaughter relationship significantly predicts alcohol / tobacco recurrence among the girls and that a lower-level family coping capability when facing difficult situations, as well as a higher frequency of the acculturation stress events experienced by the family, significantly predicts illicit drug recurrence among the girls. Further studies that not only analyze girls but compare girls with boys in relation to this issue are needed. Several strategies can be employed to engage parents and families to enhance the family function, parenting and positive parental involvement, parent-child communication, and the quality of parent-child affection (Szapocznik et al. ). In addition to the family treatment methods discussed previously, practitioners may emphasize building an alliance early with the family or key people in the family, encouraging the participation of all the family members involved, and helping all family members achieve their goals (Szapocznik et al. ). For African American families, practitioners may help the parents to better deliver “racial socialization,” which not only instills and enhances racial pride in their children but also prepares their children to deal more effectively with racial bias in the society. 3. Exploring the factors of racial identity, acculturation, and acculturative stress and incorporating them into the intervention model when appropriate. Practitioners may help to enhance African American adolescents’ racial identity by conveying certain messages to them—a process known as “racial socialization” (see Szapocznik et al. ). Messages that promote African American heritage, such as an appreciation for religion / spirituality and extended-family attachment, awareness of society’s racism, and strategies to survive racism (Stevenson, cited in

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Szapocznik et al.), can be communicated to the youth via family, group, individual intervention, and / or other social context. For Latino adolescents, their families can continue to maintain their function, serving as a protective factor and passing on their traditional anti-substance use / abuse values to their children. Enhancing the quality of the parent-child and / or mother-daughter relationship can also be a goal. On the other hand, schools may offer adolescents in general, and Latino adolescents in particular, courses in promoting cultural awareness (Torres Stone and Meyler ). Schools and communities may offer formal and informal support to Latino adolescents and families (particularly those in rural areas) to reduce their acculturation-related stress and feelings of isolation (Torres Stone and Meyler ). In delivering AOD intervention programs, practitioners must make efforts to engage Latino adolescents, as studies have reported that adolescents with stronger ethnic mistrust had a worse reaction to the treatment, whereas those with stronger ethnic / Hispanic orientation reacted better to the treatment (Gil, Wagner, and Tubman ). 4. Being sensitive about the heterogeneity within a racial / ethnic group. It is well acknowledged that multiple subpopulations exist within Latino and Asian groups (e.g., subpopulations based on gender, age, nationality, degree of racial identity, and / or acculturation) and that those subpopulations may be subject to different levels of cultural impact, experience different levels and types of AOD problems, and be exposed to different risk and protective factors. Further, some bilingual individuals may not necessarily prefer interventions offered in their mother tongue. Intervention program developers should assess the specific needs of their audience each time they offer the intervention (Resnicow et al. ). Not only do the Latinos and Asians have subgroups within themselves, subgroups that may require or prefer differing services, but a similar issue may also apply to African Americans. Resnicow et al. () noted, for example, that not all African Americans accentuate ethnic identity, and some of them may thus find Afrocentric programs / messages irrelevant or even offensive.

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Adolescent girls are a population that deserves greater attention because of their developmental needs. Although AOD abuse rates for girls are equal to those for boys, girls have received less attention regarding research and treatment because of society’s traditional bias of perceiving substance abuse to be a men’s problem. Girls are less likely to be identified and recruited for AOD prevention and treatment despite their equal AOD rates with boys. Among the various risk factors for girls’ AOD use and abuse, four are highlighted in this chapter: depression, childhood sexual abuse, family issues, and racial identity / acculturation. The onset of puberty and the subsequent hormonal changes may put girls at higher risk for depression, which may be further intensified by gender-role expectations and individual

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genetic predisposition. Depression is closely related to substance abuse in women, according to the self-medicating theory. Childhood abuse and other adverse experiences may bring shame and guilt to girls and cause trauma, affecting their emotional and cognitive development as well as impairing decision-making abilities. Parental AOD use and the quality of parent-child communication and relationship are also critical factors that affect girls’ AOD-using behaviors. A higher degree of racial identity may be a protective factor for African American adolescents’ AOD-using behaviors, and a higher degree of acculturation may be a risk factor for Latina adolescent girls’ AOD-using behaviors. Other psychiatric disorders that co-occur with AOD disorders, such as ADHD, conduct disorder, and eating disorders, also deserve attention. Although research specifically on adolescent girls is scant and more should be conducted in the future, the currently available findings suggest several treatment guidelines and strategies: () early identification of AOD among girls; () avoidance of treating adolescents (girls or boys) as “little adults”; () effective screening of co-occurring psychiatric disorders (depression, ADHD, eating disorders, suicide, etc.) and childhood maltreatment, followed up with appropriate assessment, treatment, and / or referral; () emphasis on harm reduction, thus empowering girls to be self-assertive in practicing safe sex and safe AOD-using practice if it is not possible to achieve total abstinence; () adaptation of MI / MET to be adolescent girl-specific and combination of MI / MET with CBT, as well as evaluation of treatment outcome effectiveness; () combination of individual, group, and family therapy with an emphasis on family therapy when appropriate. Individual therapy may be more appropriate for sexually traumatized girls. Possible iatrogenic effects of group therapy should be monitored and counteracted by adding more prosocial than antisocial themes and subculture; () integration of ethnic factors in understanding the risk and protective factors in AOD prevention and treatment.

Chapter 

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ubstance abuse issues among older adults, particularly women, have traditionally received little attention from the AOD treatment and research community. This lack of attention could be a result of the relatively lower AOD prevalence rate in this population,* American society’s ageism and devaluation of old age, or other factors (Graham et al. ). In the past twenty years, more research has been done regarding this population and more elder-specific treatment has been offered, but such research is still relatively scarce compared to research for younger adults. Although older adults appeared to have a lower AOD prevalence than other age groups, it is a myth that few AOD problems exist among this population. Three reasons explain why: the possibly biased low rate, the aging of baby boomers, and the greater severity of AOD consequences experienced by the older population. First, the seemingly lower rate could have been biased by several factors. The researchers who conducted the surveys, as well as practitioners in the AOD treatment field, may have adopted DSM-IV (American Psychiatric Association [APA] ) substance abuse and dependence disorders criteria in defining AOD use disorder, but some of the DSM-IV criteria are not necessarily “age-appropriate” for evaluating older adults. For example, the criterion for substance abuse diagnosis, “recurrent substance use resulting in a failure to fulfill major role obligations at work,

*According to the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episode Data Set (TEDS) (Office of Applied Studies [OAS] c), adults aged  or over accounted for % of total admissions for substance abuse treatment in  (, of the . million total admissions). OAS (c) indicated that older adults had a lower AOD rate than younger adults. Its  and  data showed that .% of older adults smoked cigarettes, .% drank alcohol, and .% used illicit drugs.

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school, or home” (APA :) is less relevant to older adults because many of them have retired (Blow, Oslin, and Barry ; Menninger ). Another substance-abuse diagnosis criterion, “recurrent substance-related legal problems” () is also less pertinent to older adults. Because of normal aging, older adults have more health problems and symptoms that can obscure some of their alcoholism symptoms (e.g., liver abnormalities, anemia, impaired cognition, falls), resulting in the practitioners’ missing the AOD diagnosis (Blow, Oslin, and Barry ; Center for Substance Abuse Treatment [CSAT] ; Menninger ). Older adults also are less likely than younger adults to perceive and self-report that they are having AOD problems (Nemes et al. ), perhaps because of their lack of AOD knowledge and largely unintentional substance abuse / misuse conduct or possibly because of cognitive impairment. They are also less likely to be referred to treatment professionals by their family and society because older adults’ substance-using behavior tends to be more readily tolerated and thus neglected (CSAT ). Second, the aging of the baby boomer generation (people born between  and ) may increase the total number of the older population in general and the number of substance-abusing older adults in particular. Although the proportion of people aged  and older did not change from  to  (.% and .%, respectively), the total number of people aged  and older increased from . million in  to . million in  (U.S. Census Bureau ). Further, the U.S. Census predicted that the proportion of people  years of age and older will increase from the current % or so to about % by the year . Not only will the sheer numbers of the aging population increase, but there may also be an increase in the rates of alcohol use, nonmedical use of prescription drugs, and illicit drug use because of the very fact that the baby boom generation is known to have embraced a lifestyle that has involved these problems (Bartels et al. ). Therefore, it is expected that more demands and pressures will be added to the current geriatric substance abuse field as the baby boomers age (Bartels et al. ). Third, the negative consequences of substance abuse could affect the older population more seriously than they affect the younger population (CSAT ). AOD may accelerate normal physiological deterioration of older people (CSAT ). Multiple chronic illnesses often encountered by this population may also be exacerbated by AOD use. The older population, particularly females, are often prescribed depressants (e.g., benzodiazepines or barbiturates) or opioid analgesics, which are likely to be harmful if misused / abused or taken in conjunction with alcohol or other drugs. Le Couteur et al.’s () literature review states that “the risk of falling is increased by % in older people taking psychotropic medications” and that “benzodiazepines are associated with a –% increase in the rate of hip fractures” (). AOD negative consequences not only affect older people and their families, but they also increase the costs of health care systems. For example, Brennan et al. () found that elderly patients with substance use disorders

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(SUD) had a significantly higher hospital-readmission rate over a four-year period than did their case controls (% versus %). Further, among the readmitted patients, those with SUD had a significantly longer stay in the hospital than those without SUD (for example . days versus . days, first year post discharge). Thus the significance of addressing geriatric substance abuse treatment issues becomes clear. The purpose of this chapter is to explore the nature of substance abuse problems among older women and to discuss treatment principles and strategies for this population. Four additional factors further highlight the importance of focusing on older women: 1. Life expectancy has increased, which means there are now, and will continue to be, more older people than previously. Among the population who are  and older, however, women greatly outnumber men; the  U.S. Census showed  males per  females in the population aged  and older (Gist and Hetzel ). 2. Although women in general have a lower rate of AOD use than men do, the gap is diminishing. A Swedish study showed that the sex ratio for admission to alcohol treatment decreased from . older men for each older woman to . older men for each older woman within a decade (Osterling and Berglund, cited in CSAT ). Further, women have been either exceeding or being comparable with men in prescription drug use problems. For example, from  to , each year women have consistently accounted for more than % of the total treatment admissions for tranquilizers (e.g., benzodiazepines) and sedatives (e.g., barbiturates); they also accounted for a similar proportion of the total treatment admissions for “other opiates” (e.g., non-prescription use of morphine, oxycodone) compared to men (SAMHSA n.d.c). 3. As mentioned in chapter , women are more vulnerable than men to the negative impact of AOD because of their different physiological makeup (body size, body fat, metabolic enzyme levels, etc.). It requires less alcohol consumption, as well as a shorter period of usage, for women to develop alcohol abuse problems (Ely et al. ). 4. Older women tend to be more isolated and have fewer resources than their male counterparts, making them less likely to be identified, referred, and/or treated. The  Census showed that more men aged  and over were married than women in that age group (% and %, respectively), that more older women were widowed (% and %, respectively), and that more older women lived alone than did older men (about . million and . million, respectively) (Gist and Hetzel ). Older women are less likely to have been employed and thus less likely to have insurance coverage and a pension, and they may be subject to the loss of insurance coverage after their spouse passes away (CSAT ). The  Census data showed that in  women aged  and over had a higher poverty rate than their male counterparts (.% versus .%) (Gist and Hetzel ).

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Nature and Characteristics of AOD Problems Among Older Women In preparing this chapter, I found fewer empirical studies available on substance-abusing older women than on other female populations. As mentioned earlier, research on geriatric substance abuse in general has been increasing in the last two decades but is still relatively scarce. Research specifically on AOD-using older women or a comparison of older men and older women on AOD issues is even more scarce (Brennan et al. ; Wilsnack et al. ). Blow (:) explained the sparse research on substance-abusing older women: Because traditional residential alcoholism treatment programs generally provide services to very few older women, sample sizes have been inadequate to study treatment outcomes among elderly women who meet criteria for alcohol abuse and dependence. The development of elder-specific alcoholism treatment programs in recent years may facilitate studies of this special population. . . . Most studies of older persons in alcohol treatment have been conducted in Department of Veterans Affairs (VA) settings, which thus limits inclusion of women. Another concern is that various empirical studies adopted different definitions for “older,” “elderly,” and “geriatric” groups. Some studies included adults aged  and over, some  and over, and some  and over. Since available empirical studies are already scarce, I decided to include all studies that contained samples of females aged  and over. Despite the rarity and incompleteness of relevant data, certain insights do emerge that can be helpful in developing some guidance for practice with this age group. Three categories of substances are particularly pertinent for older adults: alcohol, prescription drugs, and illicit drugs, and of those, alcohol and prescription drugs are especially significant to women.

Alcohol Alcohol is the primary substance abused by older women (and men). Arndt, Gunter, and Acion’s () analysis of TEDS revealed that alcohol, heroin / other opiates, and cocaine / crack are the top three “primary problem substances” at treatment admission in both older (aged  or over, N = , admissions) and younger patients (– years of age, N = ,, admissions). However, older patients are more likely than their younger counterparts to report alcohol as their “primary problem substance” (.% versus .%) at treatment admission. The younger patients have a higher rate of heroin / other opiates admission than the older patients (.% versus .%) and a higher rate of cocaine / crack admission (.% versus .%). Among older patients, Arndt et al.’s study showed,

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women and men have similar rates of alcohol as the primary problem substance at admission (.% and .%, respectively).

Consequences of Alcohol Misuse / Abuse in Older Women Decreased Lean Body Mass, Slower Metabolism, and Faster Deterioration

Drinking may affect older people more severely than younger people. Two drinks consumed by an older adult are equivalent to three drinks for a younger adult (Barry, Oslin, and Blow ). Older people’s normally declining physical condition acts to slow down the metabolic processes of AOD use, and alcohol use may also exacerbate the chronic diseases experienced by many older people, resulting in a higher risk for various negative consequences. Older women are vulnerable to alcohol effects not only because of their age but also because of their gender. See chapter  for the medical consequences of alcohol abuse among women (including liver cirrhosis, breast cancer, heart disease, and cognitive function). Older women’s exposure to prescription drugs further increases the chance of their being affected by alcohol-drug interactions; they may also suffer impairments to activities of daily living. Adverse Alcohol-Drug Interaction Effects

More older people than younger people are exposed to psychotropic and other prescription drugs, and older women are more likely than older men to be prescribed medications. This exposure increases opportunities for adverse drug-alcohol interaction effects when alcohol is consumed. Lofwall et al. () found that about % of the younger methadone / LAAM patients (aged –, n = , % female) versus .% of their older counterparts (aged –, n = , % female) were not taking prescribed drugs (other than methadone / LAAM). Also, .% of the older patients but only .% of the younger patients ( p < .) reported taking three or more medications daily. Emlet, Hawks, and Callahan () studied  “frail and functionally impaired” elders (mean age ., SD ., .% female) and found that users and non-users of alcohol were equally likely to use prescription drugs, with an average of slightly more than five medications per person (). One study of low-to-moderate-income older adults who registered in the Pennsylvania Pharmaceutical Assistance Contract for the Elderly program showed that “.% of all drug users were exposed to prescription medications that interact with alcohol and that .% of these individuals reported concomitant alcohol use” (cited in Simoni-Wastila and Yang :). Further, that study showed that .% of those who use narcotic analgesics and .% of those who use sedative-hypnotics and anxiolytics indicated concurrent alcohol use. Impaired Activities of Daily Living (ADL)

Substance-abusing women tend to suffer impairments in activities of daily living (ADL) more than their male counterparts. ADL refers to feeding, dressing,

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ambulating, bathing, and using the toilet, and instrumental ADL includes cooking meals, taking medications, managing money, and using the phone (CSAT ). Disabilities in these areas may prompt the institutionalization of older people (CSAT ). Ensrud et al.’s study (cited in CSAT ) showed that older women with a history of alcohol abuse had an ADL impairment rate twice that of their male counterparts. Brennan et al.’s () findings concurred with those of Ensrud et al. The characteristics of the index episode of Medicare inpatients with SUD in their study indicated that women (N = ,) had a significantly higher rate than men (N = ,) in all types of accidents (.% versus .%, p < .), in “accidental poisoning and adverse drug reactions” (.% versus .%, p < .), and in falls (.% versus .%, p < .) ().

Older Women as “Late-Onset” Drinkers Definitions of Early- and Late-Onset Drinkers

Experts divide older adult drinkers into early-onset and late-onset groups (CSAT ). Menninger () defines early-onset older adult drinkers as “those who have a lifelong pattern of drinking, have probably been alcoholic all their life, and are now elderly” and late-onset older adult drinkers as “those who become alcoholic in their drinking pattern for the first time late in life” (). There is no clear-cut standard as to the age of onset that is considered early or late. Menninger stated that those defined as early-onset drinkers begin to have alcohol-related problems when they are in their twenties or thirties and those described as lateonset drinkers usually develop such problems after their forties or fifties. CSAT () stated that age at onset varies widely; for the early-onset group it could be younger than , , or , and for the late-onset group, older than , , or . About two-thirds of elderly alcoholics are early-onset and one-third are late-onset (Menninger ). Although both early- and late-onset drinkers are represented among both men and women, the literature has consistently indicated that older women are more likely than older men to be late-onset drinkers (CSAT ). Arndt et al.’s TEDS analysis () showed that the older women who were admitted to AOD treatment programs had a higher no-prior-admissions rate than the older men (.% versus .%), and the men had a higher five-or-more-treatment-episodes rate than the women (.% and .%, respectively). Further, % of the women and only % of the men reported age of first AOD use as after . Characteristics of Early- and Late-Onset Drinkers

Early-onset drinkers are more likely than late-onset drinkers to have a family history of AOD and to have more-severe AOD problems, alcohol-related chronic diseases (e.g., liver cirrhosis, pancreatitis, cancers, and organic brain syndrome), and psychiatric comorbidities (e.g., cognitive impairment) (CSAT ; Menninger

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). They may also have more-severe legal, family, and other psychosocial problems, and a declining socioeconomic status (CSAT ; Menninger ). The early-onset drinkers may also be less compliant with treatment, as indicated by a lower motivation for treatment and a lower retention rate (Schonfeld and Dupree ). Both groups, however, use alcohol to cope with stressors, and they share similar relapse rates (CSAT ). Although the late-onset drinkers appear to be less affected by alcohol and more amenable to treatment, they are unfortunately also more likely to be ignored and not identified (Liberto and Oslin, cited in Menninger ). Theories of Alcohol Misuse / Abuse for Late-Onset Older Adults

Most experts consider that the early-onset drinkers among older adults simply carried the “habit” from their young adulthood into older adulthood. Theories about why late-onset drinkers among older adults abuse alcohol, however, are less uniform, and empirical studies on the topic are limited (Schutte, Brennan, and Moos ; Welte and Mirand ). One popular theory is that these older adults “react” to the life stressors that commonly occur late in life by using alcohol to reduce stress, loneliness, feelings of loss, and so on. Among the most common late-life stressors are deterioration of the older person’s own physical condition, concern about approaching death; retirement-related lifestyle changes; death or illness of a spouse and / or friends (Graham et al. ). Not only is it intuitively logical to link late-onset drinking to efforts to cope with late-life stressors, but empirical studies have suggested such an association (e.g., Brown and Chiang, cited in Welte and Mirand ). Menninger () stated that late-onset drinking is usually, but not universally, initiated because of a life stressor. However, some other studies suggested that life stressors are not necessarily associated with late-onset drinking among older adults, and that life stressors could actually be the consequences rather than the causes (Schutte, Brennan, and Moos ; Welte and Mirand ). Welte and Mirand’s study (N = ,, % female, aged  or over) found no relationship between elderly heavy drinking and stress nor any relationship between late-onset drinking and stress. Rather, chronic stress (e.g., participants were asked how much they were bothered by “caring for a sick family member, loneliness or side effects of medication” []) predicted drinking consequences. Recent literature has also emphasized the importance of differentiating between stressors that contribute to alcohol misuse and stressors that are the results of alcohol misuse (Hart and Fazaa ). Welte and Mirand also noted that studies of “clinical populations” are more likely to show a relationship between late-onset drinking and stress reduction than studies of “community populations.” Another theory to explain late-onset drinking among older adults is that older adults may simply have more time and flexibility, as well as fewer responsibilities,

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which may result in problem drinking. This scenario is especially likely if they happen to already have a tendency to drink (although not problematically), those in their immediate environment (such as friends and family members) approve of or encourage drinking, and / or their physical condition is of no immediate concern with regard to alcohol consumption. Schutte, Brennan, and Moos () compared two groups of older people. Both were non-problem drinkers at baseline, but during the following seven years, participants in one group developed problem drinking (N = , . % female) and participants in the other group did not (N = , .% female). The researchers found that at the baseline the late-onset drinkers were more likely than the non-problem drinkers to report the following characteristics: () “incipient problems” (i.e., “became high after drinking or drank to help forget worries” in the preceding twelve months), () heavier alcohol intake, () more “friend approval of drinking,” () dependence on “avoidance coping strategies” (running away from problems), and () less likelihood of having “acute medical conditions that could potentially be complicated by alcohol consumption” ( and ).

Risk Factors for Relapse Among Older Adults Studies show that “stress reduction” and “indirect social pressure” may be two of the major risk factors leading to relapse for older adults. Schonfeld and Dupree () found that both early- and late-onset older subjects (N =  each,  men and  women) reported most frequently “depression,” “loneliness,” and “lack of social support” as the antecedents to their drinking behavior prior to the admission to treatment. Likewise, Blow et al.’s () study (N = , mean age ., .% female) showed that .% of the subjects who completed an inpatient elder-specific treatment reported relapse at six months after admission because of negative emotion (grief / loneliness). Indirect social pressure, another major risk factor for relapse, was chosen by .% of Blow et al.’s subjects, who mentioned mostly situations in which the older person’s children, grandchildren, and / or spouses were drinking. Other triggers included “coping with interpersonal conflict” (.%), “enhancement of interpersonal positive states” (.%), “enhancement of intrapersonal positive emotional states” (.%), and “testing control” (.%). No subjects reported “negative physical states” or “temptations and urges” as the triggers ().

Identification of At-Risk Older Women Older women are more likely to be “hidden abusers” than older men, for four reasons. Women are more likely than men to feel guilt and shame about their AOD use, and older women further perceive more intense feelings of shame and guilt about AOD use than younger women do. Thus older women are less likely to self-report AOD problems because of the attached stigma (Blow ). Older women are more likely than older men to be widowed, live alone, and be isolated, and thus less likely to be spotted with or referred for AOD problems (CSAT ).

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Many older women do not drive and therefore have less opportunity than older men to be involved with drunk driving and the criminal justice system, which often precipitates AOD treatment referrals (CSAT). Finally, as mentioned above, more women are late-onset drinkers whose drinking problems may be less severe than those of the early-onset drinkers, and therefore these women are less likely to be identified.

Beneficial Health Effects of Drinking It is important to understand the issue of “beneficial health effects of drinking” when working with older (female) adults regarding substance abuse. Various studies in the late s and throughout the s showed that moderate drinking has beneficial health effects, including decreasing cardiovascular diseases and dementia among the elderly (see Barry, Oslin, and Blow’s review ). The media have emphasized the moderate-drinking-is-benign idea, and it has even been recommended by some to initiate drinking among people who did not drink previously (Blow, Oslin, and Barry ). Eliason and Skinstad () found that more than % of the older women in their study perceived that moderate alcohol use has more beneficial than risky health results and “believed alcohol to be more benign than it actually is” (). Some clinicians and the general public were also confused as to whether they should ask people to cut down on their drinking (Barry, Oslin, and Blow ). Consideration of three key points will help to clarify this issue: level of drinking, physical condition of the person, and gender. Level of Drinking

All of the studies that suggest beneficial health effects of drinking emphasize moderate drinking. “Moderate drinking” could be easily misconstrued, but in fact it means no more than one standard drink per day for older adults. A standard drink is equivalent to a can of beer ( oz.), a glass of wine ( oz.), a small glass of sherry ( oz.), or one shot of spirits (. oz.) (Barry, Oslin, and Blow ). At-risk or heavy drinking produces only negative results, such as falls and fractures, as mentioned above. Further, although moderate drinking decreases the risk of strokes caused by blood-vessel blockage, at-risk or heavy alcohol use heightens the risk of bleeding-related strokes (Barry, Oslin, and Blow ) (see chapter  for a detailed discussion). Physical Condition of the Individual

Moderate drinking may be beneficial for healthy people, but people with past drinking problems or chronic diseases such as depression, Alzheimer’s disease, emphysema, and diabetes should not drink (Barry, Oslin, and Blow ). Gender

Although moderate drinking does show some beneficial effects, such effects may apply more to men than to women. Not much gender-specific research has been

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done regarding beneficial effects of alcohol. One such study—the Nurses Health Study (Fuchs et al., and Stampfer and colleagues, cited in Eliason and Skinstad )—suggested that “the adverse effects of alcohol essentially canceled any potential benefits for the heart in the majority of women” (). Although moderate drinking decreases heart problems related to blood-vessel blockage, it elevates the chance of accidental injury, hemorrhagic stroke, and cirrhosis. Men are more likely to benefit from moderate drinking because they have a higher risk for heart problems but a lower risk for liver problems and accidental injuries (Jackson and Beaglehole, cited in Eliason and Skinstad ). Older women are less likely to benefit from moderate drinking also because drinking may heighten women’s risk for breast cancer (Jackson and Beaglehole, cited in Eliason and Skinstad ). Although study results are still conflicting, the overall findings suggest an association between alcohol consumption and breast cancer, and the amount of alcohol that increases the risk could be excessive or moderate (see also chapter ). Women are more likely than men to be exposed to and use prescription drugs such as a minor tranquilizer or a narcotic analgesic (Simoni-Wastila, Ritter, and Strickler ; Simoni-Wastila and Yang ), and alcohol, in spite of its beneficial effect on coronary heart disease when taken in moderation, augments the risk for adverse drug-alcohol interaction effects among women.

Prescription Medications Older people are more vulnerable than younger adults to prescription medication misuse / abuse, although it tends to be intentional among the younger adults and unintentional among the old. The National Institute on Drug Abuse (NIDA) (a) noted that people aged  and older account for % of the U.S. population, but about % of total medications are prescribed for them. They are also the largest group of consumers of OTC drugs, accounting for % of the total (Salom and Davis ). Kaufman et al.’s () study of , randomly selected noninstitutionalized participants in the United States found that women aged  and older had the highest overall rate of medication use: % of them had at least one medication in the preceding week; % had five or more medications; and % had ten or more medications (). “Medications” in that study included prescription drugs, OTC drugs, herbal / supplements, and vitamins / minerals. When the analysis is limited to only prescription drugs, women aged  and older still had the highest rate: % of them had at least one medication in the preceding week and % of them had five or more. Although many prescription drugs can be misused or abused, NIDA () identified three categories that are most frequently abused: () opioids, which are used for reducing pain and include morphine, codeine, OxyContin, Darvon, Vicodin, Dilaudid, Demerol, etc.; () central nervous system (CNS) depressants,

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which treat sleep disorders and anxiety and include barbiturates (Mebaral, Nembutal, etc.) and benzodiazepines (Valium, Librium, Xanax, Halcion, etc.); and () CNS stimulants, which manage ADHD and narcolepsy and include Ritalin and amphetamines. Recent data showed that opioid pain relievers and benzodiazepines are the two most common categories in emergency-room prescription drug abuse cases (NIDA n.d.). Further, older people, particularly women, are more likely to misuse drugs in the first two categories, and thus this discussion focuses only on them. Prescription drug misuse includes underdose, overdose, “use for other than prescribed,” and / or drug combinations (Patterson :slide ). It may also include “sharing,” “obtaining from non-medical source,” and “taking for psychoactive effects” (Simoni-Wastila :slide ). Medication (including prescription medication) misuse can also be defined as the discrepancy between the medications recorded in a patient’s medical chart and the medications actually taken / reported by the patient (Bedell et al. ). Bedell et al.’s study (N =  patients in an outpatient medical center, mean age , % female) showed that % of the participants indicated medication discrepancies. Among the discrepancies, % related to patients’ taking medications not recorded, % to patients not taking medications recorded, and % to dosage differences.

Misuse of Mind-Altering Prescription Drugs Although men accounted for a higher proportion of the total admissions for alcohol abuse and illicit drug abuse, women and men accounted for similar proportions of the total treatment admissions for abuse of psychoactive prescription drugs and OTC drugs (for example, each year from  to  women have consistently accounted for more than % of the total admissions for tranquilizers and sedatives, and they shared a similar proportion of total treatment admissions for “other opiates” with men [SAMHSA n.d.c]). In addition, although women accounted for only % of the total treatment admissions for “all substances,” they made up % of all the OTC and prescription drug admissions (SAMHSA  data, OAS c). SAMHSA (OAS ) also noted that a large percentage of the primary tranquilizer admissions were people who were  or older and that people admitted to treatment for tranquilizer, prescription narcotics, or OTC drug problems were older than their counterparts whose primary drug of abuse at admission was prescription stimulants.

Consequences of Prescription Medication Misuse / Abuse Overdose, Interaction with Other Medications or Alcohol, and Physical Dependence / Withdrawal

Opioids work to decrease the brain’s perception of pain, and CNS depressants usually increase the level of GABA in the brain, which reduces brain activities

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and thus creates drowsiness and calmness (NIDA ). When overdosed, both could severely slow down the human body’s respiratory system, thereby causing death. Opioid prescription medications must not be used with CNS depressants, such as alcohol, benzodiazepines, or barbiturates or with the OTC allergy / cold drugs and vice versa. A combination of these drugs potentiates synergistic, multiplicative effects that slow down the respiratory system and can be lethal. Also, long-term use of opioids or CNS depressant medications leads to physical dependence, and withdrawal may occur when the medication is stopped. Withdrawal may be characterized by restlessness, insomnia, vomiting, muscle pain, and seizures. NIDA () stated that to prevent withdrawal, an individual should be under medical supervision not only when he or she is prescribed opioids or CNS depressants but also when use of them is stopped. Older adults may be more vulnerable to the negative consequences of prescription medication misuse / abuse than younger adults because of their declining physical condition and slower metabolization process. Poisonings, Falls and Fractures, Confusion, Depression, and Suicide

Le Couteur et al.’s () review of the literature suggested that adverse drug reactions are common and often severe among the older population, but they are also less likely to be identified or reported by older patients. For example, people aged  and older accounted for only .% of the total calls to most poison centers in the United States in , but they represented .% of the total fatalities ( / ,; Litovitz et al., cited in Skarupski, Mrvos, and Krenzelok ). Adverse drug reactions may involve various manifestations and presentations, but falls and confusion are two of the major problems (Le Couteur et al. ). Le Couteur et al.’s literature review indicated that “the risk of falling is increased by % in older people taking psychotropic medications” and that “benzodiazepines are associated with a –% increase in the rate of hip fractures, and up to % of hip fractures among older people living in the community are attributable to benzodiazepines” (:). Le Couteur et al. also stated: “Medications cause –% of cases of delirium and –% of cases of chronic confusion or dementia” (:). Depression and suicide can also result from prescription drug misuse and abuse (Simoni-Wastila ). Le Couteur et al. advocated that drug therapy in older adults be closely monitored and that practitioners avoid prescribing another drug(s) to treat adverse drug reactions. Onder et al. () reported that .% of the hospital admissions in their study were related to adverse drug reactions and the most significant factor contributing to such admissions was the number of medications taken by the older patient.

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Etiologies of / Risk Factors for Prescription Medication Misuse / Abuse Among Older Women The Sociological Factor

Older people, particularly older women, are more likely to be exposed to prescription drugs, and greater exposure increases the risk of misuse and abuse. As mentioned earlier, although people aged  and older are only % of the total population in the United States, they are prescribed more than % of the total medications (NIDA a). Various studies have also shown that women are more likely than men to be prescribed psychoactive medications, including narcotic analgesics and minor tranquilizers (Simoni-Wastila, Ritter, and Strickler ). Pérodeau, King, and Ostoj’s  study (N =  seniors receiving home care services, mean age ., .% female) found that elderly women were more likely than elderly men to use multiple psychotropic drugs. The result was related to the fact that the women had more positive attitudes toward those medications (e.g., tranquilizers) than the men did. The Biological Factor

An aging physical condition and slower metabolism make older people in general more sensitive to alcohol, prescription medications, and OTC drugs, thus exacerbating the possibilities of overdose or adverse effects from an alcohol-drug or drug-drug interaction (CSAT ; NIDA n.d.). As mentioned earlier, women have a less efficient metabolism of alcohol, leading to a slower decrease in blood alcohol concentration, which further works against the older women as compared to younger women and to both older and younger men with respect to this issue (Blow and Barry ). Unintentional Misuse / Abuse

The nonmedical use of prescription drugs tends to be purposeful among young adults, but it could be largely unintentional among the older population (Clayton et al., cited in Simoni-Wastila, Ritter, and Strickler ). Older patients’ misunderstanding of medication-taking directions or miscommunication with their physicians may lead to their unintentional misuse / abuse of the prescription drugs. Such problems may be increased when multiple physicians (e.g., a primary physician plus some specialists) are involved in the care of the same patient but have not communicated effectively (Bedell et al. ; CSAT ). Another factor is that older adults may misuse medications simply because of a lack of knowledge or awareness. Nemes et al.’s () study indicated that despite similar rates of AOD use and abuse, older adults (age  and older, % female) were less likely than younger adults (– years old, % females) to notice that they had a substance abuse problem. And finally, in some cases an inappropriate prescription from the physician may lead to an adverse drug reaction (Curtis et al. ; Lau et al. ).

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Past Substance Abuse and / or Exposure to Longer Duration and a Greater Amount

CSAT’s () review of studies suggests that a person with a history of sedative drug abuse, multiple drug abuse, and / or methadone use is more likely to abuse benzodiazepines. Another at-risk population is the long-term benzodiazepine user who experiences acute withdrawal after a sudden stoppage (CSAT ). Older women are at higher risk not only because they are more likely to be prescribed medications but also because they are more likely to have multiple medications prescribed for longer-term use. Both factors expand the risks for prescription medication misuse / abuse (NIDA a), including dependency and withdrawal. Gorgels and colleagues’  study (N = , long-term benzodiazepine users) found that a higher amount and longer duration of use at baseline, as well as the factor of female gender, lowered the probability of quitting benzodiazepines among participants after they were exposed to a minimal intervention treatment. Current or Past Psychiatric Diagnosis

A psychiatric diagnosis or behavioral health problem (current or previously) can also be a risk factor for prescription drug misuse / abuse among older women (CSAT ; Simoni-Wastila ). Solomon and colleagues (cited in CSAT ) found that drug-dependent older adults had a much higher rate of a coexisting psychiatric disorder than their younger counterparts (% and %, respectively). The Mayo Clinic research data (Finlayson, cited in CSAT ) also showed that older adults with a psychiatric diagnosis may be at a higher risk for prescription medication abuse and dependence. Among the  older adults (predominantly women) who were hospitalized because of prescription drug dependence, % were diagnosed with mood disorder, % with organic mental disorder, % with personality disorder, % with somatoform disorder, and % with anxiety disorder. Psychosocial Stressors

Citing various studies, CSAT () stated that psychoactive drug use among older women is related to some of the life stressors occurring in middle or late life, such as widowhood, divorce, poor health, loss of social support and / or economic support, depression, and anxiety. Salzman (cited in CSAT ) found that about % of survivors developed anxiety in the first six months after a loved one passed away. More older women than men lost their spouse because of women’s longer life expectancy, and thus more women may have suffered bereavement and developed anxiety, which may have propelled them to prescription medication use / abuse / misuse. On the other hand, Pérodeau et al.’s  study suggested that the psychosocial stressor perspective does not explain why the elderly misuse / abuse prescription medications; rather, the misuse / abuse of prescription drugs is related to the factor of female gender and women’s positive attitudes toward prescription drugs.

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Perodeau et al. found that the number of “pills” taken by the older adults in the preceding three months was not related to the older adults’ level of psychological distress (symptoms of anxiety and depression) and that although the number of negative life events was associated with the number of pills taken, the relationship was inverse: more negative life events predicted fewer pills taken. Other Possible Risk Factors

Simoni-Wastila () suggested several other risk factors contributing to older women’s prescription drug misuse / abuse, among them social isolation, a lower socioeconomic status, and poor health.

Illicit Drugs Compared to alcohol and prescription drugs, illicit drugs have traditionally received less attention in investigations of substance abuse problems among older adults (Lofwall et al. ; Schlaerth et al. ). Various theories have been developed to explain this, though so far they are inconclusive. The “maturing out” theory suggests that many young adults who use illicit drugs grow out of their drug-using behavior and cease using the drugs by the time they enter older adulthood. Another theory is that people who use illicit drugs have a shorter life expectancy and are more likely to die before reaching older adulthood. It is estimated that people without a diagnosis of a drug use disorder have a life expectancy that is . years longer than that of people with the diagnosis (Neumark, Van Etten, and Anthony, cited in Lofwall et al. ). Whatever the reasons, prevalence rates for illicit drug use are much lower for older adults than for other segments of the population. It may be, however, that the situation with respect to illicit drug use among older adults will change in the near future, for several reasons: () The aging baby boomers already have a higher illicit drug use rate than previous cohorts, and they also surpass previous cohorts in sheer numbers (OAS ). () The maturing-out theory may not apply to narcotic or opiate users, who often do not mature out as cocaine or marijuana users do (Glantz and Backenheimer ). () Drug abuse treatment programs may help to prolong life for drug abusers. For example, methadone maintenance treatment (MMT) programs have successfully retained the patients and extended their lives (Addiction Treatment Forum ).

Types of Illicit Drugs and Age Categories As mentioned earlier, many people may mature out of marijuana or cocaine use, but the narcotic or opiate drug use habit tends to be carried into older adulthood. Treatment targeting aging or “graying” MMT patients has called for attention in the last decade. The number of aging MMT patients (older than ) increased by % from  to  in Maryland (Lofwall et al. ). An MMT program

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at Beth Israel Healthcare System in New York City also showed a dramatic increase in the number of older patients (older than ), from about % of the total MMT patients in  to about % in  (Addiction Treatment Forum ). A recent study by Schlaerth et al. (), however, showed that older adults’ illicit drugs of choice may not be confined to narcotics but may actually reflect the drug that is prevalent in the overall population or in the surrounding neighborhood. Those authors studied patients’ charts (N =  patients who visited the emergency department in a Los Angeles inner-city hospital; all patients were  or older and tested positive for illegal drugs; .% female). The researchers found that the majority of women used cocaine (.%), followed by illegal opiates (.%), marijuana (%), illegal benzodiazepines (.%), amphetamines (.%), illegal barbiturates (.%), and PCP (%). Of the men, .% used cocaine, .% used illegal opiates, .% used marijuana, .% used illegal benzodiazepines, .% used illegal barbiturates, .% used PCP, and .% used amphetamines. (The total percentages exceeded  because some patients were poly-drug users.) Schlaerth et al.’s study () also showed that illicit drug use may be more prevalent among the “young old” than the “old old”: the majority were in the age group – (%), followed by those – (.%), and finally those older than  (.%).

Consequences of Illicit Drug Use in Older Adults Poor Health and Multiple Medical Conditions

Older adults who use illicit drugs experience worse health and multiple medical problems compared to both younger adults who use illicit drugs and the overall older adult population. The health consequences are attributable to the older users’ chronic drug usage and their harsh drug-dependent lifestyle. These factors aggravate the normal age-related declining physical conditions (Anderson and Levy ). Schlaerth et al. () reported that % of their older ED patients ( or older) who tested positive for illegal drugs had a diagnosis of cardiovascular disease, but only % of all their older ED patients did. Lofwall et al. () reported that their older opioid maintenance patients (aged –, n = , % female) had significantly higher rates of cardiovascular, gastrointestinal, and bone / joint problems than their younger counterparts (aged –, n = , % female). The rates were .% versus .% ( p = .) for cardiovascular problems, .% versus .% ( p = .) for gastrointestinal problems, and .% versus .% ( p = .) for bone / joint problems. Both groups also had high rates of HIV (.% for the older participants and .% for the younger participants) and hepatitis C (.% and .%, respectively). They also scored lower on all eight measures of the SF -v (health-related quality-of-life, e.g., physical functioning,

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social functioning, mental health, etc.) than the gender- and age-matched population norms. The older illicit drug injectors in Anderson and Levy’s study reported multiple additional drug-related physical problems, including “abscesses,” “injured legs and shoulders,” “collapsed veins,” “gunshot wound side-effects,” “swollen limbs and scarred hands” (:). Abscesses and collapsed veins can particularly be a problem for older injectors. One participant stated: “Your veins get hard. They died out. You killed them and they gone. And then you can no longer have no more veins. Then you have to skin pop it. Then you keep skin-popping it and your body start rotting with them abscesses” (–). Anderson and Levy observed that the inability of older injectors to deliver drugs to their body not only isolates them from the main drug-using world but also diminishes their self-worth and sense of self-control. Double Marginality

Because of the illegal nature of their drug-involvement behavior, illicit drug users of any age are often marginalized from mainstream society. For older illicit drug users, such marginality extends further, to their own drug-using culture and world. In other words, not only are they perceived as deviant by mainstream society and are thus isolated from it, but they may also be relegated to the margins of the current illegal drug scene because their values on various drug-related issues are no longer compatible with those that operate there today, and their weaker physical condition discourages them from competing with younger counterparts. Anderson and Levy’s () in-depth interviews of  active drug injectors who are not in treatment (aged –) revealed that the older injectors consider today’s illegal drug world to be money / benefit driven, operated in a sophisticated, systematic, and multilayered fashion, and violence-oriented, in contrast to the old days when there was a bond between users and dealers and an emphasis on caring among users.

Etiologies and Risk Factors As mentioned earlier, little research has been done regarding illicit drug use among older adults, including why some people “mature” out of illicit drug use while others carry it into older adulthood. One study (Rosen ) (N =  methadone clients aged  and over, .% female) found that about one-third of the older methadone clients were still using drugs and that their illicit drug use was related to their exposure to an illicit-drug-using social network and / or community. For example, their “romantic partner” or family members were involved with illicit drugs, were using drugs, or were currently in need of drug treatment. The drug traffic in the neighborhood also played a role in promoting illicit drug use among the older adults. Rosen further found that older women were more likely to be

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affected by “exposure to illicit drugs”; .% of the older women who used illicit drugs had someone in their household who needed drug treatment, whereas only .% of the older men who used illicit drugs did. In addition, Rosen’s study did not find that “financial life stress” or “unstable environment” contributed to the older adults’ illicit drug use. Although more research is needed in this area, Rosen’s () findings seem to be in line with Blow et al.’s () findings regarding the role of “indirect social pressure” in leading older adults to alcohol relapse. Both studies suggest that older adults’ substance-abusing behavior is likely to be affected by the substance-abusing behavior of people in their close social network.

Treatment Guidelines and Strategies Screening and Identification AOD problems in older adults are less likely to be recognized because of the similarities of the signs and symptoms associated with AOD problems and the aging process or chronic diseases, plus society’s bias that often ignores or de-emphasizes AOD problems in the older population. This section discusses who should conduct the AOD screening and how, the signs and symptoms of AOD use among older adults, and the various AOD screening tools suitable for older adults.

Who Should Conduct the Screening? Physicians are in a unique position to identify, encourage, and refer at-risk older adults for AOD treatment. Older adults, particularly women, may visit their physicians more frequently than younger adults do because of their changing physical condition and psychological distress. The exposure gives physicians opportunities to bring up the issue. The urgent need for older adults to stop or decrease drinking because of an existing severe illness gives physicians further credibility to counsel their patients about AOD issues (Satre and Areán ). Also, the “medical” approach of physicians, rather than a “psychological” or “mental health” approach, can reduce the stigma attached to AOD abuse / misuse, to which many older adults are sensitive (CSAT ). In fact, Satre et al. () found that among adults attending alcohol treatment a higher proportion of older adults than their younger counterparts mentioned that their physician had encouraged them to get alcohol treatment. Although physicians are in an advantageous position in identifying at-risk older patients, people who are involved in the older person’s daily life can also be a powerful resource for AOD screening. For example, family members and friends of older adults, or staff and volunteers of senior centers can be trained in simple screening methods and procedures (CSAT ). CSAT also suggests that

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senior programs or community centers serving older people can provide training or information to assist them in self-identifying AOD problems and getting help.

Demeanor and Strategies for Screening AOD screening should be conducted in a confidential, nonjudgmental, nonthreatening manner (CSAT ). A medical approach is preferred over a psychological or mental health approach because of older adults’ sensitivity to the stigma attached to AOD misuse / abuse. Therefore, terms like “alcoholic” and “drug abuser” should be avoided; screening questions with a medical connotation are more acceptable. CSAT gave two sample questions: “I’m wondering if alcohol may be the reason why your diabetes isn’t responding as it should” and “Sometimes one prescription drug can affect how well another medication is working. Let’s go over the drugs you’re taking and see if we can figure this problem out” (CSAT ). Interviewing collaterals (family and friends) can also be helpful when the older adult is unable to provide coherent information, possibly because of cognitive impairment. CSAT () suggests conducting interviews with collaterals in a private and non-confrontational manner and getting permission from the older adult before interviewing family members or friends. One useful question listed by CSAT was “Has anybody in your family ever had a problem with drinking?” A positive answer would indicate the possibility of an alcohol problem and thus the need for a more thorough formal evaluation. Sometimes the interview may provoke the family members’ anger toward the older adult for his or her current and previous drinking behavior; if that happens, the practitioner should caution the family member not to confront the older adult after the interview.

Signs and Symptoms Effective identification and referral require knowledge of signs and symptoms of AOD abuse / misuse among older adults, which may be manifested in many areas of life. Among these are the following: (a) directly related to AOD, including increased tolerance to AOD or medications, blackouts, and dizziness; (b) psychological, such as anxiety, depression, and mood swings; (c) cognitive, including disorientation, memory loss, and “new difficulties in making decisions”; (d) biological, comprising headaches, sleep problems, falls, bruises, burns, incontinence, and idiopathic seizures; (e) behavioral, including poor nutrition and poor hygiene; (f ) social, including family problems, social isolation, financial problems, and legal difficulties (Blow, Oslin, and Barry ). Blow, Oslin, and Barry stated: “Because other physical and mental health conditions may have similar manifestations, it is critical to screen for alcohol and psychoactive medications in addition to other problems in this age group” ().

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AOD Screeners Appropriate for Older (Female) Adults No AOD screening tools have been developed specifically for older women. However, at least three tools have been considered valid in application to older adults in general. They are the MAST-G and CAGE, recommended by CSAT (), and T-ACE, mentioned by Stevenson and Masters (). T-ACE is considered to be effective in predicting older women at risk (Stevenson and Masters ) and CAGE to be less appropriate for women (CSAT ; Sokol, Martier, and Ager ). Additionally, CSAT suggested using AUDIT to screen older adults of ethnic minority groups because it has been validated cross-culturally. Finney et al. (cited in Eliason ) also developed the Drinking Problems Index to screen older adults for AOD risks. Some screeners measure “lifetime problems” instead of present problems (e.g., CAGE). CSAT () suggests that the interviewer, when implementing the screeners, needs to ascertain that the person presently drinks and that the items measure the person’s recent drinking behavior (within the preceding year). For each specific screening tool, see appendix A.

General Rules for Working with the Older Population Being Accepting and Respectful It is crucial to be nonjudgmental, nonthreatening, accepting, and respectful when working with older clients (Fredriksen ; Graham et al. ). Fredriksen stated that the initial nonthreatening process allowed the older women in their program to gradually build a supportive social network and integrate AOD treatment education and information. It is also helpful to emphasize the client’s strengths and past achievements and to communicate such recognition back to the client (Graham et al. ). Practitioners should express confidence in the client’s ability to complete treatment, taking care to do so “in a way that is upbeat but not patronizing” (CSAT ). CSAT () recommended the following practical suggestions: () Follow the customs of the older client. For example, address or introduce the client as she or he would like to be addressed or introduced. () Talk to the client directly, instead of a spouse or adult children, when the client is present. () Respect the client’s privacy and ownership. For example, ask the client where she or he prefers you to sit when visiting the client at her or his room. () Respond to the client’s request promptly, particularly when the client is in a treatment program. Several shorter and informal sessions pertinent to the client’s requests may be more beneficial than a scheduled, longer session. () Value the client’s spiritual needs and wishes to talk about the purpose in life. When working with the older population, the practitioner should keep the environment simple, with minimal distractions, because older adults are more likely than younger adults to be affected by distractions (Myers and Schwiebert, cited in CSAT ). When conducting educational programs, the practitioner may need

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to present visual and audio materials simultaneously. The visual material should have enlarged print. A clear goal and outline of an educational session can also increase the learning effects for older adults (CSAT ). Citing various research studies, CSAT () suggested that teaching older adults skills and knowledge may require a slower pace than teaching younger adults, information covered in each session should be limited and not overwhelming, and a group session should run for less than  minutes.

Adopting an Indirect and Flexible Approach The entry of older women into AOD treatment and recovery may be a relatively slow and incremental process (Fredriksen ). The barriers could include older women’s sensitivity to the stigma attached to AOD and strong resistance to shame, worry of losing privacy or confidentiality, uncertainty about how treatment is provided by programs, declining physical condition that interferes with easy mobility, lack of transportation, etc. Two of the common themes observed by Graham et al. () about the older population with AOD problems in a community were that “most refused to leave the home for almost any reason” and “most totally resisted any suggestion of formal treatment for alcoholism” (). Thus, an indirect and flexible approach would seem advisable in efforts to engage substance-abusing older adults in treatment. Such an approach can be tailored to the older client’s needs in several ways. No Requirement for Client to Admit or Acknowledge AOD Problem

In conventional AOD treatment, it is critical that clients first admit or acknowledge their AOD problem. The reasoning is that substance-abusing clients tend to deny that they have a problem with AOD primarily because they do not want to give up AOD use and that a person can change only after she or he admits or claims ownership of the problem. Therefore, the first step in helping these clients is to break down their defense mechanisms, which include denial, minimization, and rationalization. To help AOD-abusing older adults, however, such a strategy may need to be modified. Older substance-abusing adults may be more reluctant to admit their AOD problems than their younger counterparts, perhaps because of their higher level of sensitivity to the stigma attached to substance abuse and their stronger resistance to possible disgrace and disrespect. Graham et al. () stated that some older clients, although not willing to provide information regarding their drinking or prescription drug use, will still accept help from COPA (the Community Older Persons Alcohol Program), a treatment program designed for older substance-abusing clients. It’s important not to pressure older adults to admit their AOD problem, but to build a trusting relationship and work patiently with them, helping them understand the link between AOD abuse / misuse and problems in other life areas (Graham et al. ). According to Graham et al., once the clients understand the

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link between substance abuse and problems in other life areas, they may change their drinking behavior even without a direct discussion of their drinking or they may initiate talking with the counselors to work on their AOD problem. No Requirement for Total Abstinence

Although total abstinence has traditionally been held as the ultimate treatment goal and it is particularly important for clients who are genetically predisposed to alcoholism to maintain total abstinence, such a goal should not be required when working with older adults. The idea of harm reduction may be more flexible and appealing to this population. Treatment programs serving older substance-abusing clients have found that many older clients, despite their not maintaining total abstinence, were able to accept multiple services provided by the treatment program to cut down their drinking and to make significant improvement in their overall functioning level and various life areas, such as health, living arrangement, and leisure activities (Fredriksen ; Graham et al. ). Emphasis on Case Management, Especially During the Initial Stage of Treatment

Many older adults resist formal substance abuse treatment and even refuse to provide information about their substance use, primarily because of the stigma attached to substance abuse. At the same time, substance abuse problems often have eroded their quality of life in many areas, such as health, housing, family relationships, and social life. They may consider it more acceptable to receive treatment and service for those areas, rather than for substance abuse. Case management provision in those more acceptable areas also offers opportunities for practitioners to help older adults understand the link between substance misuse and the problems in their life, which can motivate them to reduce their substance use or to discuss substance abuse issues with their counselors (Graham et al. ).

Targeting Health Health is an important issue for the older population. Its implications for practice guidelines with substance-abusing older clients suggest at least three strategies. Emphasis on the Health Consequences of Substance Abuse / Misuse as a Motivational Tool

Several studies have shown that older adults, especially women, value health and independent living and therefore are strongly motivated to reduce or quit AOD consumption. For example, Satre and Areán’s () study (participants aged –,  female drinkers and  male drinkers) found that older adults’ medical diagnoses (e.g., heart problems and diabetes) predicted their drinking cessation. In other words, the participants may “have given up drinking in response to health concerns” (). Multiple other studies reported similar findings: that older

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adults with more medical problems were more likely to abstain or to reduce their drinking (Moos et al. ); that they decreased their drinking or looked for help owing to health concerns (Busby et al., cited in Satre and Areán ); or that they attended AOD treatment because of their physicians’ encouragement (Satre et al. ). Moos et al.’s study () further indicated an interaction effect between gender and the overall health burden on drinking, in that although both male and female older adults with more health problems were more likely to abstain or to decrease drinking, the females were particularly more likely than their male counterparts to be abstinent. This finding is in line with the previously mentioned notion that women are more prone to the negative consequences of drinking because of their slower metabolizing function, including, for example, more accidents or falls resulting from overdose, alcohol-drug, or drug-drug interactions. Experts have suggested providing treatment that “recognizes [women’s] heightened risk of accidents” (Brennan et al. :) and using the issue of health consequences of substance abuse / misuse to motivate older women (and men) to curtail AOD use (Blow and Barry ; Satre and Areán ). Thorough Assessment and Stabilization of Health Conditions

As part of the normal aging process, older adults may experience more illnesses, and illness may involve more complexity than is the case with younger adults. Older adults who abuse / misuse AOD further may suffer more severe health conditions (Lofwall et al. ). To treat substance abuse problems effectively, counselors must first thoroughly assess, deal with, stabilize, and treat health problems simultaneously (both the physical and the psychiatric) (CSAT ). Health conditions may affect the older adults’ abilities in daily living, emotional states, and other psychosocial functioning, which may trigger their AOD use and abuse, as well as compromise the effectiveness of their AOD treatment (CSAT ). Placement at the Appropriate Level of Treatment

Although it is inconclusive whether older adults experience more severe alcohol withdrawal, per se, than their younger counterparts (Wojnar et al. ), most research agrees that during withdrawal, older patients encounter an increased risk for cognitive and functional injury, such as delirium and falls (e.g., Kraemer, Mayo-Smith, and Calkins ), and potential health problems (e.g., Schucket et al., cited in Arndt, Gunter, and Acion ). Wojnar et al. () found that although there was no significant difference between older and younger patients with respect to the severity and duration of alcohol withdrawal symptoms, older patients had more frequent “concomitant somatic disorders,” “elevated blood pressure,” “hypokalaemia,” and “somatic complications of [alcohol withdrawal]” while they were hospitalized (). The older patients also had a longer hospital stay than their younger counterparts (Kraemer, Mayo-Smith, and Calkins ;

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Wojnar et al. ). It is thus important to refer older clients with alcohol withdrawal to a well-monitored setting (Kraemer, Mayo-Smith, and Calkins ). The shortage of such specialized treatment settings for older adults poses a problem (Arndt, Gunter, and Acion ). Schultz, Arndt, and Liesveld () found that only .% of the , facilities in their study offered elder-specific AOD treatment and that the number of older adults in a state did not necessarily correspond to the number of available elder-specific treatment programs. Therefore, practitioners should also advocate for the expansion of elder-specific AOD treatment in areas where there is a high density of older adults.

Enhancing AOD Knowledge and Offering AOD Education Older adults in general and older women in particular may unintentionally abuse / misuse AOD or have no awareness of such behavior (Clayton et al., cited in Simoni-Wastila, Ritter, and Strickler ; CSAT ; Nemes et al. ). Eliason and Skinstad’s  study found that older women, particularly those who drink moderately or heavily (defined by Eliason and Skinstad as “ or more drinks per week”), tended to drink or use drugs largely because they lacked accurate knowledge about AOD, rather than because of their “deeply entrenched attitudes about alcohol and drug use or alcohol dependence” (). They further found that the women, especially those who initially had greater misconceptions about AOD, made dramatic improvement in their AOD-related knowledge after exposure to the educational program. Eliason and Skinstad thus suggest that educational intervention can be effective in helping older women. The intervention can be offered through individual or group counseling, provided as workshops at local community nursing homes or senior centers, as Eliason and Skinstad did in their study, or combined with other approaches, such as motivational counseling. Educational intervention can cover topics from adverse alcohol-drug and drugdrug interactions, to prescription medication dependence and abuse, to the issue of the beneficial effects of drinking. The idea that women are more vulnerable than men and older adults are more vulnerable than younger adults with respect to the effects and negative consequences of AOD can also be emphasized and explained. One example of such a program is Eliason and Skinstad’s () -minute educational intervention program, which included the following: () definitions of moderate and heavy drinking, () discernment of false information about alcohol, () the effects of aging on the metabolism of AOD, () commonly used medications by older adults and the possible interactions between alcohol and those medications, and () more-functional ways (without using alcohol) to improve sleep and to relieve pain, stress, and boredom, such as proper diet and exercise.

Addressing Issues of Depression, Loneliness, and Boredom Among Older Women As noted earlier, older women are more likely to be late-onset drinkers. Although the etiology is still unclear, one prominent theory is that they drink in reaction to

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the stress induced by negative life events (e.g., loss of relatives and friends, retirement and lifestyle changes) that occur in late life. Empirical studies have identified depression, loneliness, and grief as antecedents to older adults’ AOD relapses, an observation that applies to both early-onset and late-onset older adult drinkers (e.g., Schonfeld and Dupree ). CSAT () emphasized that although younger adults may also drink to cope with negative life events, it is important to discern the different nature of life events between the two populations. The CSAT literature review also showed that older women’s psychoactive drug use may be associated with various stressors occurring during mid- or late life, such as divorce, widowhood, poor health, low income, depression, and anxiety. In fact, older women are about twice as likely as their male counterparts to acquire anxiety disorder, which can be triggered by bereavement (CSAT ). Graham et al. () recommended providing late-onset older adults, who often abuse / misuse AOD to cope with negative or traumatic life events, with emotional support, such as grief counseling, in addition to education about how AOD abuse / misuse affects their health and other areas of their life. Connecting the older women with non-drinking social and leisure activities, as well as a social network, is another strategy to reduce loneliness, boredom, and perhaps depression and anxiety, one that may also serve to redirect the older woman’s involvement with drinking relatives or social circle to engagement with a new, non-drinking social network. In fact, as mentioned earlier, .% of the older adults in Blow et al.’s study () indicated that their drinking involved situations where their spouses, children, and / or grandchildren were drinking.

Connecting Older Patients with Aftercare Although numerous studies have indicated that older substance-abusing clients have equivalent or better treatment compliance than their younger counterparts, research has also revealed that this population may not be as active as their younger counterparts in obtaining “aftercare” after discharge from an inpatient program or a hospital. Oslin et al. () compared elderly clients (N = , . % women) with middle-aged clients (N = ,, . % women) in a residential program for alcohol problems. They found that the middle-aged clients were significantly more likely than their older counterparts to attend aftercare (.% versus .%; p = .). Similarly, Brennan et al. () found that only a small proportion of the older patients continued to receive aftercare after being discharged from inpatient programs. They examined , Medicare patients with substance use disorder discharged from the hospital (, women, mean age = .; , men, mean age = .) and found that during the first  days after the discharge, only .% of the men and .% of the women received “mental health outpatient care” and .% of the men and .% of the women received “non–mental health care with substance abuse diagnosis.” During the first year, the rates were .% for men and .% for women for mental health outpatient care, and .% for men and .% for women for non–mental health care with substance abuse diagnosis.

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Aftercare is critical for long-term recovery, and recent treatment guidelines have stressed the importance of older patients with SUD receiving aftercare (e.g., outpatient mental health service) after discharge from the hospital (Brennan et al. ). It is uncertain why the gap exists between the inpatient program and aftercare received by the older population. Oslin et al. () suspected that the lack of engagement in aftercare on the part of discharged elderly inpatients may be related to older adults’ perception that their AOD problem is not serious enough to require aftercare or to logistical barriers such as health, financial, and transportation problems. It is also possible that practitioners in the hospital and / or AOD treatment programs are biased and perceive older patients as having less-severe AOD problems or less necessity for further treatment, and therefore do not refer the older patients for aftercare. More research needs to be done on the issue of the older population’s low participation in aftercare. In the meantime, practitioners should encourage older patients to attend aftercare and link them with it after hospital discharge. Practitioners should help clients to resolve logistical problems that hamper their access to aftercare (such as transportation) or devise alternative methods (such as telephone consultation) to accommodate individual needs (Oslin et al. ). It may also be helpful to prepare older adult clients for the very different styles of some aftercare self-help organizations (for example, AA’s emphasis on admitting one’s alcoholism, total abstinence, and breaking down one’s denial) or encourage them to form their own age-specific self-help groups if none is available (Brennan et al. ).

Treatment Methods Brief Intervention (BI) and Motivational Interviewing (MI) BI for older people is based on MI and characterized by four essential elements: accepting and motivating the substance-abusing client, providing feedback and AOD education, developing a “contract” with the client, and being brief. Controlled clinical trials have suggested that BI can reduce drinking consumption of older adults as well as younger adults. Fleming et al.’s well-cited  study Project GOAL (Guiding Older Adult Lifestyles) (N =  men and  women, mostly “young-old” adults of – years) reported that older adults receiving BI from physicians significantly decreased their drinking at follow-up. BI participants reduced weekly drinking from . (SD .) drinks at baseline to . (SD .) drinks at three-month follow-up, to . (SD .) at six months, and . (SD .) at twelve months. The respective numbers of drinks for control group participants, on the other hand, were . at baseline (SD .), . (SD .) (three months), . (SD .) (six months), and . (SD .) (twelve months). The BI group was equivalent to the control group at baseline regarding number of weekly drinks, but the BI group made significantly more progress at post-treatment compared to the control group ( p < . in all three follow-up measurements)

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Barry et al.’s () Staying Healthy Project (SHP) extended providers of BI from physicians to social workers and other professionals who work in the community senior centers or older adult health care programs. The results were less straightforward but positive. Unlike Fleming et al.’s study (), Barry et al’s study included more women (N = ) than men (N = ) and a separate gender analysis in addition to the entire pool. The number of drinks consumed weekly by women receiving intervention was . (SD .) at baseline and decreased to . (SD .) at six-month follow-up. Interestingly, the control group women also decreased their weekly drinking, from . (SD .) at baseline to . (SD .) at six-month follow-up. And statistically there was no significant difference in the progress made between the two groups of women. (There was also no statistically significant difference in the progress made between the male intervention and control groups.) Also, the percentage of women who drink excessively (i.e.,  or more drinks per week) decreased from .% at baseline to .% at six-month follow-up in the intervention group, compared to .% to .% in the control group. Again, the difference between the intervention and control groups was not statistically significant. However, the overall intervention group did make significantly more progress than the control group regarding reducing “days drinking liquor” and “beers consumed per day” (:). Barry et al. () explained possible reasons for the non-significant difference between the intervention and control groups in many of the treatment outcomes. Fleming et al.’s () study is an efficacy trial, in that more research-related support was provided to control the rigor of the research design, according to Barry et al. (), plus the interveners were physicians who usually are busier and thus were able to provide intervention only to patients designated as the intervention group. On the other hand, Barry et al. said their study is an effectiveness study, which aimed at how well intervention could be integrated into practice, and less research-related support was provided. Further, social workers may have more time with their clients in general and may have also provided intervention to some participants in the control group, whom they perceived as needing help, in addition to those in the intervention group. The BI protocol adopted by GOAL included “advice,” “education,” and “contracting” components. The physicians who delivered the intervention followed a workbook that covered “feedback on the patient’s health behaviors, a review of problem-drinking prevalence, reasons for drinking, adverse effects of alcohol, drinking cues, a drinking agreement in the form of a prescription, and drinking diary cards” (Fleming et al. :). The physician offered two sessions to the older clients, one BI session and one reinforcement session. Each session lasted – minutes, with a one-month interim between the two sessions. In addition, the clinic nurse called each client two weeks after the client’s session with the physician (Fleming et al. ). A BI session includes nine essential steps (Barry, Oslin, and Blow ): () discuss with the older client how she would like to improve her future life in areas

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of health, relationships, financial stability, hobbies, etc.; () understand and summarize her health habits, beginning with areas unrelated to drinking (e.g., nutrition), followed by the area of drinking; () help her understand what a “standard drink” means, but avoid disputes about the different definition; () compare her drinking pattern with the norms for her age group; () discuss the consequences of her drinking; () discuss how stopping or cutting down on drinking may benefit her regarding physical health, mental capacities, and independent living; () develop a drinking agreement or contract with her, which is similar to a “prescription” form, indicating whether she should stop or reduce drinking, starting when, “how frequently to drink,” and “for what period of time” (:); () help her develop strategies to cope with risk situations, e.g., “social isolation,” “boredom,” and “negative family interactions” (:); and () summarize the session. Follow-up sessions can be conducted using similar steps. For a detailed description of the elder-specific Brief Alcohol Intervention method, see Barry, Oslin, and Blow () (see also chapter  for a discussion of BI).

Cognitive-Behavioral Therapy (CBT) Most researchers and practitioners found the CBT approach useful in helping substance-abusing older clients in addition to younger clients. Blow et al.’s () study (N = , aged over ) indicated that older clients performed better when the baseline (admission) and follow-up (six months after admission) were compared in the areas of “days of drinking,” “general health,” and “psychological distress” measured by the Brief Symptom Inventory, after attending an inpatient elder-specific substance abuse CBT-oriented program. Although regular CBT is basically intended to change behavior through modifying cognition and enhancing skills, and has been applied to adolescents, young adults, and middle-aged adults, Blow et al. () tailored the regular CBT group sessions to specifically fit the needs of older adults. They observed that the older patients shared different issues than their younger counterparts but most traditional treatment groups consisted of mainly younger AOD abusers who were not interested in older adults’ issues. Their elder-specific program emphasized the challenges that older adults face, such as bereavement, loneliness, boredom, and isolation, as well as the association between these issues and AOD use / abuse / misuse. The Gerontology Alcohol Project (GAP), a well-cited program, also adopted CBT in helping late-onset elderly drinkers (Dupree, Broskowski, and Schonfeld ). GAP emphasized four group CBT modules teaching the older adults about and helping them practice: () the “A-B-C” concept (Antecedents, Behavior, and Consequences) and the identification of their own drinking chain, such as the antecedents preceding and the consequences following, their drinking behavior; () skills and methods in managing high-risk situations and antecedents that may lead to abusive drinking, such as “drink refusal or peer pressure,” “cues,” “urges,” “relapse or slipping,” “depression,” “anger / frustration,” and “tension / anxiety”

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(). () alcohol-related information and knowledge, including the theoretical, medical, psychological, and other relevant aspects. () problem-solving skills, including ways to identify a problem, to generate solutions, and to make decisions. In addition, GAP offered a module that enhanced the older adults’ skills in establishing their social activities and social network (see also chapter  for a discussion of CBT). Although both above-mentioned programs are group-oriented, CBT can and should be applied in individual sessions when appropriate, particularly when working with (older) women who often prefer individual counseling to group counseling. In addition, although both programs considered CBT the core treatment method, they nonetheless incorporated other ingredients and components, providing a holistic approach. For example, the Blow et al. program () offered case management services connecting the older clients with community resources in multiple areas (e.g., arranging guardianship, finding nursing homes, etc.); the GAP (Dupree, Broskowski, and Schonfeld ) assessed and helped older clients with problems / abilities related to activities of daily living, memory, communication, and self-esteem.

(Age-Specific) Group Treatment / Counseling The literature has suggested that many substance-abusing women prefer individual counseling to group counseling, probably because of the issues of shame and privacy (see chapter ). Older women may be even more reserved and sensitive in this respect and thus may also prefer individual over group counseling. Fredriksen () discussed experience with the North of Market Older Women’s Alcohol Program (San Francisco) that extended outreach to isolated and impoverished older women with AOD problems, stating that “the majority of program participants still preferred to examine personal recovery issues on a one-on-one basis with an individual counselor” (). She said the preference may be related to privacy and confidentiality. Despite older women’s preference for individual counseling, in reality group counseling has been practiced in many AOD treatment programs, both single gender and mixed gender. Although one of the primary advantages of the group modality is economic, it also provides therapeutic and practical advantages such as hope, universality, socialization, information exchange, and role modeling. In addition, research findings have shown that it takes less time for older adults to develop bonding in groups than it takes their younger counterparts (Finkel, cited in CSAT ). When choosing to implement a group modality, a counselor may consider certain adaptations that may make the situation more palatable to older clients, for example, a “buddy” arrangement, in which a participant is assigned a “buddy” who explains and facilitates activities of the day (CSAT ), or a “peer counselor” system, in which an older recovery adult co-leads the group with a professional and shares his or her recovery experience. The older adult peer

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counselor can bridge the gap between the professional and the clients (Kostyk et al. ). The Elders Health Program (Kostyk et al. ) is a group-oriented AOD treatment program for older adults. The clients were % female with an age range from  to  (mean = ). The four goals of the program are abstinence from alcohol, “responsible use of mood-altering drugs,” life satisfaction, and “reducing consequence of aging” (). To achieve abstinence, the counselor arranges detoxification or inpatient treatment for clients. Abstinence may be waived when the situation justifies it. The program helps older clients taper off mood-altering medications by requiring close supervision by a physician and a program social worker, as well as providing emotional support. The program also encourages clients to improve their quality of life and decrease the negative consequences of aging in addition to AOD recovery, and new and constructive methods are discussed to improve various areas of life. Three phases were involved in helping the clients: () Phase One (the first month) focuses on increasing knowledge about substance abuse and dependence (e.g., medication management, sleep and AOD, psychological aspects of AOD use / misuse). () Phase Two (the second month or so) deals with identifying negative feelings (e.g., losses and anger) and relationship problems and expressing or solving them appropriately. () Phase Three (the last month or so) focuses on lifestyle changes to prevent relapses and maintain ongoing recovery.

An Integrated Approach Older adults can also benefit from an integrated approach in which multiple services, including mental health and substance abuse treatment, are located in one place, i.e., the primary care program. Bartels et al.’s  study (N = , patients with depression, anxiety, at-risk alcohol use, or dual diagnosis, mean age of . years, % women) showed that patients who were randomly assigned to the integrated group had better treatment compliance than patients randomly assigned to the “enhanced referral” group, in which patients were referred out for AOD and / or mental health services and were assisted with scheduling and transportation to the specialty programs. Seventy-one percent of the integrated group eventually engaged in the treatment, as compared to % of the enhanced referral group. The integrated group also performed better with respect to the lapse between their appointment with the primary-care physician and their first attendance at the specialty program: .% of the integrated group patients versus .% of the enhanced referral group (X  = ., df = , p < .) had their first visit to the specialty program within  days. The integrated-group patients also had a significantly higher number of mental health / substance abuse specialty program visits per patient than did patients in the enhanced referral group (M = . SD . and . SD ., respectively, p ≤ .).

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Substance abuse problems among older persons have traditionally been deemphasized by society, but with the aging of the baby boomers, who are known to have a higher AOD use rate than previous cohorts, AOD problems among older people have begun to attract attention. As has research on other age groups, AOD research has been focusing on older men rather than older women. Much research is needed to better understand the needs of substance-abusing older women. Although the research is scant, it still provides certain insights and directions. Older women, as well as older men, are more affected by alcohol and prescription drugs than by illicit drugs because many illicit drug users “mature out” of their drug using or die earlier than the general population as a result of their drug-using lifestyle. Consequences of alcohol / prescription drug misuse may include impairment of activities of daily living, increase of physical diseases, falls and fractures, confusion and cognitive dysfunction, and other mental problems like depression and suicide. Older women tend to be “late-onset” drinkers who drink to cope with midand late-life stressors such as divorce, death of spouse, loneliness, loss of physical health, etc. Older people’s exposure to drinking behaviors in their immediate environment (e.g., spouse and adult children) may also play a role, especially if they are relatively healthy and thus have no concern for the ill impact of alcohol. Older people who enjoyed drinking but have not developed problems before reaching “old age” may be at higher risk for drinking, since they have more time and fewer family or career obligations. Prescription drug misuse / abuse is another major problem for older people, particularly older women. Although prescription drug misuse / abuse tends to be intentional among younger people, it is largely unintentional among older people. Several risk factors are characteristic: (a) older women’s more positive attitude toward prescription drugs, (b) patient-doctor or doctor-doctor miscommunication, (c) a previous AOD history and / or previous exposure to a greater amount and longer duration of use, (d) a current or previous history of psychiatric disorder, and (e) other psychosocial stressors. Although illicit drug abuse is less relevant to older people, it should not be ignored. Older illicit drug users suffer from poor health. They also face double marginality, isolated both from mainstream society and the “new school” of the world of illicit drug use. The following seven guidelines can be useful for helping substance-abusing older women: (a) Emphasize AOD screening and identification among older women, as AOD symptoms may be disguised as aging symptoms and thus go unrecognized. Physicians, professionals in senior centers, family members, and older people themselves should all be involved in screening. (b) Be accepting and respectful to older clients and adapt to their special needs when delivering treatment. (c) Adopt an indirect and flexible approach to engage older adults, by not requiring them to admit their AOD problems as a program working with younger clients would normally do, as well as not requiring total abstinence but

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emphasizing harm reduction and case management during the initial treatment stage. (d) Target health factors. Older adults, particularly women, may be highly motivated to reduce or stop drinking for the sake of their health. They should be placed at an appropriate level of treatment should detoxification be needed. Aftercare should also be emphasized. (e) Enhance older women’s knowledge about AOD. (f ) Address the issues of depression, loneliness, and boredom by providing supportive counseling and facilitating connection to a non-using social network. (g) Apply BI, CBT, self-help groups, and / or an integrated approach, emphasizing adaptation to the special needs of older adults.

Chapter 

Homeless Women

H

omelessness has caught society’s attention in the past fifteen years, particularly because the homeless population has changed from mainly “skid row” single men during the early s to a high percentage of single women and single-parent, female-headed families with children since the s. According to ’s Hunger and Homelessness Survey (U.S. Conference of Mayors ), the homeless population comprised % single men, % families with children, % single women, and % unaccompanied youth. In other words, families with children and single women accounted for half of the entire homeless population. Homeless women are a diverse group with at least two subgroups, solitary (single) women and women with dependent children (North and Smith ). “Solitary” or “single” women are not necessarily women who have never had children; they could be mothers whose children are separated from them. Zlotnick, Robertson, and Tam () indicated that .% of homeless mothers in their study did not have their children with them. One study (Zugazaga ) reported that a homeless mother in a shelter had an average of . children, with a range of  to  children. The average age of the children was . years, with a range of  days to  years. The causes of homelessness are multiple, and a single reason seldom explains why a person or family becomes homeless (Breakey ). Both individual (substance abuse, domestic violence, illness, disability, etc.) and structural factors (increasing poverty, rising housing costs, housing subsidy shortages, racism, inadequate educational systems, etc.) could operate to increase the risk for homelessness (Bassuk et al. ; Breakey ). Substance abuse has consistently been found by numerous studies, especially those since the s, to be a factor in homelessness. O’Toole, Conde Martel, et al. () (N =  homeless men,

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 homeless women) reported that .% of the homeless in their study were afflicted with substance abuse / dependence, which was higher than the %–% range reported by Lehman’s meta-analysis of s data (cited in O’Toole, CondeMartel, et al.) but more consistent with other studies conducted in the s, including .% in an Oakland, California, study and % in a  national homeless persons study. O’Toole, Conde-Martel et al. suggested that a higher percentage of the homeless in the s had substance abuse problems than their counterparts in the s. O’Toole, Conde-Martel, et al. () further considered that the higher substance abuse / dependence rate of homeless individuals in the s was attributable to the increase of drug use. In their study % of their homeless subjects had cocaine abuse / dependence problems and .% had alcohol abuse / dependence problems. This is inconsistent with the historical trend, in which “alcohol disorders far surpassed the proportion with drug disorders” (). O’Toole, CondeMartel, et al. attributed the higher rate of drug use to the lower cost of drugs in the s (e.g., a gram of pure cocaine cost $ in  but $ in ). They further suggested, citing Jencks, that the increase in homeless women and women with dependent children in the s was related to the greater availability of cocaine, especially crack. This chapter focuses on substance-abusing homeless women, both single women and mothers with dependent children. Hereafter, the term “homeless women” refers to both groups; “homeless single women” refers to homeless women unaccompanied by children; “homeless mothers” refers to homeless mothers with dependent children. Drawing upon more than  empirical studies, the chapter discusses how to effectively help substance-abusing homeless women. After a review of the literature, I agree with various authors (Galaif, Nyamathi, and Stein ; Roll, Toro, and Ortola ) who pointed out that few empirical studies focusing exclusively on substance-abusing homeless women and their predicament are available, despite the increasing number of homeless women. Although more women-specific homelessness studies have been conducted since , most large-scale studies still included predominantly men. This chapter strives to cite the women-specific studies, but may include some important studies that cover both genders with women being analyzed separately and / or accounting for at least % of the sample. This chapter first describes the background of homeless women, including their demographic details and history of childhood abuse trauma, their alcohol and other drug (AOD) problems, and their low level of family / social network support and low use of government entitlements, all of which help us understand where the women came from and the possible risk factors that led them into homelessness. Next, it discusses various problems that homeless women may face. It highlights physical and sexual assaults, domestic violence, HIV / AIDS risks, and the

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co-occurrence of problems. A comparison of the different needs of single homeless women and mothers is presented. Treatment guidelines are also included.

Characteristics of Homeless Women Background Demographic Factors Ethnicity

Although homeless women come from all walks of life and all racial backgrounds, studies indicate that African American and Hispanic (primarily Puerto Rican) mothers / women, depending on the geographic area, are more at risk for homelessness than mothers / women of other ethnic groups. This could be attributable to the high poverty rate among minority women / female-headed families. The UCLA Homeless Women's Health Study (HWHS; Arangua, Andersen, and Gelberg ) (N =  homeless women in Los Angeles) indicated that % of the homeless women were African American, % white, % Hispanic, and % Native American / Asian or Pacific Islander / other ethnic group. Wenzel et al.’s study () (N =  sheltered women and  poor housed women in L.A.) reported that .% of the sheltered women were African American, .% white, .% Hispanic, .% Native American, .% Asian / Pacific Islander, and .% mixed / other ethnic background. The Philadelphia study (N = , women of child-bearing age) revealed that more than % of the adult African American women had experienced a “documented homeless episode” during either the three years prior to or the four years after their index birth (in the period from  to ), compared to only .% of the Hispanic women, .% of the white women, and .% of the Asian women (Webb et al. ). Webb et al. showed that although African American women accounted for only % of the cohort (, women of child-bearing age), they constituted more than % of all the homeless episodes occurring between  and . Two studies on homeless mothers were conducted in Worcester, Massachusetts (in  and ); both showed that Hispanic and African American homeless mothers were overrepresented in the population. According to Weinreb et al. (), the  study (N = ) indicated that Hispanic women (primarily Puerto Rican) accounted for .% of the homeless mothers, followed by nonHispanic whites (.%) and African Americans (.%). The  study (N = ) showed that .% of the sample were Hispanic (primarily Puerto Rican), followed by non-Hispanic whites (.%) and African Americans (.%) (Weinreb et al. ). According to the  Census, the Worcester population was .% white, .% Hispanic (“may be of any race”), .% African American,

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.% Asian, .% Native American, and .% Native Hawaiian / Pacific Islander (City of Worcester, Massachusetts, n.d.; it is not clear why the total slightly exceeded %—possibly because some people may have reported more than one race). Parity

Webb et al. () suggested that exposure to homelessness is closely related to the total number of children a woman has, in that a more demanding child-bearing and child-rearing responsibility may put low-income women at higher risk for homelessness. Webb et al. found that .% of the African American women who had had three or more “previous live births” and .% of those who had had four or more “previous live births” experienced homeless episodes during the period of three years prior to and four years after their index birth. Education

Women who completed high school appeared to be less likely to become homeless than women who had less education. Bassuk et al.’s study () (N =  “female-headed homeless families” and  “female-headed poor housed families) showed that .% of the poor housed mothers, compared to .% of the homeless mothers, completed high school ( p < .). Bassuk et al. commented that research has indicated that women with a high school diploma have a better chance of being employed in secretarial or other skilled blue-collar positions, which may enable a single mother to be self-sufficient. Similarly, Wenzel et al.’s () study found that .% of the sheltered women versus .% of the poor housed women had less than a high school education ( p < .). The UCLA HWHS (Arangua, Andersen, and Gelberg ) reported the mean years of education for homeless women as . (SD = .). Consistent with the L.A. studies, Webb et al.’s () Philadelphia study showed that adult child-bearing women with fewer years of education seemed more likely to have homeless episodes than women with more years of education. Two studies indicated otherwise about the relationship between education level and homelessness. Wechsberg et al.’s () North Carolina study showed no significant difference between crack-using African American homeless women (N = ) and their not-homeless counterparts (N = ) regarding their high school graduate / GED status (the rates were .% and .%, respectively, statistically not significant). The difference between this study and the above-mentioned studies is that both groups of women in this study were crack users, while women in the above-mentioned studies may have included users and nonusers. It is likely that the negative effect of crack use in leading to homelessness is so powerful that a woman’s education becomes trivial. Caton and colleagues’ study () (N =  men and  women, single adults homeless for the first time) showed no relationship between the participants’ high school graduate status and the number

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of days being homeless (within an -month follow-up period). Among the differences between Caton et al.’s study and the above-mentioned studies is that Caton et al.’s study included both men and women (and did not analyze women separately), while the other studies covered only women. Gender may play a role in the relationship between education level and homelessness. More research is needed in this regard. Employment History

Caton et al.’s study () suggested that homeless individuals who are employed at shelter admission tended to have a shorter duration of homelessness than their unemployed counterparts (median =  days and  days, respectively, p < .). In addition, homeless individuals who were not currently employed but had a previous history of employment were more likely than their counterparts without such a history to have a shorter duration of homelessness (median =  days and  days, p < .).

AOD Abuse and Dependence High Drug Prevalence Rate

Perhaps because of the various methodologies used, AOD abuse / dependence rates among homeless women have not been completely consistent. Overall, although homeless men have a higher AOD rate than homeless women, homeless women’s AOD rates are not necessarily low and cannot be ignored, particularly their drug abuse / dependence rates. For example, Geissler et al.’s () (N =  women and  men) study indicated that .% of the homeless male participants had alcohol problems, compared to .% of the homeless female participants ( p < .). Of the homeless female participants, .% had drug problems, compared to .% of the homeless male participants ( p < .). In addition, Wenzel et al. () found that about % of the homeless women reported alcohol dependence in the preceding year and % of them reported drug dependence. The lifetime prevalence of the homeless women for alcohol abuse / dependence was % and % for drug abuse / dependence, according to Bassuk et al.'s study (). Nyamathi et al.’s () study (N = , homeless women in L.A.) indicated that % of the homeless women reported daily alcohol use and % reported daily drug use. The UCLA HWHS (Arangua, Andersen, and Gelberg ) reported AOD problems prevalent among homeless women, with % of the homeless women having “a lifetime history of alcohol abuse / dependence” and close to % of them having “a lifetime history of drug abuse / dependence” ().

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Higher AOD Rates Than Poor Housed Women or Women in the General Population

Wenzel et al.’s study () showed that with regard to AOD use and disorders in the preceding year, sheltered women had a significantly higher rate than the low-income housed women for binge drinking (.% versus .%, p < .), alcohol dependence (.% versus .%, p < .), drug use (.% versus .%, p < .), and drug dependence (.% versus .%, p < .). Likewise, a Massachusetts study (Bassuk et al. ) reported that homeless mothers had a significantly higher rate than low-income housed mothers of “frequent alcohol use” (.% versus .%, p < .), “frequent cocaine use” (.% versus .%, p < .), “frequent marijuana use” (.% versus .%, p < .), “frequent heroin use” (.% versus .%, p < .), and “ever injected drugs” (.% versus .%, p < .) (). Bassuk et al.’s logistic regression model confirmed that “frequent alcohol use” and “frequent heroin use” independently predicted mothers’ homeless status (). Tuten, Jones, and Svikis () reported that homeless pregnant women spent more money on daily cocaine use ($ versus $, p = .) and had a greater amount of daily alcohol use (. ounces versus . ounces, p = .) in the preceding thirty days than domiciled pregnant women. Nyamathi et al’s L.A. study () further indicated that the drug most used daily by homeless women was crack, followed by marijuana, cocaine, heroin, and methamphetamine (%, %, %, %, and %, respectively). Also, research showed that single homeless women had a higher AOD rate (as well as a higher rate of other psychiatric disorders) than homeless mothers, although homeless mothers still had a higher AOD rate than women in the general population (see Bassuk et al. ).

High Prevalence of Adverse Childhood Experiences (ACEs), Psychiatric Disorders, and Other Vulnerabilities History of Childhood Abuse Trauma and / or Other ACEs

ACEs may lead to adulthood homelessness, particularly when an ACE interacts with negative social and structural factors such as unavailability of affordable housing, a lack of employment, etc. (Herman et al. ). As described in chapter , an ACE is any of the following ten categories of adversity: verbal abuse, physical abuse, sexual abuse, physical neglect, emotional neglect, spousal abuse between parents, parental divorce or separation, household substance abuse, mental illness in the family, or incarcerated family members (Felitti and Anda ). ACEs initially influence a person’s cognitive, emotional, and other functions during early development, which, in turn, causes the person to make wrong decisions and adopt risky behaviors that further create diseases and disabilities in the person and that ultimately can lead to an early death (Felitti and Anda ; Felitti et al.).

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Homeless women are more likely than women in the general population or low-income housed women to have a history of childhood abuse and / or other ACEs (Bassuk et al. ; Herman et al. ; Wechsberg et al. ; Wenzel et al. ). Wechsberg et al. reported that homeless women were more likely than non-homeless women to have experienced childhood emotional abuse (.% versus .%, p < .), childhood physical abuse (.% versus .%, p < .), and childhood sexual abuse (.% versus .%, p < .). Consistently, Wenzel et al. showed that compared to low-income housed women, sheltered women had a significantly higher rate of childhood physical abuse (.% versus .%, p < .), childhood sexual abuse (.% versus .%, p < .), and childhood psychological abuse (.% versus .%, p < .). Bassuk et al. () also reported that homeless mothers had a significantly higher “ever in foster care” rate (.% versus .%, p < .) and rate of “primary female caretaker used drugs” during participant’s childhood (.% versus .%, p < .) than the poor housed mothers, although both groups had similar high rates of childhood physical and sexual abuse. Stein, Leslie, and Nyamathi’s study () (N =  homeless women in L.A.) also found that childhood maltreatment directly predicted chronic homelessness as well as other adulthood difficulties such as depression, lower self-esteem, and physical abuse. The impact of ACEs appears to better explain the occurrence of homelessness among women than men. Homeless women are more likely than homeless men to have been physically or sexually abused during childhood and to have lived in foster care. For example, Zugazaga () reported that .% of the single homeless women (n = ) and .% of the homeless mothers (n = ) versus only .% of the single homeless men (n = ) had a history of childhood physical abuse ( p < .); .% of single homeless women and .% of homeless mothers versus .% of the single homeless men had a history of childhood sexual abuse ( p < .); .% of the single homeless women and .% of the homeless mothers versus .% of the single homeless men had ever lived in foster care. One may argue that the disparities of childhood abuse rates between homeless men and women reflect the disparities between men and women in the general population, since women already have a higher childhood abuse rate than men. However, the studies examined did show that homeless women are significantly more likely than other women to have a history of childhood abuse or to experience ACEs, but research comparing homeless men and other men regarding ACEs is lacking. Further investigation of these issues is needed. Caton et al.’s () study may at least partially help clarify the issue. Caton et al., the only study reviewed that indicated findings contrary to the above-mentioned multiple studies (e.g., Stein, Leslie, and Nyamathi ), found no relationship between homelessness and ACEs. The major difference between Caton et al.’s study and the other studies was that Caton et al. included both homeless men and homeless women while the others included only homeless women.

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Mental Disorders

Homeless men are more likely to have psychotic disorders, while homeless women are more likely to have affective disorders. Lauber, Lay, and Rössler’s () study (N =  homeless women and  homeless men) reported that .% of the homeless male participants had “schizophrenia and other psychotic disorders” compared to .% of the females ( p < .). On the other hand, only .% of the homeless male participants had affective disorders, compared to .% of the females ( p < .). Weinreb et al. () found that homeless mothers (N = , Worcester, Massachusetts) in , compared to their counterparts in  (N = ), reported a significantly higher rate of “current major depression episode” (.% versus .%, p < .), “history of major depressive episodes” (.% versus .%, p < .), current post-traumatic stress disorder (PTSD) (.% versus .%, p < .), and history of PTSD (.% versus .%, p < .) (). Tuten, Jones, and Svikis () found that homeless pregnant women were significantly more likely to report anxiety than the domiciled pregnant women, both lifetime (.% versus .%, p = .) and in the preceding thirty days (.% versus .%, p = .). Bassuk et al.’s () study revealed that homeless mothers were significantly more likely than poor housed mothers to have been “hospitalized for mental health problems” (.% versus .%, p < .). “Hospitalized for mental health problems” was defined as “ years before most recent homeless episode” for homeless mothers and “past  years” for housed mothers. Bassuk et al.’s multivariate logistic model confirmed that a record of “hospitalized for mental health problems” independently predicted the status of homelessness (). Coping Skills

Caton et al.’s study () showed that homeless individuals with a more functional coping ability and ego strength tended to have a shorter duration of homelessness. Caton et al. used the Modified Erikson Psychosocial Stage Inventory to measure psychosocial adjustment. The inventory “assesses the strength of psychosocial attributes in adulthood that might reflect successful progression through Erik Erikson’s  stages of personal development”; sample questions included “I have discovered no mission or purpose in life” and “I stick with things until they’re finished” ().

Low Support from Family and Other Social Networks, Along with Low Use of Government Entitlements Low Level of Support from Family and Other Social Networks

The literature has documented the significance of social network support for poor women afflicted with multiple life stressors, including a lack of housing. Empirical studies consistently suggested that homeless women have a poorer relationship

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with their social network than do their housed counterparts (e.g., Bassuk et al. ; Tuten, Jones, and Svikis ). Bassuk et al. () found that homeless women had significantly fewer network members (defined as a nonprofessional in the network before the woman became homeless) than housed women (. versus ., p < .). Not only did they have fewer network members but their relationships with their network members tended to be more conflicted than the relationships of housed women had with their networks ( p < .). Bassuk et al.’s multivariate model found that both the number of network members and the degree of conflict attached to the women’s relationships with their network members predicted the occurrence of homelessness. Similarly, Tuten, Jones, and Svikis’s () study showed that .% of the homeless pregnant women (N = ) reported a “close long-term relationship” with their mothers versus .% of the domiciled pregnant women (N = ) ( p = .). Homeless pregnant women also had a significantly lower rate of having a “close long-term relationship” with their father than their domiciled counterparts (.% versus .%, p = .). They were also more likely to report lifetime serious conflict with their mother (.% versus .%, p = .) and serious conflict with their mother in the past thirty days (.% versus .%, p < .). Caton et al. () found that homeless individuals with “adequate family support” had a shorter duration of homelessness than those with inadequate family support ( p < .). Family support was rated “on the basis of material support (e.g., provision of housing, food, clothing, or money), companionship, and emotional support” (). Homeless women and families may have few or poor relationships with a social network for multiple reasons. The women’s AOD problems may impair the trust relationship between the two parties. The women’s families of origin may be dysfunctional and have little support to give. Page and Nooe’s () review showed that many young homeless women or mothers came from single-parent, female-headed, homeless families and that they themselves had experienced homelessness since childhood or been placed in foster care. The unstable and poor social network among these women could have been a result of such intergenerational homelessness. It is also possible that some homeless individuals may have come from out of state and may have lost contact with their families or their previous social network Low Utilization of Government Entitlements

Although some studies suggested that public assistance may be harmful to the urban poor because of the possible misuse of it to engage in risk behaviors such as drug purchase and drug overdose (e.g., Phillips, Christenfeld, and Ryan ; Shaner et al. ), many studies pointed out that the urban poor benefit from public assistance (e.g., Norris et al., Podus et al., Speiglman et al., and Swartz et al., cited in Riley et al. ). Riley et al.’s study (N = , adults in San Francisco

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–, % women; % of them “were ever homeless,” and % of them had income mainly from subsidies [MS]) revealed a link between the receipt of government subsidies and positive behavior among the urban poor in several respects: () the MS individuals were less likely to receive income from sex or drug trading and / or to engage in drug injection; () the MS individuals were more likely to sleep in a hotel or shelter than on the street (after the data were adjusted for the factor of HIV infection); and () the MS individuals were less likely to have recently been incarcerated. The data showed that homeless women were less likely than poor housed women to have received government entitlements such as Medicaid, cash assistance, food stamps, or other housing subsidies. Tuten, Jones, and Svikis () reported that homeless drug-dependent pregnant women had a significantly lower average “income from social services” than their domiciled counterparts ($ versus $, p = .). Wechsberg et al.’s multivariate model () indicated that having an income below $ in the preceding month predicted women’s homelessness ( p = .), while receiving welfare income in the preceding month predicted women’s non-homelessness ( p = .). Likewise, Bassuk et al.’s () study showed that poor housed mothers were more likely than homeless mothers to have received AFDC (.% versus .%, p < .), child support (.% versus .%, p < .), and housing subsidies (.% versus .%, p < .). Bassuk et al.’s multivariate model further confirmed that “receiving AFDC” and “receiving housing voucher” are two factors that protect families from becoming homeless (). Page and Nooe () found that only about half of the single homeless women in their study had Medicaid, although many had health problems. Nwakeze et al. () (weighted sample N =  adults attending two soup kitchens in New York City, % female) found that about half of the participants did not have Medicaid, about half did not have food stamps, and % did not have either. Nwakeze et al. reported that the domiciled subjects had the highest Medicaid-receiving rate, followed by the unstably housed subjects and the literally homeless (%, %, and %, respectively). The same pattern applied to rates of food stamp receipt (%, %, and %, respectively). The statistics showed that all three disenfranchised groups had low use of Medicaid and food stamps, with the homeless individuals being the least likely to receive the benefits. Why do homeless women have a low usage rate of government entitlements? Experts offered some possible explanations. One study indicated that % of the original Temporary Assistance for Needy Families (TANF) recipients left TANF because they were sanctioned, and another study found that % of the families who were removed from TANF rolls had no idea what they needed to do to comply with the rules (see Page and Nooe’s review ). Nwakeze et al. considered the low use of Medicaid and food stamps by homeless individuals puzzling, because those are two government entitlements that are not affected by the  Welfare Reform Act and that fulfill basic health and nutritional needs. They

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proposed three explanations for such low usage: () homeless individuals have a lower sense of self-efficacy, owing to their being unable to fulfill their basic needs, and that may lead to deficient service-seeking behavior, even if they are actually in an environment filled with resources; () agency bureaucracy and staff insensitivity and discrimination may discourage homeless individuals from seeking services; and () homeless individuals may consider their housing needs the top priority and Medicaid and other entitlements (such as food stamps) secondary and thus may not pursue the secondary needs.

Problems Experienced by Homeless Women High Prevalence of Physical and Sexual Assault Physical Assault

Both homeless women and homeless men experience high rates of physical assault, primarily because they have no shelter to serve as protection. Kushel et al.’s () multivariate model analysis of homeless / marginally housed adults in San Francisco (N = ,, .% women) reported that homeless / marginally housed women and men experienced high rates of physical assault during the preceding year (i.e., .% for women and .% for men, no statistical difference). The women’s physical assault rate in Kushel et al.’s study was similar to the % rate reported by the UCLA HWHS (Arangua, Andersen, and Gelberg ). Geissler et al. () also reported no significant difference between homeless men and women regarding “ever assaulted” (.% for women and .% for men). Sexual Assault / Rape

Homeless women, however, are much more likely to be raped than homeless men are. They are also more likely to be raped than poor housed women are. Kushel et al.’s () multivariate model analysis revealed gender to be related to sexual assault. Homeless / marginally housed women had a significantly higher rate of sexual assault (during the preceding year) than their male counterparts (.% versus .%, p < .) (Kushel et al. ). The UCLA HWHS reported that about % of the homeless women experienced sexual assault (Arangua, Andersen, and Gelberg ), a rate similar to that of Kushel et al. Kushel et al. () further noted that the housing status factor strongly affected whether a woman would be sexually assaulted, but that relationship did not exist for men. Similarly, but with a greater margin between the women’s and men’s rape rates, Geissler et al. () reported that the homeless women in their study experienced a much higher rate of rape (lifetime) than homeless men (.% versus .%, p < .). Various other studies also found a higher rape rate among homeless women than among low-income housed women (e.g., Tucker, Wenzel, et al. ; Wenzel et al. ). Kushel et al. () suggested that “women

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may have more to gain in terms of protection from sexual victimization by being housed” (). Domestic Violence (DV)

Not only are homeless women likely to encounter physical and sexual assaults by strangers, but they are at high risk for domestic violence (DV). The literature indicates a close link between poverty and DV, although DV is not limited to the impoverished population (see Stainbrook and Hornik’s review ). It’s not surprising to see a high DV rate among homeless women, as they are the poorest of the poor and many of them may still be in contact with their former partners or may have just recently left an abusive relationship. One study showed that women in homeless shelters who reported having experienced partner violence during their lifetime could be as high as %, and those who had experienced partner violence during the preceding three months could be as high as % (Stainbrook and Hornik ). Another study (Tucker, Wenzel, et al. ) found that although homeless / sheltered women were more likely than low-income housed women to report that their worst violent episode experienced during the preceding six months involved strangers, a large portion of both groups reported that their worst violent episode in the past six months involved a former or current partner (% for housed and % for sheltered). Homeless mothers may experience a higher rate of domestic violence than single homeless women, probably because of their having young children and therefore having more frequent contact with the father. Roll, Toro, and Ortola () found that homeless mothers reported the highest rate of physical assaults (including domestic violence), followed by single homeless women and single homeless men (%, %, and %, respectively, p < .).

High Prevalence of HIV Risk Behavior Homelessness increases the risks for women to engage in trading sex for survival or drugs, which in turn increases HIV / AIDS risk. Involvement of AOD use / abuse (particularly crack) before or during sex further increases the risk for unsafe sex practice (Wechsberg et al.’s review ). Thus substance-abusing homeless women are the most vulnerable group compared to other groups of women for HIV risk behavior. Multiple Sex Partners

Sheltered / homeless women are more likely to have multiple sex partners than nothomeless women. Wenzel et al.’s study () showed .% of the sheltered women, compared to .% of the low-income housed women, had multiple sex partners in the preceding twelve months ( p < .). Similarly, Wechsberg et al.’s study () reported that crack-using homeless African American women were

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more likely to have multiple partners than their not-homeless counterparts (.% versus .%, p < .). Injection Drug User (Self or Partner)

Sheltered / homeless women are more likely to be injection drug users (IDU) or to have a partner who is IDU than their not-homeless counterparts. Wenzel et al.’s study () revealed that .% of the sheltered / homeless women used injection drugs during the preceding twelve months, compared to % of the not-homeless women. In Wechsberg et al.’s () sample, both homeless and not-homeless African American crack-using women had a relatively higher rate of being “ever injected” (.% for the homeless and .% for the not-homeless women); in addition, .% of the homeless, crack-using African American women versus .% of their not-homeless counterparts had IDU partners ( p < .). Need-Based Partners and Trading Sex for Money, Food, Shelter, and / or Drugs

Wenzel et al. () found that .% of the sheltered women participants had “need-based partners,” while only .% of the low-income housed women did ( p < .). Similarly, but with a much higher rate for both groups, Wechsberg et al. () reported that .% of the homeless subjects (African American crack-using women) traded sex for shelter, food, and / or money compared to .% ( p < .) of their not-homeless counterparts. The homeless subjects also had a higher rate of “trading sex for drugs” than their not-homeless counterparts (.% versus .%, p < .). Unprotected Sex

Wenzel et al. () reported that .% of the sheltered women versus .% of the low-income housed women used no condom with casual partners ( p < .). For crack-using African American women, homeless or not, the unprotected sex rate was extremely high. Wechsberg et al. () reported that both groups indicated a high rate of having “any unprotected sex” (.% for the homeless group and .% for the not-homeless group) and having “any unprotected vaginal sex (.% for the homeless group and .% for the nothomeless group) ().

High Rates of Suicidal Thoughts and Attempted Suicide Tuten, Jones, and Svikis () reported that homeless drug-dependent pregnant women had a significantly higher rate of “serious thoughts of suicide” than their domiciled counterparts both lifetime (.% versus .%, p < .) and in the preceding thirty days (.% versus .%, p < .). They were also more likely to attempt suicide than their domiciled counterparts (lifetime rate: .% versus

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.%, p = .; past thirty days rate: .% versus .%, p = .). Geissler et al. () reported that the “seasoned homeless” women in their study had a significantly higher “ever attempted suicide” rate than the “newly homeless” women (.% versus .%, p < .) (). “Seasoned homelessness” was defined as having been homeless for more than six months during their lifetime.

High Prevalence of Co-occurring Problems Not only are homeless women more likely than not-homeless women to encounter physical / sexual abuse / domestic violence, to engage in HIV risk behaviors, and to have AOD problems, but they are also more likely than not-homeless women to have all those problems simultaneously and thus place themselves in an extremely difficult and dangerous situation. Wenzel et al. () stated that sheltered / homeless women were significantly more likely than low-income housed women to report co-occurring problems, whether using a liberal or a more stringent definition for each of the problems. When liberal definitions (“any drug use, any violence, and any HIV risk behavior”) were applied, sheltered / homeless women were “four to six times more likely” to suffer multiple problems than poor housed women; when stricter definitions (“drug dependence, major violence, and multiple HIV risk behaviors”) were applied, sheltered / homeless women were “– times more likely” to experience multiple problems ().

A Comparison of Single Homeless Women and Homeless Mothers Demographic Backgrounds Numerous studies have shown that homeless mothers are more likely than single homeless women to be African American or non-white and to be younger (Kreuger, cited in Butler ; North and Smith ; Zugazaga ). For example, Zugazaga’s study indicated that .% of the homeless mothers versus .% of the single homeless women were nonwhite. In Zugazaga’s study the mean age for homeless mothers was . (SD .), while the mean age for single homeless women was . (SD .) ( p < .). North and Smith found that homeless women in their sample were more likely than homeless men to have children in their custody; the women were also younger than the men, more likely to belong to a racial minority, and more likely to depend on welfare.

AOD Problems Numerous studies have suggested that single homeless women are more likely to have AOD problems than homeless mothers (Johnson and Kreuger, cited in Butler ; North and Smith ; Page and Nooe ; Roll, Toro, and Ortola ; Zlotnick, Robertson, and Tam ; Zugazaga ). For example, Roll, Toro, and Ortola () reported that single homeless men had the highest rate of meeting the AOD diagnostic criteria, followed by single homeless women and

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then homeless mothers (%, %, and %, respectively, p < .). Zugazaga’s Florida study () showed a similar trend, with single homeless men having the highest AOD rate, followed by single homeless women and then homeless mothers (.%, .%, and .%, respectively, for alcohol abuse, p < .; .%, .%, and .%, respectively, for drug abuse, p < .). One possibility is that homeless mothers who abuse AOD are more likely to have their children removed from them and they therefore become “single homeless women.” As Zlotnick, Robertson, and Tam’s () study indicated, women who lost their child custody rights during their participation in the study were more likely to be those who had current substance use disorders (particularly alcohol use disorders) or those who had used drugs recently.

Psychiatric Problems and Duration of Homelessness Not only do single homeless women tend to have a higher AOD rate than homeless mothers do, but various studies also found that single homeless women were more likely to have psychiatric problems or hospitalization and / or to experience chronic homelessness than homeless mothers are (Johnson and Kreuger, cited in Butler ; North and Smith ; Page and Nooe ; Zugazaga ). Johnson and Kreuger’s study (N =  homeless women in Missouri) found that single homeless women were more likely than homeless mothers to “have been hospitalized for psychiatric problems” and to “have had recent contact with a mental health professional” (–). Similarly, North and Smith’s study () revealed that solitary homeless women were more likely than homeless mothers to have a history of schizophrenia. Various studies indicated that single homeless women had a longer duration of homelessness than homeless mothers and / or that both groups had a shorter duration of homelessness than homeless single men (e.g., Johnson and Kreuger, cited in Butler ; Morris ; North and Smith ). Zugazaga’s study revealed a similar trend in that the mean “lifetime years homeless” was , days for single homeless men,  days for single homeless women, and  days for homeless mothers; although the difference between men and women was significant, the difference between the two groups of women was not. Zlotnick, Robertson, and Tam’s () study suggested an association between chronic homelessness (being homeless ≥ one year) and homeless mothers whose children were separated from them. Zlotnick, Robertson, and Tam reported that parents who experienced a long duration of homelessness may have had other problems that contributed to parental neglect.

Physical Assault (Including Domestic Violence) As mentioned earlier, Roll, Toro, and Ortola’s () study indicated that homeless mothers experienced a higher rate of physical assault (including DV) than single homeless women and single homeless men (%, %, and %, respectively, p < .). Roll, Toro, and Ortola said the higher physical assault rate among homeless

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mothers than among single homeless women could be the result of the homeless mothers’ having had more recent contact with the children’s father.

Intervention and Treatment Guidelines A holistic approach is advocated for working with substance-abusing homeless clients in general and women in particular. Homelessness and AOD issues must be addressed simultaneously by professionals working in the field of AOD treatment, at homeless projects, or in other community programs that have contact with homeless individuals. Some of the guidelines discussed below are particularly applicable to homeless women, but some may be applicable to both women and men. General guidelines for programs working with any substance-abusing women were presented in chapter  (e.g., offering gender-specific groups, making individual counseling available, having residential treatment as an option, using a nonconfrontational approach, adopting a “one-stop-shopping” model, etc.). Readers are encouraged to view the specific guidelines discussed in this section in concert with those general guidelines. In addition, since substance-abusing homeless women may overlap with women in other roles, such as pregnant women, mothers in the child welfare system, or prostitutes, readers are encouraged to supplement the treatment guidelines for this population with those developed for those other populations whenever relevant.

Triaging New Homeless Admissions and Providing Suitable Treatment Screening for AOD / Mental Disorders /Violent Trauma and Referring At-Risk Clients for Treatment Many homeless individuals are afflicted with AOD problems, but it may be more difficult to connect homeless substance abusers to treatment than it is to help nonhomeless substance abusers. Homeless substance abusers may struggle constantly with a lack of housing and other daily survival needs and thus be forced to make everything else secondary, including substance abuse, mental health, and violent trauma issues. A transient and unstable lifestyle also makes it harder for treatment professionals to reach homeless substance abusers. Homeless shelters, soup kitchens, and day centers where most homeless people are likely to gather could therefore serve a critical role in promoting AOD treatment for homeless substance abusers by identifying and referring those who are at risk. Wenzel et al. () said that screening for AOD / mental disorder / violent trauma could be arranged upon women’s arrival at the homeless shelter. Screening should be followed by referral to the appropriate services and treatments, and

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a positive screen must not be used to bar women’s admittance to the homeless shelter. Staff in homeless programs must be equipped with knowledge and skills in AOD / mental disorder / violence trauma screening and referrals. A plan that effectively helps substance-abusing homeless clients must address the client’s substance abuse / mental disorder / violence experience and his or her homelessness.

Triaging Clients to Offer Strategic Service to Expedite Their Exit from Homelessness Caton et al.’s () study identified several characteristics that are associated with a shorter duration of homelessness: younger age, “no current drug treatment,” “no arrest history,” a functional psychosocial adjustment, an employment history (recent / current), and sufficient family support (). Caton et al.’s Cox regression further confirmed that the factors of age and arrest history predict a homeless individual’s length of homelessness. That study thus suggested that homeless clients with the characteristics linked to shorter duration of homelessness could benefit from job search assistance, temporary cash assistance, and other services that promote a fast track to exiting homelessness. On the other hand, Caton et al. suggested connecting homeless individuals who are older and / or have a history of arrest with special services, which can put the client on a faster track for reentry into housing.

Enhancing Women’s External and Internal Resources: A Case Management Approach Case management is critical in helping impoverished clients, particularly homeless clients. Mercier and Racine’s () literature review identified several principles for effective case management with homeless clients: () building trust relationships with clients; () going beyond service coordination to provide direct services, because clients’ needs may be complex and multiple and community resources may be lacking; () offering tangible benefits before moving into clinical service and long-term goals; () providing services in clients’ “daily environment” instead of in “clinical settings”; () maintaining service continuity, possibly including daily contact over an unrestricted period; () allowing a high staff-to-client ratio, since homeless individuals’ needs may be complex and demand extra time on the part of the practitioner; () understanding that no case management service can substitute for a home and that being short of housing undermines the potential success of many case management services. Thus, linking clients to housing should be among the top priorities. Case management can be applied to increase homeless women’s external, as well as internal, resources.

Increasing Women’s External Resources Practitioners can help homeless women to strengthen their external resources in at least three ways: linking them with government entitlements; reconnecting them

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with their non-AOD-using families, friends, and / or other social networks; and making available a surrogate social network if a natural one does not exist. The reasons for homelessness are often multiple, nonlinear, and interactive. Enhancing “social / community resources” and “a support network” for homeless clients could be as important, or more important, than helping them with their addiction problems. This is particularly true for homeless families (Bassuk et al. ). Numerous studies have reported that government entitlements and cash assistance can delay or prevent poor individuals / families’ entry into homelessness. Trained staff should be housed in, or work closely with, shelter programs to advocate for and connect homeless women with Social Security Income, Social Security Disability Income, TANF, Medicaid, food stamps, housing subsidies, General Assistance, and / or other cash assistance. Clients will need help in clarifying TANF rules, as well as ways to overcome barriers that prevent them from getting the benefits to which they are entitled. Before government entitlements can be secured or restored, the staff may need to help homeless clients apply for identification cards, since many homeless people lose identification documents because of their unstable and sometimes chaotic lifestyle (Kurtz et al. ). Applying for or retrieving identification documents can be a tedious procedure, and shelter staff must be trained in the appropriate protocols for getting that done. Family and social network support are important in helping poor women to stay housed or helping homeless women to exit homelessness sooner. Thus, it is beneficial for practitioners to facilitate the communications between homeless women and their families or social network with the aim of restoring the relationships between the two. There are two conditions in this regard: () the family and social network must be non-AOD-using, for to reconnect a woman with her AOD-using family / social network is to set her up for relapse; and () the woman must become sober before the practitioner undertakes the work of reconnecting the woman with her family / social network. Zlotnick, Tam, and Robertson’s () study found that the support of family / social network will function only when the homeless individual is currently without substance use disorders. For individuals with current substance use disorders, it appears that the family and social network support does not affect their exit from homelessness (Zlotnick, Tam, and Robertson ). Since the sample for that study comprised about % women and % men, gender may have had an impact here. Further research is needed to investigate that effect. Some homeless individuals or families may come from out of state, may have lost contact with their families or their previous social network, or may come from dysfunctional families who can offer little support. The availability of a surrogate social network that consists of professionals and case managers could be the only possible vehicle for linking homeless individuals and families with mainstream society. Savarese et al. (cited in Mercier and Racine ) suggested that agency staff should play the role of a surrogate social network for women who do not have a family or are lacking a social network.

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Enhancing Women’s Internal Resources Practitioners can help homeless women to enhance their internal resources in at least three ways: helping them deal with depression, PTSD related to childhood and / or adulthood victimization, and other mental disorders; empowering them and helping them to develop active coping strategies, spirituality, employability, education, self-sufficiency, and self-esteem; and conveying harm-reduction messages with respect to HIV / AIDS risks and violence avoidance / minimization. The literature has consistently suggested that depression is more prevalent among women than among men in the general population and that substance-abusing women have a higher depression rate than non-substanceabusing women. Depression and other psychiatric disorders may be even more debilitating for substance-abusing homeless women and mothers because of the high prevalence of childhood and adulthood traumas in this population. Galaif, Nyamathi, and Stein () found that depression was strongly associated with homeless women’s current drug use and other drug problems. Depression could be an even more serious problem for homeless mothers because of their child care responsibilities. Research has demonstrated the strong negative impact of maternal depression on children’s well-being and development (Weinreb et al.’s review ). Maternal depression may lead indirectly to maternal AOD abuse, which is one of the most frequently cited factors that precipitate the removal of children from biological families and their placement in the foster care system (Zlotnick, Kronstadt, and Klee, cited in Zlotnick, Robertson, and Tam ). Zlotnick, Robertson, and Tam found that a homeless mother “having a current substance use disorder” independently predicted the separation of at least one child from her during a fifteen-month study period. Despite the direct and indirect negative impact of maternal depression on children, research has indicated that “homeless mothers with depression are unlikely to receive mental health services” (Zima et al., cited in Weinreb et al. :). Perhaps because of limited funding, different program missions and philosophies, and competing program goals, many shelters do not offer mental health services to homeless women or address their childhood / adult traumas. Stainbrook and Hornik () compared homeless shelters with DV shelters in three counties in New York. They found that although both the homeless shelter mothers and the DV shelter mothers shared high rates of lifetime and childhood traumas, % of the Phase II homeless shelter mothers had experienced partner violence, and % of them had suffered partner violence in the preceding three months, only the DV shelters tackled women’s trauma and violence issues. Both the homeless shelter staff and AOD treatment professionals must be trained to become sensitive to and be able to screen homeless women for depression, suicidal thoughts and attempts, childhood trauma, and adult violence and victimization. Appropriate psychiatric and specialized assessment, treatment, and / or referrals must be made available to the women if a positive screen is found. Supportive survivors’ groups and supportive individual counseling may also be provided.

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It is important to link women with both acute and follow-up care in order to help them deal with the trauma of rape. The acute care for rape victims may include elements of “identification and treatment of injuries,” “diagnosis and treatment of sexually transmitted infections (STIs),” “prophylaxis against STIs,” “prevention of pregnancy,” “the documentation of examination findings and collection of material for forensic analyses,” “emotional support,” and “a care plan for further evaluation” (Ackerman et al.'s review :). Follow-up care covers “review of test results for STIs,” “repeat pregnancy testing,” “further management of injuries,” “discussion of legal issues,” and “counseling” (). The Ackerman et al. review showed that it is critical for rape victims to receive treatment and counseling, because more than half of the victims develop PTSD and / or depression after the sexual assault and if they do not receive treatment for PTSD, they may develop various psychiatric symptoms, including anxiety, panic disorder, major depression, somatic complaints, and AOD abuse. Homeless individuals with a higher level of psychosocial functioning and a more positive coping style are less likely to resort to drug use or have drug problems (Galaif, Nyamathi, and Stein ) and more likely to exit from homelessness within a shorter period of time (Caton et al. ). Practitioners can empower homeless women by equipping them with a more positive coping style that emphasizes facing the problem, getting informed about the problem, and developing and sticking to a plan to solve the problem (Galaif, Nyamathi, and Stein). This is particularly relevant to homeless women because they are often situated in a tension-laden environment and have to constantly face multiple stressors. Greene et al.’s () qualitative study suggested that spirituality could be powerful in healing substance-abusing homeless women whose adverse childhood experiences often kept them from developing a pro-social lifestyle and left them with poor decision-making abilities. The women in Greene et al.’s () study stated that “God and faith were involved with their abstinence, the fact that they had not died from drugs, homelessness or suicide, and that they looked to their faith to guide their parenting” (). For some women, spirituality can play a powerful role in enhancing their inner strength. Opportunities should be offered to link the women to the development, discovery, or rediscovery of spirituality. Empowering homeless women with adequate employability skills and education preparation is also critical because both can foster self-confidence, self-sufficiency, self-assertiveness, and self-esteem, all of which are likely to contribute to the women’s exit from homelessness and to prevent them from engaging in unsafe sex and AOD abuse. Shelters are opportune places not only to help homeless individuals with their addiction and / or mental and health issues but also to provide them with educational and skill-building opportunities (Wechsberg et al. ). Staff in homeless settings such as shelters, soup kitchens, and drop-in centers (as well as staff in AOD treatment settings) can implement the empowerment theme through individual counseling and group-oriented treatment strategies and by connecting the women with vocational and education training.

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Practitioners can convey the following harm-reduction messages in relation to HIV / AIDS risks: (a) AOD use and abuse associates with impaired and unsafe sex, leading to increased HIV / AIDS risks. Women may fail to use condoms because of being intoxicated, in spite of having access to condoms and knowing how to use them. The risk of failing to use condoms is tripled because of the high likelihood that homeless women have multiple sex partners and trade sex for drugs, etc. (Wechsberg et al. ). (b) AOD practice on the streets is particularly dangerous because of the high likelihood of needle / syringe sharing, which increases the risk of contracting HIV / AIDS and other diseases. Practitioners can convey the following harm-reduction messages with respect to violence and trauma: (a) AOD use and abuse precipitate violence. Tucker, Wenzel, et al. () found that a high proportion of violence episodes experienced by homeless women involved substance abuse, either by both the women and the perpetrators or by one of the two parties. In many violence cases, the women may be dealing drugs, trading sex for drugs, or being high. (b) An overly optimistic view by many homeless women about the danger of violence / perpetrators and about one’s ability to protect oneself was found in various studies (e.g., Tucker, Wenzel, et al. ). Citing the literature, Tucker, Wenzel, et al. said an overly optimistic perception of and desensitization to violence among homeless women can be “adaptive in coping with stressful life events” but may minimize their precautions to protect themselves in a dangerous environment (). Practitioners should remind women not to take possible threats lightly. (c) Homeless women may blame themselves for the occurrence of violence (Tucker, Wenzel, et al.). Practitioners should be nonjudgmental and make it clear that under any circumstances, violence is completely the fault of the perpetrator and only the perpetrator (Robinson ). (d) Though homeless women experience a higher rate of rape than other populations, research has shown that they are less likely to receive follow-up care (Ackerman et al. ). Wechsberg et al. () accentuated the need to link homeless women rape victims to appropriate and friendly treatment for both acute and follow-up care.

Being Sensitive to the Different Needs of Single Homeless Women and Homeless Mothers and Providing Appropriate Treatment The Needs of Single Homeless Women As discussed earlier, single homeless women are more likely than homeless mothers to have AOD problems and other “individual dysfunctions” such as psychiatric disorders and psychiatric hospitalizations, as well as a longer duration of homelessness. Practitioners, therefore, must be sensitive to the needs of both groups and provide relevant services and treatment. Johnson and Kreuger (cited in Butler ) contended that single homeless women may need services that are more psychologically intensive, such as alcohol treatment and / or psychiatric counseling,

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while homeless mothers can benefit more from socioeconomic support. Page and Nooe () suspected that the high prevalence of psychiatric and AOD disorders among single homeless women may be related to poor discharge planning by mental health hospitals and their failure to link the women to residential aftercare. Page and Nooe reported: “At least one of the major providers of inpatient psychiatric services in our community currently provides no other discharge plan than taxi service to a local homeless shelter” (). Thorough discharge planning that ensures continuity of treatment should be implemented for substance-abusing homeless women.

Culturally Sensitive and Women-Focused Intervention for African American and Hispanic Homeless Mothers Homeless women in general are more likely to be African American; further, a higher percentage of homeless mothers are African American, compared to single homeless women. Hispanic (especially Puerto Rican) mothers may also be at high risk for homelessness. Practitioners working with homeless women, particularly mothers, should be equipped with cultural sensitivity and competence. Wechsberg et al. () found that crack-using African American women who received “women-focused” treatment had a significantly better treatment outcome in the areas of employment and stable housing than their counterparts who were assigned to a standard or a control group, although all three groups made progress in decreasing crack use and risky sexual behaviors. Women-focused treatment includes “culturally enriched content that is grounded in empowerment theory . . . and African American feminism” (Wechsberg et al. :). For example, some topics included in the women-focused treatment group but not the other two groups were “AIDS and African-American women,” “Crack or snorting risk among African-American women,” “What’s different for women and African American women? Why is it harder?” “Learning how to break free from the various forms of bondage that African American women today find themselves in,” “Reaffirmation of women,” etc. (–). Women in the women-focused treatment group received not only psychoeducation and counseling related to the reduction of AIDS risks and AOD use in the context of being African American women living in a disadvantageous environment full of violence and poverty and the linkage to social network and services, but also training in reaching life goals related to employment, education, parenting, and housing.

The Needs of Children in Homeless Families Another important aspect of helping homeless mothers is to assess the developmental and educational needs of their children and refer them for appropriate services. Zima et al. () found that % of the children of the homeless families in their study met the criteria for special education evaluation, but only % of the children with “any disability” had ever been given special education evaluation or

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placement. Citing the literature, Zima et al. said that “homeless school-aged children are at risk for not receiving the education needed to break their cycle of poverty” (). They emphasized the importance of coordination among professionals in the fields of special education, general health care, and housing services. Homeless mothers should also be helped with parenting skills, particularly with regard to effectively handling their children’s emotional distress stemming from the family’s homelessness. Page and Nooe’s () study and their review of the literature suggested that homelessness of a family may negatively impact the development of its children, including its very young children. For example, the chronicity of homelessness was associated with homeless children’s anxiety symptoms, and residential instability was associated with their acting-out problems. Page and Nooe suggested that more research is needed to understand the relationship between children’s development, emotional distress and symptoms, and family homelessness.

Maximizing Access to AOD / Mental Disorder Treatment for Substance-Abusing Homeless Women Engaging Homeless Women on Streets or in Shelters, Soup Kitchens, Day Centers, Emergency Departments (ED), and Welfare Programs Homeless individuals may give priority to survival needs, such as shelter and food, rather than to their other needs, such as AOD treatment or other health care. They may also delay seeking AOD (inpatient / residential) treatment or other health care because of a lack of health insurance, including Medicaid (Koegel et al. ; Wenzel et al. ), or lack of knowledge about available resources (Koegel et al. ). Thus outreach may be one of the primary ways to initially link substance-abusing homeless individuals to AOD treatment. It is critical that AOD professionals reach this population on the streets and in non-AOD-treatment settings (e.g., homeless shelters, soup kitchens, day centers, hospital emergency rooms, or welfare programs) and provide them with food, individual contact, advocacy, and referrals (Glasser and Zywiak’s review ). It is also critical for non-AOD-treatment professionals to be knowledgeable about AOD / mental disorder screening and referral. Koegel et al. () found that the likelihood of getting treatment for an AOD-at-risk homeless individual increased fivefold when the individual had a connection with any service providers who were able to provide advice and link the individual to formal AOD or mental health programs. For a homeless individual with serious mental illness, the likelihood increased twelvefold. With proper training, non-AOD / non–mental health professionals working with homeless individuals can serve as gateways, facilitating access to the specialized treatment for their at-risk homeless clients. Another alternative is to send a specialist from an AOD / mental health treatment program

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to work on-site in a homeless shelter or other non-AOD treatment program that serves homeless individuals.

Developing AOD Intervention and Treatment Based in Shelters, Soup Kitchens, or Other Settings This strategy requires that homeless shelters or other non-AOD treatment programs that are heavily involved with homeless individuals take more aggressive steps than merely implementing routine AOD screening at admission and referrals afterward. Experts have suggested in-house provision of multiple services and treatment (e.g., HIV / AIDS risk education, childhood and adulthood trauma treatment, and AOD intervention and treatment) for homeless individuals in settings like shelters, soup kitchens, or day centers (Glasser and Zywiak ; Wenzel et al. ). Examples are listed here to demonstrate the methods and effectiveness of this approach. Bradford et al.’s () randomized controlled trial (N = , .% female) showed that homeless clients with AOD and / or psychiatric disorders who received in-house “intervention” in the shelter were more likely to participate in AOD treatment than those of the control group (.% versus .%, p = .). The intervention group clients were also more likely to attend at least one appointment with a “community mental health center” (CMHC) than were the control group clients (.% versus .%, p = .). The intervention group participants received: psychiatric management [that] included supportive psychotherapy and pharmacotherapy. . . . The treatment approach emphasized continuity of care while in the shelter, short-term goal setting . . . availability of case management services, and close collaboration between the psychiatrist and PSW [psychiatric social worker]. Case management services, with emphasis on staying in mental health treatment and working towards housing, employment, or disability application, were provided by a full-time MSW-trained PSW. Immediately after the initial psychiatric assessment, the psychiatrist and PSW met with the subject to review specific problems, set short-term goals, and schedule a follow up appointment with the PSW. Referrals to the CMHC were made by the PSW, who assertively followed up patients missing their appointments. () Plasse () discussed how a group modality that adopts meditation and cognitive restructuring approaches was successfully implemented in a shelter in the Bronx, New York, to help substance-abusing homeless women. Rosenblum et al. () also suggested that motivational and cognitive behavioral therapy can enhance participation by soup kitchen clients in AOD intervention or treatment at follow-up. Another example is the conversion of part of a shelter to post-

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detoxification stabilization programs. Research has shown that the degree of effectiveness of post-detoxification stabilization programs offered in shelters is comparable to that for similar programs offered in traditional AOD treatment settings (Argeriou and McCarty; Argeriou; both cited in Glasser and Zywiak ).

Developing More (AOD) Treatment and Service Programs in Neighborhoods Where Homeless People Are Concentrated One of the four enabling factors found in Koegel et al.’s () study that significantly affected homeless individuals’ utilization of AOD treatment was the geographic area. Homeless individuals who stayed in the “westside” area (an area with many fewer service programs) were much less likely to be involved in treatment than those in L.A. O’Toole, Freyder, et al.’s () survey showed that facilities that were too far away and not accessible was the barrier most reported by the homeless individuals for not receiving adequate treatment. Therefore, availability of more treatment programs near where they are likely to stay is likely to maximize their access to AOD treatment.

Enhancing Homeless Women’s AOD Treatment Retention and Continuity Not only is it important to maximize homeless individuals’ access to AOD treatment but it is critical to ascertain that they receive quality treatment, and particularly that they sustain and benefit from the treatment. Lower treatment access and retention among homeless substance abusers may be related to both their perceived need to put housing and other survival needs first, before AOD treatment, and to their chaotic, transient lifestyle that lacks social support. Lauber, Lay, and Rössler () reported that hospitalized psychiatric homeless patients received less psychopharmacotherapy and more vocational training, had a shorter inpatient stay and less improvement at discharge, and were less likely to receive aftercare than their non-homeless counterparts. Likewise, Stahler’s review (cited in Glasser and Zywiak ) indicated that dropout rates for all treatments are high among substance-abusing homeless individuals. The literature has been consistently suggested a positive relationship between treatment retention and treatment outcome success. The repercussions of poor retention among homeless individuals are far-reaching, both for those individuals and for society. Orwin et al. () wrote: When homeless clients do leave treatment prematurely, they do not merely fail in a treatment episode, but tend also to return to the highly precarious circumstances that precipitated their homelessness. Once homeless and using again, they are at high risk of HIV and a host of other serious health problems . . . as well as violence and ultimately death. They also exact high

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societal costs through resumed utilization of expensive and inappropriate services. () Lauber, Lay, and Rössler () noted that homeless patients were significantly more likely than their non-homeless counterparts to be discharged from psychiatric hospitals against medical advice (.% versus .%, p < .). Also, although both the homeless men (N = ) and the homeless women (N = ) had high rates of discharge against medical advice, homeless women had a significantly higher rate than homeless men (.% versus .%, p < .). Four categories of treatment retention are identified: no-shows (the client never began treatment after initial contact), voluntary dropout from a program, involuntary discharge because of AOD use, and involuntary discharge because of being “away without leave” (Orwin et al. :). How to increase homeless clients’ AOD treatment retention? Orwin et al.’s analysis of fifteen AOD treatment programs in eight sites nationwide, as well as the research done by other experts, suggests some strategies for improvement:

Including Housing and Other Tangible Benefits in the AOD Treatment Package In order to offer a holistic AOD treatment, provision of social services and case management is critical, not only from a practitioner’s perspective, but also from the perspective of many homeless individuals. Homeless individuals in O’Toole, Freyder, et al.’s () survey perceived an AOD program’s inability to offer the services (e.g., housing, Medicaid, food stamps, employment assistance, medical care, mental health, etc.) that they needed as being one of the barriers that prevented them from receiving adequate treatment. Many substance-abusing homeless clients may enroll in treatment mainly to secure housing (Orwin et al. ). AOD programs with housing provision had a lower rate of no-shows than programs without housing provision (Orwin et al. ). Housing provision may be particularly critical for substance-abusing homeless mothers. One agency in St. Louis–Grace Hill, Missouri (% homeless women with children, mainly African American) compared its RES program (N = ; services including AOD treatment, case management, and transitional housing) with its NRES program (N = ; services including AOD treatment and case management). The results showed that .% of the RES women were no-shows versus .% of the NRES women. Further, .% of the NRES women voluntarily dropped out of the program within two weeks after beginning treatment, whereas only .% of the RES women did so (Orwin et al.). Similarly, Smith, North, and Fox’s () study showed that homeless substance-abusing mothers who attended residential programs had a lower dropout rate than their counterparts who attended nonresidential programs.

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Handling the “Waiting List” Issue Homeless clients’ no-show or premature exit from treatment may also be related to their being on a waiting list or the “delayed program start-up” (Orwin et al. :). O’Toole, Freyder, et al. () indicated that .% of the homeless individuals (N = ) reported that while waiting for their names to come up on the waiting list they changed their mind from “wanting” to “not wanting” to get treatment. Practitioners should be aware of the issue of “transience of motivation” (O’Toole, Freyder, et al. :) and avoid missing the window of opportunity for clients seeking treatment. Agencies should shorten or eliminate their waiting lists or at least offer the waiting-list clients alternative services until formal treatment is available.

Balancing Treatment Integrity and Clients’ Autonomy Program intensity (“intensity” here refers to program restrictions and requirements) is likely to affect the treatment retention of homeless individuals. They may prefer a lower, rather than higher, program intensity because the lower the program intensity is, the more personal freedom the client enjoys. Orwin et al. () noted that homeless clients may want “the housing but not the requirements and restrictions that came with it” (). For example, .% of the homeless clients in the high-intensity (HI) program of an agency in Albuquerque, New Mexico (% women) voluntarily dropped out of treatment within two weeks, compared to only .% of the medium-intensity (MI) and .% of the low-intensity (LI) program participants. HI was defined as “receiving supervised transitional housing, case management, and case manager-facilitated alcohol / drug treatment,” MI as “receiving supervised transitional housing, but only self-initiated treatment,” and LI as “receiving motel-based individual housing and self-initiated treatment” (). Note that the only % of the sample in the Albuquerque study were women. Women and men may or may not perceive the issue of treatment integrity and intensity versus client autonomy differently; more gender-specific research is needed. Some “treatment savvy” women in the St. Louis–Grace Hill residential program (% women) actually stated that their leaving the treatment program prematurely was partly related to a staff member’s loose enforcement of program rules. The women believed that this staff member’s behavior jeopardized the integrity of the program. Orwin et al. () thus suggested that retention may be viewed as the result of “an interaction between treatment intensity (real or perceived) and some client characteristic (measured or not) such as motivation for treatment” (). A thorough orientation that increases homeless clients’ understanding of the program rules and reduces their fear about the unknown helps to minimize the number of voluntary dropouts (Orwin et al. ). A clear understanding of program rules may also increase the probability of treatment compliance and decrease

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violations and involuntary discharges. A tour of the program immediately after enrollment and a meeting with a peer counselor or a current client, as well as other group-oriented programmatic activities, can also help.

Starting Early to Have Proactive Contacts with Clients This kind of contact may be particularly relevant for AOD treatment programs without housing provision. To enhance early engagement and reduce early attrition, case managers can call or visit the client when a no-show occurs. Also, although the program is unable to provide housing, it might still be able to offer the client other tangible benefits, such as clothing, food coupons, first month’s rent or security deposit, etc.

Being Flexible and Modifying Program Contents and Structure by Integrating Clients’ Needs and Feedback Here again, the program may need to be cognizant of the need to balance treatment integrity and clients’ freedom. Orwin et al. () reported that a program’s increased responses to clients’ feedback and concerns increases client retention. Mayes and Handley () described how a residential treatment program (about % women) evolved its program structure and policies by taking note of its consumers’ feedback and how it eventually achieved better treatment retention and outcomes. One example was that program staff noticed that “rather than receiving - or -day consequences for rule-breaking,” their clients “simply left the program” (). To enhance retention, the staff revised the - or -day rule to include a “mid-consequence review,” in which staff would assess the client’s progress when the client was halfway through completing his or her restriction. Staff could restore the client’s privilege before the client had completed the whole restriction period if she or he had made progress, or if no progress was found, they could require that the client complete the full restriction period. In response to its female clients’ concern and suggestions, a Tucson, Arizona, program (% women) revised its contents to include gender-specific and -separate curriculum sessions and a less confrontational style of therapeutic community approach for the women (Orwin et al. ).

Strengthening the Relapse-Prevention Component of Treatment Orwin et al.’s () analysis showed relapse to be a major factor leading to homeless clients’ low treatment retention. Relapsing clients are still likely to drop out of treatment voluntarily, despite the program’s leniency on its relapse policy and acceptance of relapse as part of recovery. According to Orwin et al., various AOD treatment programs for homeless clients have taken action to strengthen their relapse-prevention component. For example, the St. Louis–Grace Hill agency required the clients to meet with their AOD counselor to discuss relapse and related issues when three unexcused absences were accumulated. An agency in Chicago

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changed its urine screen from two times a month to three. The clients were required to develop a new contract with their case manager if a relapse occurred, and the new contract contained more-stringent rules, including more-frequent required meetings with the case manager, loss of concrete resources, and required attendance at group meetings.

Being Alert to High-Risk Periods for Dropout There are at least three high-risk periods for dropout among homeless clients: the beginning period of treatment, the transition between different phases of treatment, and the period before termination or treatment completion (Orwin et al. ). Orwin et al. suggested several strategies to combat these risks. The eight projects in Orwin et al.’s analysis all showed higher early hazards. Strategies to reduce early hazards included reducing or avoiding waiting time, providing orientation, and engaging clients early. Strategies to reduce client dropout during the transition between phases included emphasizing the importance of continuing treatment to clients, paying extra attention to clients who are between treatment phases, providing necessary services to smooth the transition (e.g., offering transportation), and imposing no new restrictions to the new phase (so that clients can have a sense of accomplishment and not feel as if they are going back to square one). To reduce late-stage dropouts, practitioners need to make sure that the aftercare or other resources linking the homeless clients to the external environment are readily available to the clients and that the clients are well prepared and ready to reenter the community.

Connecting Substance-Abusing Homeless Clients with Stabilization Programs After Detoxification or Hospitalization AOD detoxification treatment usually involves only three days to one week of inpatient stay; therefore it is critical to provide post-detoxification treatment to substance-abusing homeless clients in order to prevent the “revolving door” syndrome (Kertesz et al. ). Likewise, Lauber, Lay, and Rössler () emphasized the importance of developing a thorough discharge plan, starting on the admission day for mentally ill / substance-abusing homeless clients who are hospitalized in psychiatric settings. Research has suggested that the early stage after detoxification is the most vulnerable to relapse, and the chaotic environment in which homeless individuals are situated further exacerbates the risk of relapse. Kertesz et al.’s () prospective cohort study (N =  homeless with % females and  non-homeless with % females) reported that homeless individuals who received no stabilization program services experienced the highest relapse rate after detoxification, while homeless individuals who used stabilization programs had the lowest relapse rate. Kertesz et al. found no such impact among their non-homeless subjects. Stabilization programs normally are voluntary agencies that provide clients with short-term

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residence (two to six weeks) while clients wait for longer-term residential options. Treatment provided by stabilization programs may include group meetings, discharge planning, and case management services.

Applying Treatment Methods Motivational Interviewing / Motivational Enhancement Therapy (MI / MET) and Cognitive-Behavioral Therapy (CBT) Both MI / MET and CBT can be applied to substance-abusing homeless women (see chapter ). Fisk, Rakfeldt, and McCormack () found that the motivation of homeless clients was positively related to the outcomes of outreach intervention, in that clients with high motivation were more likely than their lower-motivation counterparts to complete the AOD referrals made by the outreach workers and enter treatment. Fisk et al. said MET has pervaded formal AOD treatment programs but not homeless outreach programs. They advocated that outreach workers for homeless individuals consider using MET to help homeless clients deal with treatment ambivalence and increase their treatment motivation. Plasse () discussed how a CBT group modality that adopted meditation and a cognitive restructuring approach was implemented in a shelter in the Bronx, New York, to help substance-abusing homeless women. The meditation and relaxation activities facilitated feelings of safety and, subsequently, encouraged the clients to share their life stories and exchange ideas about effective ways of coping with the challenges in life. The cognitive restructuring method helped the women to recognize unhealthy and dysfunctional thoughts and replace them with morefunctional ones. Group members contributed to the discussions of functional thinking and behavior, as well as problem-solving methods and skills. Multiple issues relevant to homeless women in their daily lives emerged in the group, including adaptation to the chaos, non-anonymity, and tension of group living (e.g., shelters); problems in dealing with authorities; fear of AOD relapse; worries about children’s well-being while homeless; the relationship with the family of origin; the relationship with intimate partners; and death. This CBT group approach not only helped the women assist other women in the group but also eventually made it possible for the women to “discover their own resourcefulness in devising healthier methods of self-care” (). Rosenblum et al. () randomly assigned  self-reported AOD-abusing “soup kitchen guests” (% female) to a control group (information and referral plus peer advocacy; N = ) and an experimental group (information and referral plus peer advocacy, twelve motivational group sessions, and thirty-six cognitive-behavioral group sessions, N = ). The researchers found that the experimental group was significantly more likely than the control group to have participated in AOD intervention or treatment at follow-up and to have reduced (heavy) drinking during the follow-up period. This effect is particularly relevant for homeless individuals with a higher severity of AOD problems at baseline.

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Contingency Management (CM) The contingency management approach has been considered effective in treating AOD problems, particularly cocaine addiction (Rawson et al. ). Researchers have also applied CM methods to help substance-abusing / mentally ill homeless clients (Milby et al. ; Milby et al. ). CM in AOD treatment is defined as the “delivery of a reinforcer that is contingent upon the reduction of drug use” (Rawson et al. :; see also chapter ). Rawson et al.’s study () is used here to exemplify a CM method and its results. The investigators randomly assigned subjects to three groups: the CM group, the CM+CBT group, and the CBT-only group. For subjects under the CM or CM+CBT condition, Rawson et al. gave a voucher value of $. for each stimulant-free urine sample; the value was increased by $. if the next urine sample was negative as well. A bonus of a $ voucher was given if the subject submitted three consecutive negative urine samples. However, if urine samples were missed or tested positive, the voucher was retuned to a lower value. The results showed that subjects in the CM or CM+CBT group performed significantly better than subjects in the CBT-only group in three outcomes: () retention: the CM and CM+CBT groups stayed in treatment significantly longer than the CBT group (. weeks,  weeks, and  weeks, respectively, p < .); () in-treatment outcomes: the CM and CM+CBT groups submitted a significantly higher average number of stimulant-free urine specimens than the CBT-only group during the sixteen-week treatment course (., ., and ., respectively, p < .); and () more subjects in the CM and CM+CBT groups than in the CBT-only group achieved three (or more) consecutive weeks of abstinence (.%, .%, and .%, respectively, p < .). Although the study found that CM is more efficacious than CBT for in-treatment outcomes, Rawson et al. concluded that the two produced comparable outcomes in the long term. Various researchers have investigated the effectiveness of applying CM to help substance-abusing and / or mentally ill homeless clients. The results basically suggested that abstinent-contingent-housing AOD treatment is more effective than regular day treatment only (Milby et al. ); the abstinent-contingent-housing approach may be more effective or equally effective compared to the abstinent-noncontingent-housing approach (Milby et al. ; Tsemberis, Gulcur, and Nakae ); and both the abstinent-contingent-housing and the abstinent-noncontingent-housing approaches are more effective than a no-housing treatment approach (Milby et al. ). () Day-treatment-only versus the additional abstinent-contingent-housing treatment comparison. Milby et al. () randomly assigned homeless individuals (N =  homeless individuals, % female) to two groups: the day-treatment-only (DT) group and day-treatment-plus-abstinent-contingent-housing group (DT+). The DT+ method involved two phases. During the first phase (weeks –), DT+ participants had access to a free, program-provided, furnished apartment / house if they tested AOD negative for four consecutive urine tests. However, they were

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pulled out of the housing and transferred to a shelter if they tested AOD positive for any subsequent urine test. They could regain the housing access by showing two consecutive drug-free urine tests. During the second phase (weeks –), DT+ participants were still under the same abstinence-contingency-housing policy and continued to have access to the program-provided housing, but they had to pay a small rent during the period of aftercare. They also had access to work therapy, but were removed from work therapy if any positive urine toxicology occurred. They could return to the work program if they obtained two consecutive drug-free tests. Milby and colleagues () found that homeless individuals who participated in the DT+ program were more likely than their counterparts who participated in DT to establish abstinence, maintain complete abstinence and partial abstinence for a longer time period, relapse later in the treatment course (if relapse occurred), and reestablish abstinence (if relapsed). Although DT+ appeared to perform better than DT, Milby and colleagues alerted readers that their study was limited to treatment outcomes evaluation for a period of only twenty-four weeks of day treatment and aftercare and that more studies are needed to explore the long-term effects of a abstinent-contingent housing program, as well as by implementing a more frequent urine monitoring system. () Abstinent-contingent housing versus abstinent-noncontingent housing versus no housing treatment matchup. Tsemberis, Gulcur, and Nakae () (N = , % women) found that mentally ill / substance-abusing homeless individuals who received abstinent-noncontingent-housing treatment (receiving “immediate housing without treatment prerequisites”) performed as functionally as their counterparts assigned to the abstinent-contingent-housing treatment (receiving “housing contingent on treatment and sobriety”) (:). Although the abstinent-contingent-housing treatment subjects were significantly more likely to use AOD treatment, the two groups were no different regarding their substance abuse and / or psychiatric symptoms. On the other hand, Milby et al. () (N =  cocaine-dependent homeless individuals, about % female) found that a “housing contingent on drug abstinence” (ACH) group and a “housing not contingent on abstinence” (NACH) group had a significantly higher prevalence rate of abstinence than a no-housing (NH) group. Although the ACH group had a higher abstinence rate than the NACH group in the sample, the difference did not reach statistical significance. However, the ACH group appeared to perform slightly better than the NACH and NH groups regarding the average number of “consecutive weeks of abstinence.” The mean consecutive weeks of abstinence for the three groups were . (SD = .) for NH, . (SD = .) for NACH, and . (SD = .) for ACH; ACH was significantly better than NH ( p = .), but NACH was not significantly better than NH ( p = .), although there was no significant difference between ACH and NACH ( p = .). Although women accounted for only % of the

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participants in the study, Milby et al. said gender did not act as an “effect modifier or a confounder” that affected the treatment outcomes (). There are three things practitioners might need to keep in mind when considering the application of a CM treatment approach to help substance-abusing homeless individuals. First, the practitioner may want to ascertain that the CM approach is consistent with his or her philosophical ideology and theory about human behavior and behavior change (Schumacher et al. ). A successful implementation of CM requires “strict and consistent enforcement of the contingencies.” Forcing a homeless individual to leave an assigned apartment and move to a shelter when a relapse occurs may not always be a reasonable endeavor for a practitioner (Schumacher et al. ). Second, CM may require extra resources and expenses, including the routine weekly urine testing and awards (housing, vouchers, and prizes) that reinforce drug-free urine results. Schumacher et al. suggested that urine testing should not be a problem if it is already in place in the program; however, the costs could be substantial if urine testing is not part of what the program has been doing. However, Schumacher et al. argued that urine testing itself can be “treatment” and helps clients reinforce their drug-free urine testing. They also suggested “creative means for obtaining rewards from the business community using vouchers and lottery awards” (:). Third, many empirical studies available so far suggested that although CM is superior to other treatment approaches (e.g., CBT or regular treatment), such superiority is limited to the treatment period and CM is comparable to other treatment approaches regarding follow-up outcomes. See chapter  for other discussions on CM.

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The homeless population has changed dramatically since the s, moving from being composed mainly of “skid row” single men to now being nearly % single women and single-mother families. The reasons for homelessness may include both individual (e.g., substance abuse, domestic violence, disability) and structural factors (e.g., poverty, rising housing costs, racism). Studies suggest that the homeless population in the s appeared to have a higher AOD rate than their counterparts in the s. Homeless women may have higher AOD abuse and dependence rates than (poor) housed women. Psychologically and mentally, they are also more likely than (poor) housed women to have a history of childhood abuse trauma and to adopt an “avoidant” or “emotion-focused” coping strategy instead of a “problemfocused” one. They often have a lower level of family and other network support and a lower utilization of government entitlements such as cash assistance, food stamps, subsidy housing, and other financial support. Both homeless women and men suffer a high rate of physical assault, but homeless women suffer a significantly higher rate of sexual assault / rape than homeless

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men. Homeless women develop a high risk for HIV / AIDS by engaging in trading sex for survival needs or drugs, having multiple sex partners, injecting drugs or having a sexual partner who injects drugs, and engaging in unprotected sex. Pregnant homeless women may have a higher rate of “serious thoughts of suicide” than domiciled pregnant women; seasoned homeless women (women who have been homeless for more than six months of their life) may have a significantly higher “ever attempted suicide” rate than newly homeless women. Further, homeless women may be significantly more likely than poor housed women to experience multiple co-occurring problems, which puts them in an extremely difficult and dangerous situation. Seven treatment guidelines and strategies have been developed to help substance-abusing homeless women: (a) triaging new homeless admissions and providing suitable treatment through screening for AOD and other psychiatric disorders, as well as assessing the clients’ strengths (such as age, current AODusing status, job skills, psychosocial adjustment, etc.) in order to offer strategic services aimed at expediting their exit from homelessness; (b) increasing their external resources via case management, connecting them with government entitlements such as housing subsidies, Social Security Disability Income, TANF, Medicaid, etc., and helping them build a non-AOD-using social network; (c) referring them for appropriate treatment for depression, PTSD, and other psychiatric disorders and empowering them with effective coping skills and vocational skills; (d) infusing harm-reduction messages in relation to safe sex practice and safe drug-using practice if total abstinence is not feasible, as well as emphasizing ways to reduce exposure to violence and rape; (e) being sensitive to the different needs of homeless single women and homeless single mothers (single women may be older, have a more severe psychiatric / AOD problem, and have been homeless for a longer time, and therefore their treatment may emphasize specialized AOD and psychiatric treatment, whereas single mothers may be more likely to be African American, and culturally sensitive practice may need to be incorporated), and the needs of children from homeless families must also be addressed; (f ) employing various strategies to maximize substance-abusing homeless women’s access to AOD treatment and increase treatment retention; and (g) applying MI / MET, CBT, and / or CM to help homeless women.

Chapter 

Street Prostitutes

O

ne of the oldest professions, prostitution is perceived by society to be immoral. Prostitutes are marginalized and stigmatized as being associated with not only a low social status but a status tinged with shame. Prostitution is defined as the exchange of sex for money, drugs, or other objects that have monetary value. A hierarchy exists within the prostitution profession, ranging from “call girls” and other indoor prostitutes at the top to streetwalking or outdoor prostitutes at the bottom (Dalla ; Goldstein ; Romero-Daza, Weeks, and Singer's review ). Although all prostitutes may be subjected to unpredictable and dangerous working environments, street prostitutes usually work in a more dangerous environment and make less money than their indoor counterparts (Church et al. ). They are more likely to be exposed to risky situations and are less able to avoid violence from customers, police officers, other prostitutes, or random biased people. Street prostitutes are also more likely than indoor prostitutes to abuse drugs, particularly drugs that are injected. For example, Cusick, Martin, and May’s () study (N =  female and  male sex workers, mostly from London) showed that % of the “outdoors or independent drifter” sex workers had “problem drug use” versus % of the “indoor associated or independent entrepreneurial” sex workers (). Voluminous studies reported in the literature have indicated that more street prostitutes enter the profession to meet the needs of their (and their partner’s) drug habits, while more indoor prostitutes start using drugs only after they go into the profession (Cusick ; Dalla ; Goldstein ). Street prostitutes, because of the nature of addiction and withdrawal, tend to use drugs just so they can function normally and be able to “work.” They may also use drugs to help them cope

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with the harsh realities of their lives (such as poverty, street chaos, and violence) (Cusick ). The indoor or “higher-class” prostitutes, on the other hand, tend to use drugs more recreationally, to help them deal with boredom in life or at work and / or to enhance their job performance and socialization with their clients (Cusick ). Not only do street prostitutes make less money than their indoor counterparts, but they are more likely than indoor prostitutes to spend most of their money on drugs. Drug abuse and poverty, along with limited formal education and few marketable job skills, often propel the women into what they see as their only option—street prostitution. Although they may enter prostitution to support their drug habit, prostitution may actually make their drug habit worse, which in turn forces them to engage in more prostitution in order to get more money for drugs. Although not all street prostitutes are afflicted with alcohol and / or other drug (AOD) problems, % or more of them are. For example, % of the prostitutes in Green and Goldberg’s () study (Glasgow) were drug users. Jeal and Salisbury () indicated that all of the sex workers in their study (N =  street prostitutes in Bristol, UK) had recent or current AOD problems, and % of them had current AOD problems. On the other hand, of course, not all substance-abusing women engage in prostitution, but % to more than % of them may, particularly women of lower socioeconomic status. For example, El-Bassel et al. () showed that % of the drug-using women recruited from “street corners, housing projects, parks, unoccupied buildings, and other public places” in the Harlem area in New York City “had exchanged sex for money or drugs in the previous  days” (–). Kuyper et al. () reported that % of their sample, which included females using injection drugs (N = , Canada) were involved with prostitution during the baseline of their study. These figures highlight the importance of a practitioner’s being sensitive to the possibility of substance abuse problems when working with prostitute clients and to prostitution issues when working with substance-abusing female clients. Although it is obvious that street prostitutes may encounter multiple risks and traumas, including violence and homicide, sexually transmitted diseases, in addition to substance abuse and its risks, not many (outreach) treatment programs have been developed to help them, nor have major research studies been conducted to better understand and serve this population (Arnold, Stewart, and McNeece ). Since the s, however, interest in the topic of street prostitution has increased, perhaps fueled by the HIV / AIDS epidemic, campaigns that promote public awareness, and issues spawned by feminists (Bullough and Bullough, cited in Arnold, Stewart, and McNeece ). A review of the literature reveals several critical issues that affect the daily life of a substance-abusing street prostitute. Seven factors are identified: lower socioeconomic status background, involvement with the criminal justice system, drug and alcohol abuse and dependence, physical health needs, psychological distress and

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traumas, violence, and discrimination. These factors frequently act in concert with each other. A woman’s health status may be related to her socioeconomic status; for example, an HIV / AIDS positive woman may be more likely to be homeless (Weiner ). Or a woman’s socioeconomic status may be related to her risky druginjecting behavior; for example, a woman who has been homeless in the past six months may be more likely to engage in risky drug-injecting behavior (Paone et al. ). Fine practice guidelines based on the seven identified issues are presented

Characteristics and Needs of Street Prostitutes Lower Socioeconomic Background Less Formal Education Studies have shown that substance-abusing women who engaged in prostitution tend to have received less formal education than substance-abusing women who did not engage in prostitution. El-Bassel, Simoni, et al. () interviewed women attending methadone clinics (N = , U.S.) and found that the women who had engaged in sex work were slightly less educated than their counterparts who had not engaged in sex work (M = . ± . years versus M = . ± . years, respectively; p < .). Jeal and Salisbury’s () study revealed that % of the prostitutes in the study left school at the age of fourteen or younger, whereas only .% of the general population in the General Household Survey  indicated leaving school at such a young age. Paone et al.’s () study (N = , women, New York, Rochester, Buffalo, Los Angeles, and Chicago) found that % of the sex workers, compared to % of the sexually active non–sex workers and % of the non-sexually active non–sex workers, were high school graduates ( p = ., approaching significance). Fewer years of formal education may have a negative impact with respect to vocational and other problem-solving skills.

Poverty Substance-abusing prostitutes were more likely than substance-abusing nonprostitutes to experience poverty. Paone et al.’s () study showed that during the six months before their participation in the survey only .% of the prostitutes, versus .% to .% of the non-prostitutes, had “any paid employment,” and .% of the prostitutes versus .% to .% of the non-prostitutes had used “panhandling and / or illegal sources” for income. Surprisingly, only .% of the prostitutes, versus .% to .% of the non-prostitutes, had received “welfare and other entitlements.” El-Bassel, Simoni, et al.’s () study, however, found the percentages of non–sex workers and sex workers who received welfare to be similar (.% and .%, respectively). As in other studies, the El-Bassel, Simoni, et al. study found that sex workers had a significantly higher rate (.%) than non–sex workers (.%) of having illegal activity as a source of income (p < .).

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Homelessness Most empirical studies have shown that substance-abusing female prostitutes are more likely to be homeless or have unstable housing than their non-prostitute counterparts. This perhaps at least partially explains the extremely impoverished situation that leaves these women with no option except prostitution. Homelessness rates among street sex workers could range from about % to %, and “unstable housing” rates could range from % to %. For example, Weiner () (N = , streetwalking prostitutes, New York City) reported that .% of the street prostitutes in her sample were homeless, .% were living in an unstable housing arrangement (living with relatives, a boyfriend, in a hotel, or on the streets), and .% were living in their own house or apartment. (The total exceeded %, possibly because some women may have reported more than one living arrangement.) Among El-Bassel et al.’s () sample (N = , all women, mostly substance abusers), .% of the “sex traders” versus .% of the non-sex traders ( p < .) were currently homeless. Nuttbrock et al. () (N = , New York City) reported that .% of the street sex workers in their sample “spent one or more days sleeping on the streets, or some other place not meant for sleeping” during the preceding month (). Paone et al.’s study () indicated that .% of the sex workers in the sample versus .% to .% of the non–sex workers had been homeless in the past six months. In addition, .% of the sex workers lived in “someone else’s house,” compared to .% to .% of the non–sex workers. Only .% of the sex workers lived in their own house, versus .% to .% of the non–sex workers. Kuyper et al.’s () study showed that % of the sex workers in the sample versus % of the non–sex workers reported unstable housing currently ( p < .). Jeal and Salisbury ()’s study indicated that two-thirds of the women in their sample were either homeless or under the threat of becoming homeless. They “stayed in bed and breakfast accommodation, on floors, in homeless hostels, in crack houses, slept rough, or with clients” ().

Involvement with the Criminal Justice System Empirical studies have consistently indicated that substance-abusing sex workers, particularly street sex workers, are significantly more likely than their non–sex worker counterparts to be involved with the criminal justice system. El-Bassel, Simoni, et al.’s study () showed that .% of the non–sex workers were incarcerated during the previous year versus .% of the sex workers ( p < .). Nuttbrock et al.’s () study indicated that about .% of the street sex workers “had been arrested one or more times” during the preceding month (). El-Bassel, Simoni, et al.’s () results also showed that the sex workers had a significantly higher rate (.%) than their non–sex worker counterparts (.%) of having illegal activity as a source of income ( p < .). Alexander (cited in Arnold, Stewart, and McNeece ) noted that about % to % of prostitution

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arrests are street sex workers, although only % to % of all urban sex workers are street sex workers.

Alcohol and Other Drug (AOD) Problems Type of Drug Street sex workers may abuse various illegal drugs, but studies have indicated that heroin and crack cocaine are among the most common. Green and Goldberg () found that heroin was the drug of choice for % of the injecting drug users (N = ). Other drugs used by this group were temazepam (%), buprenorphine (%), cocaine (%), and amphetamines (%). Studies done in New York City tended to indicate crack cocaine as the primary drug abused by street workers, followed by heroin. For example, Nuttbrock et al.’s () study showed that during the previous month .% of the street sex workers had used crack cocaine and .% had used heroin. Weiner’s () study revealed that .% of the street sex workers in the study used crack, followed by marijuana (.%), cocaine (.%), IV heroin (.%), and nasal heroin (.%). Weiner also reported that .% of the women used alcohol and .% of them smoked cigarettes.

Severity of the AOD Problems Studies have consistently shown that although both prostitutes and non-prostitutes used substances, prostitutes tended to have a more severe and extreme AOD problem. It may be that the extreme AOD problem itself dragged these women into prostitution as a way to get drugs or money to buy drugs. El-Bassel, Simoni, et al. () found that substance-abusing prostitutes were more likely to use alcohol regularly than their non-prostitute counterparts (.% versus .%, p < .) and to use crack and / or cocaine regularly (.% versus %, p < .). Kuyper et al. (:) also found that sex traders were more likely than non–sex traders to engage in “daily heroin injection” (% versus %, p < .), “daily cocaine injection” (% versus %, p < .), and “daily crack cocaine smoking” (% versus %, p < .). In addition, substance-abusing prostitutes may also be more likely to experience (accidental) drug overdose than their non-prostitute counterparts. Gilchrist, Gruer, and Atkinson’s () study (N =  women, Glasgow) showed that % of the prostitutes versus % of the non-prostitutes had experienced drug overdose.

Drug Injecting and Sharing of Needles and Injecting Equipment Empirical studies have consistently suggested that substance-abusing prostitutes are more likely to inject drugs than are substance-abusing non-prostitutes. Green and Goldberg’s () study (Glasgow) found that not only were the majority of the prostitutes in their study using drugs, but a large portion of the drugusing women were injecting drugs. Gilchrist, Gruer, and Atkinson () found

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that % of the prostitutes in their study versus % of the non-prostitutes had injected drugs in the preceding thirty days. Paone et al.’s () study showed that the current sex workers were engaging in drug injecting considerably more frequently than their non–sex worker counterparts,  times a month for the sex workers as compared to about  times for the non–sex workers ( p < .). Jeal and Salisbury () found that drug-injecting women, compared with women who did not inject drugs, appeared to see significantly more customers weekly and to have sexual intercourse more often. Not only are substance-abusing prostitutes more likely than their non-prostitute counterparts to inject drugs, but they are also more likely to share needles and other drug equipment. Jeal and Salisbury’s () study found that although % of the drug-injecting street sex workers were aware of the risk of sharing needles and injecting equipment, % of them had shared needles in the preceding month and % of them had shared injecting equipment. Weiner () reported that only about .% of the drug-injecting street sex workers in her study used new needles; .% of them cleaned needles, and .% of them shared needles. In Green and Goldberg’s () study, about % of the drug-injecting sex workers shared injecting equipment. In summary, about % of the women shared needles, and between % and % shared injecting equipment. Paone et al. () suggested that the current sex workers were at a higher risk than their non–sex worker counterparts regarding blood-borne infection because of the sex workers’ risky drug-injecting behaviors. Compared to the non–sex workers, the sex workers were more likely to be “injecting with rented, bought, borrowed or otherwise previously used syringes” ( p < .), “backloading (a sharing technique used to distribute drugs from one syringe to another . . . with a used syringe)” ( p < .), and “visiting a shooting gallery” ( p < .) ().

Health Needs Street sex workers tend to have a higher percentage of HIV / AIDS infection and / or other sexually transmitted diseases (STD). Further, although they may be conscientious about using condom protection when having sex with commercial clients, the majority of them do not use condoms with their intimate sexual partners, who are more likely to be injecting drug users and therefore more prone to HIV / AIDS infection. Street sex workers reported a history of significantly higher percentages of sexually transmitted diseases, including AIDS / HIV. About % of the street prostitutes in Weiner’s () study were infected with HIV, and about % of the street sex workers in Nuttbrock et al.’s () study tested positive for HIV. Paone et al. () reported that .% of the sex workers (n = ) had a history of gonorrhea and that they were more likely than the non–sex workers (n = ,) to report such a history ( p < .). They also reported that .% of the sex workers had

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a history of syphilis and that the sex workers were more likely than the non–sex workers to report such a history ( p < .). Rekart () summarized various studies suggesting that sex workers tended to use condoms less often with their spouses, regular partners, or non-paying customers than with their commercial customers. Weiner () reported that about % of the street prostitutes in her study never used condoms when having sex with their boyfriends. In addition, % of the street prostitutes had boyfriends with a history of IV drug use. Similarly, Yahne et al. () indicated that the sex workers in their study “usually or always used condoms with their paying ‘dates’ but not with their ‘boyfriends’” (). The sex workers were at greater risk of contracting STDs or other diseases from their intimate partners than from their commercial customers, not only because of a lack of condom protection but also because many of the women’s boyfriends / spouses were injecting drug users (Weiner ; Yahne et al. ), which increased their vulnerability to HIV / AIDS infection.

Psychological Distress Numerous studies have confirmed that substance-abusing sex workers experience a higher level of psychological distress than substance-abusing non–sex workers. No studies reviewed so far have shown otherwise. One study further reported that the outdoor sex workers experience a higher psychological distress level than their indoor counterparts (Alegría et al. ). Gilchrist, Gruer, and Atkinson () studied  substance-abusing female sex workers and  substance-abusing female non–sex workers from “drop-in centers,” a “crisis center,” and a medically led methadone treatment program in Glasgow, Scotland. They found that more sex workers met the criteria for “current depressive ideas” and “lifetime suicide attempts.” El-Bassel, Simoni, et al.’s () study (N =  women attending methadone programs in New York City) indicated that substance-abusing sex workers reported a significantly higher score on the Brief Symptom Inventory than their non–sex worker counterparts (M = . ± . versus M = . ± ., p < .). The Brief Symptom Inventory includes dimensions of depression, anxiety, hostility, phobic anxiety, paranoid ideation, interpersonal sensitivity, somatic symptoms, etc. Such a difference remains significant even after controlling for demographics, childhood abuse, partner abuse, and drug use. El-Bassel et al.’s () study indicated that sex workers reported a significantly higher “General Severity Index” score than their non–sex worker counterparts ( p < .), and the difference continued to be statistically significant ( p < .) after controlling for confounding factors such as ethnicity, age, and so on. Paone et al.’s () study also showed that sex workers had a significantly higher mean than their non–sex worker counterparts on “emotional distress” ( p < .), “feel hopeless about the future” ( p < .), “worry too much about things” ( p < .), “feel blue, depressed, lost interest” ( p < .), and “considered suicide”

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( p < .). Alegria et al.’s () study (N =  sex workers in Puerto Rico) found that .% of the street sex workers reported high depressive symptoms, compared to .% of the brothel sex workers. The psychological distress experienced by sex workers can be traced to various sources. The literature has indicated that both the stigma attached to this illegal profession and the subsequent shame invoked, as well as the act of having indiscriminate sex and hypersexuality may create depression and distress among the women (El-Bassel, Simoni, et al. ). The childhood (sexual) abuse that some of the women experienced (El-Bassel, Simoni, et al. ) and / or being in “foster care as a child” (Gilchrist, Gruer, and Atkinson :) may be other sources of depression and distress. Particularly for the outdoor or street sex workers, the sources of psychological distress could include the impoverished environment the women were living in; their daily struggle to meet basic needs such as housing and food; their feelings of being trapped in the vicious cycle of doing prostitution to fulfill their drug needs as well as doing drugs in order to be able to function and “work” (Cusick and Hickman ); and the withdrawal symptoms and / or side effects of their substance abuse. Very importantly, the women’s psychological distress may stem from their experiences of adulthood sexual, physical, and / or emotional abuse (Gilchrist, Gruer, and Atkinson ), including daily exposure to various dangerous situations and the enormous violence (El-Bassel et al. ; Farley and Barkan ) perpetrated by their customers, boyfriends or spouses, other sex workers, drug dealers, random strangers in the neighborhood, and / or policemen. Unfortunately, these factors may be ignored by some mental health practitioners, according to Farley and Barkan (). They illustrated the issue by citing one of the participants in their study, who complained about her therapists’ failure to link her adulthood abuse to her symptoms of post-traumatic stress disorder: “I wonder why I keep going to therapists and telling them I can’t sleep, and I have nightmares. They pass right over the fact that I was a prostitute and I was beaten with  ×  boards, I had my fingers and toes broken by a pimp, and I was raped more than  times. Why do they ignore that?” ().

Violence Although sex workers, particularly street sex workers, often encounter extreme violence, ranging from beating to murder, from multiple sources, the public has shown little interest in this issue, and little research has been done on it. Rather, society seems to focus more on the possible harm—such as the threat of HIV / AIDS and other sexually transmitted diseases—that the sex workers may bring to their clients and, subsequently, to the partners of the clients (Church et al. ). Church et al. stated: “Features of female prostitution that have a direct impact on the health of prostitutes but not the health of others have . . . tended to be overlooked” ().

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Violence experienced by sex workers may include verbal abuse, robbery, confinement, physical and / or sexual abuse, emotional trauma, and / or gang rape, all of which are likely to result in low self-esteem, disability, and morbidity (Rekart ). The violence can even be a murder (Brewer et al. ; Ward, Day, and Weber ). El-Bassel et al.’s study () showed that .% of the sex workers versus .% of the non–sex workers had been raped in the preceding year ( p < .). Arnold, Stewart, and McNeece () cited a study conducted in San Francisco (N =  prostitutes) indicating that % of the sample had been raped and another study that found that % of the street prostitutes had experienced abuse by customers and % had experienced violence by policemen. Farley and Barkan’s () study (N = , San Francisco) also reported high percentages of physically assault (%), threats with weapons (%), and rape (%). The violence may come not only from paying clients and policemen but also from the women’s intimate / non-paying partner (husband or boyfriend), other prostitutes, their own family, “random people,” and vicarious or witnessed violence.

Violence from Commercial Customers What factors contribute to prostitutes’ being more likely to encounter violence from commercial clients? El-Bassel, Witte, et al.’s () study found that homelessness, sex work as the major source of income, and drug injection increased the likelihood of commercial clients’ violence, while having a “regular intimate partner” decreased the likelihood of such violence. El-Bassel, Witte, et al.’s results suggested that perhaps because of an impoverished environment and their survival needs, financially constrained women were less likely to screen and select their customers and more likely to trade sex under any circumstances, and thus more likely to put themselves in situations that made them vulnerable to abuse from clients. Likewise, drug-injecting sex workers who have more-severe drug problems and are more desperately in need of drugs or money for drugs may be less likely to screen and select customers and more likely to be in situations that make them vulnerable to clients’ abuse. Drug-injecting women may also experience a higher level of distress and depression, which reduces their motivation and ability to discern the warning signs of violence and thus renders them more likely to become vulnerable to violence. Finally, the notion of a “regular intimate partner”—be it a pimp, ponce, boyfriend, or spouse—may serve the function of depicting the woman as not alone and thus may deter commercial clients from becoming aggressive, whether the regular intimate partner is actually protecting the woman or not. Church et al.’s () study indicated that significantly more outdoor or street sex workers than indoor sex workers experienced violence from their customers (% versus %, p < .). These findings are consistent with those of El-Bassel, Witte, et al. et al. (), which showed that homelessness, sex work as the major income source, and drug injection increased the likelihood of prostitutes’ suffering violence from commercial clients. As mentioned earlier, outdoor sex workers usually had lower income or more reliance on sex work as the major income than

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indoor sex workers, were more likely to be homeless, and had more severe drug problems, including drug injection. Specifically, Church et al. found that the outdoor sex workers were more likely than their indoor counterparts to experience being punched, slapped, or kicked (% versus %, p < .), being “threatened with physical violence” (% versus %, p < .), attempted rape (% versus %, p = .), robbery (% versus %, p < .), being beaten (% versus %, p < .), being “threatened with weapon” (% versus %, p < .), strangulation (% versus %, p = .), being kidnapped (% versus %, p < .), being raped (vaginal) (% versus %, p < .), or being “slashed or stabbed” (% versus %, p = .). Church et al.’s () multiple logistic regression further showed that “working outdoors rather than indoors was associated with higher levels of violence by clients than was the city, drug use, and duration of, or age that women began, prostitution” (). The violence from commercial customers experienced by the outdoor sex workers may involve various contexts. Considering that it is dark and the woman is alone, the customer may mug her for the funds she is carrying or assault her to avoid paying for the sex, and may even have hidden accomplices working with him to attack the woman (Green and Goldberg ). He may assault the woman if she refuses to perform a specific sex act (e.g., anal sex) for him (Romero-Daza, Weeks, and Singer ). Women’s cheating and / or stealing objects from a customer may provoke violence from the customer (Green and Goldberg ). A customer may assault the woman for pathological reasons if he perceives the woman to be an easy target, and he may attack or even murder her for pleasure (Green and Goldberg ).

Violence from Other People / Systems Not only are sex workers likely to encounter violence from their commercial clients but they may also experience it from their intimate partners (boyfriends or spouses). El-Bassel, Simoni, et al.’s () study noted that although the abuse level appeared to be high among all the subjects, sex workers were more likely than non–sex workers to have suffered physical abuse from their boyfriend or spouse, including being physically threatened, strangled, or choked. In addition, pimps may use verbal and physical abuse to ensure that the women continue to work and bring in income (Boynton ). Sex workers are also likely to encounter “violence” or negative forces from the police, the state, and / or the criminal justice system. Perhaps because of street prostitution is illegal, El-Bassel, Simoni, et al. () showed, more sex workers were incarcerated than non–sex workers in the preceding year (.% versus .%, p < .). Day and Ward () stated that sex workers may experience violence from the state: “The most harrowing entailed the occasional removal of prostitutes’ children by the state” (). They also asserted that “everyday arrests, imprisonment, fines, and police raids led women to move within the industry to

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minimize their risks” (). Finally, sex workers, particularly those who work on the street, may be subjected to violence from random strangers. Boynton () stated that “women involved in street prostitution experience high levels of verbal (and physical) abuse from those who pass through the red light area. We observed for ourselves the seemingly endless hatred directed at street prostitutes from those who see them as an easy target” ().

Vicarious, Indirect, or Witnessed Violence The women may experience violence secondhand by seeing it. Working on the street in the commercial sex business certainly increases the chances for women to witness violence. Post-traumatic stress disorder literature has suggested that vicarious violence can be as damaging as actual violence, resulting in severe emotional trauma. Romero-Daza, Weeks, and Singer () described five categories of violent acts that street prostitutes may see repeatedly on a daily basis: disputes between drug sellers and clients over drug quality or unpaid debts, fights among drug abusers because of shared drugs, physical violence perpetrated on other prostitutes by pimps or commercial customers, random drive-by shootings, and police abuse. Maria, a woman in Romero-Daza, Weeks, and Singer’s  study, clearly depicted the impact of witnessed violence on the women: So, he beat her up, he punched her, kicked her, and slashed her face, and at the end had sex with her anyway. She was badly bruised and cut up. I felt angry, I hurt a lot and I cried a lot. . . . I was scared [thinking that] it could happen to me. After I took her to the hospital and all that, I went out and I bought four bags [of heroin], I dumped them in the cooker and I shot up. () Another woman, Ana, stated: He dragged her behind a tree and shot her. . . . I saw everything. . . . I knew her. . . . I went to court for that a witness. . . . The guy swore that when he comes out he’s gonna kill me. So y’know I think that’s why I use so much. . . . I can’t sleep at night, I keep having bad dreams about it. . . . And now I do much more drugs than before. I do  or  bags a day . . . I just take it just to be able to sleep. Before that I was just doing about  or  bags a day. ()

Discrimination Because their work is illegal and involves sex, prostitutes, particularly street prostitutes, suffer enormous discrimination from society. Such discrimination is further reinforced by the public’s fear that sex workers transmit HIV / AIDS. The stigmatization of sex workers has taken an enormous toll on these women and is evidenced

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by the problems that they face: poverty, psychological distress, health, AOD use and abuse, and violence. The women feel ashamed for engaging in prostitution, and their drug addiction and lack of other options for survival contribute to their feeling hopeless about the prospects of leaving the profession. The resulting low self-esteem and negative emotions may disempower them and diminish their motivation and capacity to protect themselves through safe-sex practice and non-risky drug-injecting behavior. Discrimination also promotes violence toward sex workers from the commercial clients, intimate partners, law enforcement officers, and random “neighborhood” strangers who often direct their hatred and bias toward the prostitutes simply because the women are easy targets (Boynton ). Society’s discrimination may also lead to denying services to the women (Rekart ) or to directly and indirectly discouraging them from seeking necessary treatment and services that they are entitled to. The literature has indicated that sex workers may feel hesitant to seek substance abuse treatment or other health / social services at a “regular” program because of the stigma attached to their vocation (Kurtz et al. ; Weiner ). Studies also showed that sex workers are less likely to receive welfare benefits than their non–sex worker counterparts. Further, Church et al.’s study () reported that only % of the sex workers who had encountered violence from a commercial client reported the crime to the police. Sex workers may tolerate violence from their commercial clients (El-Bassel, Witte, et al. ) perhaps because they perceive that since their own job is illegal, they have no legal recourse for the job-related violence they suffer. Another perceived or real discrimination is that the sex workers may think they are being treated as second-class citizens when it comes to the investigation of violent crimes against them. Maria, in Romero-Daza, Weeks, and Singer’s study (), noted that although she and her friend provided the police with detailed information about the attacker, their case was never solved. In Maria’s view, “If it was any other girl not turning tricks, the guy would be in jail now, but because it was a whore nothing gets done” ().

Treatment Guidelines and Strategies Collaboration Between the Criminal Justice System and Substance Abuse Treatment Programs As mentioned earlier, statistics have shown that sex workers are more likely than non–sex workers—and street sex workers are more likely than non–street sex workers—to be involved with the criminal justice system. Scholars have advocated that the criminal justice system handle prostitutes differently than other criminals because prostitution usually involves multiple psychosocial problems and a purely

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punitive approach will not effectively deter the crime of prostitution or rehabilitate the women (Arnold, Stewart, and McNeece ; Pyett and Warr ). The close relationship between prostitution and the criminal justice system, as well as the prevalence of other problems among street sex workers, highlights the importance of collaboration between the criminal justice system and treatment programs in helping substance-abusing street sex workers.

Substituting Treatment for a Jail Term The involvement of a substance-abusing prostitute in the criminal system often creates an opportunity for the woman to access treatment. Arnold, Stewart, and McNeece () stated that women are more likely to enter substance abuse treatment while they are under the care of the court system. Although a woman’s own individual motivation is related to her participation in treatment, court-ordered treatment that can substitute for a jail or prison term provides her with the incentive to enter and complete treatment. Substance abuse treatment staff have commented that it is easier to engage women while they are still in jail and that their motivation usually declines once they are released (Arnold, Stewart, and McNeece ).

Developing AOD Screening and Referral Skills Among Professionals in the Criminal Justice System For successful identification and referral of women in the criminal justice system for substance abuse treatment, at least three prerequisites are required. First, both the professionals in the criminal justice system and those in substance abuse treatment must overcome their differences about values and views on drugs and prostitution and treatment methods. Young, Gardner, and Dennis () constructed a “five clock” concept, depicting the conflicting values and required time frames at work in four areas—the child welfare system, TANF, substance abuse treatment, and a child’s developmental stage—and then proposing a fifth “clock” that emphasizes coordination among the various systems to help a substance-abusing mother in the child welfare system. Similarly, the police department or parole / probation officers may have a very different view and approach to drugs and prostitution than the social service agencies or substance abuse treatment programs, and it is critical for the two systems to negotiate and find some middle ground (Arnold, Stewart, and McNeece ). Second, professionals in the criminal justice system must be equipped with substance abuse screening skills and knowledge so that they can effectively identify women who are at risk for substance abuse. Dual diagnosis screening knowledge and skills must also be covered when training the staff in the system. Third, they must have information about substance abuse treatment programs in the community so that they can effectively refer clients to an appropriate treatment program.

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Development of Street-Based Outreach Programs For many reasons—discrimination, marginalization, low self-esteem, fear of arrest, conflicts between agencies’ office hours and the women’s working hours, location, lifestyle issues—many sex workers, particularly street sex workers, hesitate to seek treatment or services at a “regular” program or “through normal agency service delivery” (Weiner :). Kurtz et al.’s () study delineated “structural barriers” and “individual barriers” that prevent the women from accessing treatment or services. The agencies may be located far from the women and the women do not have transportation. Programs that target (street) sex workers need to provide “user-friendly” services at locations near this population (Kail, Watson, and Ray ). Studies have shown that street-based outreach programs could increase the women’s motivation to seek treatment. For example, Nuttbrock et al.’s () study reported that about .% of the prostitutes in their study who were exposed to their mobile street-based outreach programs had received “detoxification or some other type of treatment during  months of follow up” (). Yahne et al. () indicated that the application of motivational interviewing methods to a harm-reduction outreach program located near where the prostitution was concentrated significantly increased the sex workers’ percentage of drug-abstinent days (% before treatment versus % after treatment) and decreased the women’s percentage of sex work days (% before treatment versus % after treatment). A functional or successful street-based outreach program includes three components: engendering the women’s trust and confidence in the outreach program staff, facilitating the women’s word-of-mouth advertising and soliciting sex workers who have successfully recovered as peer counselors, and providing essential components of concrete resources and counseling.

Engendering Trust in Outreach Program Staff As mentioned earlier, the street sex workers may not necessarily be motivated to seek treatment. In order for the outreach program to truly “reach out to” the women, the program staff must build trust with them (Nuttbrock et al. ), a task that may take an enormous amount of time and effort, requiring patience and persistence on the part of the staff. As Arnold, Stewart, and McNeece () noted, “Program staff did not take ‘no’ for an answer and might have reached out to a woman on the street for months before she was ready to try to get help. The staff did what they describe as a great deal of ‘hand holding,’ as well as home visits and numerous attempts to locate women in the community. Several of the women in the program stated that they had known the outreach workers with the program for several months before deciding to take advantage of the offer for help” ().

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Facilitating Word-of-Mouth Advertising and Using Successfully Recovered Sex Workers as Peer Counselors Because of the stigma of prostitution, sex workers (particularly street sex workers) may be ostracized by mainstream society, even by their family of origin, church, and community. Reaching this client population thus presents challenges. Experts have suggested that although the women are marginalized by mainstream society, they may organize their own networks to meet their survival needs. The outreach program staff should recognize the importance of such created networks as an asset in generating word-of-mouth information dissemination and discovering indigenous leaders who can encourage other women to seek the services to which they are entitled (Weiner ). Peer counseling is another powerful strategy in reaching this client population. Weiner () stated that women who have successfully completed their detox programs or those who were able to abolish their street prostitution career should be enlisted as peer counselors because these women not only know the culture of street life but also can serve as positive role models for other women who are still involved in prostitution. Summarizing various studies, Kurtz et al. () noted that peer counseling can be effective in increasing needle cleaning among injecting drug users; peer counselors can even be more effective than public health professional counselors with interventions to reduce risky behaviors related to drug use.

Providing Concrete Resources and Counseling The top five social service needs identified by  female sex workers in Miami were shelter (.%), employment (.%), medical care (.%), drug treatment (.%), and mental health counseling (.%) (Kurtz et al. ). A smaller study of  street sex workers in Albuquerque, New Mexico (Yahne et al. ) indicated three top priorities: decent housing, safety, and health care; mental health care; and drug treatment. All of these stated needs are consistent with the above-mentioned characteristics of street prostitutes. Practitioners seeking to help these women must incorporate all of these concerns in their short-, middle-, and long-term assessment and treatment plans, and connect the women with appropriate community resources. For street outreach programs, it is also critical to address the women’s immediate needs and offer crisis intervention. Among the immediate needs are: () a place to shower and / or access to bathroom facilities and personal hygiene products such as tissues (Kurtz et al. ; Nuttbrock et al. ), () a storage place, since many of the women are homeless or lack a stable place to store their property (Kurtz et al. ), () permission to use the agency’s address as a mailing address, () fresh water (instead of coffee or juice) (Kurtz et al. ) and a bag lunch (Nuttbrock et al. ), () condoms and HIV prevention literature (Nuttbrock et al. ), and () brief counseling in relation to addiction, psychological distress, violence, HIV / AIDS, and other STDs.

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Case Management Housing and Other Financial or Medical Support Poverty and homelessness may combine with substance abuse problems to propel women to street sex work. Women who are poor, homeless, and addicted to drugs are extremely vulnerable with regard to violence, losing custody of their children, and risky sexual and drug-taking behaviors. Poverty may also be the major deterrent to women’s leaving street sex work. It is therefore critical for practitioners to connect homeless substance-abusing women to a residential treatment program, a halfway house, or a transitional living situation while referring them for AOD treatment. The practitioners should also link them with governmental welfare benefits, Medicaid, and other emergency financial assistance. As mentioned earlier, street sex workers are less likely than their sex worker counterparts who work inside to receive welfare or Medicaid.

Substance Abuse Treatment AOD problems could be the single most important factor contributing to the women’s poverty, homelessness, and their eventual involvement in street prostitution. Connecting the women with professional AOD treatment programs must be a top priority. Cusick and Hickman’s () study indicated that % of outdoor prostitutes versus % of their indoor counterparts felt that they were “trapped” in their sex work careers and in drug use; these authors commented that “outdoor and drift sex markets are so thoroughly saturated with drug-use problems that it is difficult to conclude that one can be addressed without the other” (). Gilchrist et al. () suggested that if the women’s AOD problems are effectively treated, their need to work as prostitutes, along with the attendant risks, may be reduced. Women should be referred to gender-sensitive and -specific programs. The appropriate level of treatment (residential, intensive outpatient, regular outpatient, or detox) should also be a consideration. In many cases, simple detox is necessary but not sufficient. For example, Cusick, Martin, and May (:) noted that “the links between ‘outdoor’ . . . sex work sectors and problematic drug use were overwhelming. Sex workers in these sectors are characteristically vulnerable—exposure to environments where the sex market and drug selling share the same pavement space may reinforce their vulnerability. Residential-based treatment has the benefit of removing these sex workers from this environment.”

Employment, Vocational Training, and Education As mentioned earlier, women in this group tend to have fewer years of education and few marketable job skills. More education and a higher level of job skills are long-term goals that will empower the women to combat the problems of poverty and homelessness directly and the problem of substance abuse indirectly. However, researchers cautioned that the women “did not intend to ‘flip burgers’ in a

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fast food restaurant for minimum wage when they could make more than they would make all day by turning a couple of tricks” (Arnold, Stewart, and McNeece :). Another factor is age. Some middle-aged or older women may feel embarrassed working in a fast-food restaurant because they perceive such jobs to belong to teenagers. The key, as well as the challenge, is to prepare the women for and link them to a job that is both realistic and pays sufficiently well (Arnold, Stewart, and McNeece ).

Help with Psychological Distress and Other Mental Health Needs Street sex workers experience considerable psychological distress, which may undermine their motivation and ability to pursue safe sex or less-harmful AOD-using behaviors (Alegría et al.  ;El-Bassel, Simoni, et al. ). Paone et al.’s () findings also confirm the theory that a person’s psychological state is associated with his or her likelihood of engaging in risky behaviors. El-Bassel, Simoni, et al. () suggested that “psychotherapeutic or psychopharmacological intervention to address the underlying depression may lessen feelings of personal worthlessness, apathy and lethargy and lead to greater motivation for and commitment to behavioral change” (). As mentioned earlier, the women’s psychological distress may be the result of previous abuse and violence during childhood and / or adulthood, as well as from society’s prejudice and the effects of living in an impoverished environment. Arnold, Stewart, and McNeece () suggested that the women’s abuse history needs to be included in the assessment and treatment and that they should be encouraged to explore the impact of their history on their beliefs about their work in prostitution. In addition, not all defense mechanisms that a sexual abuse survivor has developed are detrimental; practitioners must exercise extra caution when handling such issues (Arnold, Stewart, and McNeece ).

Education in Harm-Reduction Messages and Practice This strategy is particularly relevant in helping young street sex workers, inexperienced sex workers who have been engaged in the street sex trade for less than one year, and street sex workers who have multiple other problems such as homelessness, severe AOD issues, social isolation, and / or a history of childhood sexual / physical abuse. These women tend to have no skills for “active risk management” other than simply relying on their “sixth sense” or being fatalistic about and passively accepting of what could happen to them. Therefore they are most vulnerable to the risks of violence and unsafe sex (Pyett and Warr ).

Violence Avoidance and Minimization Since partner violence (both intimate and commercial partners) is a huge risk facing street sex workers, the practitioners in an AOD treatment program or other

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outreach program must integrate violence risk into their assessment and treatment when helping street prostitutes (El-Bassel, Witte, et al. ). El-Bassel, Witte, et al. suggested that prevention efforts should focus on: () sensitizing the women to the heightened risk of violence perpetrated by commercial and intimate partners; () providing them with strategies for increasing their personal safety, including problem-solving skills, alternative coping mechanisms, help-seeking skills, and safety planning for risky situations; and () implementing intervention at the macro level and extending prevention efforts to all sex workers through various programs, such as AOD treatment programs, hospital emergency rooms, outreach programs, soup kitchens, and homeless shelters. Pyett and Warr’s () qualitative study (N = ) reported that although young and inexperienced street sex workers have no risk-management skills, some older, experienced street workers do manage to establish their “routines” to prevent possible violence from customers. The strategies the women adopted included () taking charge and being clear with the customer as to what they would do and where they would go (e.g., familiar hotels or streets), () avoiding a car that has more than one man inside and / or that has out-of-state plates, () finding a chance to check the car, including making sure the door handle can be opened from inside and determining if any weapons are hidden inside the car, and () memorizing the car make, color, and plate number. Another strategy could be to involve another member of the sex worker’s own social network. Hansen, Lopez-Iftikhar, and Alegría () noted that some Puerto Rican sex workers who came from the same housing project would look out for one another. They would jot down the car’s license number and note the amount of time that a worker spent with each customer.

Safe Sex Practice and HIV / AIDS Prevention Several guidelines are important here. First, practitioners should discourage the women from using AOD, alone or with a commercial or other customer, while they are working. AOD use often decreases mental and physical capacities, and therefore undercuts the ability to ensure safe sex and personal safety (Gilchrist, Cameron, and Scoular ; Pyett and Warr ). Since needle and drug equipment sharing is prevalent among street sex workers, prevention efforts must also promote no sharing of needles or drug equipment and making needle exchange programs more available and accessible. Second, practitioners should make the women aware of the possible dire consequences of having sex without a condom, and they should be trained in “condom negotiating skills” to prevent consensual condom non-use; “active risk management” skills can help them to avoid being coerced into not using a condom. As mentioned earlier, the women, particularly those who are desperately in need of drugs or money, may be vulnerable to the enticement of extra money offered by customers to forgo condom use. Women who suffer withdrawal may be taken

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advantage of by their customers. As a woman in Hansen, Lopez-Iftikhar, and Alegría’s () study said, “If you look desperate for a fix . . . [the client] wants to use you” (). Strategies for a more functional and less harmful response should be shared with the women. For example, some more-experienced street sex workers in Pyett and Warr’s () study would check to see if the client has any signs of STDs (herpes, warts, cuts, etc.). The women should also keep information on emergency community resources handy so they can have a choice to seek help with respect to drug craving, withdrawal, or other survival needs, instead of giving in to the customer. The practitioners may introduce, model the use of, and distribute female condoms, which have been perceived as acceptable alternative devices to male condoms by sex workers in poor inner cities (Witte et al. ). The female condom is the only “women initiated intervention” method to prevent transmissions of STDs, and it is as efficacious as the male condom (Lancet Infectious Diseases ). Witte et al. (), however, warned that a female condom may still require “male involvement and willingness to advance its use. Women may put themselves at risk for ridicule or abuse if they attempt to use the device without informing their partners” (–). Other obstacles that need to be overcome are that it is not as well known as the male condom, is more expensive (e.g., $. for a female condom versus $. for a male condom), and requires practice to become familiar with how to use it (Lancet Infectious Diseases ; Witte et al. ). Lancet Infectious Diseases (:) said that although female condoms may not be the magic bullet to prevent STD transmission and may not be liked by everyone, we need everything “we have got in the tool kit” to help tackle the rising threat of STDs. Third, practitioners should help the women understand that it is as important to use condoms with an intimate / non-paying partner as with a commercial customer, particularly if the intimate / non-paying partner is an injecting drug user. This often poses difficulties for the women for two reasons. Using condoms with an intimate partner may turn off romantic feelings toward the partner since it resembles sex with a commercial client. As a woman in Day and Ward’s study () put it: It’s all right for you [Sophie Day] [to put on a condom with your boyfriend / husband]. You don’t work with a gross of condoms by the bed, six days a week. How could I use condoms outside work? . . . The mere thought of putting a condom on a boyfriend or watching him put it on just leaves me cold. I’d rather not have sex. () Another reason is that the women are afraid of provoking anger in their intimate partners, who may exercise violence against the women or threaten to discontinue the relationship if they choose to use condoms. Again, practitioners should

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introduce various “condoms-negotiating skills” and other functional solutions to the women. In addition, Day and Ward () suggested that sex workers may differentiate between sex with a customer and an intimate partner by distinguishing the actual sexual activities involved. For example, a woman may provide various “fantasies,” instead of penetrative sex, to the customers, and thus condom use with the intimate partner may become less of an issue. Day and Ward suggested that the women may also use different types of condoms for different relationships.

Development of Sex-Worker-Specific Treatment Programs, Plus Couple Therapy Sex-Worker-Specific Treatment Group If possible, substance abuse treatment programs should provide a sex-workerspecific treatment group, separating substance-abusing women who are or were sex workers from their non–sex worker counterparts. Traditionally, substance abuse treatment programs have not been aware of this being an issue. However, Arnold, Stewart, and McNeece () pointed out that many substance-abusing prostitutes perceive themselves to be very different from other substance-abusing women who do not have a prostitution history. Women with a prostitution background prefer to receive treatment with other prostitutes who have gone through similar experiences and who can therefore better understand where they are coming from and will be less likely to judge, criticize, or embarrass them (Arnold, Stewart, and McNeece ).

Couple Therapy If possible, substance abuse treatment programs should provide family / coupleoriented treatment and group therapy. More and more experts have recognized the importance of and advocated for couple therapy when working with female substance-abusing clients (Cavacuiti ; Hedrich ; Romero-Daza, Weeks, and Singer ). Voluminous research has verified a strong link between women’s substance abuse and the substance abuse of their spouse. Women tend to be introduced to drugs by their spouse, and the women’s substance-abusing behaviors are heavily influenced by their men’s AOD-using behavior, including needle sharing, drug of choice, and relapses. Kail, Watson, and Ray () noted that needle sharing between some of the couples is constant and consistent, and outreach efforts need to be simultaneously extended to the women’s reluctant spouses while helping the women. Some women in Romero-Daza, Weeks, and Singer’s  study indicated that in order for a woman to successfully abstain from drugs, her drug-abusing spouse must be engaged in treatment at the same time. Those women suggested that drug treatment programs allocate “at least a few slots” for drug-using couples (). The couple’s mutual support of each other’s efforts to

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achieve abstinence is critical to the recovery of both. The process, however, could be difficult, because both are involved with “giving and receiving support from the partner while trying to curb one’s own ‘substance abuse’” (Cavacuiti :).

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•

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Substance-abusing street prostitutes are one of the most vulnerable populations, subjected to numerous risk factors and disadvantageous conditions. They possess not only a marginal social status but a status regarded as shameful. They are frequently exposed to dangerous environments, putting themselves at risk for possible violence from their customers, their partners, other prostitutes or drug dealers, law enforcement officers, and random street people. The nature of their work puts them at high risk for unsafe sex, and their AOD addiction often compels them to forgo safe sex protection, particularly when they need a “quick fix.” Both of these situations place them at high risk for HIV / AIDS and other STDs. They also suffer a tremendously high level of psychological distress. On the other hand, they often have limited, if any resources. They tend to have very few marketable job skills. They make much less money than indoor prostitutes, and they may spend most of their money on drugs. Without external support and assistance, it is very difficult, if not impossible for substance-abusing street prostitutes to escape the vicious cycle. Practitioners can help the women in multiple ways, especially through collaboration with the criminal justice system, homeless shelters, social service and / or substance abuse treatment outreach programs, and other community agencies. Street-based outreach programs can also help engage the women. Certain strategies must be emphasized in helping this vulnerable population. Practitioners should build trust relationships with the women and engender the women’s confidence in the practitioners. They should implement treatment and service in a flexible and practical manner that accommodates the women’s unstable lifestyle and irregular schedules and addresses immediate needs first before working on a long-term plan. Harm-reduction strategies and ways to promote safe drug-using behaviors (when total abstinence is not feasible), safe sex, and safety from violence are also part of the treatment strategies. Sex-worker-specific AOD treatment programs or groups tailored to the women’s special needs and concerns should be made available whenever possible.

Chapter 

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esbians are a diverse group, not only because they come from various ethnic and sociocultural backgrounds, socioeconomic statuses, and age groups but also because of the various meanings they assign to the concept of lesbian as a sexual orientation. Beiner and Hannam () said, “Some lesbians are sexual with men at times, yet see themselves as lesbians. Some women have same-sex relationships, but do not see themselves as lesbians. There are also women who choose to self-identify as lesbians on the basis of emotional attraction to other women and in spite of being sexually attracted to men” (). There are other women who de-emphasize the sexual-orientation aspect of lesbianism and consider lesbianism a frame of reference or subculture related to feminism (Jani Martell, MSW, personal communication, October ). The discordance between sexual identity and sexual behavior has been noticed. For example, Kerker, Mostashari, and Thorpe () studied women in New York City and found that regardless of sexual behaviors, % of the women self-identified as heterosexual, .% as lesbian, and .% as bisexual. However, among the women who had sex with women (WSW), % self-identified as heterosexual, % as lesbian, and % as bisexual. Valanis et al. () differentiated lifetime lesbians who have “sex only with women ever” from adult lesbians who were women who had lived as heterosexuals for the first part of life but fell in love with another woman in midlife (e.g., having sex with women after  years of age). Because of the possible discordance between sexual identity and actual sexual behavior, this chapter covers all WSW, including mainly lesbians but also bisexual women and WSW who selfidentify as heterosexual. Many studies, although not all, have suggested that lesbians /WSW have a higher AOD rate than heterosexual women. Earlier studies suggesting a higher AOD problem rate among gays and lesbians were criti-

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cized for recruiting participants primarily from gay / lesbian bars. The later studies recruited participants from various sources, thus correcting that sampling bias. These later studies still report a (moderately) higher AOD abuse / dependence rate in gays and lesbians /WSW than in heterosexual samples (see Cochran and Cauce's review ). Although some studies suggested no difference in alcohol abstinence rate between non-heterosexual and heterosexual women, they did indicate that significantly more lesbians than heterosexual women reported being in recovery or having been treated for AOD problems (e.g., Hughes ). Results of two population-based studies, one indicating a higher alcohol rate and the other a higher drug rate among lesbians / WSW / bisexual women than among heterosexual women, are presented here. Drabble, Midanik, and Trocki’s () analysis of the  National Alcohol Survey data reported that bisexual women, lesbians, and WSW who self-identified as heterosexual were significantly more likely than exclusively heterosexual women to be heavier drinkers (the percentages were .%, .%, .%, and .%, respectively; all p values were < .). There was no significant difference among bisexual women, lesbians, and WSW who self-identified as heterosexual regarding heavier drinking. In addition, bisexual women and lesbians reported more alcohol dependence / alcohol-related negative social consequences and previous help-seeking for problems related to alcohol than did the exclusively heterosexual women. The secondary analysis of the  National Household Survey on Drug Abuse data by Cochran et al. () revealed that “homosexually experienced” women (n = ) had a moderately higher drug use and dependence rate than exclusively heterosexual women (n = ,). The women with “any female partners” had a significantly higher rate of dysfunctional drug use (defined as a “yes” answer “to any of the six symptoms of drug dependence” in the preceding year) of marijuana (% versus .%, p < .), cocaine (.% versus .%, p < .), hallucinogens (.% versus .%, p < .), and any drug class (.% versus .%, p < .), than women with “male partners only.” The women with “any female partners” also had a significantly higher rate of drug dependence syndrome (defined as a “yes” answer to “three or more of the six symptoms of drug dependence” in the preceding year) for marijuana (.% versus .%, p < .) and any drug class (.% versus .%, p < .) than women with “male partners only” (). Lesbians, bisexual women, and WSW who self-identified as heterosexual are a group with unique needs in relation to health, AOD treatment, mental health, and legal matters. They tend to have a higher level of use of counseling and psychotherapy but a lower level of health care use (particularly preventive care) than heterosexual women. They have also reported dissatisfaction with the (preventive) health care services (see Kerker et al.’s review ) and AOD treatment they received (Matthews and Selvidge ). An analysis of the  National Alcohol Survey (N = ,) (Drabble and Trocki ) revealed that lesbians / bisexual women were no different than heterosexual women with respect to “reasons for seeking treatment,” “problem type (alcohol, drugs or both)” or “program type

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(alcohol or drug)” except for of “satisfaction with treatment” (–). Lesbians / bisexual women were significantly less likely than heterosexual women to report satisfaction with the service received (.% versus .%, p < .). Matthews and Selvidge’s () study ( same-sex-oriented clients who are in recovery from AOD, .% female) showed that the clients perceived that their addiction counselors practiced affirmative treatment only “some of the time” (). Studies have also shown that close to half of addiction treatment counselors hold a negative or uncertain attitude toward same-sex-oriented clients (Eliason ; Eliason and Hughes ). These counselors are deficient in formal and continuing education regarding gay / lesbian-specific knowledge, particularly in the areas of internalized homophobia, legal issues / power of attorney / domestic partnership, and current family / family of origin. More than % of them were unfamiliar with the legal issues pertinent to same-sex-oriented individuals; about % were unfamiliar with domestic partnership; about mid-% were unfamiliar with the family issues; nearly % were short on knowledge regarding “internalized homophobia,” more than mid % regarding the “coming-out” process; and more than % had no knowledge about AOD prevalence in the gay / lesbian community (Eliason and Hughes). This chapter discusses aspects directly and indirectly related to lesbian /WSW’s AOD problems and recovery. Treatment guidelines and strategies are also covered.

Characteristics and Needs of Lesbians and WSW The Identity Formation Process (“Coming Out”) The Interrelation Between “Coming Out” and Substance Abuse Although lesbians’ (and gay men’s) AOD problems cannot be completely explained by the issues involved in coming out, the two are closely related. To effectively treat the AOD problems of a lesbian, practitioners need to be sensitive to her possible struggle with her coming-out process. As the PRIDE Institute (a gay / lesbianspecific AOD treatment program) stated, “How can you recover if you can’t be yourself?” (n.d.). Likewise, to effectively help a lesbian with her confusion and distress because of the identity formation process, practitioners cannot ignore any AOD problems that may be present. An untreated AOD problem and intoxicated mind will only add more distress to the individual and make the coming-out process even more difficult. The risk factors for lesbians’ AOD problems are discussed in detail later in this chapter. First the chapter will focus on an understanding of the coming-out process for homosexuals in general, and lesbians in particular.

Stage-Sequential Model Versus Nonlinear Model Various theories were developed regarding the coming-out stages (e.g., the Cass model, the Troiden model, the Coleman model, and the Grace model, cited in

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Ritter and Terndrup ). The Cass model is presented here because not only is it the most frequently cited model (Schneider ) but also because it accurately predicts the order of the various tasks / milestones among the lesbian population (Levine ). However, researchers (Garnets and Kimmel, cited in Schneider ) cautioned that the coming-out process should not be perceived as totally linear, as is implied by the stage-sequential models; rather, a gay / lesbian person may navigate back and forth from one stage to another and may repeatedly experience and engage the same issues and tasks.

Recent Research Current studies (e.g., Floyd and Bakeman ) have suggested that the more recent cohort of homosexuals is more likely to be “identity-centered” (i.e., having self-identified as lesbian / gay before engaging in same-sex sexual activity), while the older cohort is more likely to be “sex-centered” (i.e., having engaged in samesex sexual activity before establishing a homosexual identity). This change may be related to progress in sociocultural attitudes in that the climate of stigmatization of homosexuality has been changed to one that is more accepting and inclusive. In addition, more attention has finally begun to focus on the lesbian-specific coming-out process after a historical emphasis first on gay men and later on homosexual adolescents (Rickards and Wuest ).

Stages of Coming Out: The Cass Model Cass () presented six sequential stages in explaining the identity formation / “coming-out” process: 1. Identity Confusion Stage. The individual becomes aware for the first time of same-sex attraction and the possibility that she is not a heterosexual. She is confused as to who she really is. She may eventually successfully reject the idea that she is a homosexual (foreclosure) or she may move on to the next stage, with either a positive or a negative feeling. 2. Identity Comparison Stage. The individual begins to assess and compare the rewards (e.g., being able to be self ) and costs (a sense of loss of the already planned heterosexual life continuity, alienation, etc.) involved in self-identifying as a homosexual. When perceiving high costs and low rewards involved, the individual may strive to and eventually successfully inhibit her homosexual thinking and behavior (foreclosure). She may move to the next stage if the inhibition is unsuccessful or if she perceives high rewards and low costs. 3. Identity Tolerance Stage. The individual is no longer stuck in searching for an explanation for her homosexual thinking and behavior. During this stage, she focuses more on the “social, sexual, and emotional needs that arise from seeing self as probably homosexual” and begins to look for other lesbians and gays ().

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4. Identity Acceptance Stage. Although the individual has begun to understand herself as a homosexual during the third stage, her “inner sense of self ” as a homosexual may still be tenuous at the beginning of the fourth stage. Her continuous contacts with other lesbians and gays strengthen her sense of being a lesbian during this stage. 5. Identity Pride Stage. Realizing the difficulty of fully expressing herself as a homosexual because of the world’s dominant heterosexual culture, the individual develops a strong identification with the lesbian / gay community and divides the world into “them and us,” with “them” being discredited heterosexuals and “us” being credible lesbians / gays. The combination of pride and anger, according to Cass, leads the individual to abandon her intention to pass as a heterosexual. 6. Identity Synthesis Stage. The individual may change her perception that the world is simply divided into discredited heterosexuals and credible lesbians and gays when the notion of homosexuality is being accepted or supported by at least some heterosexuals. Cass states that during this stage the individual’s “level of anger, alienation, and frustration is lessened as the ‘enemy’ is reduced in number at a personal level. Issues of oppression are now addressed in a less defensive manner and the level of identification with the lesbian or gay group seen in Stage  is reduced” (–). The individual’s interaction with the public as an openly lesbian or gay person fortifies her inner sense of identity and there is “a sense of belonging to the world at large and of being ‘more than just a lesbian or gay man’” ().

Although Cass’s model is applicable to both gay men and lesbians, it’s essential to integrate some lesbian-specific features in understanding the identity formation process of lesbians.

The Importance of Relationships and Emotional Intimacy for Lesbians Schneider () emphasized the significance of relationships, friendships, and emotional intimacy in lesbians’ identity formation process: A variety of relationships play important roles in the development of a lesbian identity. Their nature depends upon the age of the individual at the time— falling in love with one’s best friend at age  is qualitatively different, and has different consequences, from falling in love with one’s best friend and leaving one’s husband to live with each other at age —but both can be called relationships. In addition, the relationships do not necessarily have an erotic component. They can include close friendships, mentorships, or other emotional attachments, but the hallmark of these relationships is the intense feeling that persists over an extended period of time. . . . Regardless of whether or not the feelings were mutual, however, the awareness of sexual feelings emerged in the

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context of an existing friendship or emotional attachment to a particular individual, rather than as a generalized attraction to the same sex. (–)

Other Differences Between Lesbians and Gay Men Regarding the Coming-Out Process Studies have suggested that () women tend to be older than men when they reach various milestones in the identify formation / coming-out process, () a higher proportion of women than men report bisexual orientation, and () women are more likely than men to be “identity-centered” rather than “sex-centered.” For example, Floyd and Bakeman () studied  homosexual individuals (% female, aged –) and found that the mean age for women to first become aware of their same-sex attraction was . (SD = .), which was significantly older than the mean age for men, . (SD = .), p < .). The women also first engaged in consensual sex with another woman at an older age than men (. [SD = .] versus . [SD = .], p < .) and self-identified themselves as lesbian / bisexual at an older age than the men who self-identified as gay / bisexual (. [SD = .] versus . [SD = .], p < .). Further, women were more likely to report a bisexual milestone than men (% of the homosexual women versus % of the homosexual men).

Lesbians Coming Out in Midlife: The “Confronting the Taken-for-Granted” Model A woman may live as a heterosexual for the first part of her life but become a lesbian in midlife after falling in love with another woman. Schneider () stated that women who come out in midlife belong to a unique subgroup of lesbians who usually report that it’s a choice for them to become a lesbian and that living the first part of their life as a heterosexual was not necessarily a result of their authentic homosexual orientation’s having been suppressed for all those years. Schneider said these lesbians not only represent a coming-out process that is inconsistent with the traditional coming-out model but also challenge the very concept traditionally held by the gay / lesbian community that “sexual orientation does not change over the life course” (). Despite the fact that those who come out in midlife constitute a sizable portion of lesbians, little research has been done about this group (Schneider ). Rickards and Wuest () recently developed the “confronting the taken for granted” model, based on their qualitative study of  women, discussing the coming-out process of lesbians who came out during midlife and identifying three stages: 1. “Facing Scary Love” Stage: The woman first realizes that she has fallen in love with another woman (i.e., “. . . and then I met this woman” [Rickards and Wuest :]) and is undergoing a shift from a heterosexual self to a homosexual

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self. At the same time, however, she is experiencing tremendous guilt and shame because she has long internalized the heterosexist value that woman loving woman is unnatural and wrong. She therefore faces the challenge of losing self-credibility (e.g., becomes uncertain about her ability to make sound decisions), as well as the possibility of losing public credibility (e.g., losing respect from family and community) if she discloses her sexual identity. On the other hand, her striving to rebuild her self-credibility, together with her authentic self-identification, her relationship with the woman she loves, and the support obtained from the lesbian / gay community, motivates her to enter the next stage. 2. “Finding Me” Stage: The woman works on rebuilding her self-credibility while integrating lesbian identity into her life. Strategies engaged may include “doing what’s in front of me,” so that she can maintain “a sense of control and stability” in her life (Rickards and Wuest :). Another strategy is to seek affirmation through careful self-disclosure. Having regained her self-credibility during this stage, the woman may consider further reestablishing her public credibility. This leads her into the third stage. 3. “Settling-In” Stage: Self-credibility and public credibility are closely related. In order to regain public credibility, the woman must have intact self-credibility as a base; in turn, the public credibility that she has regained further enhances her self-credibility. Rickards and Wuest () noted that the women perceived that the best strategy for rebuilding a credible self and showing that lesbians are as normal as heterosexual women was to continue daily routines (e.g., family chores, jobs, and community activities) while integrating lesbian experiences into their lives. In addition to restoring credibility, the woman faces the challenges of “enduring perpetual outing” or the reality that “one never stops coming out” (GalatzerLevy and Cohler, cited in Rickards and Wuest :). Although the woman may manage the challenge by taking “the bitter with the sweet” and by standing up and staying put in confronting discrimination, should it occur, it is critical that continuous support be available to her in order for her to successfully settle in ().

Mental Health Homosexuality Is Not a Mental Disorder Historically, homosexuality has been considered abnormal and deviant. It was classified as a mental disorder in the Diagnostic and Statistical Manual (DSM) until . Schneider () noted that Evelyn Hooker’s s study that compared gay and non-gay men with respect to various psychological characteristics sparked a line of research comparing lesbians and gay men with heterosexual women and men with respect to a number of psychological characteristics. These studies

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pointed out that lesbians and gay men possess no higher level of pathology than do their heterosexual counterparts and that they can be as healthy as their heterosexual counterparts. Such findings eventually became the scientific basis for the removal of homosexuality from the mental disorders listed in DSM II (Bayer, cited in Schneider ). Although homosexuality is officially no longer a pathology or deviance and society, in general, has become more accepting of lesbians and gay men, the prevailing value of society today is still heterosexism. Lesbians and gay men still live in a relatively more marginal and oppressive sociocultural context than do their heterosexual counterparts.

Lesbians and Gay Men at Greater Risk for Psychiatric Disorders Because of Exposure to Discrimination Studies of racial oppression and other types of discrimination have clearly revealed the link between exposure to discriminatory behavior and psychological stress / psychiatric disorders (see Gilman et al.’s review ). Although homosexuality is not a mental disorder itself, lesbians, gay men, and other sexual minorities may be at a greater risk for psychiatric disorders because of exposure to discrimination. Much like members of other oppressed groups, homosexual individuals have been shown to be at greater risk for psychological stress / psychiatric disorders, which is closely related to their being subjected to prejudice. Mays and Cochran’s () analysis of the National Survey of Midlife Development in the United States showed that homosexuals / bisexuals more frequently reported experiencing discrimination than heterosexuals did. Specifically, % of the lesbian / bisexual women reported experiencing at least one of eleven types of lifetime discrimination identified (“not given a job promotion,” “fired from job,” “prevented from renting or buying a home,” “denied or given inferior medical care,” etc.), followed by .% of the gay / bisexual men, .% of the heterosexual women, and .% of the heterosexual men (). For day-to-day discrimination, both the lesbian / bisexual women (.%) and the gay / bisexual men (.%) more frequently reported experiencing at least one of the nine types of discrimination identified (“people act as if they think you are not as good as they are,” “treated with less respect than other people,” “get poorer service than others do at restaurants or stores,” “you are called names or insulted,” etc.) than did the heterosexual women and men (.% and .%, respectively) (). Mays and Cochran () further pointed out that the level of an individual’s perceived discrimination is associated with the individual’s perception of life quality and mental health status. For example, .% of the lesbian / bisexual women reported that “discrimination has made life harder,” followed by .% of the gay / bisexual men, .% of the heterosexual women, and .% of the heterosexual men (). Experiencing any lifetime or day-to-day discrimination significantly increased the likelihood of psychiatric disorder. Such individuals were more likely to rank their current mental health as “fair” or “poor.” Further, when

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the variable of the level of discrimination experienced was controlled statistically, the association between sexual orientation and psychiatric morbidity was reduced. This suggests that mental distress among lesbians and gay men has less to do with their sexual orientation per se than with the discrimination they experience as homosexuals. Some studies, such as Koh and Ross’s () study and Balsam et al.’s () study, report no significant difference between sexual minority individuals and heterosexuals regarding level of current psychological distress. Both of those studies reported, however, that sexual minority individuals were significantly more likely to have had suicide ideation and / or attempts than heterosexuals, and both studies, accordingly, interpreted their findings to mean that homosexual orientation itself does not produce psychological distress but society’s stigmatization contributes to homosexuals’ more serious psychological distress and psychiatric symptoms.

Higher Rates of Suicide Ideation and Attempts Among Lesbians and Bisexual Women, Particularly Youth Hughes’s study () (N =  lesbians and  heterosexual women) found that the lesbians had a significantly higher rate of suicide ideation than the heterosexual women (% versus %). They appeared to also have a higher rate of suicide attempts than the heterosexual women (% versus %). About % of the , lesbians in Bradford, Ryan, and Rothblum’s study () had had suicide ideation, including % who “had such thoughts only rarely,” % who had them “sometimes,” and % who had them “often” (). Bradford, Ryan, and Rothblum’s study also showed that % of the lesbians had made suicide attempts. Koh and Ross () reported that lesbians who were not out about their sexual orientation were more than “. times more likely to have reported suicidal ideation occasionally or very often” ( p < .) than the heterosexual women (). Lesbians who had disclosed their sexual orientation were more likely to have had suicidal ideation than the heterosexual women, a distinction that approached significance (odds ratio = ., p < .). The bisexual women who had disclosed their sexual identity were “twice as likely to have reported suicidal ideation occasionally or very often” ( p < .) than the heterosexual women (). Regarding suicide attempts, the not-out lesbians were “% more likely to have had a suicide attempt” (odds ratio = ., p < .) and the not-out bisexual women were “three times more likely to have had a suicide attempt” (odds ratio = ., p < .) than the heterosexual women (). Although the lesbians in Hughes’s study () had a higher lifetime suicide attempt rate than the heterosexual women, their suicide attempts tended to occur during their adolescent years or in their twenties. Similarly, Bradford, Ryan, and Rothblum’s () study showed that older lesbians were less likely to attempt suicide than younger lesbians—% of the lesbians aged – reported suicide attempts, followed by % for the – age group, % for the – group, and % for the -or-older group. Kitts’s review () showed that homosexual

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youth are significantly more likely than heterosexual youth to attempt suicide. For example homosexual youth were “more than twice as likely” to attempt suicide as heterosexual youth were in Russell and Joyner’s study (cited in Kitts :). D’Augelli et al.’s () study showed that % of the homosexual youth in the sample (N =  gays, lesbians, and bisexuals) reported suicide attempts. Female homosexuals had a higher percentage of suicide attempts than male homosexuals (% of the females versus % of the males, p < .). Not all homosexual youth suicide attempts were related to sexual orientation. Gay men had a higher percentage of sexual-orientation-related suicide attempts than lesbians—% and %, respectively. Three factors may explain the high number of suicide attempts among teen lesbians. First, adolescents and younger adults may be more likely than older adults to attempt suicide, and women more likely than men (Kessler, Borges, and Walters ; Larkin, Smith, and Beautrais ), although older persons and men may be more likely to die by suicide (NIMH ). Second, an individual’s sexual identity formation / coming-out process often starts during the preteen or teenage years, and often the beginning stages of the process are full of confusion and distress (Hughes ). Third, teenage lesbians are less established financially, emotionally, and socially than adults, and they rely primarily on their family and the community, which unfortunately often are heterosexism-dominant and thus may subject the youth not only to the loss of his or her family as a coping resource but also to more rejection and distress (see Kitts’s review ).

Higher Counseling-Use Rates Among Lesbians Studies have consistently reported that lesbians have a higher counseling use rate than heterosexual women. Morgan () found that .% of the lesbians versus % of the non-lesbians reported having used counseling. Similarly, about % of the lesbians in Bradford, Ryan, and Rothblum’s study () indicated use of current or previous mental health support. Koh and Ross (), recruiting outpatient participants from health care sites across the United States, reported that % of the lesbians (N = ) and % of the bisexual women (N = ) versus % of the heterosexual women (N = ) were using or had used counseling for depression. Koh and Ross said that the high counseling-use rate among lesbians was true regardless of whether they had come out or not. Three reasons may explain lesbians’ high counseling use: (a) Homosexuals experience a higher level of discrimination, which leads to a higher level of mental distress (Mays and Cochran ). In other words, although homosexuality itself is not a pathology, the “normal development tasks faced by every individual are complicated for lesbians by societal oppression” (Morgan :). (b) Heterosexism excludes lesbians from many common privileges enjoyed by the general population. Compared to the general population, lesbians have less access to emotional support from their community, religious organizations, and even their own

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families. Seeing a counselor counteracts the deficiency and provides lesbians opportunities to receive acceptance, support, and guidance (Morgan ). (c) Lesbians have a higher level of trust and a more positive attitude toward mental health professionals. Morgan’s study showed that the lesbians, whether they had actually experienced counseling or not, scored significantly higher than the non-lesbians on “Surgenor’s revision of the Attitudes Toward Seeking Professional Psychological Help Scale” (). In addition, lesbians may be more likely than non-lesbians to place high value on “introspective growth,” which often can be achieved through counseling (Morgan ). What are the problems that lesbians bring to counseling? Although many of the issues are oppression- and discrimination-related, lesbians also seek counseling for the same problems commonly experienced by heterosexuals. Bradford, Ryan, and Rothblum’s () study indicated that % of the lesbians reported seeking counseling for depression, % for “feeling anxious or scared,” % for “loneliness.” One major issue for lesbians is “personal relationships”; % sought counseling for “problems with lovers,” % for “problems with family,” and % for “problems with friends.” Other reasons included “personal growth issues” (%), “being gay” (%), “alcohol and drugs” (%), “upset at work” (%), “problems due to racism” (%), and “loss of significant other” (%) ().

Health Needs HIV / AIDS and Other Sexually Transmitted Diseases (STDs) Although it is not unusual to link gay men with issues related to HIV / AIDS, many people would not consider HIV / AIDS much of a threat to lesbians, perhaps because of the belief that HIV / AIDS is less likely to be transmitted through female-to-female sex. However, lesbian and bisexual women can be at a higher risk for HIV / AIDS than heterosexual women for at least three reasons. First, Koh and Ross’s () study showed that compared to heterosexual women, lesbian and bisexual women had a significantly higher number of gay / bisexual male sexual mates. Their study also indicated that although most heterosexual women had engaged in sexual acts with men only and most bisexual women had engaged in sexual acts with both women and men, slightly less than half (%) of the lesbians had had sexual contact with women only and slightly more than half (%) of them had had sexual contact with both men and women. The literature has consistently suggested that the sexual orientation identified by an individual does not necessarily match the individual’s actual sexual behavior. Hutchinson, Thompson, and Cederbaum ()’s literature review showed that more than % of lesbians have had intercourse with a man at some point in their life, % reported that they had had four or more men over a lifetime, and more than a quarter revealed that they had had sex with a man within the preceding year. Not only do lesbians face HIV / AIDS / STD risks from their male partners,

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but it’s possible for them to face such risks from their female partners as well. Marrazzo () and others found that sexual practice between women may involve digital-vaginal / digital-anal acts and the use of shared sex toys, which make it possible to transmit contaminated cervicovaginal secretions between women. Second, non-heterosexual women tend to choose heroin as their primary substance, while heterosexual women tend to choose alcohol; heroin use increases drug-injecting practice, and thus increases HIV / AIDS / hepatitis / STD risks. Cochran and Cauce’s () study of sexual-minority individuals receiving AOD treatment at public-funded programs in Washington State found that although both the non-heterosexual women (n =  lesbian, bisexual, and transgender women) and the heterosexual women (n = ,) had alcohol as their top primary substance abused, followed by methamphetamine, heroin, marijuana, cocaine and / or crack, and “other” drugs, a higher proportion of heterosexual women than non-heterosexual women chose alcohol as their primary substance (about % versus %, p < .). On the other hand, a higher proportion of the nonheterosexual women than the heterosexual women chose heroine as their primary substance (about % versus %, p < .). In addition, non-heterosexual women had a higher mean frequency of primary substance use ( p < .), and thus a more severe primary substance abuse problem than heterosexual women. Third, empirical studies have strongly observed that woman injecting-drug users (IDU) who have sex with women (WSW) are at a significantly higher risk for HIV / AIDS infection than non-WSW women IDUs. Those studies also showed that a somewhat larger portion of women IDUs may be WSW. For example, Friedman et al.’s () study (N =  female IDUs aged –, from five cities in the United States) reported that % to % of their female IDUs, depending upon the site, were WSW. Young et al.’s () review of  studies found that the rates of WSW among the female IDUs / crack users ranged from less than % to %. Compared with non-WSW female IDUs, WSW IDUs are more likely to: () have (or have had) a negative environment, such as having been homeless, () engage in high-risk drug behavior, such as sharing the receptive syringe and / or rinse water, and () connect with high-risk partners, such as IDU men who have sex with men (MSM), WSW IDUs, HIV- or hepatitis-positive IDUs, and older IDUs (Friedman et al. ). Perhaps because of all these risk factors, WSW IDUs have been shown, in multiple empirical studies, to have a significantly higher HIV rate than non-WSW female IDUs. Eight of the studies reviewed by Young et al. () suggest a higher HIV rate among WSW IDUs than among non-WSW female IDUs, whereas only two of the reviewed studies suggested no difference between the two groups.

Gynecological and Reproductive Health Although the actual prevalence results have not been completely consistent, many studies have shown that lesbian and bisexual women may be at a higher risk for

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developing breast cancer than heterosexual women (Brandenburg et al. ). Valanis et al.’s study (:) reported that the bisexual women had the highest breast cancer rate (.%), followed by .% of the adult lesbians (“sex only with women after age  years”), .% of the “no adult sex” women, .% of the “lifetime lesbians” (“sex only with women ever”), and .% of the heterosexual women. The bisexual women also had the highest rate of any cancer (.%), followed by lifetime lesbians (.%), “no adult sex” women (.%), adult lesbians (.%), and heterosexual women (.%). However, Cochran et al.’s () study, despite showing that lesbian / bisexual women were more likely to engage in risky behavior (e.g., smoking, dysfunctional drinking, and obesity) linked to breast and other cancers, found that they did not have a higher breast cancer rate than the U.S. female population (standardized estimates). The two different outcomes could be attributed to the fact that Valanis et al. studied women aged – where Cochran et al. studied women aged mostly –; breast cancer tends to be a disease of older women. Although fewer studies compare heterosexual and non-heterosexual women regarding ovarian and cervical cancers, theories suggest a higher risk for ovarian cancer and a similar risk for cervical cancers in lesbian / bisexual women. In addition to the negative impact of smoking, drinking, and being overweight, nonheterosexual women’s low parity and other reproductive-behavior-related factors may increase the risk for ovarian and breast cancers (Dibble et al. ; Hutchinson, Thompson, and Cederbaum ). As for cervical cancers, it’s a misperception that lesbians are less likely to be afflicted with these than heterosexual women; many lesbians have had sex with men, and cervical human papilloma virus has been found in % of lesbians who had had no previous sex with men (Marrazzo et al., cited in McNair ). Furthermore, many lesbians who wish to have children may choose selfinsemination or work with donor-insemination clinics. They can benefit from information about donor screening and other safety issues, as well as information about suitable donor-insemination clinics (McNair ).

Lower Use of (Preventive) Health Services Although the study results were not consistent, many reported that WSW / lesbians / bisexual women are less likely to use health care services, particularly preventive service like mammograms or Pap smears (Cochran et al. ; Kerker, Mostashari, and Thorpe ; Valanis et al. ). Kerker, Mostashari, and Thorpe’s study reported that % of the WSW had had a Pap test in the past three years compared to % of the other women ( p < .) and that % of the WSW had had a mammogram in the past two years compared to % of the other women ( p < .). After controlling for other factors (e.g., insurance status), Kerker, Mostashari, and Thorpe’s multivariate model showed that WSW were ten times “more likely to have had no Pap test” in the preceding three years and four times “more likely to have had no mammogram” in the preceding two years than

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non-WSW (). Considering the fact that lesbians / bisexual women may be at either a higher or a similar risk for breast, ovarian, and cervical cancers, it’s important for practitioners to be alert to the issue of WSW’s low use of preventive services. Many factors may lead to WSW’s low use of health service (e.g., a lack of insurance or a misperception that there is no need), but one primary reason could be the climate of heterosexism that is prevalent in the health care system, including homophobia and discriminatory attitudes of physicians and other medical staff. Several empirical studies reviewed by Kerker, Mostashari, and Thorpe () identified the issue. One intriguing finding of their own study was that although WSW in general had a lower health service use than non-WSW, WSW who selfidentified as lesbian were more likely to have had a timely Pap test / mammogram than WSW who self-identified as heterosexual (i.e., % of the former group versus % of the latter group [p < .] had had a Pap test in the preceding three years). The researchers thus suggest that women with discordant identity may be more likely to avoid health care because they are more likely to feel uncomfortable about addressing sexual topics with the health professionals.

AOD Abuse and Dependence Type, Severity, and Social Consequences of AOD Problems Cochran and Cauce’s () study showed that lesbians / bisexuals / transgender women attending public-funded treatment programs in Washington State reported alcohol (%) most as the primary substance abused, followed by methamphetamines (%), heroin (%), marijuana (%), cocaine or crack (%), and other (%). Although the order of primary drug abused by heterosexual women was the same as it was for non-heterosexual women, the two groups were different in certain ways. The heterosexual women were more likely than the non-heterosexual women to report alcohol as their primary substance (% versus %, p < .), while the non-heterosexual women were more likely than the heterosexual women to report heroin as their primary substance (% versus %, p < .). In addition, the non-heterosexual women reported a more severe substance abuse problem than did the heterosexual women (M = . and ., respectively, t[,] = ., p < .). Older lesbians may be more likely to drink, smoke, or use tranquilizers daily than younger lesbians. Younger lesbians, on the other hand, may be more likely to smoke marijuana. Bradford, Ryan, and Rothblum’s study () showed that % of those aged  or older drank daily, followed by % for those aged –, % for those aged –, % for those aged –, and % for those aged –. For tobacco use, % of the lesbians aged  or older used daily, followed by  % of those aged –. The tobacco use rates for the younger age groups were % for those aged –, % for those aged –, and % for those aged –. Only a small percentage of the lesbians, mainly those  years of age

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and older, used tranquilizers daily. Finally, about half of the lesbians used marijuana at least occasionally; % of the – age group versus % of the oldest group smoked marijuana “less than once a month” (). Lesbian / bisexual women may be more likely than heterosexual women to experience negative AOD-related social consequences. Drabble, Midanik, and Trocki () reported that lesbians / bisexual women in their study had a significantly higher rate than heterosexual women of experiencing  of  items measuring negative social consequences (gay / bisexual men differed from heterosexual men on none of the  items). The  items were “fights” (.% for the lesbians / bisexual women and .% for heterosexual women, p < .), “arguments” (.% and .%, respectively, p < .), “a spouse being angry because of drinking” (.% and .%, respectively, p < .), “a physician suggesting reduction in drinking” (.% and .%, respectively, p < .), “lost time at work” (.% and .%, respectively, p < .), and “trouble with the law about drinking when driving was not involved”(.% and .%, respectively, p < .) ().

Risk Factors for AOD Abuse and Misuse for Lesbian / Bisexual Women In addition to theories about AOD risk factors in general (e.g., biological / genetic, psychological, sociological, multivariate, etc.) and refinements of such theories that pertain specifically to women (e.g., the effect of the AOD behaviors of their family of origin and the environment in which they are embedded)—both of which were covered in chapter —non-heterosexual women may face a set of AOD risk factors that are unique to them: () internalized homophobia and heterosexism, () general and lesbian / bisexual women-specific stress, () gay / lesbian bars, and () childhood sexual abuse. Internalized heterosexism and homophobia among lesbian / bisexual women often cause them to devalue themselves while valuing heterosexuals, resulting in low self-concept, anger toward self, and self-blame for the victimization suffered (CSAT b). They may use AOD to self-medicate negative feelings and shame (CSAT b). The relationship between lesbians’ internalized heterosexism and their alcohol use and abuse has been widely emphasized by practitioners and researchers, although the research findings have not been completely consistent (see Amadio’s review ; CSAT b). Cabaj () stated that many women and men used alcohol during their first same-sex sexual experiences so that they could overcome feelings of fear, anxiety, or repulsion about same-sex sex. Several studies suggest the relationship between the internalized heterosexism and AOD abuse, particularly among lesbians. Rickards and Wuest’s () qualitative study (N =  substance-abusing self-identified lesbians, coming out between the ages of  and ) revealed that lesbians may struggle “to reconcile the recognition of having a lesbian identity with the internalization of negative messages overheard since early childhood” (). As a lesbian in the study stated, “I was very attracted to lesbians, but I was convinced that I was a pervert for

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thinking like that. I had such feelings . . . that I was ‘bad,’ that I began to selfmedicate those feelings away” (). Amadio’s study () (N =  lesbians and  gay men) also reported some relationship between the internalized heterosexism and alcohol use / abuse, primarily among lesbians. Amadio found that “the number of days consuming  or more drinks over the past month” and “the number of days being very high or drunk over the past year” significantly associated with the lesbians’ internalized heterosexism, but such relationships do not exist among gay men (–). The tool (Szymanski and Chung :–) used to measure the internalized homophobia among the lesbians in Amadio’s study () covered five dimensions: () “Connection with the Lesbian Community,” e.g., the item “Social situations with other lesbians make me feel uncomfortable”; () “Public Identification as a Lesbian,” e.g., “I try not to give signs that I am a lesbian. I am careful about the way I dress; the jewelry I wear; and the places, people, and events I talk about”; () “Personal Feelings About Being a Lesbian,” e.g., “I hate myself for being attracted to other women”; () “Moral and Religious Attitudes Toward Lesbians,” e.g., “Female homosexuality is a sin”; and () “Attitudes Toward Other Lesbians,” e.g., “I can’t stand lesbians who are too ‘butch.’ They make lesbians as a group look bad.” While the factor of internalized heterosexism involves more of the issues of self-acceptance, guilt, and shame, the factor of the general and the lesbian / bisexual women-specific stress implies more of the overall prejudice encountered by lesbian / bisexual women. Hughes’s review () showed that work-related harassment may have a stronger impact on lesbians’ /WSW’s drinking than on heterosexual women or gay men’s. Heffernan () (N =  lesbians), however, found that although lesbians’ perceived stress is significantly related to “the frequency of getting drunk” ( p < .) (), it is “not predictive of substance use” (). Heffernan used two scales to measure stress. One measured general stress (items such as “how often have you felt that you were unable to control the important things in your life?”) and the other measured the stress related to discrimination (items such as whether they have been “denied custody or visitation of children” because of being lesbians) (). Society’s discrimination and rejection have basically forced lesbians and gay men to rely mainly on gay / lesbian bars, clubs, or private homes for social outlets. Alcohol and other drugs are prevalent in such places, and younger homosexuals are likely to meet older homosexuals who use AOD (Cabaj ). Gay / lesbian bars are widely available to lesbians, as % of lesbians in Bradford, Ryan, and Rothblum’s () study indicated. Several studies found that lesbians’ (and gay men’s) AOD problems are highly correlated with frequent attendance at gay / lesbian bars and reliance on those bars for socialization and peer support. For example, Heffernan’s () study reported that lesbians’ degree of “bar orientation” was the main factor predicting alcohol use (R  = ., p < .) and the “number of days

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of getting high” (b = ., p < .; R  = ., p < .) (). The “bar orientation” variable was measured by asking participants to rank, with one of five alternatives (from “completely agree” to “completely disagree”), three items: (a) “Bars are one of the few places where I feel comfortable socially,” (b) “Bars are about the most important place for me to meet new people,” and (c) “At times when I am stressed or need personal support I go to a bar” (). Trocki, Drabble, and Midanik () found that lesbians /WSW go to bars more often than exclusively heterosexual women. Heffernan () further noted that single rather than partnered lesbians (F [ / ] = ., p < .), as well as younger rather than older lesbians (r = -., p < .) were more likely to be bar-oriented. Some studies have indirectly confirmed Heffernan’s “bar orientation” theory. Kerby et al.’s study () (N =  lesbian / bisexual women) showed a paradoxical finding that lesbians who reported more-positive self-esteem and social identity were likelier to use AOD more frequently. Kerby et al. noted that one way to interpret the finding is that gay / lesbian bars traditionally provide homosexuals a safe place where they are protected from outside prejudice and provided with acceptance and support. Thus lesbians who frequently attend the bars are more likely to develop positive self-esteem. But at the same time, those bars also promote drinking and possibly drug use. Therefore, lesbians who frequently visit bars are more likely to develop AOD problems. Another study (Rosario, Schrimshaw, and Hunter ; N =  gay, lesbian, and bisexual youth aged –; recruited from college and other gay-focused organizations in New York City) found that substance use over time among homosexual youth did not associate with childhood sexual abuse history or experience of recent gay-related stress. Rather, it was related to “the number of gay-related social activities” they had participated in. Further, this relationship was curvilinear—the youth increased their substance use initially when they were first involved in gayspecific social activities, but decreased it after continued participation in such activities. One interpretation offered by the investigators was that homosexual youth may initially attempt to connect themselves with gay-related activities by going to bars where AOD is prevalent but may find more non-drinking gay / lesbian social activities later on when she or he becomes more familiar with the gay / lesbian community, and thus decreases AOD use. Numerous studies have suggested the association between childhood sexual abuse (CSA) and the later development of AOD problems in women (see chapter  for a detailed discussion). In Bradford, Ryan, and Rothblum’s () widely cited study, % of the lesbians indicated that they “had been raped or sexually attacked at least once” (); among the victims, % reported that the sexual assault happened during growing up, % reported it occurred during adulthood, and % said it happened to them during both childhood and adulthood. In addition % of the lesbian respondents who answered the question whether they had “sex with one or more relatives while growing up” reported yes. Hughes’s () study indicated that both the lesbian and the heterosexual women reported a high

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rate of sexual abuse (% and %, respectively), but significantly more lesbians met Wyatt’s CSA criteria ( p = .). Hughes’s review () however, revealed that not all studies indicated higher CSA rate among lesbians than heterosexual women. Further, Hughes stated that the higher CSA rate among lesbians could be due to reporting bias—women seeking counseling may be more apt to recall and report CSA and lesbians are more likely than other women to seek counseling.

Treatment Guidelines and Strategies Providing Lesbians with Affirmative AOD Treatment Non-heterosexual clients perceive that affirmation is a necessary quality in a practitioner or program if AOD treatment is to be successful. Affirmation means that a practitioner is willing to “accept a client as is regardless of sexual orientation” (Cheng :). Matthews and Selvidge () found that substance-abusing homosexual clients ranked the level of affirmative behavior of a counselor in the most successful treatment experienced by them significantly higher than that in the least successful treatment experienced by them (mean = . versus ., p < .; with a higher score representing a higher level of affirmative behavior). Sample items measuring a counselor’s affirmative behavior included: “My counselor helped me establish connections in the gay, lesbian, and bisexual community”; and “My counselor used language that did not assume I was heterosexual” (). The homosexual clients also ranked the most successful treatment program they had experienced significantly higher in affirmative behavior than the least successful treatment program they had experienced (mean = . versus ., p < .; with a higher score representing a higher level of affirming environment). A sample item measuring affirming climate was: “On the form the program used to collect personal data from new clients, it would have been possible for me to indicate that I was in a same-sex relationship (if this applied to me)” (). Following are four strategies to enhance affirmative attitudes in addiction counselors / treatment programs.

Fostering Self-awareness in Practitioners Addiction practitioners must be aware of their own possible homophobia and internalized heterosexism as well as those of society. They should pursue continuing training to enhance knowledge about lesbians and other non-heterosexual women and to become less heterosexism-centered (Cheng ; CSAT b). Cheng noted that, most importantly, the counselor should avoid engaging in or referring the client to reparative therapies.

Using Inclusive Language Practitioners should not assume that the client is heterosexual and should use inclusive or gender-neutral language if his or her sexual orientation is unknown

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(Bonvicini and Perlin ). This practice should be applied to both verbal interchanges and forms. For example, the practitioner could ask the client who her partner / significant other is instead of simply asking her marital status or ask if she is currently in a relationship rather than asking whether she is married. Such an approach not only creates a supportive atmosphere for the lesbian (or gay man) but also allows her (or him) to “come out” to the practitioner (Bonvicini and Perlin ; CSAT b).

Bringing Forth the Client’s Accurate Sexual Orientation Consistent with findings of several other studies (e.g., Beals and Peplau, Hughes and Evans, and McNair, cited in Rickards and Wuest ), women in Rickards and Wuest’s study found that hiding true self and maintaining a heterosexual façade could be counterproductive, whereas accepting authentic self and “being out” counterbalanced the losses of social status and credibility associated with coming out, increased personal well-being, and strengthened functional lesbian identity. CSAT (b) noted that it is a disservice to a client if a practitioner / program simply treats the client’s “false self ” without asking about her true self. Bonvicini and Perlin () suggest three strategies to elicit a client’s accurate sexual orientation: () The counselor can send a message normalizing the disclosure. For instance, “I realize that discussing sexuality can sometimes be difficult. Many people struggle with this issue, whether they are straight, gay, or bisexual. How do you feel about it?” (). () The practitioner should explain to the client the importance of such information and the rationale for requesting it (e.g., telling her that the information can help the practitioner to understand her lifestyle and thus better assess her needs). () Although it is important to provide opportunities for the client to disclose, practitioners must not push her if she is not ready. They should respect her and allow her to reveal her sexual orientation at her own pace (Bonvicini and Perlin ; Cass ; CSAT b).

Making Program Policies on Confidentiality, Equal Treatment, and a Safe Environment Clear to All Clients Although safeguarding confidentiality is important in working with any client population, it is of paramount importance for substance-abusing homosexuals because of the double stigma of substance abuse and homosexuality. The implications could be devastating if a client’s homosexual orientation were revealed to a third party without her consent. Many areas of her life, such as employment and child custody, could be damaged as a result, and very few laws exist to protect homosexual individuals from discrimination. Making policies that protect clients’ confidentiality rights clear and known to the clients can alleviate their worries about having their sexual orientation exposed. Consequently they will be more likely to feel comfortable and safe to reveal to their counselors who they really are. Of course, it is also important to inform clients of the limitations of confidentiality

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rights with respect to AOD treatment information: a practitioner can break confidentiality in cases of medical emergency, child abuse, or a possibility of harming others (duty to warn) or self (Cheng ). Making policies on equal treatment clear can also help to alleviate homosexual clients’ apprehension in coming out to their practitioner. Rostosky and Riggle’s study (cited in Pachankis and Goldfried ) showed that the existence of a nondiscrimination policy in the workplace relates positively to homosexuals’ coming out in their workplace. Policies on equal treatment have a stronger impact on clients’ perception of discrimination than other factors, such as the number of homosexual coworkers or whether the supervisor is a homosexual (Ragins and Cornwell, cited in Pachankis and Goldfried ). Although the two aforementioned studies are relevant to workplace and the workplace setting is different from that of a treatment program, the impact of a treatment program’s formal policy on equal treatment in alleviating homosexual clients’ worry and in encouraging their coming out should not be underestimated. A formal policy on equal treatment can be enhanced by informal policies and practices. For example, inviting the partner of a homosexual employee to a workplace’s social events was found to be most powerful in affecting coming out (Ragins and Cornwell, cited in Pachankis and Goldfried ). Practitioners should treat clients’ same-sex partners the same way they treat the significant others of any clients and should encourage the partners’ participation in treatment (CSAT b). Treatment programs can also post the written policy that includes an explicit commitment to equal treatment regardless of a client’s sexual orientation, along with the patients’ bill of rights (Bonvicini and Perline ). An agency’s waiting room can convey the equal treatment policy informally by having on hand gay / lesbian-related educational or resource materials (e.g., gay / lesbian-specific self-help groups, AA, NA, etc.) and displaying images of gay / lesbian role models (Bonvicini and Perline , CSAT b). A treatment program’s non-harassment and safe environment policy can also reduce homosexual clients’ apprehension and thus facilitate their coming out. It should be made clear to all clients at admission that any sexual harassment (between same or different sexes) is prohibited, that all clients and staff should be respected regardless of their sexual orientation, and that any bashing or harassment toward a person for the person’s sexual orientation will not be tolerated (CSAT b). Grievance procedures must be established and violations of the rules must be handled promptly (CSAT b).

Assessing the Relationship Between the Client’s Sexual Identity and Substance Abuse Problems Although substance-abusing homosexual clients share similar issues with the general population who undergo treatment, they often experience additional issues that are

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specific to their sexual identity (CSAT b). In treating substance-abusing homosexual clients, practitioners must integrate the AOD issue and the sexual-identity issue. To recover from substance abuse, the client may need to conquer her sexual identity struggle, and vice versa. Lesbians in Matthews, Lorah, and Fenton’s () study reported that “struggles with accepting their sexual orientation fed their addiction, as they used chemicals as a means of coping with something they could not face. At the same time . . . sobriety was necessary to face and accept their sexual orientation. . . . Self-acceptance was crucial for ongoing sobriety” (). Cochran and Cauce () noted the importance of practitioners’ exploring the relationship between an openly gay / lesbian client’s AOD problems and the client’s sexual identity in several key areas. For example, how did her “drinking or drug use change during the process of coming out to friends and family?” How often do her “sexual encounters involve alcohol or drug use?” And does she “ever drink or use drugs to cope with the discrimination that [she experiences] as a sexual minority?” (). Substance-abusing homosexual clients may be afflicted with AOD problems for different reasons during the different stages of coming out (Eliason ). In the early stages, they may suffer internalized heterosexism and experience overwhelming identity confusion, guilt and shame, and low selfesteem, or worry about rejection from their family and friends and loss of their job. Consequently, they may use AOD to self-medicate all these negative feelings. In the latter stages of coming out, they may become more involved with the homosexual community and more likely to socialize in gay / lesbian bars, activities that can increase their risk of AOD use and abuse. For homosexual individuals who have matured in their coming-out process and fully embraced their true sex identity, the issues that trigger AOD abuse might be a lesbian couple relationship problem or a workplace discrimination problem (Eliason ). To effectively help substance-abusing lesbians and other non-heterosexual women, practitioners should prepare themselves not only with the knowledge and skills needed for working with the general substance-abusing population but also with the knowledge and skills needed to help women deal with the coming-out struggle itself and the various issues involved, such as spirituality, health and mental health, relationship with family of origin, couple relationships, and relevant legal issues. The following are some guidelines and strategies.

Working with Clients Who Are Engaged in the Coming-Out Struggle Experts suggest that practitioners should be sensitive to a client’s coming-out process and help her work through the stages of it accordingly (Cass ; CSAT b; Ritter and Terndrup ). Cass suggests the following principles when working with such clients:

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1. Do not lump all the clients into one big category of lesbians (or gays). Different clients may be at different stages of coming out, and even within the same stage, distinctions exist. 2. If a client is at the beginning stage of coming out, the practitioner should neither assume that she is ready to accept the same-sex identity label nor refer to her as a lesbian (Cass ; CSAT b). Doing so may intimidate the client and jeopardize the client-worker trust relationship. The practitioner should give the client time and respect to work out her confusion and struggle. 3. Engaging in homosexual behavior does not necessarily mean homosexual identity; for example, prison inmates who do not identify themselves as homosexual may engage in homosexual behavior. Likewise, a person with a homosexual identity may initiate the process with fantasies, particularly during the early stages, without necessarily exhibiting overt homosexual behavior (Cass). 4. Practitioners should not impose their own values and judgment regarding the particular stage where the client is at the moment; the client’s assessment of where she is in the process should be accepted. Cass gave an example: If an -year-old woman happily claims that she is a lesbian, the practitioner should not respond with “You’re too young to know” (). 5. Since Western ideology tends to value maturation and self-actualization, practitioners need to be careful not to impose on the client their own personal or clinical judgment that the later stages of coming out are better than the earlier stages. 6. The identity formation issue “does not occur in isolation,” so practitioners need to be thorough in assessment and treatment of the client’s other issues as well, such as illness, ethnicity, aging, family dynamics, psychological dysfunction (). 7. Practitioners’ responses to the client should correspond to her specific needs and issues at the specific stage where she is. For example, practitioners should help the client deal with her internalized heterosexism and the subsequent guilt and shame during the beginning phase of coming out and help her overcome personal, social, and cultural barriers to reach out to lesbian role models, mentors, peers, and the community, as well as connecting her with non-drinking lesbian-specific social events and activities during the mid-stage. Cass () noted that “talking about the ideological aspects of lesbian and gay oppression is inappropriate when someone feels he or she has no future (Stage ) or wants to meet other homosexuals (Stage )” ().

Fulfilling Lesbian Clients’ Spiritual Needs Spirituality and Self-acceptance Self-acceptance is critical for recovery for substance-abusing lesbians (Matthews, Lorah, and Fenton ). As mentioned previously, lesbian women tend to have a deeply rooted internalized homophobia and heterosexism, resulting in a

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tremendous sense of shame, guilt, and self-rejection and, consequently, the use of AOD for self-medication. Finnegan and McNally (cited in Bobbe ) noted that internalized homophobia makes lesbians believe that “the very center of their being is sick and disgusting” (). To treat lesbians’ AOD problems, practitioners must give priority to helping them deal with such entrenched guilt and shame. Studies have shown that positive relationships with their family and community, along with contact with peers and role models in the lesbian / gay community, can enhance self-acceptance and reduce shame and guilt among lesbians (Matthews, Lorah, and Fenton ; Rickards and Wuest ). Another important factor is their “relationship with something bigger than self ” (Matthews, Lorah, and Fenton :). “Something bigger than self ” refers to the quest for and redefinition of spirituality. Matthews, Lorah, and Fenton’s () interviews of the lesbians did not initially include the question of spirituality, but they added it to the study after the early respondents “repeatedly and poignantly addressed it without [the researchers’] asking” (). The women addressed their struggle with traditional religion and were able to differentiate between religion and spirituality and to redefine spirituality. For example, “I pray differently. I look at God differently. I have more of a relationship with God rather than fearing God like I did growing up,” one woman said. “You can’t stay sober without it [spirituality]. You can’t do the tough stuff without it” (), another said. “It is kind of a surprise,” yet another said. “I guess I never really thought I would be like this. I never thought I would be spiritual. . . . It has been a great thing and it has been a huge gift” (–). Matthews, Lorah, and Fenton noted that the women’s ability to redefine spirituality and draw strength from it nourished their self-acceptance.

Spirituality Versus Religion Spirituality and religion, which are often interrelated, play an important role in the journey of substance-abusing homosexual individuals to recovery (CSAT b). Spirituality emphasizes an individual’s sense of purpose, meaning, and morality regarding his or her life, whereas religion involves an organization or practice of standardized beliefs and experiences related to spirituality (Tan ). Unfortunately, most Western formal religions, although accepting and embracing other vulnerable populations (such as racial minorities), often reject the notion of homosexuality and homosexual individuals (Tan ). Experts suggest that the gay and lesbian population would benefit from spiritual sustenance because of the oppressive background in which they live. Tan’s study divided spirituality into “religious well-being” (“how one relates to God”) and “existential well-being” (“how one feels about life”) and found that existential well-being but not religious well-being, predicts adjustment among homosexual individuals, including “having high self-esteem,” “accepting one’s homosexual orientation,” and “feeling less alienated” ().

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Strategies for Fostering Spirituality in Sexual Minority Individuals Ritter and O’Neill () suggest that practitioners can employ strategies of recasting images, reframing loss, and facilitating a spiritual path to foster gay and lesbian individuals’ spiritual journey. As mentioned previously, many homosexual individuals internalize society’s homophobia and heterosexism and perceive their own homosexual lifestyle as “disgusting,” “sick,” or “dark.” This self-hatred can be cleansed or released by helping homosexual individuals to recast their images. Ritter and O’Neill’s () review of literature found that there were positive images and qualities linked to homosexual individuals. For example, there have been, throughout history, highly esteemed shamans and spiritual leaders who were homosexual. Also, homosexuals may be more advanced than the heterosexuals in Kohlberg’s Moral Development (see Ritter and O’Neill’s review). Ritter and O’Neill suggest that practitioners help clients to view themselves in relation to these inspirational images instead of accepting society’s judgment. In addition to internalized heterosexism, homosexual individuals experience external heterosexism and discrimination from society. As a result, they suffer many profound losses, including disconnection with their church, family, or workplace and a general loss of decency, feeling their lifestyle is despised by others (Ritter and O’Neill ). This second strategy is to help lesbians and other nonheterosexual women transcend “losses” and move to “growth.” A sense of loss can be reframed as redemptive instead of alienating, such that the loss experienced by homosexual individuals would make them more sensitive and compassionate to other oppressed and vulnerable populations (Fox, cited in Ritter and O’Neill), as well as generate in them an authentic sense of autonomy, initiative, industry, and integrity. For homosexual individuals who are interested in religion in conjunction with spirituality but experience discrimination by mainline churches, practitioners can help them find gay / lesbian subgroups of certain “reformed” churches, alternative churches like the Metropolitan Community Church, or other gay / lesbian-friendly churches (CSAT b; Ritter and O’Neill ). Non-Judeo-Christian spiritualities can provide another option. Some themes are “to relate to the search for a more integrating, less dualistic approach to faith, a return to prepatriarchal mysteries and traditions,” an emphasis on “the sacred nature of the earth and humanity’s oneness with it,” or an emphasis on “the oneness of all beings and experience with a divine Source” ().

Other Strategies to Enhance Spirituality CSAT (b) emphasizes the importance of practitioners’ recognizing the difference between religion and spirituality and conveying such messages to their homosexual clients, so that the clients may be able to find spiritual comfort even if religious comfort is lacking. Bobbe () proposed several strategies for helping

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substance-abusing lesbians to deal with relapse issues in general and to enhance their inner self in particular. Among the methods suggested is teaching clients stress management skills, including meditation and relaxation, which can be built upon the AA’s spiritual basis, with the purpose of furthering clients’ self-worth. For example, mediation and spirituality development enable a client to better cope with the oppression she suffers (Bobbe ). Another method is expressive therapy (e.g., art therapy), which helps to nurture the client’s intuition and provides a link to her higher self.

Addressing Harm Reduction: HIV / AIDS / STD and Other Gynecological Health Problems The contents of safe sex or harm reduction in relation to sexual behavior must be infused into individual and group treatment, as well as educational components of other treatment for lesbians / non-heterosexual women. The women need to be reminded that it is not only gay and other sexual minority men who are at high risk for HIV / AIDS / STD; lesbians / non-heterosexual women may also be at high risk, and it is imperative that safe sex practice be followed, even if the sex is between two women. There are two key reasons for this. As mentioned previously, women who use injection drugs and have sex with other women are more likely to engage in risky drug-using behavior and have been shown to have a higher HIV rate than IV-drug-using women who have sex only with men (Friedman et al. ). In addition, some of the women who have self-identified as lesbians may have sex with men. Further, as mentioned earlier, lesbian and bisexual women may be more likely than heterosexual women to have gay and bisexual men as sexual partners (Koh and Ross ). The myth that lesbians / non-heterosexual women are less likely to develop gynecological health problems should be dispelled, and the importance of routine health examination and preventive care should be emphasized. Practitioners should also convey to the clients the negative impact of smoking, drinking, and obesity on women’s (gynecological) health and suggest ways to achieve a healthier lifestyle.

Screening for Suicide Attempts (Particularly Among Sexual Minority Female Teens) and Childhood Sexual Abuse As mentioned earlier, lesbians tend to have a higher lifetime suicide attempt rate than heterosexual women (Hughes ); teen lesbians have a higher suicide attempt rate than older lesbians (Bradford, Ryan, and Rothblum ; Hughes ); homosexual youth have a higher suicide attempt rate than heterosexual youth (see Kitts’s review ); and female homosexual youth have a higher suicide attempt rate than male homosexual youth (D’Augelli et al. ). In summary, younger or teen lesbians and non-heterosexual women appear to be at the highest

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risk for suicide attempts. Suicide is considered closely related to AOD abuse / dependence (see chapter ). Therefore, practitioners must screen substance-abusing lesbian / non-heterosexual women clients, particularly teens, for suicide history, ideation, and attempts at admission and routinely throughout treatment. Appropriate monitoring and treatment procedures should be in place, and a family-oriented approach, if appropriate, should be implemented when working with teens. Screening for CSA history must also be part of a treatment plan. As mentioned earlier, CSA is closely related to the occurrence of women’s substance abuse, and women may self-medicate the pain resulting from their CSA trauma. Hughes’s study () showed that more lesbians than heterosexual women said that they were sexually abused during childhood. Practitioners must integrate the issue of CSA with AOD treatment by referring the woman to a specialist, providing her with specific individual counseling, and / or offering therapeutic groups that consist of only female CSA survivors.

Helping Lesbian Clients Deal with Relationship Issues Women tend to emphasize relationship more than men do. Not only are women more likely to have a closer relationship with their family of origin, but a lesbian-couple relationship also tends to be more “relationship” focused than a gay-couple relationship. Many lesbians seek counseling for relationship problems with family of origin or lovers (Bradford, Ryan, and Rothblum ).

Relationship with Family of Origin “Family of origin” is one of the most difficult and painful areas to deal with in gay / lesbian psychotherapy (Hancock ). Bradford, Ryan, and Rothblum () reported that % of the lesbians in their study were out to other homosexual people, while only % of them were out to all members of their family and % of them were out to no one in their family. Radonsky and Border’s study (N =  lesbians) (cited in Ritter and Terndrup ) showed that only .% of the women initially came out to their family members, whereas .% initially came out to other lesbians. Family of origin is the most important institution for a person during the years of growing up. This is where the person is nurtured and seeks approval. Most families of origin, however, adopt the heterosexism view of society and thus may reject a member who is gay or lesbian. Matthews, Lorah, and Fenton’s () qualitative study revealed that the women’s recovery was associated with their self-acceptance and that one major component related to their self-acceptance was their relationship with their family of origin. The women frequently mentioned the need to “renegotiate the relationship with the family of origin” for both their addiction issues and their sexual identity issues (). Practitioners should assess several aspects of a client’s family of origin, including the rules and expectations for each member, whether there is any history of

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trauma, and whether the topic of sex was ever discussed (CSAT b). CSAT also suggests that practitioners explore whether or not anyone other than the indexed client in the family is gay / lesbian and how the family reacted to that member, as well as whether the indexed client is out to her family and, if yes, how the family reacted. A family’s reaction may range from abusive or avoiding to tolerant or supportive (CSAT b). A family’s negative, disapproving response often has a distressing and long-lasting effect on the person (CSAT b). Practitioners can help the client process the negative messages coming from the family and can also help her negotiate with the family regarding her sexual identity. For clients who are considering whether to come out to their families of origin, Ritter and Turndrup () provide some strategies for the practitioner: () Remind the client that her family’s response to her coming out may resemble its response to other crises; that is, if the family usually responds to a crisis with rigidity and commotion instead of flexibility and rationality, it is likely to receive her disclosure with rigidity and commotion rather than flexibility and rationality. Such a reminder allows the client to assess more objectively the prospect of her upcoming disclosure and better prepares her for planning it. () Remind the client that it takes time for the family to adjust to her coming out. () If the client is a less assertive person, lacks effective communication skills, or has unresolved negative feelings, help her deal with these issues before she comes out to the family so that combative communication can be avoided and effective communication can take place. () If possible, involve the parents in homosexuality education workshops or expose them to such materials before the client’s revelation. One study showed that laying such a foundation for parents before their child’s disclosure better prepares them to adjust to the news and thus reduces the likelihood of an emotional crisis (Ben-Ari, cited in Ritter and Turndrop ).

Relationship with the Same-Sex Partner Homosexual couples share many characteristics and problems with heterosexual couples with respect to their relationships. Hancock’s () literature review showed that both undergo similar stages in the relationship, i.e., from the early stage’s obsession with sex and love, to conflicting feelings, to the later stage’s engaging in activities that preserve the relationship (Kurdek and Schmidt, cited in Hancock ). Sexual minority couples can be as satisfied with their relationship as heterosexual couples are and may adopt comparable power strategies (see Hancock’s review). Sexual minority couples and heterosexual couples also have similar conflicts, including issues related to money, the interference of a partner’s career on the relationship, etc (see Hancock’s review ). In addition, sexual minority couples face unique stresses and challenges: (a) They do not have public and legal recognition and validation (Ritter and Terndrup ), which may make their relationship more vulnerable, since public

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acknowledgment can strengthen a relationship and a legal marriage is more likely to forestall separation (Kurdek and Schmidt, cited in Hancock ). (b) Because most families of origin adopt a heterosexist viewpoint, the homosexual couple may not have access to emotional and other support from their families, and the lack of family support can create substantial tension in the relationship (Ritter and Terndrup ). (c) They also suffer other forms of deprivation, financially, legally, socially, and religiously / spiritually. Many cannot extend their health and life insurance or other benefits to their partner. Because of the lack of the legal verification of marriage, they may be limited in power to make medical decisions, property transfer power, and so on. Ritter and Terndrup’s review () showed that homosexual couples may even be treated differently than heterosexual couples by retail store salespersons or hotel reservation policies. Plus, homosexual couples may face obstacles in attending regular churches. All may amplify the tension and frustration in the relationship. (d) Sexual minority couples are more likely than heterosexual couples to be interracial, and thus may encounter more cultural conflicts (Garcia et al., cited in Hancock ). Lesbian couples are further different from gay couples in the emphasis on relationship (Hancock ; Schneider ). Because of the impact of gender role socialization, “gay men and heterosexual men tend to resemble one another in their relationships more than gay men resemble lesbians in theirs, while lesbians and heterosexual women are more similar to one another in relationships than gay men and lesbians” (Hancock :). In other words, while gay couples may emphasize sex in the relationship, lesbian couples tend to emphasize emotional attachment. Hancock noted that the problems of lesbian couples are very much related to their being women, in that the gender role socialization process has cultivated them to place relationship above autonomy. Therefore, lesbian couples may encounter difficulties if the relationship is not balanced between autonomy and intimacy and if one partner wishes to reestablish autonomy. Practitioners should be equipped with basic knowledge of the nature of sexual minority couple relationships in general, combined with an understanding of the unique characteristics of lesbian couple relationships, and they should take that information into account in helping the couple or referring them to a specialist.

AOD Treatment Approaches with Lesbians Specialized, Affirmative Lesbian AOD Treatment Programs Substance-abusing homosexual clients share similar AOD risk factors with the general population but also face additional risk factors unique to them. A specialized gay / lesbian affirmative AOD treatment program would address specific issues such as coming out, internalized heterosexism, socialization, and spirituality—issues that are ignored by mainstream treatment programs (Hicks ). Also, many

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lesbians (and gay men) may be hesitant to go to treatment for fear of prejudice (Hicks). Gay / lesbian-specific AOD treatment programs are available in certain cities (e.g., PRIDE nationwide; the Community Counseling Center in Las Vegas, Nevada), and if possible, the mainstream treatment programs or practitioners who provide only limited or no gay / lesbian-specific treatment should refer their homosexual clients to a specialized, affirmative program. HMOs and third-party payers should also be urged to authorize such specialized AOD treatment for homosexual clients (Hicks).

Principles for Conducting a Mixed Group When no gay / lesbian-specific programs are available in the community, the mainstream treatment programs need to provide an affirmative climate for their gay and lesbian clients. In addition to the aforementioned strategies, CSAT (b) suggests the following approaches if a program provides group treatment: (a) The practitioner should be inclusive in conducting group treatment by encouraging each member, heterosexual or homosexual, to talk about any issues relevant to treatment, making sure that all members are informed that the group will be a mixed group, providing sensitivity training regarding sexual minority issues, and ensuring that sexual minority clients are treated appropriately and therapeutically and that no hostility or homophobia will be tolerated. (b) The practitioner should not require sexual minority clients to discuss issues related to their sexual orientation in a mixed group if they prefer not to, although a mixed group, if conducted by an experienced and competent leader, may provide sexual minority clients with powerful affirmation and acceptance. (c) A separate group should be established if there is a sufficient number of sexual minority clients, since such a group may provide a safer and more cohesive setting for the clients to discuss issues related to sexual orientation. But, again, the sexual minority clients should not be forced to join such groups if they do not feel comfortable. Such a group can also provide a good opportunity for practitioners to address safe sex issues.

Lesbian-Friendly Self-help Groups Alcoholic Anonymous (AA) and other self-help groups provide important aftercare for long-term recovery. Although AA embraces sexual minority individuals, sexual minority individuals may not be enthusiastic about attending mainline AA meetings, for at least two reasons (CSAT b). First, AA meetings include various kinds of people, and some of them may be prejudiced against homosexual and non-heterosexual individuals. Second, AA’s emphasis on God may discourage sexual minority individuals who link AA with religions and have been rejected by those religions because of their sexual orientation. Practitioners may refer them to gay / lesbian-specific AA groups or other self-help groups, which have gradually become more available. On the other hand, practitioners can help clients to

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understand the difference between religion and spirituality and link AA’s philosophy to spirituality rather than religion.

Connecting Clients with Lesbian-Specific Community Resources Non-drinking Lesbian Social Activities, Organizations, Peers, and Role Models One risk factor, mentioned above, for lesbians’ AOD problems is their frequent attendance at gay / lesbian bars. Practitioners need to be equipped with knowledge of various lesbian-specific non-drinking social activities and events and organizations in the community so that substance-abusing lesbians can be linked to a non-drinking social network, instead of the gay / lesbian bars, for affirmative, socialization, and emotional or other support. Practitioners can also help lesbians and non-heterosexual women organize such a non-drinking social network if none exists in the community. Practitioners need to connect those who seek religion and spirituality yet have been rejected by mainline churches with alternative churches that accept and embrace homosexual individuals.

Legal Services Unlike racial minorities, who often are protected by federal or state laws from formal discrimination, sexual minorities do not have such a privilege and may encounter oppression regarding employment, military service, housing, child custody, adoption, etc. Prohibition against legal marriage of same-sex couples creates legal barriers to their extending health and life insurance and other benefits to their partner, their medical decision-making power, disposition of assets, inheritance rights, etc (Bonvicini and Perlin ). To combat the oppression and counteract legal barriers, practitioners can connect their lesbian clients with legal services and resources in various ways. Practitioners can offer legal education and information to program staff and clients regarding current laws and regulations pertaining to lesbians’ general rights and well-being (CSAT b). They should link the client to various legal experts or sources (e.g., the Lambda Legal Defense and Education Fund, the largest national organization committed to the civil rights of sexual minorities and people afflicted with HIV / AIDS). Although coming out is therapeutic and can strengthen the client’s identity, the client must be advised to disclose her homosexual orientation carefully and only to those who she believes will respect her privacy (CSAT). Revelation of homosexual orientation may cause tremendous legal repercussions, resulting in a negative impact on the client’s employment, child custody disputes, or other well-being issues (CSAT). Practitioners can also help the client develop an individualized legal inventory and assess her specific needs and the steps she might need to take to protect her

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rights (CSAT b). For example, they may refer a client with children to an attorney who specializes in family law as related to lesbian couples (Mravcak ). For medical decision-making rights, the client may need a legal referral to establish a “health care proxy” or a “medical power of attorney” so that one partner can make health decisions for the other should the other become incapacitated (CSAT b:; Mravcak ).

Lesbian-Friendly Health Care Systems, AOD Treatment Programs, and Aftercare Practitioners must be knowledgeable regarding lesbian-friendly health care clinics in the community, encourage clients to engage in preventive and other medical care, and refer them to the appropriate clinics. As mentioned earlier, many lesbians / non-heterosexual women may avoid or delay their regular checkups or health care simply because of fear of prejudice from medical personnel. Practitioners who are aware of specialized, affirmative gay / lesbian AOD treatment programs in the community will be able to refer their clients to such programs. It is particularly important to pay attention to clients’ aftercare, to accumulate information about available lesbian-friendly self-help groups and AA / NA / Al-Anon meetings in the community, and to relay information about such resources to the women.

•

•

•

“Lesbian” is a complicated concept that may encompass a diverse group of women; in this chapter the term refers to any woman who is not exclusively heterosexual. Research has shown that lesbians / WSW generally have a higher dysfunctional alcohol use rate than heterosexual women. They also suffer more severe social consequences than heterosexual women do with respect to AOD use, whereas no such difference exists between gay men and heterosexual men. Although not all of the AOD problems that lesbians have are related to their sexual orientation issues / coming-out process, there is a close association. Lesbians and heterosexual women share similar risk factors for AOD misuse / abuse, but lesbians also face other risk factors that are unique to them: (a) their own internalized homophobia and heterosexism, which may lead them to blame the non-heterosexual orientation to which they are inclined and to use AOD to self-medicate the subsequent shame, guilt, confusion, and struggle; (b) general and lesbian-specific stress arising from formal and informal discrimination and rejection, which affects various core parts of their life and may lead them to AOD use as a way of coping; (c) gay / lesbian bars and clubs, which offer an alcohol-prevalent culture and directly or indirectly can endorse and increase gays / lesbians’ drinking behavior; and (d) childhood sexual abuse, which may be more prevalent among lesbians than among heterosexual women and which has been linked to later development of AOD problems.

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Nine treatment guidelines and strategies have been developed to help substance-abusing lesbians: (a) providing affirmative AOD treatment via equal treatment program policies regardless of sexual orientation, the involvement of the gay / lesbian community and resources, and the use of inclusive language; (b) assessing the relationship between a client’s sexual identity and her AOD problems and intervening accordingly, with respect to the client’s current stage in the coming-out process; (c) working with clients who are in the midst of their coming-out struggle; (d) fulfilling lesbian clients’ spiritual needs and thus nourishing their self-acceptance; (e) infusing harm-reduction messages with respect to the risks for AIDS / HIV / STD and other gynecological health problems; (f ) screening for suicide (particularly among lesbian youths), childhood sexual abuse, and other psychological distress, and providing the client with appropriate treatment; (g) helping clients deal with relationship issues, including the relationship with the same-sex partner and that with the family of origin; (h) adopting lesbian-specific AOD treatment approaches, if feasible, and emphasizing specialized content (coming-out issues, internalized heterosexism, socialization, and spirituality) and lesbian-friendly AA groups; and (i) connecting clients with lesbian-specific community resources such as non-drinking lesbian social network, legal services related to child custody, health decision power, and so on, and lesbian-friendly health care systems and AOD treatment programs.

Appendixes

Appendix A

Screening Tools

CAGE CAGE is one of the most popular alcohol screening tools. Although it is a very valid and reliable screener for men (Ewing, cited in Stevenson and Masters ), it is not a recommended screener for women (Sokol, Martier, and Ager ), adolescents (Knight et al. ), or older adults (Culberson ). Other screeners, based on CAGE or not, have been developed to more effectively screen women, adolescents, or older adults. 1. Have you ever felt you should cut down on your drinking? 2. Have people annoyed you by criticizing your drinking? 3. Have you ever felt bad or guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves

or get rid of a hangover (eye-opener)? Source: Ewing ; Ewing and Rouse, cited in Mayfield, McLeod, and Hall . Clinically significant if a total score ≥  points (i.e., two or more “Yes” responses) (according to Mayfield, McLeod, and Hall). Indication of need for further assessment if a total score ≥  point (according to Ewing).

Modified CAGE for Pregnant Women Modified Alcohol CAGE for Pregnant Women 1. In the  months before you found out you were pregnant, did you feel

you ought to cut down on your drinking? 2. In the  months before you found out you were pregnant, did people

annoy you by criticizing your drinking? 3. In the  months before you found out you were pregnant, did you feel

bad or guilty about your drinking?

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4. In the  months before you found out you were pregnant, did you drink

first thing in the morning (eye-opener)? Source: Midanik, Zahnd, and Klein :.

The Alcohol CAGE had high sensitivity and specificity with a cut-point of  (Midanik, Zahnd, and Klein, ).

Modified Drug CAGE for Pregnant Women 1. In the  months before you found out you were pregnant, did you feel

you ought to cut down on your drug use? 2. In the  months before you found out you were pregnant, did people

annoy you by criticizing your drug use? 3. In the  months before you found out you were pregnant, did you feel

bad or guilty about your drug use? 4a. Sometimes people feel bad when a drug wears off. Did that ever happen to

you during the past year?* 4b. Did you ever take another drug when that happened?*

*In order for the “eye-opening” item to be counted as Yes, both items need to have positive responses. Source: Midanik, Zahnd, and Klein :. Reproduced with permission from Dr. Lorraine Midanik. For more information, contact Dr. Lorraine Midanik at [email protected].

The Drug CAGE “had a high sensitivity rate with a cut-point of ” for heavier drug use, but it “was not a useful screener for periconceptional lighter drug and marijuana use” (Midanik, Zahnd, and Klein :).

T-ACE The original four items in T-ACE were “How many drinks does it take to make you feel high (tolerance)?” “Have people annoyed you by criticizing your drinking?” “Have you felt you ought to cut down on your drinking?” and “Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)?” (Sokol, Martier, and Ager :). The following four items, however, have been used by some other researchers: 1. How many drinks does it take to make you feel high? ( or more drinks is

considered positive). (Tolerance)

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2. Do you feel annoyed (A) when someone criticizes your drinking? 3. Do you wish to cut (C) down on your drinking? 4. Do you ever take a morning drink (E = eye-opener) to feel better? Source: Sokol, Martier, and Ager :. Reproduced with permission from Dr. Robert Sokol. Note: A total score of ≥  is considered positive for “at risk” for heavy drinking (“≥  ounce absolute alcohol per day”) among pregnant women (Sokol, Martier, and Ager :). A total score of ≥  indicates the need for a formal AOD evaluation for older women (Stevenson and Masters ).

Sokol, Martier, and Ager () suggested that one reason T-ACE outperformed CAGE in screening pregnant women was the inclusion of the “tolerance” question. They said that “a woman who unconsciously or deliberately seeks to minimize the extent of her drinking will be less apt to perceive the tolerance items as an indication of drinking and thus be more apt to answer the tolerance item honestly” (). The authors assigned a value of  to the “tolerance” item and  to each of the other three items. (Note: Sokol and colleagues originally defined the tolerance item to be positive if it took more than two drinks to make a woman feel “high” or intoxicated. Some later studies, however, have used the standard of equal to or more than two drinks [e.g., Chang et al. ].) Chang et al. suggested that the standard “more than two drinks” to feel intoxicated in defining tolerance increases the “specificity” of the screener, whereas the standard “two or more drinks” increases the “sensitivity” of the screener. “Sensitivity” here refers to the likelihood that a person “who is a risk drinker tests positive,” whereas “specificity” refers to the likelihood that a person “who is a nonrisk drinker tests negative” (Russell :). An ideal screener would have both a high sensitivity and a high specificity, but in reality, there is usually a tradeoff between the two (Russell, Chan, and Mudar ). A screener with high sensitivity may be less likely to produce false-negative cases, whereas a screener with high specificity may be less likely to produce false-positive cases. Chang et al. (:) suggested that “in the case of risk for prenatal exposure to alcohol, it is probably better to have more false positives than false negatives, given the potential consequences.”

TWEAK for Pregnant Women TWEAK-HOLD: Version recommended for populations with high levels of binge drinking To determine whether to administer the TWEAK, ask: Do you sometimes drink alcohol beverages, that is, beer, wine, or liquor? Yes (Continue) No (End TWEAK, or ask about drinking in the past)

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1. How many drinks can you hold?*

Record # drinks _____. If  or more, circle  at right.



Don’t know ⇒ If alcohol never made R sick, pass out, or fall asleep, ask: What’s the largest number of drinks you have? Record largest # drinks _____. If  or more, circle  at right.



2. Have close friends or relatives Worried or complained about your

drinking in the past year? If yes, circle  at right



3. Do you sometimes take a drink in the morning when you first

get up? (Eyeopener) If yes, circle  at right



4. Are there times when you drink and afterwards you can’t remember

what you said or did? (Amnesia or blackouts) If yes, circle  at right



5. Do you sometimes feel the need to Kut down on your drinking?

If yes, circle  at right Add numbers that were circled

 Total _____

Source: Russell ; personal communication with Marcia Russell . *How many drinks can you hold before the alcohol makes you sick, pass out, or fall asleep? A drink is a  oz. beer, a  oz. glass of wine, or a drink containing  ½ oz. liquor.

A total score ≥  points indicates risk drinkers among obstetric patients.

TWEAK-HIGH: Version recommended for populations with low levels of binge drinking To determine whether to administer the TWEAK, ask: Do you sometimes drink alcohol beverages, that is, beer, wine, or liquor? Yes (Continue) No (End TWEAK, or ask about drinking in the past) 1. How many drinks* does it take before you begin to feel the first

effects of the alcohol? (Tolerance) Record # drinks _____. If  or more, circle  at right



2. Have close friends or relatives Worried or complained about your

drinking in the past year? If yes, circle  at right



3. Do you sometimes take a drink in the morning when you first

get up? (Eyeopener) If yes, circle  at right



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4. Are there times when you drink and afterwards you can’t remember

what you said or did? (Amnesia or blackouts) If yes, circle  at right



5. Do you sometimes feel the need to Kut down on your drinking?

If yes, circle  at right Add numbers that were circled

 Total _____

Reproduced with permission from the author. For more information, contact Dr. Marcia Russell at [email protected]. *A drink is a -oz. beer, a -oz. glass of wine, or a drink containing  ½ oz. liquor. A total score ≥  points indicates risk drinkers among obstetric patients.

TWEAK has been validated among women and requires no special training to administer. TWEAK appears to be more sensitive but less specific than T-ACE in identifying risk drinkers among pregnant women (Russell ). Further, TWEAK with the “hold” version (“how much can you hold”) tends to have a higher sensitivity than TWEAK with the “high” version (“how many drinks does it take to get you high”) among disadvantaged African-American pregnant women (Russell ; Russell et al. ). Likewise, the “hold” version of T-ACE tends to be more sensitive than the “high” version of T-ACE (Russell et al. ).

The IHR (Institute for Health and Recovery) Screeners for Pregnant Women The IHR P’s Did any of your parents have a problem with using alcohol or drugs? Yes a No No answer Do any of your friends (peers) have a problem with drug or alcohol use? No No answer Yes a Does your partner have a problem with drug or alcohol use? No Yes a

No answer

Before you knew you were pregnant (past), how often did you drink beer, wine, wine coolers or liquor? Not at all Rarely a Sometimes a Frequently a In the past month (present), how often did you drink beer, wine, wine coolers or liquor? Not at all Rarely a Sometimes a Frequently a Plus a question about tobacco use Source: Kennedy et al. :. a Considered positive responses. Patients with a positive response for one or more of the items are referred for further assessment.

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Appendix A

The IHR Behavioral Health Risk Screening Tool

Source: IHR , personal communication with IHR June . Reproduced with permission from the authors and Institute for Health and Recovery. For more information, contact Dr. Norma Finkelstein at normafinkelstein@healthrecovery. org or Enid Watson at () - or [email protected]

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According to the IHR, the P’s screening tool is based on Ewing’s ()  P’s (Parents, Partner, Past, and Pregnancy). Although P’s was designed specifically for pregnant women, it may be used for childbearing-age women. The rationale for the sequence of the five questions is to move from the least- to the most-threatening question, i.e., from asking first about AOD problems related to the woman’s parents, her friends, her partner, and last to herself. (Note: Use of significant others indicates a risk factor for use of the pregnant woman.) One major advantage of the P’s is that it is easier for a client to answer questions about use of other people and that she may deny her own use but be more open to questions about others’ use. (personal communication with IHR, June ). AOD use of a (pregnant) woman’s significant others indicates a risk factor for AOD use of the woman. The IHR also developed the Behavioral Health Risk Screening Tool based on the P’s. The new tool includes three additional areas: frequency / quantity of AOD use, emotional health (e.g., depression), and violence.

AUDIT (Alcohol Use Disorders Identification Test) AUDIT: Self-report Version PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential so please be honest. Place an X in one box that best describes your answer to each question. Questions 0

1

2



3

1. How often do you have a drink containing alcohol?

❑ Never

❑ Monthly or less

❑ – times a month

❑ – times ❑  or more a week

times a week

2. How many drinks containing alcohol do you have on a typical day when

you are drinking? ❑  or  ❑  or 

❑  or 

❑  to 

❑  or more

3. How often do you have six or more drinks on one occasion?

❑ Never

❑ Less than ❑ Monthly monthly

❑ Weekly

❑ Daily or almost daily

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4. How often during the last year have you found that you were

not able to stop drinking once you had started? ❑ Never ❑ Less than ❑ Monthly ❑ Weekly monthly

❑ Daily or almost daily

5. How often during the last year have you failed to do what was

normally expected of you because of drinking? ❑ Never ❑ Less than ❑ Monthly ❑ Weekly monthly

❑ Daily or almost daily

6. How often during the last year have you needed a first drink in

the morning to get yourself going after a heavy drinking session? ❑ Never ❑ Less than ❑ Monthly ❑ Weekly ❑ Daily or monthly almost daily 7. How often during the last year have you had a feeling of guilt or

remorse after drinking? ❑ Never ❑ Less than monthly

❑ Monthly

❑ Weekly

❑ Daily or almost daily

8. How often during the last year have you been unable to remember what

happened the night before because of your drinking? ❑ Never ❑ Less than ❑ Monthly ❑ Weekly monthly

❑ Daily or almost daily

9. Have you or someone else been injured because of your drinking?

❑ No

❑ Yes, but not

in the last year

❑ Yes, during the last year

10. Has a relative, friend, doctor, or other health care worker been

concerned about your drinking or suggested you cut down? ❑ Yes, but not ❑ Yes, during in the last year the last year

❑ No

Total _____ Source: Babor et al. :.

AUDIT: Interview Version Read questions as written. Record answers carefully. Begin the AUDIT by saying “Now I am going to ask you some questions about your use of alcoholic beverages during this part year.” Explain what is meant by “alcoholic beverages” by using local examples of beer, wine, vodka, etc. Code answers in terms of “standard drinks.” Place the correct answer number in the box at the right.

Screening Tools 1. How often do you have a drink containing alcohol?

307

_____

() Never [Skip to Questions –] () Monthly or less ()  to  times a month ()  to  times a week ()  or more times a week 2. How many drinks containing alcohol do you have on a typical day

when you are drinking? ()  or  ()  or  ()  or  () , , or  ()  or more 3. How often do you have six or more drinks on one occasion?

_____

_____

() Never () Less than monthly () Monthly () Weekly () Daily or almost daily Skip to Questions  and  if total score for Questions  and  =  4. How often during the last year have you found that you were not able

to stop drinking once you had started? () Never () Less than monthly () Monthly () Weekly () Daily or almost daily

_____

5. How often during the last year have you failed to do what was

normally expected from you because of drinking? () Never () Less than monthly () Monthly () Weekly () Daily or almost daily

_____

6. How often during the last year have you needed a first drink in

the morning to get yourself going after a heavy drinking session? () Never () Less than monthly () Monthly () Weekly () Daily or almost daily

_____

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Appendix A

7. How often during the last year have you had a feeling of guilt or

remorse after drinking? () Never () Less than monthly () Monthly () Weekly () Daily or almost daily

_____

8. How often during the last year have you been unable to remember

what happened the night before because you had been drinking? () Never () Less than monthly () Monthly () Weekly () Daily or almost daily 9. Have you or someone else been injured as a result of your drinking?

_____

_____

() No () Yes, but not in the last year () Yes, during the last year 10. Has a relative or friend or a doctor or another health worker been

concerned about your drinking or suggested you cut down? () No () Yes, but not in the last year () Yes, during the last year Record total of specific items here

_____

_____

If total is greater than recommended cut-off, consult User’s Manual. Source: Babor et al. :. Reproduced with permission from the World Health Organization. For more information contact Dr. Thomas Babor at [email protected] (For interpretation of the screening results, refer to Brief Intervention and table . in chapter .)

AUDIT has been validated cross-culturally.

Screening Tools for Child Welfare Clients Various resources are available to CPS workers for “screening” a client for AOD problems, including: () examining the nature of the allegation of a child maltreatment referral, () investigating the client’s previous child maltreatment and other criminal records, () observing the signs and symptoms the client displays; and () administering a self-report screener. A combination of information obtained from the four items should give a CPS worker a better idea regarding

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309

referring or not referring a client for a lab test / the AOD specialist’s diagnosis and assessment.

Nature of the Allegation • Does the initial allegation (referral) involve parental / caretaker

AOD use? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (yes / no) For example, an anxious grandparent may report to the CPS hotline: “My daughter-in-law has gone for weeks without contacting us. She left all her kids with us. . . .We don’t know where she is. She has been using crack cocaine for quite a while . . .”

Previous Records • Does the (alleged) case have previous child maltreatment records

showing AOD involvement (e.g., drug-tested-positive babies or at birth for mother, list drugs detected)? . . . . . . . . . . . . . . . . . . . . . (yes / no) • Does the (alleged) case have previous criminal records

indicating AOD involvement (e.g., DUI, drug possession, or others, etc.)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (yes / no)

Observation Checklist • Is evidence of alcohol abuse and / or drug paraphernalia present

in the home (e.g., visible bottles / cans, pipes, charred spoons, and so on)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (yes / no) • Does the client demonstrate physical symptoms (e.g., agitation,

sweating, trembling, nervousness, and so on)? . . . . . . . . . . . . . . (yes / no) • Does the client demonstrate signs of AOD use (e.g., smell

of alcohol, scratching, dilated or constricted pupils, needle track marks, skin abscesses, burns on the inside of the lips, and so on)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (yes / no)

Self-report Screeners So far, no scientifically tested self-report AOD screeners have been developed to screen for substance-abusing parents in the child welfare system. Therefore, most child welfare workers can only rely on the aforementioned three methods (i.e., the nature of the allegation, previous child welfare or other criminal and legal records, and the observation checklist), the “regular” AOD self-report screeners, and their

310

Appendix A

own professional experience to determine whether or not to refer the client for an AOD lab test and / or AOD specialist evaluation. One issue worth mentioning is the accuracy / dependability of self-report data and its enhancement. The literature indicates that in many situations people with AOD problems will not lie about their AOD-using behavior, despite the longrecognized “denial” symptoms among this population. For example, people may share honestly their AOD problems with their health care practitioners and report honestly their AOD using behavior in an anonymous research study. However, Russell, Chan, and Mudar () noted the importance of employing techniques that “maximize the validity of patient responses.” McNeece and DiNitto () suggested that it is unrealistic to expect clients to volunteer information about their AOD behavior when the context involves child maltreatment allegations. Child welfare clients may perceive that admitting AOD use equals admitting child maltreatment, or they may believe that the social worker tends to connect AOD use with child maltreatment and thus would be more likely to use the admission to substantiate their cases or even to remove the children. Citing various studies, McNeece and DiNitto summarized factors that may affect the quality of selfreported data: () “whether the client is detoxified and psychologically stable at the time of the assessment,” () “the rapport established by the interviewer with the interviewee,” () “the clarity of the questions asked,” () “whether the client knows that his or her responses will be corroborated with other sources of information (particularly laboratory tests),” and () “the degree of confidentiality that can be promised to the individual” ().

CRAFFT C Have you ever ridden in a car driven by someone (including yourself ) who was “high” or had been using alcohol or drugs? R Do you ever use alcohol or drugs to relax, feel better about yourself, or fit in? A Do you ever use alcohol or drugs while you are by yourself, alone? F Do you ever forget things you did while using alcohol or drugs? F Do your family or friends ever tell you that you should cut down on your drinking or drug use? T Have you ever gotten into trouble while you were using alcohol or drugs? © Children’s Hospital Boston, . Reproduced with permission from the Center for Adolescent Substance Abuse Research, CeASAR, Children’s Hospital Boston. For more information, contact [email protected], or visit www.crafft.org.

Knight et al. () recommended a score of  or higher as a cut-point for a further formal assessment. However, they also stated that since CRAFFT has a

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311

relatively lower risk for a false-positive result (i.e., the person does not have AOD problem but CRAFFT recommended a formal assessment) and a relatively higher risk for a false-negative result (i.e., the person has an AOD problem but CRAFFT did not recommend a formal assessment), some practitioners may choose a cutpoint of .

The S-MAST-G (Short Michigan Alcoholism Screening Test—Geriatric Version) YES () NO () 1. When talking with others, do you ever underestimate how

much you actually drink?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

9. Have you ever made rules to manage your drinking?

Yes

No

10. When you feel lonely, does having a drink help?

Yes

No

2. After a few drinks, have you sometimes not eaten or been

able to skip a meal because you didn’t feel hungry? 3. Does having a few drinks help decrease your shakiness or

tremors? 4. Does alcohol sometimes make it hard for you to remember

parts of the day or night? 5. Do you usually take a drink to relax or calm your

nerves? 6. Do you drink to take your mind off your problems? 7. Have you ever increased your drinking after experiencing

a loss in your life? 8. Has a doctor or nurse ever said they were worried or

concerned about your drinking?

Total S-MAST-G Score (–)

_____

(A “Yes” to  or more of the  items indicates a need for a complete evaluation / assessment.) Source: Blow . Copyright  by the Regents of the University of Michigan. Reproduced with permission from Frederic C. Blow, Ph.D. For more information, contact Dr. Blow at () - or [email protected]

The S-MAST-G has excellent sensitivity and specificity for screening older adults (Blow et al., cited in Culberson ).

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Appendix A

The ARPS (Alcohol-Related Problems Survey) or CARPS (Computerized Alcohol-Related Problems Survey) (for Older Adults) Some researchers have suggested that the ARPS tool (Fink et al. :–) is more sensitive in identifying older persons who are at risk for drinking-associated problems. The ARPS includes four sections: health problems, medications, recent alcohol use, and questions about the older person in general. ARPS provides algorithms in assigning older persons to the non-hazardous, hazardous, or harmful group, based not only on an older adult’s alcohol consumption but also on its interaction with and relationship to the person’s medication use, declining health, and weakening functioning level. Studies showed that ARPS is more sensitive than AUDIT (Fink et al. ; Moore et al. ), SMAST (Fink et al. ), and SMAST-G (Moore et al. ) in identifying older persons who are at risk for drinking-associated problems or experiencing drinking-associated harms. Fink et al. () assert that “The AUDIT screens for hazardous and harmful drinking; the CAGE and SMAST identify abusive . . . and dependent . . . drinkers” () and their findings show that “the ARPS identified nearly all drinkers detected by the CAGE, SMAST, and AUDIT and detected hazardous and harmful drinkers not identified by these measures” ().

Appendix B

Relapse Among Substance-Abusing Women Components and Processes

T

his appendix is based on part of a project in which  women who experienced substance abuse problems were interviewed* (Sun ). It explores factors related to the women’s relapse so that practitioners can better understand the nature of women’s relapse and more effectively help them. Qualitative in-depth interviews were conducted, audiotaped (with the exception of  women), and transcribed. The interviews were guided by open-ended questions exploring factors that led to the women’s initial substance abuse, abstinence, and relapse; factors that prompted them to come for treatment; and their experience with the treatment. These open-ended questions were supplemented with follow-up questions probing further critical elements initially shared by participants. The mean age of the sample was  years; more than half were white, followed by Latina / Hispanic, African American, and Native American. Most women reported being poly-drug users, followed by methamphetamine / amphetamines, heroin, cocaine, and alcohol. The average education was  years. Four major factors were identified as contributing to the women’s relapse: () low self-worth and its connection to intimate relationships with men; () interpersonal conflicts and / or negative emotions; () less ability to sever ties with the using network and to establish ties with a non-using network; and () a lack of AOD-related knowledge and relapse-prevention coping skills. The qualitative approach enabled the study to report not only these four general factors but also the multiple dimensions and building blocks underlying each one so that the pertinent contexts and specific meanings of relapse among women could be understood. Many of the factors appeared to be related to women’s socialization and the gender role formation process as well as their disadvantageous social reality. The study suggests several topics for a women’s relapse-prevention curriculum and

*This appendix is a variation of the author’s  article, “Relapse among substance-abusing women: Components and processes,” Substance Use and Misuse  (): –.

314

Appendix B

program. It also suggests a holistic life approach that combines both the environment and the individual and emphasizes both habilitation and rehabilitation to help women prevent relapse. Suggestions for future research are also discussed. The field of AOD treatment has emphasized that a lapse or relapse is a normal part of the recovery process and should not be judged as a failure of the client or the client’s therapist. On the other hand, it is beneficial if a client can be prepared to recognize the risk of and effectively deal with lapses or relapses. “Relapse prevention” has gradually come to be considered as important as “primary treatment” in the AOD treatment field, but little investigation has been done about the relapse process among women (Saunders et al. ). Saunders et al. recognized that various studies have demonstrated a close link between social embeddedness and women, but the issue has not been fully explored in the relapse research. Saunders et al., who conducted a quantitative study investigating relapse among men and women, advocated that more qualitative data be collected to allow women to “explain more fully the nature and meaning of their relapse events” (). The following examples underscore Saunders et al.’s assertion that more qualitative data are needed to understand women’s relapse. Although studies have found that substance-abusing women, compared to their male counterparts, appear to experience more interpersonal conflicts (Grella, Scott, and Foss ) or that women reported more interpersonal than intrapersonal problems—compared to their male counterparts—as determinants of relapse (Hodgins, el-Guebaly, and Armstrong ), those quantitative studies have not specified the multiple dimensions underlying the women’s interpersonal conflicts—i.e., with whom they tend to have conflicts, or why and how such conflicts occur. In addition, studies have emphasized the severance of the old using circle and establishment of a new non-using network for people seeking AOD recovery but have not delineated the specific multiple dimensions involved—i.e., the elements that may hinder women’s ability to accomplish these tasks. Using a qualitative research approach, this study not only identifies general factors related to women’s relapse but also lays out specific multiple dimensions underlying each factor and provides support for each dimension through the words of the women themselves. Such in-depth and specific information may help practitioners to more precisely target women’s unique needs when designing relapse-prevention programs and providing other treatment.

Methods Design and Procedure Data for this study were part of the data collected for a larger project that aims to explore the overall treatment and other needs of women afflicted with AOD problems. The project was approved by the university institutional review board

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and sponsored by the Southwest Interdisciplinary Research Center. A letter was e-mailed or snail-mailed to a list of AOD residential / outpatient treatment agencies (women only or coed) in a metropolitan area in the Southwest requesting permission to conduct the proposed study. Three agencies responded positively to the request. The three programs included one single-sex residential program (average length of stay was three months), one single-sex halfway house (average length of stay was six months), and one coed outpatient methadone clinic. In-depth interviews were conducted with women from the three programs (N = ). All participants were given a copy of the informed-consent form and allowed ample time to read it and ask questions about it. It was emphasized that participation in the study was voluntary and participants could drop out of the study whenever they wished. After the participant agreed to participate, she was further given options regarding an agreement to be audiotaped. For those who agreed to be audiotaped, a second signature was acquired. The participant and the author each kept a copy of the signed consent form. Each participant—whether she consented to be audiotaped or not—received $ compensation for her time spent with the interviewer. Twenty-nine of the participants agreed to be audiotaped; three who were concerned about pending legal involvements declined to be audiotaped. All the interviews were conducted by one interviewer (the author), who is a middle-aged Asian American woman with a background as an AOD-user counselor. Each interview was conducted individually and lasted about . hours. The interviews were conducted mainly in a private room designated by the agency (two follow-up interviews were conducted at two of the women’s houses). The interview was semi-structured and in-depth, audiotaped if the woman had agreed to it; if she had not, notes were taken. The tapes were transcribed. Subthemes were identified and labeled after examining the verbatim transcriptions and the researcher’s notes. Themes that cut across various related subthemes were organized.

Instrument The interview included four guiding questions: () factors / elements that led to the women’s AOD abuse, initially as well as relapses, () factors / elements that led to their seeking / or receiving treatment, () their experience with treatment received, and () other related areas. The four guiding questions were supplemented with follow-up questions probing further critical elements initially shared by participants. Information about participants’ demographic background was also collected.

Sample Thirty-two women were interviewed, with ages ranging from  to , with a mean age of ). With respect to ethnicity, the group was % Native American,

316

Appendix B

% Latina / Hispanic, % African American, and % white. Number of years of education ranged from  to , with a mean of  years. Among the subjects, four obtained a GED (counted as  years) through the help of their treatment programs. Primary drugs of choice included cocaine (%), methamphetamine / amphetamines (%), heroin (%), and alcohol (%). Most women (%) were poly-drug users. They combined different “uppers” (e.g., cocaine, crack, amphetamines, and / or methamphetamines) or used both “uppers” and “downers” (e.g., cocaine, amphetamines, painkillers, alcohol, heroin, and / or marijuana). The women who used both uppers and downers mainly used downers to help them sleep and uppers to help them stay up.

Results and Discussion To safeguard confidentiality, fictitious names were used and identifiable information was altered. On the basis of the interviewees’ narratives, a conceptual framework depicting the components and / or processes involving women’s relapse has been developed (figure AB.). Four themes are identified: () low self-worth and men, () interpersonal conflicts and / or negative emotion (anger, loss, depression, powerlessness, boredom), () less ability to sever the tie with the using network and to establish a tie with the non-using network, and () a lack of AOD-related knowledge (poor judgment on the nature of addiction) and relapse-prevention coping skills. It should be emphasized that although these four themes were presented separately, they often interact with each other in connection with a relapse. For example, one woman felt extremely distressed by her husband’s infidelity and abuse and the constant fights between them (interpersonal conflicts and negative emotion); her coworker, who tried to comfort her by giving her crystal meth, finally persuaded her to use again (the old using network). It should also be noted that human behavior, including lapse and relapse, is often complicated and dynamic, and not all human behavior reflects a linear, cause-and-effect course of action (e.g., a strained couple relationship may contribute to the wife’s depression, which may further worsen the already strained relationship). The above-posited four themes should not be treated as the isolated “causes” of relapse. The reason to present them as isolated entities has been to provide a conceptual framework to help understand relevant components and processes related to women’s relapse. Each theme and its related subtheme(s), as well as the women’s own words supporting these subthemes, is presented in the following.

Low Self-worth and Men One of the prominent factors in a woman’s relapse is her low self-worth, which is often related to the issue of men. A woman may identify with or derive life values

Figure AB.1. Factors related to women’s relapse. * A woman’s relapse experience may be related to more than one subtheme. **Number of women who fall into the subtheme / total number of women in the sample.

318

Appendix B

from her male partner. She may perceive life as meaningless, empty, and purposeless when her man abandons her or leaves her for other reasons. Two related subcomponents constitute the “low self-worth and men” component. First is the issue of men; a woman may use because the man is using, stop using for the sake of the man rather than for herself, relapse because the man relapsed or because he “abandoned” her. The second is the issue of a woman’s low level of resources, including employment. The issue of abandonment by men may have less of an impact on a woman when she has a relatively higher level of resources available to her.

The Issue of Men: Dependence, Abandonment, and Self-identity The women use, recover, and / or relapse because they do not want to lose men. Abby illustrated this point. She not only used drugs to please her man but also stopped using because of him, as well as relapsed again simply because he relapsed. She stated: My husband was using meth. . . I put on a lot of weight. He constantly told me “you are fat,” “you are ugly,” “I don’t want to be with you.” This was my thought: If I started using meth, I’ll be able to lose weight. . . I want to lose weight because he kept saying how fat I was. I was not aware he was turning down my self-esteem. I started using with him. I lost lots, lots of weight. She talked about how the crisis of losing child custody did not stop her using; it was her (ex-)husband, who had just been released from jail, who changed her heart and influenced her to get treatment: My CPS worker said if you want your kids back, you would need to go to rehab . . . but I was like . . . you know . . . I continued my drug use. I continued to go from one drug house to another. Until my husband got out [from jail], he asked me to go to rehab. I was in love with him. He said “you got to get help . . .” and he picked me up when he is out of jail and brought me to the rehab. Abby stated how she relapsed again: He [the husband] started using again. . . He was no longer with the probation, so he started using again. He wanted me to start using with him. So I started using with him again. . . My whole world revolved around him. The women also mentioned the trigger “abandonment” by men or that the men were not around (e.g., went to jail). They stated how much they relied on

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319

the men, and the men leaving them was like the end of world. Betty was working on her treatment to regain child custody; she relapsed because of her sudden abandonment by the baby’s father, resulting in her failure to meet the -month permanency requirement and the consequent permanent severance of her parental rights. Caitlin relapsed after  years of sobriety because her husband asked for a divorce. She stated: The whole thing changed. Because he [ex-husband] had left and I was alone. He just said he didn’t want to be in this relationship anymore. He walked out of the door. Just walked out, broke my heart. I felt so worthless. I couldn’t deal with the situation. That’s how I started using cocaine and drank again.

Low Level of Resources The factor of abandonment may have a different degree of impact if a woman has something other than a man to hold on to, such as education, employment, and support from other networks. Losing a man is equal to losing self-worth, whereas holding a job she loves or having a family member whom she can lean on may provide both practical and psychological support for the woman. Dawn said: You know I have given up my job. I had put everything towards this relationship . . . You know, I lost my independence. I was always a very independent person. I was on top of the world. I made good money, had good friends. Some of them were using drugs, or were drinking. I didn’t want to. I was just so proud of myself. I was doing so good. It didn’t bother me. I was happy, I didn’t want any [drugs]. I just said “No,” and you know, it kind of feels good even to say “No.” When he [ex-husband] came along, we did everything together . . . and after a while, he was just taking care of me. But after he left, I just couldn’t handle it any more. On the other hand, Ellen described why she did not relapse after she broke up with her fiancé, with whom she had lived for many years, and was forced to move out of his place. Fortunately, my sister accepted me. I was able to move to her place. I did not relapse. . . Of course, I was mad, hurt, and extremely sad and depressed. But hey, I still have a fabulous job which I love. It is bad, but it is not that bad . . .

Interpersonal Conflicts and / or Negative Emotions The literature has strongly suggested that interpersonal conflicts and negative emotions are among the risks for relapse. Cummings, Gordon, and Marlatt ()

320

Appendix B

identified six categories of relapse risk: “negative emotional states,” “social pressure,” “interpersonal conflict,” “negative physical states,” “testing personal control,” and “interpersonal positive emotional state” (–), stating that three of the categories—negative emotions, interpersonal conflict, and social pressure— accounted for % of all the relapses. The literature further suggests that gender may be associated with different risk categories for relapse (Annis ; Walton, Blow, and Booth ). Annis’s () study showed four different categories of relapse risk, including the “high negative profile” (situations involving interpersonal conflicts and / or negative emotions) and the “high positive profile” (situations involving pleasant interactions with others, pleasant emotions, and social pressure to drink). She found that high negative profile relapsers were more likely to be women and to drink alone, while high positive profile relapsers were more likely to be men and to drink with other people. Walton, Blow, and Booth () reported that men were more likely to be exposed to peer pressure (negative social influence) and to use AOD in social situations. Hodgins, el-Guebaly, and Armstrong’s () study revealed a “counterintuitive” finding. They found that although both intra- and interpersonal factors contributed to men’s and women’s relapse, women were more likely than men to indicate interpersonal determinants and less likely to indicate intrapersonal ones. Grella, Scott, and Foss () found that women are more likely to have serious interpersonal problems than men both at intake and at - and -month post-intake follow-ups. The present study reveals that the women perceived negative emotions and interpersonal conflicts as one of the major triggers to relapse. It also points to the difficulty of differentiating between the precipitants of interpersonal conflict and intrapersonal negative mood—a woman’s interpersonal conflict may have led to her negative mood, and vice versa. But the study findings shed light on the unique contents of women’s interpersonal conflicts, as well as the bilateral impact of those conflicts and intrapersonal negative mood. The women’s negative emotions and interpersonal conflicts often were interwoven with () their ineffective communication skills in dealing with the various authoritative systems, such as child protective service (CPS), the criminal justice system, and the substance abuse treatment program, all three of which they frequently encounter, particularly during their treatment and recovery stages; () their lack of resources, which often puts them in a poor environment—physically and psychologically—which, in turn, contributes to the interpersonal conflicts (with their family members or other relatives, in particular) and negative emotions; () interpersonal conflicts with their male partner as a result of the partner’s infidelity and mental / physical abuse; () undiagnosed and / or untreated dual diagnosis, such as bipolar disorder, depression, and eating disorder, all of which not only directly create negative emotions but may also jeopardize the woman’s functional communications with her partner, other family members, and people in the “systems,” resulting in even more negative emotions; and () other negative

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emotions, particularly “loss” (death of her infant, suicide of a best friend, death of a close relative, “abandonment” by men, etc.).

Interpersonal Conflicts with Authorities It is not uncommon for substance-abusing women to have to deal with representatives of systems like CPS workers, parole probation officers, and substance abuse treatment counselors. The women’s ineffective communication, lack of problem-solving skills and inadequate strategies (e.g., hiring a competent lawyer), in addition to the red tape of the various systems, may frustrate them and trigger relapse, particularly during early recovery. Emily stated that she had been sober for three months and was ready to visit her two children at a foster family but was rejected by the foster family. Her CPS worker further warned her that there would be consequences if she kept bothering the foster family. Emily collapsed and relapsed, stating: She (the CPS worker) told me that I can visit my son. I have prepared many presents to give my son . . . clothes . . . toys . . . I missed him so much. It’s holiday time . . . but the foster family do not let me visit my child. They were mean. . . I called my CPS worker, but was only told that I should not intervene in the foster family. She [the CPS worker] did tell me that I can visit my children after three months. . . I had a big fight with my CPS worker, which only made things worse. I felt so outrageous and yet, so helpless. No one could help me. No one would help me. I relapsed . . . after three months of sobriety. Fran relapsed because she was being accused by her outpatient drug treatment counselor of lying for not having a urinalysis done. She said: I told her [the counselor] I did not go to the lab for UA because I didn’t have the money to pay for the test. She did not believe me, and started to accuse me of lying. I told her I didn’t use drugs now, I am clean. . . She does not trust me. . . It’s her attitudes that really pissed me off! You have to look at her face. She looked at me like I am some type of dirty, low skunk. I was so mad that the way I was being accused of. I left the clinic and went right into the dope house. It’s you who said I used drugs, so I’ll be just using it!!!

Poor Environment Resulting from Lack of Resources Another factor that contributes to negative interpersonal relationships is the women’s lack of resources, specifically a shelter where they can stay. This may mean that the women will have to return to their old, dysfunctional environment after being discharged from the treatment program. Gwen, a newly sober but homeless woman, returned to her ex-husband’s apartment. Although she felt disgusted

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about staying with her ex, she had no other place to go, she said. She brought with her their six-year-old daughter, and they had to share the small apartment with not only her ex-husband but also his aging mother and his sister. She described the chaos of such a living arrangement and the strained relationship with her exhusband and his sister: I was constantly being bothered by everyone. Everybody was shouting and yelling at everybody else! Five people in a small apartment. . . My ex’s sister was lazy. I have to do all the cleaning. . . She accused me of not being responsible, blaming me for things I didn’t do. She acted as if she were my boss. My ex, which I do not have any feelings for, even asked me for sex, threatening me either do it or leave. . . I just want peace. No peace here. The drug gives me peace . . . Harriet, who completed treatment and returned to the community, went to stay with her aging father. Like Gwen, Harriet needed a place to stay, despite the fact that she had not gotten along with her father ever since she was a teenager. She later moved to her sister’s because she could no longer tolerate her father’s “mental abuse.” She was doing fine, maintaining sobriety, holding a job, attending AA, and enjoying the company of her sister and her nephews. This perfect picture was ruined after the return of her sister’s boyfriend. Harriet was forced to return to her aging father, and she relapsed. She said: He [sister’s boyfriend] wanted to kick me out. . . My sister said she cannot ask him to leave ’cause he is the father of her children. . . We had a big fight. So I have to leave. Although I was working, I spent most of my money buying things for my nephews. I didn’t really have extra money left to find an apartment for myself. I returned to my father’s apartment again. I knew all along my father did not like me. . . I went out to get drugs. . . I just didn’t care any more . . .

Interpersonal Conflicts with the Intimate Male Partner The women’s interpersonal conflicts with their intimate male partner mainly stemmed from their partner’s infidelity and / or mental and / or physical abuse. Lou felt extremely distressed by her husband’s cheating on her, his abuse, and the constant fights between them; Lou’s coworker, who tried to comfort her by giving her crystal meth, finally persuaded Lou to use again. Like Lou, Mia’s boyfriend was also cheating on her and had been very abusive. She was crying while talking: He constantly ridiculed me in front of his friends, my friends, and everybody else. He thinks that I am stupid, and he said that in front of everybody. . . He oppressed me to the degree I began hating myself. I don’t have any self-

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confidence. I felt so bad. I even tried to cut myself. I started using again. This time I shoot. It’s much more serious, you know.

Delayed Diagnosis of Mental Disorders The literature suggests that addicted women are more likely to be diagnosed with depression, anxiety, post-traumatic stress disorder, and eating disorders, while addicted men are more likely to be diagnosed with antisocial personality disorder, pathological gambling, and “residual attention-deficit disorder” (Blume’s review ). It is also suggested that women often self-medicate their psychological or psychiatric disorders when proper medications are not prescribed for them (Root ). The findings of the present study point out that undiagnosed and untreated mental disorders, such as bipolar disorder, not only undermine treatment effectiveness, contributing to frequent relapses, but also negatively affect communication with the spouse, particularly if the spouse is not supportive, and thereby add even more interpersonal conflict and negative emotions, which leads to relapse. This progression is consistent with the findings of the National Depressive and Manic Depressive Association  survey: % of the bipolar participants reported “difficulty maintaining long-term intimate relationships” and “% were separated or divorced” (cited in Glick :). Irene described herself as having been chubby as a young child and often ridiculed by other kids. She had attended several different residential treatment programs since her early s. She did not remember exactly what happened during those treatments, except that each time when she completed the treatment and returned to the community, the old cycle repeated: she would begin to use again and would be admitted again to a treatment program. She did remember that her longest period of sobriety was three years. She was in her early s at the time of that relapse, and only then did she become aware that she had a mental illness. A psychiatrist diagnosed her with bipolar disorder. When asked what happened after the three years of sobriety, she said: I was off the alcohol and drugs, but I went into . . . I flipped right into eating disorder. . . So I was off alcohol and drugs, but I was basically doing anorexia. . . I would, like, not leave the house, unless I weighed a certain amount. . . Making sure I weighed exactly what I was supposed to weigh, I wouldn’t eat. And I ended up going to a treatment center treating eating disorders. Irene believed that one of the reasons it took so many treatments for her to get where she is now is that she wasn’t aware of her “mental illness” until her early s and that many of the treatment programs targeted only one of her two diagnoses instead of treating both simultaneously. She said:

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When you’re not working on your mental illness along with it [alcoholism], it is almost nil. . . You can’t do it. . . Most time, my chemical use is like self-medication. I was dealing with those feelings, putting them away. . . If you are bipolar, you are manic, you use booze to bring yourself down. I didn’t really have a chance to make it until I knew I was dual diagnosis. Then I started working on that, I go to behavioral centers and psychiatric units, to work on that . . . then I was not working on alcohol. So, I was working on one or the other. . . That was all messed up, too! I was finally going to centers that work on both. That’s what I am doing here. Joan, who suffered postpartum depression, stated how her (ex-) husband changed the way he treated her after their baby was born. While it is uncertain whether Joan’s depression negatively affected her husband’s behavior toward her, it is clear that his unsupportive behavior exacerbated her depression. Joan relapsed after two and half years of sobriety. I got postpartum depression, I suffered depression. My life was terrible. When I was pregnant with [the baby], he treated me really good (Her tone became sad and almost crying). . . After [the baby] was born, he started picking on me. Everything I did was wrong . . . and my depression was terrible. Everything was awful. I tried to tell everybody that I wasn’t feeling good. No one would listen to me. His family said I was being selfish . . . just wanted attention and just tried to take attention away from the baby, I knew I was in crisis, I knew I was in trouble, but I don’t know what to do. I said to myself, I just take a little drink. . . I went to take a little bit, and that was it. . . I started drinking again . . . Karen, a victim of multiple rapes by multiple perpetrators by the age of , described her struggle with bipolar disorder and how the disorder has affected her relationship with her (ex-) husband: He [ex-husband] was very nice. He does not use drug nor alcohol. Our relationship was fine. But I was so insecure . . . I constantly worried that he was unfaithful to me. I would hit him. Hit him really hard. I even put a knife on his neck. He was scared to death. I was so insecure and full of rage . . . to the degree I couldn’t control myself. He finally left me. . . The psychiatrist here is helping me now. I was diagnosed with bipolar and I am taking medications.

Feelings of Loss and / or Other Negative Feelings The women’s negative feelings, particularly the traumatic experience of “loss,” were related to their relapse. The women revealed a variety of losses, including the death of an infant due to the woman’s negligence; infant being shaken to death by fiancé; suicide of best friend; death of a grandfather who raised the woman; death

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of an aunt who was her best friend. “Abandonment by men” not only contributes to losing a sense of identity and self-worth but also creates multiple negative emotions for the women, including loss. The feeling of loss usually was accompanied by feelings of betrayal, anger, and self-blame, all of which precipitated a relapse. Another negative factor that contributed to relapse was boredom.

Difficulty of Moving from Using to Non-using Social Network Avoiding things, people, and places that might trigger AOD use is perceived as an important strategy for success by some researchers and practitioners in the AOD user treatment field. The second of the six steps in the recovery process, as suggested by Gorski (), is “separating from people, places, and things that promote chemical use and establishing a social network that supports recovery” (). The concept of “cue reactivity” was introduced more than a half century ago when Wikler reported that some opiate addicts who returned to New York City after a period of abstinence felt symptoms of opiate withdrawal upon experiencing the sights and sounds of the city. This feeling was so intense that some would become nauseated or vomit and eventually relapsed (cited in Chiauzzi ). Chiauzzi stated that craving is a conditioned withdrawal syndrome in that the stimuli connected to withdrawal later become triggers for AOD use. These triggers could include drug-using friends, drug paraphernalia, or AOD-involved conversations. Cummings, Gordon, and Marlatt () proposed the concept of “apparently irrelevant decisions” (AIDs), suggesting that “some individuals engage in a series of mini-decisions, or AIDs, that set the stage for relapse” () and that the client should be urged to “recognize the AID as a decision, and to assume responsibility for this choice” (). (Similar factors are relevant to the “naturally recovered” as well. Russell et al. [] stated: “Another factor that may have contributed to a stable recovery is the fact that current network drinking scores for the naturally recovered were lower than those for ‘hazardous problem drinkers,’“ even though they were similar during their worst period of drinking. This observation is consistent with previous research that found naturally recovered alcoholics who changed their environment, avoiding their old drinking buddies, were more likely to maintain their recoveries” []). The present study, however, reveals some gender-specific difficulties and barriers affecting both women’s attempts to cut ties with the old using circle and their efforts to establish a new non-using circle. The findings suggest that the barriers to severing the (old) ties with the using network and establishing new ties with a non-using one may have to do more with the larger sociocultural context, which has deeply influenced women’s values and behaviors, than with the “apparently irrelevant decisions” theory. Humans are social animals, and the importance of the social network has been emphasized for all people—non-using, using, or in recovery. Particularly for women, cultural and sociological cultivation has influenced them to depend on a social network or interpersonal relationships more so

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than for men (Straussner ). Straussner, summarizing Horney and Chodorow’s work, states: “Gender identity formation is . . . an outcome of different processes in boys and girls: whereas boys need to separate and individuate in order to form a masculine identity, girls form their identity through attachment” (). Falkin and Strauss () found that a woman’s social supporters may also be her drug-use enablers, and vice versa. Women’s emphasis on “relationships,” combined with other effects of genderrelated socialization—such as society’s emphasis on feminine virtues like caring, nurturing, loyalty, and compassion, as well as women’s interdependence with other family members—may lead to difficulties in their attempts to sever the tie with the old using circle. Society’s double standard, which often imposes more shame and guilt on a woman who uses AOD than on a man (Finkelstein ), as well as women’s lack of resources, which may result in low employment and social mobility, may further impede women’s efforts to establish new ties with a non-using circle.

The Difficulty of Cutting Ties with the (Old) Using Circle Loyalty, Friendship, Love / Caring, and Sympathy

The “built-in” feminine characteristics and virtues that emphasize loyalty, friendship, love and caring, and sympathy may prevent a woman from leaving her old using circle. Lucy, a young woman whose lifetime best friend is still using, stated in a very firm tone: “I’ll never leave her . . . We grew up together since we were little. We have gone through so much together. We helped each other. Nothing can ever ruin our relationship.” Mary recalled how her feelings of sympathy and caring for her childhood friend led her to relapse: I was clean. . . My friend . . . my childhood friend . . . We grew up together. She asked me to bring her to the dealer to get some heroin. I know how painful it is if she couldn’t get it . . . I went through heroin withdrawal myself. . . So I brought her there, after that, I relapsed. She further stated that her thoughts back then were that even though she was clean, it did not make her better than her friends who were still using, and therefore it was not justified to not associate with them. Ann’s situation was similar to Mary’s in that one of her girlfriends was craving cocaine and was contemplating suicide. Ann, who was clean then, worried about the friend’s suicide attempt and felt obligated to “help” her. As a result, she bought cocaine and got high together with the friend. Nina described herself as a loner since high school and recalled perceiving herself as being more likable and acceptable by the people surrounding her if she was

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using AOD. She recalled that she graduated from a -day residential program and moved to free transitional housing offered by the same treatment program. She only stayed there for three days before she went out and started getting high again. She said: I don’t have very many friends. . . My best friends are some people who also sell drugs. . . But I thought I can go over there and see them just say hi . . . and let them know that I was doing good and not doing drugs. . . But I can’t . . . I was still too weak. These are my best friends. They were very supportive of me for going to treatment . . . but I wanted drugs. When asked why the drug dealers sold her drugs if they were supportive of her treatment, she attributed the fault to herself, stating, “They do not use drugs themselves although they sell drugs. . . They did remind me that I am under treatment, but I was able to talk them into letting me have some.” Nina, at the time of the interview, was in a three-month residential treatment program and had stayed there for more than two months. Perhaps because of the new insights she had learned from the treatment program, the steadier physical and psychological sobriety she had achieved through the longer residential treatment, and / or her stronger motivation to quit using this time, she said: It’ll be a whole new start this time. I am really going to try this time. . . The friends I was telling you about, I just can’t go see them any more. I relate getting high to seeing them. It’s sad because part of them were good friends to me. They would give me a place to stay when I needed a place to stay, shower when I needed shower, but I just can’t see them anymore. Opal explained how her sympathy, love, and caring for her boyfriend drove her back to him and led her to relapse: I still love him. . . He is still using even though I am in treatment. I always have feelings for the underdog. I felt I was his motivation to do well. After his repeated coming to me . . . saying how much he needed me, I melted. I knew I shouldn’t go with him, but I still finally left with him. Blood-Related Network

Another gender-specific factor was that the “blood is thicker than water” concept usually takes high priority in a woman’s decision-making process. As a result, a woman may continue the tie with a drug-using male to avoid severing the tie between a father and a child or the tie with a drug-using family member to preserve either giving aid to the individual or receiving it from the individual.

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Opal returned to her boyfriend not only because she thought he needed her but also because he is the father of her baby. She said: “My mother said he should not be involved with the baby because he is still using, but I think he is the baby’s father, I would never sever the tie between them.” Penny, an unwed mother who lived separately from the baby’s father, had a similar situation as Opal. She stated: I have been clean and doing fine. . . I brought my baby to see his father. His entire family used drugs. I went there periodically because I don’t want my baby to lose bond with his father. . . But everybody in the house was using. He was using. His mom was using. His sister was using. . . I relapsed. Rose became sober when she moved to her sister’s place because her sister, a non-user, disliked her use. Rose said: “I stopped using all together because I knew my sister would find out if I use . . . and she doesn’t like me doing the drug.” However, things changed later after Rose moved to another town to stay with her cousin so she could be near her boyfriend. There, Rose relapsed because her cousin was using. Sybil described how she pulled her cousin to relapse when her cousin came to her aid during pregnancy and labor: “I was pregnant but was using . . . I have nobody to help me except my cousin. She was clean then. She served as my coach [baby delivery], she relapsed because I was using.” Inability to Move Out of the Drug-Infested Community

Women, particularly those of lower socioeconomic status, were unable to sever the tie with their old using environment either because they were unable to move to a new place due to the financial constraints or because the drug-involved place was where their home was located. Terry, who lived in a public housing project, said: I lived in a project that was full of drug activities. . . I have been clean and was raising my son. I cannot afford to move out of the project. I cannot pay the rent. So I stayed. . . Each day I would see the boy standing in front of our apartments, waiting for people to buy dope from him. . . One day, I approached him. Vicky stated: After treatment, I returned home. . . I was back to my old neighborhood . . . a drug- infested neighborhood. . . Everyone there was using drugs. . . I

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can easily get drugs from my friends whom I grew up with . . . or from my cousins who were drug dealers. Whitney, a young woman, said: Most of the teenagers in the reservation were using “glass.” My boyfriend was a drug dealer . . . my best girl friend whom I grew up with also dealt drugs. They gave me drugs. . . When a big pile of drugs is in front of you, how can you not use it?! Why do I not use it when it’s right in front of me!

Difficulty of Establishing a (New) Non-using Circle The results indicated that although the women were aware of the importance of making new non-using friends, many of them hesitated or felt strange doing so. Among the factors that stood in the way were deeply embedded feelings of inadequacy, shame, and low self-esteem; a low rate of employment, which decreased the opportunities to meet new people; a relatively high caution about meeting strangers, and a lack of transportation and child care, which further decreased opportunities to meet recovering and non-using people in AA or other self-help groups. Shame

The woman may feel ashamed to return to her non-using network, be intimidated by non-using people, and / or fear being looked down or rejected by non-users. One young woman, Zoe, stated how she chose to return to the drug dealers and stay in their “dope houses” instead of returning to her aunt’s place after she broke up with her boyfriend and moved out of his place: I knew my aunt would accept me . . . but I felt so ashamed to go back to her ’cause I have not listened to her. We had many long talks and I have not listened to her . . . and now it proves that I was all wrong. I felt so ashamed to go back to see her. I am a failure. I don’t know how I can face her. Zoe became homeless. She chose to stay with dope friends and drug dealers one after another. She said it’s not because of drugs per se, but because they always accept anyone and because they were her only friends. Anna said, “I never had any friends who were not using . . . Although not all of them, they may look down on me.” Brittany said: Even I am clean now . . . but if you ask me to pick a man from a list of men to be my boyfriend, I most likely would choose someone who is shaggy, full

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of tattoos, and probably using alcohol or drug . . . I don’t know why . . . of course I like a man who is clean cut and successful . . . but at the bottom of my heart, I don’t feel I deserve a good man. I feel I’m more matched with a notso-good man. Difficulty of Workplace as Source of New Non-using Friends

Making non-using friends through the workplace may not be easy for women primarily because of their lower rate of employment. Both Fiorentine et al. () and Grella, Scott, and Foss () showed that substance-abusing men had a significantly higher post-treatment employment rate than did their female counterparts (.% versus .%, p < . in the former; .% versus .%, p < . in the latter). As noted by various women, the barriers to getting a job included less education and job skills, a drug-affected brain (which prevented them from getting and / or keeping jobs that required concentration), criminal and AOD-use background, age, and / or lack of basic tools such as a car, child care, or appropriate clothing for a job interview. The women stated that because their world was limited to their old network—the same family, same neighborhood, and same community—they had little opportunity to make new, nonusing friends. Issues with Post-treatment Self-help Groups

Although the literature (Grella, Scott, and Foss ) suggests that women are more likely than men to participate in post-treatment self-help groups, three women in this study mentioned barriers to such participation. Both Diana and Gayle stated how much they wanted to go to AA meetings but were unable to. For Diana, it was a lack of child care and a car; for Gayle, it was the conflicts between her night shift job and the AA meeting schedules (she lives in a rural area, and the meetings were available only at night). Cathy, a newly recovered woman who had just completed her residential program and was attending an outpatient group twice a week, stated: I attended groups and had the opportunities to meet people there. However, I wouldn’t want to make friends with them because I don’t really know them, plus, their motivations may be very different. . . Some may be coerced to attend the group and not necessarily really want to quit using. . . It is difficult to tell if the person is really in recovery or still using.

A Lack of AOD-Related Knowledge and Relapse-Prevention Coping Skills Gorski () stated that the warning signs for relapse included those related to “core psychological issues” and those related to “core addictive issues.” A core

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psychological issue creates pain and dysfunction; a core addictive issue is a false belief that suggests AOD use is the only way to make a person feel better, to resolve a problem / crisis, or to create a positive situation. Gorski suggested that the core psychological issues alone do not necessarily lead a person to relapse; it is the combination of the core psychological issues and the core addictive issues that causes the relapse. If some of the components addressed in the previous discussions are considered core psychological issues (e.g., men, interpersonal conflicts, etc.), the components presented in this section may be perceived as core addictive issues. The study revealed that an interaction between the two kinds of issues, along with the women’s lack of accurate knowledge about the addictive nature of drugs, may contribute to their relapse.

A False Belief That AOD Use Is the Only Way to Solve a Problem or Create a Positive Situation Sue stated: “As my drug addiction increases, my problems increase. And instead of solving my problems, I was starting using more drugs.” Chantal, whose infant boy was shaken to death by her boyfriend, said that using meth was the only way she knew to help her stay out of despair and to function: I found out this [boyfriend killed the infant boy] . . . I was crushed mentally, physically . . . was just strained. Because I am now in a very big, big depression. . . I had three children. I couldn’t function. I was depressed. All I want to do is sleep. I laid down and woke up three days later. The only thing I knew, you know, was to use [drugs] to cope with the pain. So I started using again. . . That way I can take care of my kids. Some women may perceive using drugs as the only way to be liked by other people or to have a positive interpersonal relationship. Flo said: I was clean and fine . . . I went grocery shopping. When finished shopping and ready to go home, I met my old friends whom I haven’t seen for a while. . . They were and still are using meth. . . We chatted . . . and the next thing I know I was inviting them to my home and started using meth with them again. Leah stated: I was clean after I finished the treatment program. . . I was smoking a cigarette outside my apartment. A man next door approached me and asked me whether I had used meth and offered me some. . . That’s how I relapsed. . . I think that man had a crush on me.

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“One Hit Won’t Hurt” Both Gina and May described how their naiveté about the addictive nature of drugs led them to relapse. One said: It [the drug] tells you that you need it. . . You know, maybe one hit won’t do me nothing. I’ll just take one hit, and I will be done. But now I know, once you take one, you’ll continue to take them, continue to take them . . . The other: I felt I am doing so good [have been sober for quite a while]. . . I kind of think I deserve to be rewarded [with drugs] . . . and just “one hit” wouldn’t hurt. . . But that one hit, however, led to my uncontrollable relapse. Gayle stated: I met someone and got married again. He did not use. . . Behind his back, I started using crystal again. They [old friends] were using. . . They had some, so I asked . . . remembered the lust, the energy. I wanted it. . . I thought I can just use a little bit and stop . . . just one hit . . . but from there . . . Josephine said that she had been very cautious to avoid alcohol because both her mother and her brother were alcoholics and she personally observed all the vicious consequences they had suffered. However, she had not known that drugs, such as meth or crystal meth, are also addictive. She had thought she could control when and when not to use the drug.

•

•

•

The women who participated in this study shared their stories and experiences to help practitioners better serve their future clients. Some of the women felt good about doing so. They said that being able to help other people made them feel good about themselves; being able to tell their story gave them a sense of relief and a feeling of being understood and accepted. One limitation of the study was that all the women were from a relatively lower or middle socioeconomic status (SES), and thus the results might be useful for understanding only women with a similar SES. A second limitation was that the study included only women, making it impossible to directly compare and contrast women with men. A more thorough description of the participants’ backgrounds—e.g., their internal and external strengths / resources / limitations

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and types of roles they fulfill in their family and community contexts—would have also helped us better understand how the women adapt daily. Finally, because the findings were based on a qualitative study, future quantitative studies are needed to further differentiate the importance and priorities of the various identified components. Nonetheless, the study revealed many themes that do help practitioners better understand the specific issues, dilemmas, and needs related to women’s recovery. The findings showed that many of the issues that trigger relapse in women had to do with their socialization and the gender role formation process as well as the disadvantageous social reality in which they exist. This study suggests that practitioners need to address multiple issues in a relapse-prevention program. Relevant topics are healthy relationships with men; effective communication skills with the staff in the systems and with family members; screening for and treatment of dual diagnosis; development of a coping repertoire and skills in dealing with negative emotions and other adverse life situation; strategies for resolving the dilemma of moving from the old drug-using circle to establish a new, non-using social network; a knowledge of the addictive nature of all drugs; and, of course, identification of relapse warning signs and triggers and ways to handle the crises. However, the above-noted topics should not be viewed as a “recipe” or “magic bullet.” Rather, the issues serve as a frame of reference to help practitioners understand the context of the women’s lives and the risk for relapse. Each one of the population of substance-abusing women has unique characteristics regarding her strengths and limitations, as well as her mezzo (couple and family relationship) and macro (community resources and constraints) environment. A thorough and ongoing assessment must be conducted to determine the focus for each individual woman with regard to relapse prevention. Equally important to help women prevent relapse, practitioners should adopt a holistic life approach. They must target both environmental and individual components, not only enhancing the individual but also improving the environment the individual is in, particularly during the early stages of recovery. For example, professionals in the “systems” (CPS, criminal justice, and substance abuse treatment) that the women encounters must hold a nonjudgmental attitude and must be equipped with the knowledge of co-occurring disorder diagnosis / treatment referrals. Quality halfway houses and transitional housing must be made available, particularly during early recovery. A holistic approach also emphasizes “habilitation” in addition to “rehabilitation” (Farkas ), focusing not only on restoring what may have been impaired in a woman’s life due to AOD use but also on engendering the growth of certain new life areas that the woman may have missed the opportunities to develop while growing up—for example, development of life skills (self-worth and self-identity, independence, self-discipline, money management, sound decision making) and vocational training or education enrichment.

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To achieve the above recommendations, policymakers and program administrators need to be informed of the significance of the research results and subsequently allocate more resources and funding for staff training and provision of gender-specific treatment. Efforts should also be made in future research to explore the cross-cultural dimension, as well as urban versus rural issues, in relation to promoting relapse prevention among women.

Acknowledgments This study is based on part of a project supported by sabbatical leave from the University of Nevada Las Vegas and funded by the Southwest Interdisciplinary Research Center at Arizona State University (National Institute on Drug Abuse / National Institutes of Health [R DA]). The author would like to thank all the women who participated in the study and the three programs that helped facilitate the process. Without their support and participation, the study would have been impossible.

Appendix C

Turning the Child Welfare System’s Involvement from Crisis into Opportunity

A

review of the literature shows that a high proportion (%–%) of child neglect and abuse cases have to do with caretakers’ AOD behaviors (Younger, Dennis, and Gardner ). The crisis of being caught in the child welfare system can serve as an opportunity for caretakers, particularly mothers who might not otherwise have sought treatment, to pursue treatment. Inspired by the stories of eight substance-abusing mothers in the child welfare system, we present in this appendix data from their stories, as well as from the existing literature, to help readers understand where these mothers came from and how they ended up in the “other world” (Sun ).* Both their strengths and their problems are discussed in relation to the factors involved in their recovery journey. In addition, we present practice guidelines based on the findings of the study and the relevant literature. Practitioners should keep in mind that this is a qualitative study, with a small number of subjects, and therefore findings can only be suggestive. Further, mothers who participated in the study were probably successful or promising cases who complied with their case plans and retained—or will retain—their child custody rights. Future studies should have a larger sample and overcome the difficulties in recruiting clients who do not comply with their case plans or whose children have been removed. Notwithstanding these caveats, this study may provide practitioners with a beginning understanding of why some mothers “made it” and what contributed to their success. As the literature suggests, certain factors were associated with AOD use and abuse among these mothers. More important, the data show that the mothers possess strengths and hold dreams for better lives, meaningful relationships, and self-actualization, perhaps because of and for the sake of their children. In order for them to achieve those dreams, however, they

*This appendix is a variation of the author’s  article, “Helping substance-abusing mothers in the child welfare system: Turning crisis into opportunity,” Families in Society: The Journal of Contemporary Human Services  (:–).

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need the support of various external systems and the attention of child protective service caseworkers, who can serve as key resources to help these mothers turn crisis into opportunity.

Results and Discussion The Journey of Recovery Several themes emerged from the interviews with these mothers, providing a framework that coherently explains their journey of recovery (figure AC.). Among the themes, some were new and have not been highlighted by the existing literature; some were not new and were consistent with or reinforced the existing literature; and some, although not new, added new dimensions or definitions to old concepts. A major finding across the group was that all of them were eager for a mainstream (normal and meaningful) life, perhaps because of, as well as for the sake of, their babies or children. Such a desire appeared to be the primary force driving them to come as far as they had—to the point of complying with “case plans” and receiving treatment. The dreams of these mothers can be achieved and sustained only through the involvement of legal systems (like the child welfare system [CWS], for example) and / or the support of various other systems. Their desire for a normal and meaningful life was in itself insufficient to influence them to change, to escape the insidious bonds of addiction, their childhood and backgrounds, and the vicious and perpetually disadvantageous environment they found themselves in. The intervention of CWS not only presented a crisis for these mothers (being caught violating the law) but also served as a turning point for them (they now had an opportunity to break the vicious cycle). Various other community resources—treating mothers and children as one unit, facilitating non-using social networks, and case management / life-skills training—were necessary to empower them to leave behind “that other world” and enter a better world.

A Dream for Mainstream Life Each of these mothers, like any other human being, has dreams for a better life, meaningful relationships, and self-actualization. They all expressed the longing for a normal and peaceful life. Like any mother or wife, they would like to have dinner every night with family—instead of using or selling drugs on the street. They perceived street life, often the result of their substance-abusing lifestyle, as “chaotic,” “disgusting,” “sick,” and “scary.” As one mother put it: I want to have dinner every night at home, sit down with my family. . . It’s nice and peaceful. . . I don’t like being on the street, it’s scary . . . selling and using drugs . . . being chased by policemen . . . going to jail.

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Figure AC.1. The Journey of Recovery of Substance-abusing Mothers in the Child Welfare System

Another mother, who along with her husband, had just completed a “case plan,” stated: I now have my son back from the court . . . my husband and I no longer fight that much like in those days when we were using [drugs]. . . We bought a house, and we have a car now. . . I will never ever touch drugs

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again. No way! . . . I know I will lose everything I’ve got now if I touch the drugs again. . . It’s not worth it! It’s so stupid! These mothers yearn for meaningful relationships, particularly with their children. Losing a child to the court because of drug abuse and noncompliance with case plans often imposes enormous guilt. One mother said: I have lived with the pain every single day since I lost her. . . I asked myself every morning when I woke up, how can I do this to my daughter? how can I not try . . . Delivering a baby can be the impetus for them to turn their lives around. One postpartum mother stated: When I felt the first kick of my son in my stomach, I was suddenly awakened. I told myself, I want to give my baby a chance, start my life all over again. These mothers care about how people who are significant in their lives (e.g., their mothers and their children) view them. They are ashamed to disclose their deteriorated lives, and they crave respect. One mother said: “I don’t want my daughter to remember me this way . . . I want my children to respect me.” Another said: I don’t want to see my mother . . . the drugs made me sick, and the drugs made me look old, very old—like a fifty-year-old woman [she was in her early thirties]. . . To let her know that I am doing drugs is difficult; to let her see how I look is even worse. Obtaining a job or getting more schooling is also among their wishes. They want to become emotionally and financially independent and thereby be able to afford to raise their children to a normal and successful life. One mother said: “I want to be independent . . . get a job . . . be part of the society.” Another stated: I want more out of life . . . I want to have a good job in my life. . . I would like to start my own business . . . or go back to college to finish my studies. A young mother, who was sexually abused by her stepfather, kicked out by the stepfamily, and has been living on the street and using “all kinds of drugs” since her early teens, stated calmly and assertively:

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I want more for my son and for myself now . . . I didn’t know there was another kind of life before, but I know now . . . I want to set up goals and prioritize things . . . goals for myself and my son.

Entering and Staying in “the Other World” Although these mothers shared the same dreams as others, they had not followed the path that most people take. Instead, they took another journey, ending up in the other world and, as some of them put it, “going downhill.” They used, abused, and dealt drugs. To obtain the drugs they needed, or to get money for those drugs, they were compelled to steal, fight, use men to get money, or commit other crimes. They gave many reasons for being involved with CWS: “I am supposed to supervise my kids, making sure they are not doing things they should not. . . I didn’t, ’cause I was on drugs.” “My relatives reported me because I left my baby with them for weeks without contacting them.” “I forgot to send my kids to school.” “My two-year-old was out fooling around in the neighborhood.” “My baby was tested drug-positive when delivered.”

Factors Related to Substance Abuse Why did these women take this other route? What are some of the factors that led them to enter that other world? Four themes emerged from the interviews: childhood trauma, multiple stress and losses, their AOD-using peers and networks— particularly male partners, and their inability to get out of the vicious cycle. Each factor may stand alone, but often they interact, exacerbating the downward spiral. Although the four themes are mostly consistent with the existing literature regarding substance-abusing women, stories from these eight mothers may shed some new light. Childhood Abuse

Two of the eight mothers indicated that they had suffered childhood sexual or other types of abuse. They started using drugs at an early age, both to help cope with pain, depression, and shame and because of affiliation with drug-abusing peers and gangs. One started smoking “weed” at  years old. She was then kicked out of her home at  because she revealed sexual abuse incidents, causing her stepfather, the breadwinner of the family, to be jailed. Another stated that she ran away from home to escape her alcoholic stepfather’s abuse. Each, consequently, was exposed to the street lifestyle at an early age, hanging out with peers or gangs who abused and dealt drugs, engaging in drug-related illegal activities. Those peers and gangs were all they had. Although a connection between childhood sexual abuse and women’s development of substance abuse is still debatable (Hutchins ), the theory appears to be accepted in the substance abuse treatment field. Experts contend that women’s

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addictive behavior is often a “posttrauma coping response,” an attempt to selfmedicate to ease the pain and shame caused by childhood sexual abuse or other abuse (Root ; Russell and Wilsnack ). One mother in our study did believe that she used AOD to cope with the pain caused by sexual abuse. However, our findings point to an additional theory to explain the association of childhood abuse and women’s development of substance abuse problems. The two young mothers’ stories suggest that women who suffer from childhood abuse may be forced, or may choose, to leave the abusive family environment, thus ending up on the street at an early age. Exposure to the street lifestyle usually increases the risk for affiliation with gangs, abusing drugs, and committing drug-related crimes. Multiple Losses and Other Stress

Although only two mothers suffered childhood abuse, all eight of them mentioned that they had been overwhelmed by multiple losses and other stress, and were confused and helpless as to how to handle those issues. Two experienced the death of significant others to whom they were really close (e.g., mothers, husbands, grandmothers, etc.). Two others stated that drugs made them “feel high,” “feel better about life,” and they used drugs to “pass time.” Other stresses alluded to ranged from parental divorce to domestic violence, rape, inability to pay rent and other bills, and losing jobs. One young mother said: My parents were going through their divorce when I was in th grade. . . I was so hurt . . . I dropped out of school, because I simply couldn’t deal with it. . . They didn’t care that I dropped out. . . They were too busy with their divorce to care about me. . . I started using drugs and hanging out with people who do drugs. The literature suggests that women tend to use and abuse AOD to self-medicate psychosocial stress more often than men do (Pape ; Schutte, Moos, and Brennan ). Kirkpatrick believes that “women drink because of frustration, loneliness, emotional deprivation, and various kinds of harassment, while men drink for power” (cited in Kasl :). (This parallels gambling addictions, in that [the literature suggests] women gamble to avoid pain or to escape from reality, while men gamble to compete or to seek control [Brubaker and Cohen ].) The narratives of the women in this study seem to reflect the portrayal in the literature. AOD-Using Peers and Networks, Particularly Male Partners

All of these mothers used to live in drug-using circles that often were their only social networks, because they were isolated by their non-using family members. One young mother said: “They [mother and sisters] completely shut me out of their lives when I was using drugs.” Another: “My family does not trust me anymore

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because I repeatedly lied to them to get money for drugs.” One more said: “You’re hanging out with them, partying with them, using drugs, buying drugs from them.” Still another stated: My husband was very abusive. . . I ran away from him and moved to a remote small town. . . One day, someone asked me whether I wanted a line, and I said yes . . . because I was so lonely, had no friends, and I wanted to fit in. And finally, one said: All my friends used drugs. . . It was not a big deal . . . I didn’t have friends who didn’t use drugs. . . They were all I had. . . I don’t know anyone who didn’t use drugs. All of the eight mothers had male partners who either abused drugs or abused and dealt drugs. Four of them were introduced to drugs by their male partners; four, although not initially introduced to drugs by them, were married to or stayed with a male drug abuser and / or dealer. One woman began using drugs by watching and imitating her mate: I was curious. . . I found that each time he used heroine, he became totally different—he became a much better person. . . He had better mood . . . was nicer to me. . . So I became curious and wanted to try the drug myself. Many studies have suggested that female substance abusers are more likely than male substance abusers to associate with substance-abusing opposite-sex partners (Bresnahan, Zuckerman, and Cabral ; Wells and Jackson ). For example, women are more likely than men to be introduced to drugs by partners of the opposite sex (Eldred and Washington ). Wilsnack and Wilsnack’s () study indicated that husbands’ self-reported drinking problems were not strongly associated with their perceptions of their wives’ drinking frequency, but wives’ selfreported drinking problems were associated with their perceptions of their husbands’ drinking frequency. They cited Haavio-Mannila’s interpretation and noted: “Women are more likely to imitate the drinking behavior of higher status males, whether in the family or in the workplace, than men are to imitate female drinking behavior” (). Our study shows that there might be two more reasons why female substance abusers are more likely to associate with substance-abusing opposite-sex partners than are males. First, they have more opportunities to meet with, or be accepted by, men in drug-using circles than in non-using circles because of society’s double

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standard, which imposes a stigma on drug-abusing women more so than men (Burman and Allen-Mearse ); and second, remaining with a substance-abusing man, especially a drug dealer, may offer a more convenient source of drugs. Some women hook up with drugs through people, male and female, in drug-using circles even before they meet and settle down with male substance-abusing partners. One mother said: “I met my husband in a crack house where I usually got high. . . He was a dealer.” Another: “I met my boyfriend at a pot party. . . He sells pot. . . We talk about drugs. It’s our common topic.” Unable to “Get Out of the Vicious Cycle”

Although these mothers longed for a normal and peaceful life, they also pointed out that it is difficult to get out of the vicious cycle caused by drug addiction. Some stated that if it were not for the legal system’s intervention, they probably would still be in the other world—not because they wanted to stay in that chaotic place but because they did not know the way out. One mother put it this way: “It was just like you are sucked into a powerful drain—you want to get out, but you can’t.” A mix of factors prevented them from changing. They all emphasized the power of addiction, stating: “You now needed the drugs more than you wanted them.” One mother said: “Drugs are the center of your life. . . You are controlled by the drugs. All you think of is drugs.” They worried about their inability to raise a family should they leave their AOD-using male partners, and they did not have confidence to make that change. One mother said, “I don’t think I can make it relying on myself.” These mothers did not know where to get help. This was the first time that four of them had received treatment (after years of drug use and abuse) or learned about the existence of various self-help groups and sponsors. Or perhaps it was the service-delivery systems that failed these mothers. One of them, after her caseworker told her to get treatment, said she found that no programs would take me . . . a woman with a young child. . . I tried one program after another. . . No one would accept me. . . I told myself, maybe it was meant for me not to receive any treatment. . . Maybe I should stay just as I am. Another stated: My caseworker gave me a list of  things to complete, I ended up doing only one. . . It’s too overwhelming. . . I don’t feel I’m capable of completing the plan. . . The plan is not feasible for me, so I gave up . . . and my daughter was taken away from me.

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Bringing These Mothers Back to the “Mainstream World”: Practice Guidelines Four practice guidelines were developed on the basis of the interviews and the literature:

Turning CWS Involvement from Crisis into Opportunity Being reported to CPS for child abuse or neglect incidences is certainly a crisis for most mothers. It is, however, one that can be transformed into an opportunity that will help them to restart their lives. As mentioned earlier, many of them felt that if the legal systems had not intervened, they probably would still be in “the other world.” For example, one mother said: “Actually, it was a good thing to be caught by CPS because it gave me the chance to change.” How can the crisis be turned into an opportunity? CPS workers can be the key. Maintaining a Nonjudgmental and Non-authoritative Attitude

Three mothers mentioned that an authoritative attitude only makes the social workers / practitioners seem like policemen, causing the clients to withdraw or rebel. Abundant literature has suggested that practitioners (especially those in CWS) should not have judgmental attitudes toward substance-abusing parents (Finkelstein et al. ; Klein, Friedman-Campbell, and Tocco ; Tracy and Farkas ; Young, Gardner, and Dennis ). Klein, Friedman-Campbell, and Tocco () state: “Acknowledging that ‘substance abuser’ is just one aspect of a caregiver’s [mother’s] identity can be the basis of a helping alliance different from others the caregiver [mother] has experienced” (). Dore, Doris, and Wright () state: “The caseworker must be able to empathize with the substance abusing parent, to recognize and understand the fear and pain that underlies addiction. This requires special training and, even then, can be difficult, especially for child protective services workers who repeatedly observe damage to children resulting from caregiver [parental] addiction” (). Klein, Friedman-Campbell, and Tocco stress the use of neutral words when communicating with these clients. For instance, avoid the use of terms like “clean” or “dirty” with reference to urine, breath, or blood testing; instead, use “positive” to refer to test results containing substances, and “negative” for those that do not. Yaffe, Jenson, and Howard () suggest that traditional confrontational approaches may not be effective with substance-abusing females who suffer from low self-esteem or psychological trauma. Helping Clients Recognize Their Dreams

As noted earlier, all the mothers in the study held dreams for the mainstream life (better lives, meaningful relationships, and self-actualization), and those dreams were what drove them to where they were at the time of the study—complying

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with case plans and receiving treatment. Such a dream may serve as an incentive for these mothers to change. Hepworth and Larsen () state: “Motivation for change . . . is enhanced when clients receive a payoff (want) that justifies their subjecting themselves to an alien and threatening venture” (). Miller and Rollnick () pointed out the importance of helping clients “explore” their “goals” to motivate them to change—”What values or goals does this person hold most dear?” (). The purpose of such exploration is to help clients realize how their problematic behavior may be inconsistent with their goals and may hinder their pursuit of those goals. Caring About and Having Faith in Clients

When the women were asked what had made them change, one of the things they mentioned was their social workers / counselors. One mother stated, for example, “Because my social worker cares. . . She cares about me. Having someone care about me makes me care about myself.” Another said, “Her faith in me. . . My social worker has faith in me . . . which, in turn, gives me confidence in myself.” These mothers’ feelings seem to concur what Hepworth and Larsen () state: “Although many clients acknowledge problems and manifest incentives to change, their motivation may be severely dampened by skepticism about their capacity to change. . . Hope is an indispensable component of motivation, one must often assume responsibility for fostering this precious ingredient. . . [Social workers] must believe that clients can take constructive action” (). “Self-efficacy” is one of six elements pointed out by Miller and Rollnick () to motivate people to change. These authors suggested that even if clients know they have problems, if they do not believe they can change, their only option is to deny the problems. It is critical for practitioners to nurture and reinforce clients’ “hope” and “optimism” in their ability to change. Creating Feasible Case Plans

The literature has suggested that practitioners should team up with their female or mother clients in the development of individualized case plans, to empower the clients and ensure an equal relationship (CSAT ; Ramlow et al. ; Tracy and Farkas ). In this study, three mothers underscored this theme, adding a new dimension to it from a practical point of view. They said that CPS workers need to, within reasonable limits, develop feasible case plans for their clients. A feasible case plan may be more easily structured when the worker and the mother work on developing it together. Requiring a newly recovering mother to complete too many tasks too soon can be stressful and overwhelming, resulting in noncompliance or even triggering relapse. While Fisher and Harrison () identified several strategies for lifestyle changes to help prevent relapses, they cautioned that such changes must be “prioritized” and implemented “in increments” so as to avoid overwhelming clients and possibly prompting relapse.

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Treating Mothers and Children as One Unit This concept has been strongly emphasized for about a decade now. Experts have begun to notice that the fear of losing child custody may be a major factor that prevents these mothers from pursuing treatment (National Council of Juvenile and Family Court Judges ). They might also worry about the lack of child care support should they enter treatment. Foster care is sometimes the only option for a woman who needs residential treatment, and she may be concerned about regaining custody once her child enters that system (Brown ; Wells and Jackson ). Our study adds one more dimension to the custody issue. One young mother, whose son was two months old, stated: It is important to place my son together with me in the same place so that I can recover with him. . . If you separate a mother from her baby . . . it’s going to be too much when you put them back together later. . . Being freshly clean plus a fresh baby is tough. The experience of recovering along with the baby is qualitatively different from doing so without the baby. Raising infants and young children can be challenging, often creating stress, especially if the child is a baby who was exposed to drugs while in utero (Howard ; Kelly ). Such stress can trigger relapse of the mother, as well as neglect and abuse of the child. When mothers and babies are treated as one unit, parenting issues and their accompanying stress can be dealt with during the mothers’ treatment course and recovery process.

Facilitating and Strengthening Non-using Social Networks The findings of this study reinforce the importance of non-using social networks, as documented in the literature (Daley and Marlatt ; Gorski ). All eight mothers pointed out that it is a must to completely cut the tie with the AODusing circles. To empower themselves to cut the AOD-using network, it is necessary that they establish a new non-using network (e.g., AA / NA) and / or restore their old non-using associations (e.g., family and friends). Self-help groups and sponsors can be the major non-using network for the mothers who do not have spouses or other family support. When asked whom they will turn to when they face crises, the five single mothers unanimously said: “Call my sponsor.” This coincides with what the literature suggests. Pape’s study () points out that many women who had not relapsed emphasized their involvement in -steps and with their sponsors. However, the three married mothers who had the support of recovering spouses or non-using family and friends perceived the value of sponsors differently. They also attended AA / NA meetings, but did not rely on sponsors as much as the single mothers did. One mother said:

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I go to [AA / NA] meetings, but I don’t have a sponsor. . . I am not used to sharing my stuff with a stranger. . . I just don’t feel comfortable. . . How do I handle crises? I talk to my girlfriend. She lives close to me. . . We’ve known each other for a long time. Another: I have sponsors. . . But my mom and my sisters help me most. . . They are very supportive. . . I can always cry on my mother’s shoulder. . . They completely shut me out of their lives when I was using drugs, but they now are very supportive because I am receiving treatment and no longer use drugs. Kaskutas’s study () found that one of the major reasons women attend AA was “to make and maintain friends. . . For these women, AA serves an important social role in their lives, and perhaps for some this is a replacement of former drinking friends and socialization found at bars . . . that is . . . ‘it’s like a second home’” (). Perhaps sponsorship is more important for single mothers who do not have social support than for mothers who have the support of spouses, family members, or friends.

Incorporating Case Management and Life-Skills Training The literature has consistently emphasized the incorporation of case management into treatment for substance-abusing women (CSAT ; National Council of Juvenile and Family Court Judges ; Siegal and Rapp ). For substance-abusing mothers, such services are even more critical. For example, one mother said, “I am required to go to meetings [AA] . . . but I don’t have a car . . . plus, I have to find a baby-sitter. . . It is so inconvenient.” When asked about their future plans after discharge, four of the five single mothers indicated they had no place to go except the possibility of getting “transitional housing” arranged by their current treatment program. One mother said: “They took away my apartment [housing project] when I signed up for [residential] treatment. . . All my other kids are now with my sister. . . I don’t know what to do when I leave here.” Case management services should provide necessary housing, child care, and transportation, all of which are essential to continuing recovery after leaving the treatment facilities. Case managers can also advocate for clients’ benefits / entitlements, link clients with health care, and coordinate various service systems for them (CSAT ). Case management ensures the continuity and comprehensiveness of the services that are critical for those mothers’ long-term recovery. Life-skills training is another component emphasized in the literature. Many substance-abusing mothers are ill-equipped with regard to parenting skills, vocational skills, financial management, decision-making skills, assertiveness, stress

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management and coping skills, personal image building, and community resource utilization—factors that often place them at higher risk of relapse (Farkas ; Sullivan ; Zankowski ). As noted earlier, although only two mothers in our study suffered childhood abuse, all had been overwhelmed by various losses and stress. How to help them cope constructively with psychosocial stress is thus an important consideration. Farkas () contends that these women require “habilitation” rather than “rehabilitation” in order to achieve long-term recovery. Vocational training may be particularly important for substance-abusing mothers, for four reasons: (a) many such women have only minimal schooling or job skills; (b) many are single mothers living in poverty but are primarily responsible for their children (Sullivan ); (c) being financially dependent on men, family members, or the welfare system may put these women into a powerless role, leading to a sense of ineffectiveness (Zankowski ); and (d) with the implementation of Temporary Assistance for Needy Families (TANF), mothers relying on public assistance may be required to find a job within two years. The situations of the mothers in our study seem to point to a need for vocational training: None of the mothers were currently employed—six relied on TANF and two on their recovering spouses; although the majority had high school or above education, two had completed only the seventh grade; one has been out of the work force for ten years, and none of them had a stable job history. Although these mothers were doing relatively well so far, it may be necessary to provide them with such service and training to ensure long-term recovery.

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Index

AA (Alcoholics Anonymous), –, , , , –,  abstinence issues, older women, , ; pregnant women,  access services (transportation and outreach), –, , , –,  accidents (falls, etc.), , ,  acculturation issues. See race / ethnicity ACE (adverse childhood experience). See childhood sexual abuse (CSA) / childhood physical abuse / adverse childhood experience (ACE) ADD / ADHD (attention-deficit disorder / attention-deficit hyperactivity disorder), – addiction. See AOD (alcohol and other drugs) abuse ADH (alcohol dehydrogenase),  ADI (Adolescent Drinking Index),  ADIS (Adolescent Drug Involvement Scale),  ADLs (activities of daily living), impairment of, – Adolescent Drinking Index (ADI),  Adolescent Drug Involvement Scale (ADIS),  adolescent girls, drug types used, –; dysfunctional family history, –, , –; eating disorders (ED), , –, –; experimentation and risk of lifelong dependence, –; meth admissions, –; substance abuse rates, , ; unlikelihood of

problem identification, , –, ; unsafe injection drug use, –; victimization risk, ; vulnerabilities, x, xi, –,  adolescent girls, characteristics and theories of AOD problems, age, ; childhood sexual abuse (CSA) and / or other adverse childhood experiences (ACE), –, ; depression and other internalizing behaviors, –, –; developmental, –; eating disorders (ED), –; family environment, –, ; overview, –; race / ethnicity, –, –; risky behaviors for HIV / AIDS, STDs, etc., ; suicide risk, –, – adolescent girls, treatment guidelines and strategies, AOD screening tools, – , –; counseling overview, – ; early identification and intervention, –; female-adolescent-specific programs, –; harm reduction, ; identifying and recruiting, –; MDFT (multidimensional family therapy), ; MFTG (multifamily therapy groups), –; MI, MET, and CBT combinations, –; MST (multisystemic therapy), –; need for more study, ; overview, –; race / ethnicity factor, –; screening for childhood maltreatment and dysfunctional family background, –; screening for dual diagnosis and suicide,

400 adolescent girls (continued ) ; screening tools, –, –; stages of change, facilitating, – Adolescent Health Review, – adverse childhood experience (ACE). See childhood sexual abuse (CSA) / childhood physical abuse / adverse childhood experience (ACE) affective disorders,  African Americans, adolescent suicide, ; AIDS / HIV estimated rate, –; AOD dependence / abuse rates, t, t, , , ; AOD use during pregnancy, , , , ; cigarette use, t, ; cigarette use, prenatal, , ; crack cocaine use, ; culturally sensitive practice, –, ; family involvement in treatment, ; FAS or FASD rate, , , ; female role models for adolescents, ; heterogeneity among, ; homelessness rate, –, , ; multiple sex partners, –; pregnant women, ; prenatal alcohol use, ; racial identity issues, –; racial socialization, ; treatment center admission rates, –; treatment completion rates, ; unsafe injection drug use, ; unsafe sex,  aftercare, for older women, –; for pregnant women, –; for homeless women,  age; as factor for employability, ; as factor in AOD dependence / abuse, –, t, ; for lesbians and gays “coming out,” – AIDS, . See also HIV / AIDS risk Alaska Natives, AOD dependence / abuse rates, t, , t, –; AOD use during pregnancy, ; cigarette use, t, ; FAS or FASD rate, , ; HIV / AIDS estimated rate, – alcohol dehydrogenase (ADH),  alcohol use disorder (AUD), – alcoholism, gender and demographics, t alcoholism in women. See also AOD (alcohol and other drugs) abuse; brain damage and cognitive function impairment, –; breast cancer, –; harsh

Index treatment in nineteenth century, ; heart problems, –; higher BAC and “telescoping effect,” –; liver diseases, ; mortality rates, –, ; reproductive system dysfunction and fetal alcohol syndrome, – allergy medications,  American Indians / Native Americans, AOD dependence / abuse rates, , t, t, , ; AOD use during pregnancy, –; cigarette use, t, –; FAS or FASD incidence, , , ; HIV / AIDS estimated rate, –; homelessness rate, –; names and imagery, ; treatment completion rates, ; unsafe injection drug use,  amphetamines, , , ,  AN (anorexia nervosa), , – anorexia nervosa (AN), , – Antabuse (disulfiram), – anxiety disorder,  AOD (alcohol and other drugs) abuse. See also alcoholism in women; specific vulnerable populations; addiction as choice versus disease, ; consequences as more negative for women, –; consequences for physiology and health, –; consequences in psychosocial sanctions, –; factors, –; historical background, –; HIV / AIDS risk, –; prevalence, –, ; primary drug used at treatment admission, –; unsafe injection drug use, –; unsafe sex, – arousal, sexual, relationship to alcohol consumption,  ARPS (alcohol-related problems survey) screening tool,  art therapy,  Asians, AOD dependence / abuse rates, t, t, , ; AOD use during pregnancy, ; cigarette use, t; heterogeneity among, ; HIV / AIDS estimated rate, –; homelessness rate, –; unsafe injection drug use,  attention-deficit disorder (ADD) / attention-deficit hyperactivity disorder (ADHD), –

Index AUD. See alcohol use disorder AUDIT (alcohol use disorders identification test) screening tool, –, , – baby boomers, xi, , ,  BAC (blood alcohol content or concentration), – “bar orientation,” – barbiturates and sedatives, , , ,  BCT. See behavioral couples therapy BED (binge eating disorder), – behavioral couples therapy (BCT), , – beneficial health effects of drinking, –, – benzodiazepines, , , ,  BI. See brief interventions (BI) binge eating disorder (BED), – biological risk factors, – biological theory of AOD abuse,  biopsychosocial theory of AOD abuse,  bipolar disorder, –, – birth defects. See FAS (fetal alcohol syndrome) and FASD (fetal alcohol spectrum disorder) bisexual women, , , , , , ,  blood alcohol content (BAC) and “telescoping effect,” – body image / appearance dissatisfaction, –, –, – boredom,  brain function and brain damage, –, , , ,  breast cancer, –, , – “brief counseling” intervention,  brief interventions (BI), –, –, –, –, – buddy arrangements,  bulimia nervosa (BN), –, –,  buprenorphine,  CAGE screening tool, , ,  cancer, –, , – CARPS (computerized alcohol-related problems survey) screening tool,  CASA. See National Center on Addiction

401 and Substance Abuse at Columbia University case management, advantages, ; community reinforcement approach, –; homeless women, –; mixed results of studies, –; older women, ; one-stop shopping model, –, ; pregnant women, –; prevention and outreach, –; street prostitutes, –; treatment methods,  cash and / or vouchers, –, , –, , – Cass model of “coming out” stages, – CBT. See cognitive-behavioral therapy (CBT) CD (conduct disorder), , – CDC. See Centers for Disease Control and Prevention Center for Substance Abuse Prevention,  Center for Substance Abuse Treatment (CSAT), , , –, –, , –, –, –, –, , –, , – Centers for Disease Control and Prevention (CDC), , , –, , –, , , , , – cervical cancer,  CHD. See coronary heart disease. child protective services (CPS), , . See also child welfare issues child welfare issues, AOD screening tools, –; child abuse / neglect charges, , , , –, ; child care availability, –, ; child custody issues, –; children of homeless women, –; crack cocaine babies, ; environment for mothers and infants, –; interventions for drug-exposed infants, –; substance-abusing mothers, , – childhood sexual abuse (CSA) / childhood physical abuse / adverse childhood experience (ACE), of adolescent girls, –, ; as factor for risky sex practices, –; as factor in AOD dependence / abuse, , –, , ; of homeless women, –, ;

402 childhood sexual abuse (CSA) / childhood physical abuse / adverse childhood experience (ACE) (continued ) of lesbians and other non-heterosexual women, , –, ; of pregnant women, –, –; as psychological risk factor, – choice, assumption of, on part of abuser,  cigarette use, by adolescent girls, , , ; by adolescents, ; body image / appearance dissatisfaction, –; by lesbians and other non-heterosexual women, ; and partner’s physical abuse, ; as predictor of prenatal drinking, ; by pregnant women, , , , ; and psychiatric disorders, ; sensation- or pleasureseeking factor, ; and socioeconomic / education status, –; studies of, , , t Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach,  CM (contingency management). See contingency management (CM) cocaine use, , , , , , , , , ,  cocktails,  COD. See co-occurring disorders (COD) cognitive function impairment and brain damage, –, , , ,  Cognitive-Behavioral Approach: Treating Cocaine Addiction,  Cognitive-Behavioral Coping Skills Therapy Manual,  cognitive-behavioral therapy (CBT), for adolescent girls, ; for homeless women, ; for older women, –; overview, –; for pregnant women,  communication skills, , ,  Community Older Persons Alcohol Program (COPA),  community reinforcement approach (CRA); components, –; effectiveness, ; functional analyses (FA), ; practitioners, –; skills training, ; strategies, – Community Reinforcement Approach to Addiction Treatment, 

Index Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction, ,  community resources. See also social networks; for homeless women, –; for lesbians and other non-heterosexual women, –; for pregnant women, – comorbidity, , . See also co-occurring disorders (COD) Computerized Alcohol-Related Problems Survey (CARPS) screening tool,  condom use for safe sex, –, , –, –, , , – condoms, female,  conduct disorders (CD), , – confidentiality, – confusion (on part of older people),  contingency management (CM), combining methods, ; components, –; efficacy / effectiveness, ; for homeless women, –; for pregnant women, –; principles / strategies, – contracts, behavioral couples therapy, –; contingency management,  contractual mediation, – co-occurring disorders (COD) and dual diagnosis, of adolescent girls, –, ; of homeless women, ; of older women, ; of pregnant women, –, –; psychological risk factors, –,  COPA (Community Older Persons Alcohol Program),  coping skills, , ,  coronary heart disease (CHD), – counseling, group and / or individual. See also under specific vulnerable populations;AA (Alcoholics Anonymous), , , –; for hetero- and homosexuals, ; issues with, –; peer counseling, –, –, ; self-help groups, –; and staff supportiveness, –, –; vocational, ,  counselors. See practitioners couples therapy, –. See also behavioral couples therapy (BCT); family history, dysfunctional

Index CPS. See child protective services CRA (community reinforcement approach). See community reinforcement approach (CRA) crack cocaine babies,  crack cocaine use, , , , , , ,  CRAFFT screening tool, , – crime, commission of, by male addicts, ; as reason to admit woman has AOD problem, , , ,  criminal justice system. See also child welfare issues; adolescents, , ; assumption of choice on part of abuser, ; double standard, –; Harrison Anti-Narcotic Act, ; older women, ; pregnant women, –; street prostitutes, –, –, – criminalization of drug possession,  CSA (childhood sexual abuse). See childhood sexual abuse (CSA) and / or other adverse childhood experiences (ACE) CSAT. See Center for Substance Abuse Treatment. cultural issues. See race / ethnicity DAP (Drug and Alcohol Problem) Quick Screen,  “deep structure” dimension of race/ethnicity, – delinquent behaviors, – delirium,  dementia,  denial (of women’s AOD problems), culture of, – dependence compared to abuse,  depressants, – depression, addicted women, ; adolescent girls, –, , –; homeless women, , ; menopausal, ; older women, –; postpartum, , ; pregnant women, –; street prostitutes, –, ,  detoxification programs, –, – Diagnostic and Statistical Manual of Mental Disorders (DSM), , , –,  disadvantaged background. See income and socioeconomic status (SES) discordant identity, , 

403 discrimination. See stigmatization, shame and guilt disease theory of AOD abuse,  disulfiram (Antabuse), – domestic violence (DV). See also violence; and emotional abuse, ; family history of, –; of male partners, substance-abusing, ; toward homeless women, ; toward pregnant women, ,  domestication of drinking,  donations from local stores, ,  donor-insemination clinics,  double standard, on pregnant AOD-abusing women, –; on rape of drunken women, –; on women’s AOD abuse, , ; on women’s drinking, ,  Drinking Problems Index,  Drug and Alcohol Problem (DAP) Quick Screen,  Drug Use Screening Inventory-Revised (DUSI-R),  drugs, illicit. See also AOD (alcohol and other drugs) abuse; amphetamines, , , , ; cocaine, , , , , , , , , , ; cost, ; crack cocaine, , , , , , , ; Ecstasy, ; heroin, , , , , , , , , ; life expectancy of users, ; marijuana, , , , , , , , ; methamphetamines, , –, , , , ; opiates / opium / morphine, , , , , , , , ; overdose, ; PCP (phencyclidine), ; for street prostitutes, ; traffic in,  drug-exposed infants / children, – DSM. See Diagnostic and Statistical Manual of Mental Disorders) dual diagnosis. See co-occurring disorders (COD) and dual diagnosis DUSI-R (Drug Use Screening Inventory-Revised),  DV (domestic violence). See domestic violence (DV) “early-onset” drinking, – eating disorders (ED), , –, –

404 Ecstasy use,  ED (eating disorders), , –, – ED (emergency department),  education levels and educational intervention, for adolescents, , ; on alcohol use / abuse, ; on false belief that “one hit won’t hurt,” ; on false faith in AOD use as solution, ; for homeless women, –; for older women, –, ; for pregnant women, –, –, –; on risk of lifelong consequences of AOD abuse, ; for street prostitutes, ,  Elders Health Program,  emergent mediation,  employment status, difficulty of making new non-using friends in workplace, ; employers’ double standard, ; for homeless women, ; for pregnant women, –, ; for street prostitutes, –; therapeutic workplace approach, – empowerment, , , , ,  entitlements (from governments), food stamps, ; for homeless women, – , –; Medicaid, , , , , ; welfare, –, ,  enzymatic processing of alcohol,  epidemiology of women’s AOD problems, age, race / ethnicity and family income factors, –; prevalence, ; primary drug used at treatment admission, – ethnicity. See race / ethnicity; evidence-based practice, viii; externalizing behaviors, –,  FA. See functional analysis (FA) falls (accidents, etc.), ,  families / familial factor. See also heredity / genetics; for adolescents, –, ; dually addicted couples, –; for homeless women, –, ; for lesbians and other non-heterosexual women, –; multidimensional family therapy (MDFT), ; multifamily therapy groups (MFTG), –; multisystemic therapy (MST), –;

Index for older women, , ; unclear operation,  family history, dysfunctional, for adolescent girls, –, –; childhood sexual / physical abuse, –; counseling in CRA, –; mothers of crack cocaine babies, ; as risk factor, –; substance-abusing parents, , – FAS (fetal alcohol syndrome) and FASD (fetal alcohol spectrum disorder), association with low SES background, , , –; criteria and characteristics, ; estimated rate, ; need for early identification of AOD use during pregnancy, –; unknown alcohol threshold, ; unpredictability,  fathers. See family history, dysfunctional fetal alcohol spectrum disorder. See FAS (fetal alcohol syndrome) and FASD (fetal alcohol spectrum disorder) fetal alcohol syndrome. See FAS (fetal alcohol syndrome) and FASD (fetal alcohol spectrum disorder) “five clocks” issue,  food stamps, ,  foster care, ,  “four clocks” issue,  Freud, Sigmund,  functional analysis (FA), ,  funding issues, donations from local stores, ; for pregnancy-specific treatment,  gambling,  GAP (Gerontology Alcohol Project), – gastric ADH (alcohol dehydrogenase),  gay men, identity issues compared to lesbians, – gays. See lesbians and other nonheterosexual women gender role expectations, boy-girl gender bias, –, ; expression in adolescence, –; in historical background of women’s AOD problems, –; independence versus dependence, ; men’s freedom to experiment, ; treatment implications of AOD-abusing family

Index history, ; unequal sexual relationships and condom use,  gender-based studies. See also relapse interviews study; adolescent girls’ behavioral problems, ; AOD abuse, t, t; cigarette use, t; co-occurring psychiatric disorders, , –; depression prevalence gap, –; eating disorders (ED), –; emphasis on, –; heredity as factor, –; homeless persons’ AOD abuse / dependence, –; identification of women-specific risk factors, –; Internet addiction, , ; lacking for homeless people with ACEs, ; lacking for homeless women, ; need for coping skills, , ; reactions to stress, ; self-medication for emotional pain, , ; sensation- or pleasure-seeking factor, –; unpleasant affect and interpersonal conflicts, – gender-specific treatment, for adolescent girls, –; for body image / appearance dissatisfaction, ; need for, , ; for negative emotions and stress, –; single- versus mixed-sex treatment programs, – genetics. See heredity / genetics, role in AOD abuse geriatric women. See older women GOAL (Guiding Older Adult Lifestyles), – gonorrhea,  government entitlements. See entitlements (from governments) Great Depression,  grief / loss, –, – guilt. See stigmatization, shame and guilt hard liquor,  harm-reduction component of treatment, –, , , –,  Harrison Anti-Narcotic Act,  health issues, health care system’s failures to diagnose AOD abuse, ; heart benefits of drinking for older women, –; problems of lesbians and other nonheterosexual women, –, ;

405 problems of older, illicit drug users, –; targeting in counseling of older women, – heart problems, –, – herbal supplements,  heredity / genetics, role in AOD abuse, ADHD, –; gender-based studies, –; as one of many theories, ; treatment implications,  heroin use, , , , , , , , ,  hidden drinking, –, ,  high school diploma, . See also education levels and educational intervention Hispanics and Latinos, adolescent suicide, ; AOD dependence / abuse rates, t, t, –, , , ; AOD use during pregnancy, , ; bilingual practitioners, ; cigarette use, t, ; cultural awareness, ; family involvement in treatment, ; heterogeneity among, ; HIV / AIDS estimated rate, –; homelessness rate, –, ; prenatal tobacco use, ; treatment completion rates, ; unsafe injection drug use,  historical background of women’s AOD problems, – HIV / AIDS risk, for adolescent girls, ; gender disparity and injection drug use, –; for homeless women, , –, ; for lesbians and other non-heterosexual women, –, ; for pregnant women, ; for street prostitutes, , –, – homeless women. See also street prostitutes; need for more study, ; overview, –, –; vulnerabilities, x, xi homeless women, characteristics, AOD abuse and dependence, –; AOD abuse prevalence, –; co-occurring problems, ; education levels, – ; employment history, ; ethnicity, –; HIV risk behavior, , –, ; low support from family, social networks, and government, – ; physical / sexual assault and trauma

406 homeless women (continued ) –, –, –; pregnancy, , –; psychiatric disorders and adverse childhood experiences, –; psychiatric disorders and duration of homelessness, ; single compared to homeless mothers, –, –; suicide, –; trading unsafe sex for drugs,  homeless women, intervention and treatment guidelines, access maximization, –; case management, –; children’s needs, –; cognitive-behavioral therapy (CBT), ; contingency management (CM), –; culturally sensitive practice, ; geographic considerations, ; holistic, gender-specific, nonconfrontational approach, ; housing access, , –; motivational interviewing (MI) / motivational enhancement therapy (MET), ; program intensity considerations, –; relapse prevention, –; resource enhancement, –; retention and continuity enhancement, –; sensitivity to differing needs, –; triaging new admissions, –; “waiting list” issue,  homophobia and internalized heterosexism, –, , , –,  homosexuality. See lesbians and other nonheterosexual women hormones and depression, – hospitalizations, of homeless women, –; for mental health problems as predictor of homelessness, ; of older people, ,  housewives, –,  housing access, , –, – housing subsidies,  husbands. See families / familial factor; male partners iatrogenic effects, , – identification and screening issues. See also screening tools; adolescent girls, , –, ; homeless women,

Index –, , , ; lesbians and other non-heterosexual women, –; need for gender-based studies, –; older women, –, – ; pregnant women, –; street prostitutes, – identification cards,  identity formation and “coming out” for homosexuals, Cass model, –; midlife reorientations, –; relationships and intimacy, importance of, –; stage-sequence model versus linear model, – IDU (injection drug user). See injection drug user (IDU) IHR (Institute for Health and Recovery) Behavioral Health Risk screening tool, – illicit drugs. See drugs, illicit impaired activities of daily living (ADL), – income and socioeconomic status (SES), of family as factor in AOD dependence / abuse, t, , ; and FAS or FASD incidence, –; low level of resources, , –; older women, ; pregnant women, –, –; street prostitutes, –,  infants, drug-exposed, interventions for, – injection drug user (IDU), –; adolescent girls, ; homeless women, , ; lesbians and other non-heterosexual women, , ; needle sharing, –; older women, ; possible gender disparities, –; street prostitutes, , –; unsafe sex, – interaction effects of alcohol and prescription drugs,  internalized heterosexism and homophobia, –, , , –,  internalizing behaviors, –,  Internet addiction, ,  interpersonal conflicts and unpleasant affect, –, – jobs. See employment status John Barleycorn ( Jack London), 

Index knowledge inadequacies. See education levels and educational intervention Lambda Legal Defense and Education Fund,  “late-onset” drinking, –,  legal services, – legal system. See criminal justice system lesbians and other non-heterosexual women, AOD (alcohol and other drugs) abuse rate, –; Cass model stages of coming out, –; heterogeneity among, ; overview, –, – ; stage-sequence versus nonlinear models, –; vulnerabilities, x–xi lesbians and other non-heterosexual women, characteristics and needs, AOD abuse and dependence risk factors, –; health needs, –; identity formation and “coming out,” –; mental health issues, – lesbians and other non-heterosexual women, treatment guidelines and strategies, affirmation / acceptance factor and specialized programs, –, –; coming-out struggle, –; community resources, –; harm reduction, ; mixed groups, ; relationships with family and partner, –; self-help groups, –; sexual identity and substance abuse, –; spiritual needs, –; suicide risk screening, – life crises as psychosocial risk factors,  life expectancy of illicit drug users,  liver diseases,  London, Jack,  loneliness, – loss / grief, –, – Lydia Pinkham’s Vegetable Compound,  male partners, as a woman’s “whole world,” , ; connection to children’s father, ; dependence, abandonment, and self- identity, , –; dually addicted couples, –; empowering girls for safe relationship with boy, –; interpersonal conflicts,

407 –; psychosocial risk factors and treatment implications, –; risk factors for pregnant women, –, –; of street prostitutes, –; substance-abusing, – males. See families / familial factor; gender role expectations mammograms, – marijuana use, , , , , , , ,  marital relationships. See families / familial factor; male partners marital status, for pregnant women, – MAST-G screening tool,  maturation rates of adolescents,  maturing-out theory, ,  MDFT (multidimensional family therapy),  mediators, practitioners as, –. See also practitioners Medicaid, , , , ,  medication component of CRA, – medications. See prescription drugs meditation / relaxation therapies, ,  menopausal depression,  mental disorders. See psychiatric disorders MET. See motivational interviewing (MI) / motivational enhancement therapy (MET) metabolic rate and AOD clearance rates, ,  methadone, , ,  methadone maintenance treatment (MMT), – methamphetamine use, , –, , , ,  Mexican Americans. See Hispanics and Latinos MFTG (multifamily therapy groups), – MI / MET. See motivational interviewing (MI) / motivational enhancement therapy (MET) MMT (methadone maintenance treatment), – mobility issues for older women,  Modified CAGE for Pregnant Women (screening tool), –

408 “moral” issues. See also stigmatization, shame and guilt, AOD abuse as immoral choice, , , ; drunken women, , ; homosexuality, ; prostitution, , – morphine / opium addiction, , ,  mortality rates and alcoholism, –,  mothers. See families / familial factor; homeless women; pregnant women “Mother’s Little Helper” (popular song),  motivational interviewing (MI)/motivational enhancement therapy (MET), for adolescent girls, –; for homeless women, ; for older women, – ; overview, –; for pregnant women, – MST (multisystemic therapy), – multidimensional family therapy (MDFT),  multifamily therapy groups (MFTG), – multiple problem occurrence. See cooccurring disorders (COD) multisystemic therapy (MST), – multivariate theory of AOD abuse,  naltrexone,  NAS (neonatal abstinence syndrome),  National Center on Addiction and Substance Abuse at Columbia University (CASA), –, , , , , –,  National Institute on Drug Abuse (NIDA), , , , –, , ,  National Survey on Drug Use and Health (NSDUH), , , , – Native Alaskans. See Alaska Natives Native Americans. See American Indians / Native Americans Native Hawaiians or other Pacific Islanders, AOD dependence / abuse rates, t, t; AOD use during pregnancy, ; cigarette use, t; HIV / AIDS estimated rate, –; homelessness rate, –; unsafe injection drug use,  needle sharing by injection drug users, –, , , , – negative emotion,  neonatal abstinence syndrome (NAS), 

Index networks, social. See social networks nicotine. See cigarette use non-heterosexual women. See lesbians and other non-heterosexual women NSDUH. See National Survey on Drug Use and Health nutrition for pregnant women,  OAS. See Office of Applied Studies ODD (oppositional defiant disorder),  Office of Applied Studies (OAS), xi, , , , , ,  older women, AOD abuse rates, ; consequences of substance abuse, –; lack of attention to problems of, – , ; overview, –, –; problem with definitions, ; reasons for targeting in this book, ; vulnerabilities, x, xi older women, theories and characteristics of AOD problems, alcohol misuse and consequences, –; alcohol’s beneficial health effects, –; identification issues, –; illicit drug abuse, –; lack of studies, ; “lateonset” drinking, –; prescription medications misuse, –; relapse risk factors,  older women, treatment guidelines and strategies, aftercare, –; agespecific group counseling, –; AOD screening and identification, –, –, , ; brief intervention (BI) and motivational interviewing (MI), –; cognitive-behavioral therapy (CBT), –; integrated approach with multiple services, –; need for elder-specific programs, ; practitioner guidelines, – one-stop shopping model of treatment, –,  opiates / opium / morphine, , , , , , , ,  oppositional defiant disorder (ODD),  OTC (Over-the-counter) drugs, Lydia Pinkham’s Vegetable Compound, ; overuse by older women, xi, , ,  outcomes, need to assess, viii

Index outpatient treatment versus residential, – outreach efforts, ,  ovarian cancer,  Pacific Islanders. See Native Hawaiians or other Pacific Islanders Pap smears, – parent-child relationships, –. See also family history, dysfunctional parents. See families / familial factor; family history, dysfunctional patients’ bill of rights,  PCP (phencyclidine),  peer counseling, –, –,  peer influence with adolescents, – Personal Experience Screening Questionnaire (PESQ),  PESQ (Personal Experience Screening Questionnaire),  pharmaceutical industry,  pharmacotherapy. See prescription drugs physicians, , , , –, . See also practitioners poison centers, calls to,  POSIT (Problem Oriented Screening Instrument for Teenagers),  postpartum depression, , ,  posttraumatic stress disorder (PTSD), , , , , –, , ,  power / control factor,  practitioners, advocacy for pregnancyspecific treatment, –; attitude toward same-sex clients, , –, ; bilingual, ; as case managers in CRA, –; compatibility of values with treatment methods, ; confidentiality, –; culturally sensitive practice, –; inclusive language, ; interagency turf issues, ; as mediators, –; one-stop shopping model of treatment, –, ; patience, persistence, ; peers as counselors, ; self-awareness, ; sensitivity to differing needs of homeless, –; sexism and sex role stereotyping in obstetrics community, –; supportiveness, optimism, –, –, ; as surrogate social networks, ; working

409 with adolescents, , ; working with older women, –; working with street prostitutes, , ,  pregnant women, homeless, , –; overview, –, ; vulnerabilities, x,  pregnant women, theories and characteristics of AOD problems, childhood maltreatment, –; disadvantaged background, –; domestic violence, –; education, –; employment status, –; FAS incidence and low SES background, –; income, –; intimate partner, –; knowledge inadequacies, –; psychiatric disorders, –; racial background, –; severity of AOD dependency, ; tobacco use,  pregnant women, treatment principles and strategies, advocacy for effective policies and laws, –; AOD screening tools, , –; brief interventions (BI), –; challenges, –; cognitive-behavioral therapy (CBT), ; connecting with community resources, –; contingency management (CM), –; contraception, ; education on biological / medical impact of AOD, –; enhancing inner strengths and other resources, –; maternal detoxification, –; motivational interviewing (MI) / motivational enhancement therapy (MET), –; screening and brief intervention, –, –; STDs,  prejudice. See discrimination; stigmatization, shame and guilt prescription drugs, alcohol interactions with, in older people, ; Antabuse (disulfiram), –; benzodiazepines, , , , , ; buprenorphine, ; depressants, –; medication component of CRA, –; methadone, , , ; methadone maintenance treatment (MMT), –; morphine, , ; multiple medications, ; naltrexone, ; overuse by older women, xi, –; psychotropic, , ; sedatives and barbiturates, , , , ;

410 prescription drugs (continued ) tranquilizers, , , , , –; unintentional misuse, ; Valium, , ,  PRIDE Institute,  privacy issues,  Problem Oriented Screening Instrument for Teenagers (POSIT),  problem-solving skills, ,  Prohibition,  prostitutes, street-walking. See street prostitutes psychiatric disorders, delayed diagnosis, –; of gay men and lesbians, –; of homeless women, –, –; of older women, ; of pregnant women, –, – psychological and psychosocial risk factors, body image / appearance dissatisfaction, –; childhood sexual / physical abuse, –; comorbidity, dual diagnosis, and co-occurrence, –; dysfunctional family history, –; life crises and transition, ; for older women using prescription drugs, –; overview and overlap, –; socioeconomic deficiency of mothers of drug-exposed children, ; street prostitutes, ; substance-abusing male partner, –; treatment implications, –; unpleasant affect and interpersonal conflicts, – psychological theory of AOD abuse,  psychosocial sanctions of AOD abuse, –. See also stigmatization, shame and guilt psychotic disorders,  psychotropic drugs,  PTSD. See posttraumatic stress disorder. puberty. See adolescent girls public assistance (government entitlements). See entitlements (from governments) quality of life, perceptions of,  race / ethnicity, acculturation and acculturative stress, –; of adolescent girls, –, –, , –; bias

Index contaminating studies, ; culturally sensitive practice, –, ; heterogeneity within groups, ; of homeless women, –; of pregnant women, –; and racial identity, –; structural dimensions, surface and deep, –; studies of, t, t, t, – race/ethnicity as factor in AOD dependence/ abuse. See also African Americans; Alaska Natives; American Indians / Native Americans; Asians; Hispanics and Latinos; Native Hawaiians or other Pacific Islanders; whites RAFFT screening tool,  Rape, of drunken women, –; of homeless women, –, , ; of lesbians, ; of street prostitutes,  RAPI (Rutgers Alcohol Problem Index),  recreational activities, – recreational drinking,  refusal skills,  reinforcement. See rewards, reinforcement, “bribes,” and consistency, and followup relapse / relapse prevention, , , , , , , , –, . See also relapses after treatment, relapse interviews study. relapse interviews study, factors contributing to relapse, delayed diagnosis of mental disorder, –; difficulty of cutting ties with blood-related network, –; difficulty of cutting ties with old, using friends, –; difficulty of establishing non-using social network, –; difficulty of making new non-using friends in workplace, ; difficulty of moving to non-using social network, –; false belief that “one hit won’t hurt,” ; false faith in AOD use as solution, ; feelings of loss and / or other negative feelings, –; inability to move out of drug-infested community, –; interaction of factors, ; interpersonal conflicts and / or negative emotions, –; interpersonal conflicts with authorities, ; interpersonal conflicts with intimate male partner, –;

Index issues with post-treatment self-help groups, , –; low level of resources, ; men: dependence, abandonment, and self- identity, , –; overview, –, f ; poor environment resulting from lack of resources, –; suggestions for future programs and research, –, – relapses after treatment, assessing, , ; factors contributing to, ; gender disparity, , , , ; life crises and transition, ; life stressors for older people, , ; need for more study, ; negative emotions, , , ; prevention plans, –, –; relationships with authority figures, ; relationships with men, ; residential programs, ; smoking, , –; stages of change, , ; unaddressed psychiatric disorder, ; weight gain,  religion and spirituality,  reproductive system, dysfunction and fetal alcohol syndrome, –; hormones and depression prevalence gap, –; lesbians and bisexual women, –, ; residential treatment versus outpatient, –, , –; “resource” factor as women’s dependence on / independence from men,  respiratory system, effects on,  “revolving door” syndrome,  rewards, reinforcement, “bribes,” consistency, and followup, , – risk factors, and relationship to negative consequences, –. See also specific vulnerable population runaways,  Rutgers Alcohol Problem Index (RAPI),  “saloon” culture and manliness,  SAMHSA. See Substance Abuse and Mental Health Services Administration SAPW (substance-abusing pregnant women). See pregnant women schizophrenia,  schools, referrals from, 

411 screening. See identification and screening issues for problem populations screening tools, ADI (Adolescent Drinking Index), ; ADIS (Adolescent Drug Involvement Scale), ; Adolescent Drinking Index (ADI), ; Adolescent Drug Involvement Scale (ADIS), ; Adolescent Health Review, –; ARPS (alcohol-related problems survey), ; AUDIT (alcohol use disorders identification test) screening tool, , –; CAGE, , , ; CARPS (computerized alcohol-related problems survey), ; child welfare and maltreatment referrals, –; CRAFFT, , –; DAP (drug and alcohol problem) Quick Screen, ; Drinking Problems Index, ; DUSI-R (drug use screening inventory-revised), ; IHR (Institute for Health and Recovery) Behavioral Health Risk, –; MAST-G (Michigan alcoholism screening test—geriatric version), ; Modified CAGE for Pregnant Women, –; PESQ (personal experience screening questionnaire), ; POSIT (problem oriented screening instrument for teenagers), ; RAFFT, ; RAPI (Rutgers alcohol problem index), ; S-MAST-G (short Michigan alcoholism screening test—geriatric version), ; T-ACE (tolerance, annoyance, cutting down, eye-opener), , –; TWEAK, , , – “seasoned homelessness,”  secondary diagnoses, . See also cooccurring disorders (COD) sedatives and barbiturates, , , ,  self-efficacy, , , ,  self-esteem, , –, ,  self-help groups, –, . See AA, TSF, -step facilitation self-medication, for alleviation of negative emotions, ; cocaine or heroin use, ; co-occurring disorders (COD), ; morphine and opium addiction, , ;

412 self-medication (continued ) sensation- or pleasure-seeking factor, –; Valium,  senior centers,  sensation- or pleasure-seeking factor in AOD abuse, – SES (socioeconomic status). See income and socioeconomic status (SES) sex, trading for money or drugs, , ,  sex, unsafe, –, , –, –, , , – sex workers. See street prostitutes sexism and sex role stereotyping,  sexual arousal,  sexual partners. See male partners; lesbians and other non-heterosexual women sexual / physical abuse in childhood. See childhood sexual abuse (CSA) / childhood physical abuse / adverse childhood experience (ACE) shame. See stigmatization, shame and guilt shelters for homeless, , , , , ,  “simple advice” intervention (BI), – single- versus mixed-sex treatment programs, – skills training,  sleep disorder medications, – S-MAST-G (Short Michigan Alcoholism Screening Test—Geriatric Version),  smoking. See cigarette use sobriety sampling approach,  social networks. See also community reinforcement approach (CRA), socialization disempowering girls, ; socialization for domestication and interdependence, , ; difficulty of cutting ties with blood-related network, –; difficulty of cutting ties with old, using friends, –; difficulty of establishing non-using, –; difficulty of making new non-using friends in workplace, ; difficulty of moving to non-using circle, –; feminine characteristics prizing loyalty, friendship, love and caring, ; for homeless women, ; importance,

Index –, , ; inability to move out of drug-infested community, –; influencing older women toward illicit drug use, ; non-drinking, ; for older women, ; relationships as, ; severing ties with substance-abusing culture, – social pressure,  societal sanctions, –. See also stigmatization, shame and guilt socioeconomic status (SES). See income and socioeconomic status (SES) sociological theory of AOD abuse,  spirituality and spiritual needs, , – sponsor, , , . See also AA / NA, selfhelp groups stages of change, . See also motivational interviewing (MI) / motivational enhancement therapy (MET), brief intervention stage-sequence model of homosexual identity formation, – STDs (sexually transmitted diseases), , , –,  stereotypes. See gender role expectations sterilization,  stigmatization, shame and guilt, adolescent girls, ; child abuse / neglect charges, ; childhood sexual abuse, ; heredity as factor in addictive behavior, ; homophobia and internalized heterosexism, –; importance of practitioner role, –, , ; lesbians and gay men, , –, , –, ; need for progress, ; older women, , , , ; of older women, double marginalization of, ; pregnant women and mothers, , –; prostitutes, , , –; societal sanctions, –; victimization risk, –; victims of double standard, , , –, , – stimulants, , , , ,  street prostitutes, overview, –, ; vulnerabilities, x, xi,  street prostitutes, characteristics and needs, AOD abuse problems, –; criminal justice system involvement,

Index –; exposure to violence and risk, –, –; homelessness, ; psychological distress, –; sex worker hierarchy, ; socioeconomic status (SES), –; supporting drug habit, , , , ; trading unsafe sex for drugs,  street prostitutes, treatment guidelines and strategies, case management, –; couple therapy, –; criminal justice system, collaboration with treatment programs, –; harm-reduction component, –; priority of substance-abuse treatment, ; resources needed, , ; sexworker-specific groups, ; street-based outreach, – stress reactions, , ,  substance abuse. See also AOD (alcohol and other drugs) abuse, definition,  Substance Abuse and Mental Health Services Administration (SAMHSA), xi, –, , , , , , .  See also CSAT, NSDUH, OAS, TEDS, TIP substance use disorder (SUD),  SUD. See substance use disorder suicide, adolescent girls’ risk of, –, –; dysfunctional family history as risk factor, ; homeless women’s risk of, –; lesbians’ risk of, –, –; older women’s risk of, ; screening for risk of, ; street prostitutes’ risk of,  surface structure dimension of race / ethnicity,  syphilis, ,  T-ACE (tolerance, annoyance, cutting down, eye-opener)screening tool, , – TANF. See Temporary Assistance for Needy Families TEDS. See Treatment Episode Data Set teenage girls. See adolescent girls telescoping effect, –,  temazepam,  Temporary Assistance for Needy Families (TANF), , , , 

413 therapeutic workplace (TW) approach, – thrill-seeking, – TIP. See Treatment Improvement Protocol tranquilizers, , , , , – transgender women. See lesbians and other non-heterosexual women transitional life crises,  transportation / access services, , , ,  trauma. See posttraumatic stress disorder (PTSD) trauma history,  Treatment Episode Data Set (TEDS), – , , , , , , , – treatment implications, biological risk factors, ; family history of AODabuse, ; heredity as factor in addictive behavior, ; male partners, substance-abusing, –; psychological risk factors, –; psychosocial risk factors, – Treatment Improvement Protocol (TIP), , , , – treatment methods, behavioral couples therapy (BCT), –; brief interventions (BI), –; cognitive-behavioral therapy (CBT), –; community reinforcement approach (CRA), –; contingency management (CM), –; motivational interviewing (MI) / motivational enhancement therapy (MET), –; overview, –; -step facilitation (TSF) intervention, – treatment programs. See also relapse interviews study; relapses after treatment; specific vulnerable populations, case management and one-stop shopping model, –, ; child care availability, –; gender of staff, ; intensity of treatment, –, ; overview, ; recommendations for program development, ; single- versus mixed-sex, –; staff supportiveness and individual counseling, –, –; weakness of available studies, need for additional work, –, , –, , – truancy, 

414 TSF (twelve-step facilitation), – turf issues between agencies,  TWEAK (tolerance, worry, eye-opener, amnesia, k(c)ut down) screening tool, , , – Twelve Step Facilitation Therapy Manual,  -step facilitation (TSF), – twins, studies of, ,  unemployment. See employment status “unequal footing” theory,  unsafe sex, –, , –, –, , , – urine testing, , ,  urine toxicology tests,  Valium, ,  veins, collapsed,  victimization risk, of AOD-abusing women, –; ; homeless women, –, –, –; street prostitutes, –, – Victorian era morality,  violence. See also domestic violence (DV), AOD-abusing women at risk of, –; homeless women as victims of, –, –, –; street prostitutes as victims of, –, – vitamins/minerals,  vocational counseling / training, , . See also counseling, group and / or individual; employment status vouchers and / or cash, –, , –, , – vulnerable populations. See adolescent girls; homeless women; lesbians and other non-heterosexual women; older women; pregnant women; street prostitutes

Index “waiting list” issue, community reinforcement approach, ; for homeless women,  websites, CBT manuals, ; CM manual,  weight and body image. See body image / appearance dissatisfaction welfare payments. See entitlements (from governments) whites, AOD dependence / abuse rates, t, t, , , ; AOD use during pregnancy, , ; cigarette use, t, ; FAS or FASD incidence, , ; HIV / AIDS estimated rate, –; homelessness rate, ; meth admissions, ; pregnant women, ; prenatal alcohol use, ; prenatal tobacco use, , ; treatment completion rates, ; unsafe injection drug use,  WHO. See World Health Organization withdrawal symptoms, , – women. See also gender role expectations; gender-based studies; gender-specific treatment; specific vulnerable populations, improvement in research and practice needed, –; increase in rates of drinking, ; reasons for targeting in this book, viii, x–xi Women for Sobriety,  women’s movement,  word-of-mouth advertising,  World Health Organization (WHO), ,  World War I,  World War II,  WSW (women having sex with women). See lesbians and other non-heterosexual women