In Treatment

Published in the Spring 2009 issue of SSA Magazine

Researchers are learning more and more about how to help women who need substance abuse treatment, but the reality is, the best options aren't always available.

-Carl Vogel

Women and men are not exactly the same.

For more than two decades, the profound implications of that simple truth have begun to permeate how substance abuse treatment programs approach their work. Gender differences are expressed in many different ways. However, there are no easy answers when it comes to addiction, and researchers and policymakers are still exploring the complicated mix of what works best for women who want to end a dependence on drugs or alcohol.

"Typically, women go into substance abuse programs with more problems—often with more family issues, the demands of being a single mother, a history of domestic violence. Sometimes, these problems make it more difficult to get into a program at all. Then, once women are in a program, how it is structured and what it offers can impact how well it serves female clients," says Jeanne Marsh, the dean of SSA and the School's George Herbert Jones Distinguished Service Professor.

Marsh has been interested in the issue of women and substance abuse for nearly 25 years, since she herself was in graduate school, when she studied one of the first treatment programs in the country just for women. A major part of its approach was to provide participants with health care, legal services, childcare, and other supports to help clients return to a life that had more opportunities— and therefore help the women stay away from alcohol and drugs.

The idea of comprehensive or "wrap-round" services has become increasingly accepted as a key component of substance abuse treatment for any population. For the past several years, Marsh has led a team of researchers to explore the impact of comprehensive services on the effectiveness of treatment, breaking down the impact by gender and by racial/ethnic groups.

"Jeanne's research finds, and this is replicated by other research, that targeted services do keep women in treatment and when they stay in treatment, it increases their chances of success," says Dionne Jones, the deputy chief of the Services Research Branch of the National Institute on Drug Abuse's Division of Epidemiology, Services and Prevention Research, which is the major funder of Marsh's studies.

"Researchers are examining the issue of women and substance abuse from a number of perspectives, and the research findings are having an impact on the field," Jones says. "Over the past 20 years or so, researchers have become very interested in gender-sensitive treatment and services. Today, we're exploring the details of what that means. The next step for this program of research is to transform the research to everyday practice."

Different approaches to treatment for women work in part because women tend to arrive at a treatment facility with a different set of life circumstances then men. Studies have shown that they have more health and psychological issues, family and employment problems, and are more likely to report past and current physical and sexual abuse.

In an article in the Journal of Family Violence from last April, SSA Assistant Professor Malitta Engstrom and co-authors drew upon interviews with more than 400 women in methadone treatment. They found that 58 percent had experienced childhood sexual abuse, 90 percent had experienced intimate partner violence (78 percent within the past six months), and 29 percent met diagnostic criteria for post-traumatic stress disorder.

"There is a complicated relationship between trauma and substance abuse, including heightened risks for continued substance use during treatment and quicker return to substance use following treatment among women with co-occurring posttraumatic stress disorder. When so many women in treatment have a history of intimate partner violence or childhood sexual abuse, it means that services should be trauma-informed and should include integrated treatment to address both substance use and trauma related concerns," Engstrom says.

Joan Blakey, a doctoral candidate at SSA who is studying the intersection of the child welfare system and substance abuse treatment, says that she was surprised at how many of the women she interviewed at a women-only treatment center in Chicago reported various forms of abuse. "The rates of sexual abuse and rape were really high, as well as domestic violence. Many of the women also had a history of prostitution. It was very troubling to me, and I'm still mulling over the impact that this abuse has on their treatment," Blakey says.

Women in treatment are also more likely to have childcare needs and employment troubles, including a lack of financial independence. "I think that it's very important for the programs to recognize the role of parenting in the lives of many women in treatment. Often a mother can't go into treatment simply because she doesn't know who'll watch her children," says Sydney Hans, a professor at SSA whose own research has included studies of ways to mitigate the demands of motherhood on substance abuse treatment.

Gender differences are often not a case of whether men or women do better or worse in treatment. Both women and men benefit from substance abuse treatment overall. But more men enter substance abuse treatment through the criminal justice system, for example, and more women through the child welfare system. Researchers are studying how the factors that lead to a successful treatment outcome— including the characteristics of the organization's therapeutic approach and specific services that are available—may differ for women and men.

A decade ago, there was a debate in drug-treatment policy circles: Did services connected to treatment dilute the impact f treatment, or were they a useful scaffold to allow he client to build a more successful life? By early in his decade, findings were accumulating that comprehensive supports re essential in substance abuse treatment, particularly when they are "tailored" to he client's specific needs.

In 2004, the U.S. Department of Health and Human Services' Substance Abuse and Mental Health Services Administration (SAMH SA) launched one of the biggest boosts for comprehensive services in the form of the Access to Recovery (ATR) program, which has provided approximately $300 million to states for vouchers for clinical substance abuse treatment and recovery support services. The program has provided treatment and support to an estimated 160,000 individuals and is now in its second round of funding.

"Through Access to Recovery, for the first time the federal government has been paying for these recovery support services," says Charles Curie, a graduate of the School, former head of SAMHSA, and now the principal of the Curie Group, a substance abuse and health policy consulting firm. "The vouchers give individuals an opportunity for choice and it captures the uniqueness and individuality of recovery."

In Illinois, Access to Recovery has funded vocational, educational, and other services through more than 40 community-based organizations. "We have been able to provide $12 million annually to help people who have received treatment keep engaged with services that may not necessarily be available at the treatment program. We've done a lot of evaluation, and there are good indications that people do well in recovery with these services," says Maria Bruni, the department's research director and an alumae of the School.

What has not been as clear was who benefited the most from these services and how. "We know that comprehensive services are useful, but we don't have a thorough understanding of the complexity of how they work. It's a bit of a black box in the theory—go through and it helps, but we're still figuring out the details. Knowing that will allow us to create treatment programs that do a better job of providing help to women, men, people with HIV / AID S, the homeless, members of different racial/ ethnic groups—you name it," Marsh says.

In 2004, Marsh and co-authors provided the first glimpse into gender differences in comprehensive services for substance abuse treatment in a paper in the Journal of Substance Abuse Treatment. Their analysis of data about more than 3,000 clients from 59 treatment facilities from the National Treatment Improvement Evaluation Study (NTIE S) showed that both women and men benefit from comprehensive services.

But it also showed some notable differences. More women received comprehensive services and, when used them, had greater reductions in their post-treatment substance use than men. At the same time, women and men differed in how they reacted to the organization's characteristics: The availability of on-site services and more frequent counseling sessions resulted in reduced post-treatment drug use for men but not for women.

Marsh has continued to use the NTIE S to dig deeper into what makes comprehensive services work. Her most recent research looks into the next logical question: If tailored services are a benefit to participants, then how often are clients able to access them?

"There was a natural progression from what clients said they needed in health and social services to whether these services were available. We found a real service gap," Marsh says. In fact, in a paper that has been accepted in Social Work Research, Marsh's research team shows a substantial number of clients of both genders who are not able to access health and social services they need during treatment, including fewer than a third who receive vocational, housing, and financial services (see "Mind the Gap").

Marsh's research into the service gap illustrates how substance abuse treatment for women can get derailed by fiscal and programmatic realities. A 2008 study of gender differences within racial/ethnic subgroups that she co-authored revealed another gap: They found that African Americans and Latinos who are in treatment receive fewer and lower quality services than whites, and African Americans and Latinos were also less likely to receive the services they needed.

The paper, now in press for the Journal of Evaluation and Program Planning, also has a quirk in the data that may be a marker for how site level details can impact whether treatment is fully successful: Matched services were found to be effective in treatment for whites and African Americans, but not Latinos. "We found in our data that when Latinos receive matched services, they stay in treatment longer, but their post-treatment drug use does not go down," says SSA doctoral candidate Erick Guerrero, who, with doctoral students Christina Andrews and Melissa Hardesty, has worked for the last several years as a research assistant with Marsh.

The study also found that compared with whites, Latinos on average are younger, less experienced in treatment, and are generally serviced by smaller organizations, with less services and thinner schedules. In his dissertation, Guerrero is exploring how these smaller organizations can be better equipped to improve Latinos' treatment experience.

"High-resourced programs with culturally sensitive managers are more likely to have bilingual and culturally competent counselors for Latinos. By structuring organizations in ways that reflect cultural inclusion and understanding, treatment programs have the potential to make a significant impact on Latinos post-treatment drug use," Guerrero says.

Even when a program is explicitly created for women, real-world demands and details can affect its success. E. Summerson Carr, an assistant professor at the School, spent more than three years observing the operations of a substance abuse treatment center created for homeless women in a Midwestern town, starting from the program's inception. She found in her day-to-day ethnographic research that despite the best of intentions, many of the program's features did not work as planned.

Over and over again, program administrators would say, 'We're a feminist program. We're culturally appropriate.' But it was hard to see that in practice in the therapy room. People's jobs were so demanding—there were so many crises, and clients were coming in and out of the program—that maintaining a philosophical base became a real challenge," says Carr, who is using her case study of the program as the basis of a book to be published in 2010, Scripting Addiction: The Politics of Therapeutic Talk and American Sobriety.

The clients in the program Carr studied were recommended by one of several local housing programs, which meant that the women typically had many services already in place, and the program itself provided transportation to the facility and childcare during therapy sessions. These services were well-run and certainly made a difference in how well the treatment worked, notes Carr, who teaches "Drugs, Culture, and Context" in the School's master's program.

At the same time, however, many of the women were mandated to attend treatment as a condition of remaining in transitional housing. In practice, that meant that many of the clients in treatment were not self-motivated to end their substance use. Blakey has observed the same dynamic in her study of a Chicago substance abuse treatment program for women.

"For my research, I was studying women who had been told by the child welfare system that they needed to get treatment in order to keep their children or to get them back. There really is the question of motivation. Do these women really want to quit? Yes, a court order will get them into the program, but unless their point of view shifts and they say, 'I want to be here; I want to make that change,' it will not last," Blakey says. And yet, she is far from sure that mandating treatment is a recipe for failure, either, pointing out that some clients who did not enter of their own volition, genuinely wanted to stop using once they had begun to get the drugs out of their system.

When it comes to problems in how substance abuse treatment serves women, the biggest issue is not culturally insensitive programs or programs that don't supply sufficient services. It's a shortage of any kind of program at all.

In 2006, 314,000 people nationwide knew they needed substance abuse treatment, but were unable to find care, according to SAMH SA, and a whopping 21.1 million total needed treatment but did not receive it— a mix of those who did not consider themselves as having a problem and those who did not have enough information to identify the problem.

"We have significant access problems for substance abuse treatment in this country because we're doing a poor job of financing the system. Today we're below even where we were seven years ago in that funding for SAMSHA, when you take inflation into account," says Harold Pollack, an associate professor at SSA and the faculty chair at the Center for Health Administration Studies.

"We now know so much more about how to provide effective services, but due to budgets, we're declining to offer these services," Marsh says. "There is widespread concern that our substance abuse treatment system is in decline due to reductions in funding for services and research. The next wave of research is likely to focus on issues of cost effectiveness as well, so that we learn how to serve clients most effectively and efficiently."