Substance-abusing Women Research Articles

Revisioning the process: A case study in feminist program evaluation

AbstractAttention to the interpersonal and relational processes of feminist evaluation is overdue. In this chapter, we describe three aspects of a negotiated evaluation process, based on our experience as team members charged with the evaluation of a women's substance abuse prevention program.

Mental health, substance use and disclosure are significantly associated with the medical treatment adherence of HIV-infected mothers

This study examines the association between mental health, substance abuse and family factors and medical treatment adherence in 128 HIV-infected ethnic minority mothers. Data were collected by structured individual interviews for a longitudinal study on psychosocial factors influencing HIV medical treatment adherence. Medical chart data were collected on CD4 cell counts and HIV RNA viral load. Results of baseline interviews are presented herein. The majority of participants were African American (58%) and Latina (35%) single parents (70%) living below the poverty line. Nearly 50% of the women met screening criteria for a current psychiatric disorder, and 25% for a substance abuse disorder. Two-thirds of the women were currently on antiretroviral medication; 20% of them reported missing pills in the past two days. Presence of a psychiatric or substance abuse disorder and parenting stress were the strongest correlates of non-adherence to antiretroviral medication. Less HIV disclosure to children and single parent status were associated with missing medical appointments. The results support the need for integrated mental health, substance abuse and medical treatment for HIV-infected women.

Marital Violence Victimization and Perpetration Among Women Substance Abusers

This study reports descriptive data assessing the impact of an intensive outpatient treatment for alcohol dependence on alcohol use, marital violence, psychological abuse, and marital satisfaction among 10 heterosexual female patients and their partners. Patients received 5 to 6 days of substance abuse treatment in a partial hospital program. Patient and partner assessments were conducted at baseline, 6-month follow-up, and 12-month follow-up. Results revealed decreased alcohol use in female patients as well as declines in the prevalence and frequency of husband-to-wife marital violence over time. Men evidenced no changes in their psychological abuse or marital satisfaction. Results also showed decreases in the prevalence and frequency of wife-to-husband violence and psychological abuse. Female patients reported no changes in their marital satisfaction. Overall, the study suggests that marital violence victimization and perpetration by female patients and their male partners declined following the females' substance abuse treatment. The clinical implications of the findings are discussed

The Personality Assessment Inventory Drug Problems Scale: A Validity Analysis

An analysis of the relationship among the Personality Assessment Inventory (PAI; Morey, 1991, 1996) Drug Problems (DRG) scale scores, the Addiction Severity Index (ASI; McLellan et al., 1992) scores, and urine toxicology reports revealed that the PAI Drug Problem scale scores of 100 substance-using and substance-abusing men and women were distributed in a manner that was in agreement with the guidelines suggested by Morey (1991, 1996) in the PAI manual. There were significant correlations among the PAI DRG scale and the ASI scales related to frequency of use, negative consequences of use, and need and desire for treatment. Overall, higher scores did reflect both more serious involvements with drug use and more serious problems as a consequence of their involvement.

Comorbidity among Oxford House residents: A preliminary outcome study

This study used a structured diagnostic interview to investigate the prevalence of psychiatric comorbidity among 29 men and 23 women substance abusers residing in 1 of 11 Oxford House communities located within a Midwestern metropolitan area. The Diagnostic Interview Schedule (DIS) was used to measure current and lifetime DSM-III-R diagnosis in addition to sociodemographic and substance abuse information. Considerable psychiatric comorbidity was present. Antisocial personality (ASP) disorder, affective disorders, and anxiety disorders were the most frequently observed comorbid disorders among these substance abusers, whose drugs of choice were cocaine, alcohol, and cannabis. Chi-square and t tests revealed diverse psychiatric diagnoses and variability of client characteristics, demonstrating heterogeneity within this sample of substance abusers. Gender differences were identified on several client characteristics as well. Peer social support was the most common reason why participants entered an Oxford House. Outcome measures at 6 months found that 42% of participants was still residing in an Oxford House while 27% left on good terms, demonstrating a 69% overall success rate among participants in this study. Implications of this study suggest that substance abusers with psychiatric comorbidity are heterogeneous groups that benefit from living in an Oxford House.

A women's health track for internal medicine residents using evidence-based medicine.

Evidenced-based medicine has established itself as an integral part of medical education and practice. The explosion of new knowledge in women's health and the need to teach this to internal medicine residents in an evidence-based fashion have presented a challenge to medical educators. To address this need, we developed and implemented an evidence-based women's health curriculum to be used in addition to clinical training in a women's health center for internal medicine residents. The objectives of the curriculum are to (1) define and utilize basic evidence-based medicine concepts to critically analyze women's health literature, (2) understand recent innovations in women's health from an evidence-based viewpoint, (3) gain clinical experience in women's health, and (4) apply evidence-based medicine to the clinical practice of women's health. We designed our curriculum based on recommendations from the National Academy of Women's Health Medical Education, the American Board of Internal Medicine, the Fifth Report of the Council on Graduate Medical Education, and the results of needs assessments of internal medicine residents at our institution. Using Medline to create a women's health bibliography, an extensive literature search was performed on the following topics: osteoporosis, breast cancer, hormone replacement therapy, domestic violence, coronary artery disease in women, menopause, headaches, substance abuse in women, urinary incontinence, dementia, sexual dysfunction, and evidence-based medicine. Peer-reviewed journal articles were compiled by subject matter for placement in our clinic's resource center and were entered into a computerized database that will link with online journals and be available for electronic access. Most articles were selected based on the criteria of data published since 1990, and randomized, double-blinded, placebo-controlled studies were given preference. Weekly 45-minute sessions preceding the resident clinic in the women's health center are held in a journal-club format to review literature in a systematic fashion. Faculty and residents review and analyze one to two articles weekly. Content experts provide context and clinical expertise to resident discussions. Clinical questions, such as "Should I prescribe hormone replacement therapy to my postmenopausal patient?" are addressed in each session. Evidence-based medicine core concepts are reviewed and applied; these core concepts include the number needed to treat, absolute risk reduction, and relative risk. The women's health curriculum, weekly conferences, and clinical experience serve to update residents and clinicians in women's health literature, to exchange ideas for the improvement of women's health as it is taught in internal medicine, and to further elucidate the evidence behind what we practice and teach. The curriculum equips physicians to provide patients with solid, evidence-based interpretations of new scientific knowledge to discern truth from fallacy.

Optimizing Treatment Effects for Substance-Abusing Women With Children: An Evaluation of the Susan B. Anthony Center

Substance abuse among women is a significant national problem. Historically, the treatment of this condition has been difficult, but it has been even more challenging when the woman in treatment has had children. This article reports the results of an evaluation of the Susan B. Anthony Center (SBAC), a residential treatment facility for recovering women and their children. Researchers studied outcomes for 41 women who were first treated in a detoxification program, then referred to either SBAC or a day treatment program. Although random assignment to groups was not possible, the groups were comparable on four major demographic variables. The SBAC groups reported better outcomes on three psychosocial variables: abstinence, arrest, and employment. They improved their total score on the Functional Assessment Rating Scale substantially more than did the comparison group. Consumer satisfaction was also high.

Reduction of Co-Occurring Distress and HIV Risk Behaviors Among Women Substance Abusers

SUMMARY Women who abuse alcohol and drugs may have a number of co-occurring distress issues, such as depression, traumatic stress, and violence, that impede their ability to make changes in the behaviors that place them at risk for contracting HIV. The objective of this article is to evaluate the influence of participating in an enhanced HIV risk-reduction project on reducing women's co-occurring distress. Study participants were 206 predominantly African-American women who participated in the North Carolina CoOperative (NC CoOp) Study that provided AIDS outreach to crack and injection drug users. The women participated in a two-session standard risk-reduction intervention and were then randomly assigned to either receive no further intervention or to participate in an additional three-session-enhanced intervention. The enhanced intervention was designed to work with individual participants in the context of their specific needs and co-occurring distress issues. Co-occurring distress, including depression, anxiety, traumatic stress, victimization, aggression, and physical health, was measured at intake and at 3 months after the intervention. The reduction in co-occurring distress was much more substantial for participants receiving the enhanced intervention. In addition, the difference in reduction of co-occurring distress between the standard and enhanced intervention groups was the greatest for women who reported the highest levels of baseline co-occurring distress. These findings suggest that a longer, more personalized intervention may be expected to produce greater positive changes in the lives of women who exhibit a high degree of distress. Reduction in co-occurring distress can improve women's quality-of-life and may enhance their ability to subsequently reduce their HIV risk behavior.

Single-gender treatment of substance abuse: Effect on treatment retention and completion

Increasing emphasis has been placed on the development of gender-specific treatment programs to address the unique needs of women substance abusers. Some authors have suggested that this task can be accomplished by simply providing single-gender programs; yet others have argued that simply segregating substance abuse clients by gender has no effect on outcomes. The latter have suggested that in addition to providing women-only programs, different treatment approaches must be adopted. The purpose of the study described in this article was to investigate the effect of one agency's change from mixed-gender to single-gender treatment on client retention and treatment completion. Data were collected on 305 men and 102 women who were treated in either mixed-gender or single-gender settings. Results indicate that substance abuse treatment provided in single-gender settings does not significantly increase treatment retention and completion. These findings lend support to the contention that to improve treatment outcomes for women substance abusers, gender-specific treatment must do more than provide traditional treatment in a single-gender environment. Key words: gender; retention; substance abuse treatment ********** Although women have struggled with chemical dependency for centuries, society has generally viewed substance abuse as a male problem (Blumenthal, 1998; Goldberg, 1995). Not until feminist theory and the women's liberation movement questioned male-dominated societal norms did addicted women begin to receive attention in their own right (Kandall, 1998). Because women have been underrepresented in research studies and treatment groups, the effects of and treatment for drug abuse among women are less understood than for men (Mondanaro, 1989; Wilke, 1994). Recognition of this fact has led to an increasing emphasis on the development of treatment programs that address the unique needs of women substance abusers. Despite a number of articles describing gender-specific treatment programs (Burman, 1992; Coletti et al., 1995; Finkelstein, 1993; Finkelstein, Kennedy, Thomas, & Kearns, 1997; LaFave & Echols, 1999; Schliebner, 1994; Wald, Harvey, & Hibbard, 1995; Yaffe, Jenson, & Howard, 1995; Zankowski, 1987), few studies have examined the outcomes of these programs (Beckman, 1994; Hodgins, el-Guebaly, & Addington, 1997; Wallen, 1998). LITERATURE REVIEW It has become accepted generally that the patterns, consequences, and reasons for substance abuse are different among women and men (Lex, 1994). Studies comparing men and women in chemical dependency treatment have found that women report more psychiatric symptoms than men, more depression and anxiety, lower self-esteem, and higher rates of childhood sexual abuse (Wallen, 1992). Also, chemically dependent women differ from men in patterns, psychosocial characteristics, and physiological consequences of drug use (Nelson-Zlupko, Kauffman, & Dore, 1995). Rates of treatment entry, retention, and completion are significantly lower for women than for men, and current substance abuse treatment models are less effective for women than for men (Beckman & Amaro, 1984; Blume, 1990; Reed, 1985; Stevens, Arbiter, & Glider, 1989). Because of these differences, it is not surprising that treatment strategies designed for men fail to adequately address the needs of female substance abusers (Schliebner, 1994), thus preventing treatment programs from attracting and retaining female substance abusers (Wells & Jackson, 1992). Gender-Specific Treatment Blumenthal (1998) noted that to increase retention of women in substance abuse treatment, treatment approaches must address gender differences in the etiology and treatment of addictive disorders and respond to the unique needs of women. Gender-specific programming gives women an opportunity to concentrate on their needs and desires away from their traditional concerns of social approval and the welfare of others (Copeland, Hall, Didcott, & Biggs, 1993). …

The use of incarceration and forced detention as a method of fetal protection for substance-abusing pregnant women

In May 1989, a Rockford, Illinois, woman was found guilty of prenatal child abuse and neglect for abusing cocaine during her pregnancy. In 1993, an Arizona woman was indicted on child abuse charges because of heroin ingestion during her pregnancy. In 1995, a Wisconsin state court ruled that a drug-abusing pregnant woman’s “viable fetus was in need of protection” because of the potential endangerment to its health and issued a protective custody order. In 1996, the Supreme Court of South Carolina affirmed the conviction of a woman of child abuse who tested positive for cocaine during a prenatal visit. The infant was born unharmed but with cocaine metabolites in its system. She was sentenced to 8 years in prison. Wisconsin and South Dakota have recently passed a fetal protection law that would allow forced incarceration to substance-abusing pregnant women. These laws, charges, and convictions are made in an attempt to prevent harm to a fetus by punishing those women who abuse drugs during their pregnancy. Although the effects are not consistent, substance abuse, ie, cocaine, alcohol, and even tobacco, by pregnant women has been shown to have detrimental effects on the fetus. These effects include increased physical abnormalities, spontaneous abortion, increased perinatal mortality, and impaired intellectual function. No doubt exists that measures need to be taken to prevent this harm to the fetus. However, would laws such as those proposed actually protect the fetus? Although substance abuse is not to be condoned, legal interventions, such as incarceration and forced detention, to protect the fetus from the effects of substance abuse by the pregnant woman are not only ineffective, but also increase harm to the fetus. The implementation of laws mandating physicians to report substance abuse with subsequent forced detention to pregnant women is not the best approach at protecting the fetus. In fact, these laws would likely cause more harm than good to both mother and fetus. Likewise, forced detention or incarceration is counterproductive. These sanctions would require the physician to report suspected substance abuse to the proper authorities. This practice would likely deter many substance-abusing women from seeking prenatal care for fear of possible imprisonment or detention. The patient consequently will not receive any prenatal care, during which the physician would be able to educate, treat, and counsel the patient effectively on the effects of her substance abuse. This method of education and good prenatal care is more effective than are incarceration and detention at protecting the fetus and is the treatment of choice of many health care workers. However, even if the physician is unable to convince the woman to abstain from drugs or if she is physically unable to stop her substance abuse, “prenatal care alone, in the presence of continued drug abuse, can improve perinatal outcome for the drug-exposed fetus.” The prenatal visits would also prepare the physician for the birth of a child with potential complications. Because the developing fetus is so vulnerable to the teratogenic effects of some of these substances, it is absolutely vital that the pregnant woman not be deterred from seeking prenatal care. Therefore, as the Connecticut court ruled in 1992, because these laws could prevent prenatal treatment, this would “lead to more, rather than fewer babies being born without adequate prenatal care or damaged by prenatal drug abuse.” These sanctions would prevent these drug-exposed newborns who are the “most fragile and sick, and in the most need of hospital neonatal care” from receiving that exact type of care as stated by the Florida court in 1992. In addition, the number of women who would actually be convicted of potential harm through the courts would be much fewer than those who would avoid care. We would consequently be sacrificing the possible health of many for a few. Therefore, because these laws may prevent many from seeking the proper care needed, greater, instead of less, harm would actually be done to the fetus. If a pregnant woman decides to seek prenatal care, these laws will still increase risk to the unborn child because of their detrimental effects on the patient–physician relationship. The foundation of the patient–physician relationship relies on the establishment of trust between the 2 individuals. These legal Correspondence: Inquiries to Andrea J. Evenski, MS III, Department of Medical Humanities (2S-17), Brody School of Medicine, East Carolina University, 600 Moye Blvd., Greenville, NC 27834; fax: (252) 816-2319; e-mail: aje1027@mail.ecu.edu.

Correlates of expressed and received violence across relationship types among men and women substance abusers.

This study examined expressed and received violence among men and women in substance abuse treatment. Rates of past-year partner violence (PV) did not differ by gender, although men reported markedly higher rates of nonpartner violence (NPV). Compared with PV, NPV was associated with more demographic and background factors (e.g., childhood aggression and conduct problems, family history of violence). The most consistent correlates of violence across relationship types were age, minority status, drug-related consequences, psychiatric distress, and frequency of childhood aggression. Only a few gender-specific correlates were identified; most notably, witnessing father-to-mother violence was related to received PV only for women. Identification of correlates of expressed and received violence in partner and nonpartner relationships is essential for the assessment and treatment of individuals in substance abuse treatment settings.

Witnessing violence among inner-city children of substance-abusing and non-substance-abusing women.

To determine if children of substance-abusing mothers witness more violence than children of non-substance-abusing (control) mothers, and to determine if children who witness violence have more behavioral problems and higher stress scores than children who do not witness violence. Cross-sectional research design comparing exposure to violence among children of substance-abusing mothers and control mothers of low socioeconomic status. An inner-city pediatric clinic. Forty substance-abusing mothers and their children, and 40 non-substance-abusing mothers and their children, examined when the children were 6 years old. Maternal report of children's exposure to violence was assessed using the Exposure to Violence Interview and the Conflict Tactics Scale. Maternal report of children's behavior was assessed using the Child Behavior Checklist and the Children's Response to Stress Inventory. Children of substance-abusing mothers did not witness more violence than the control children (P>.05). However, 6-year-old inner-city children in the present study witnessed a high rate of violence: 43% had seen someone beaten up, 13% had seen someone threatened with a knife, and 7% had seen someone stabbed or shot. Children witnessing violence had significantly higher aggressive, delinquent, anxious/depressed, withdrawn, attention, and social problems (P<.05) on the Child Behavior Checklist, and higher stress scores (P =.05) on the Children's Response to Stress Inventory. More than half of the 6-year-old inner-city children in the present study witnessed some form of violence. Witnessing violence was associated with more behavioral problems and higher stress scores as assessed through maternal report. Subsequent research should examine the long-term effects of this exposure to violence among young children.

Correlates of expressed and received violence across relationship types among men and women substance abusers.

This study examined expressed and received violence among men and women in substance abuse treatment. Rates of past-year partner violence (PV) did not differ by gender, although men reported markedly higher rates of nonpartner violence (NPV). Compared with PV, NPV was associated with more demographic and background factors (e.g., childhood aggression and conduct problems, family history of violence). The most consistent correlates of violence across relationship types were age, minority status, drug-related consequences, psychiatric distress, and frequency of childhood aggression. Only a few gender-specific correlates were identified; most notably, witnessing father-to-mother violence was related to received PV only for women. Identification of correlates of expressed and received violence in partner and nonpartner relationships is essential for the assessment and treatment of individuals in substance abuse treatment settings.

Self-Sufficiency and Sobriety

Substance abuse presents formidable challenges to a welfare reform that has employment as its primary goal. This study reviews the literature on substance abuse and women and reports what substance-abusing women on welfare perceive as unmet needs and barriers to their recovery and ability to join the workforce.

CROSS-CULTURAL COMPARISON OF CLINICAL SAMPLES OF NORWEGIAN AND IOWAN WOMEN WITH SUBSTANCE-RELATED DISORDERS

The purpose of this study was to compare two clinical samples of women substance abusers, one from Iowa and one from Norway, along several dimensions: “substance abuse” history, current “abuse” pattern, parental and spouse drinking history, symptoms of psychological distress, and “vulnerability” to relapse. A higher percentage of women substance abusers from Iowa were divorced and lived alone, were “vulnerable” to relapse, and reported more life problems secondary to their substance use than women from Norway. The Iowa women had used more substances in addition to alcohol than had the Norwegian women. The Norwegian women reported greater intensity of emotional distress than the women from Iowa.

Facilitation of Maternal-Fetal Bonding in Pregnant Substance-Abusing Women Attending Outpatient Treatment

Prenatal alcohol and drug use is regarded as a critical public health problem. Most pregnant women report that they try to limit alcohol and drug use because of concern for the fetus. This concern indicates that bonding, the foundation of maternal caregiving, has begun to develop. This paper introduces the Interactional Model of Prenatal Maternal-Fetal Bonding. This model incorporates and overcomes limitations of two earlier models of maternal caregiving behavior: an object relations model, which focuses on the mother's internal working model of attachment but neglects environmental factors, and an ecological model, which incorporates a systems approach but fails to address intrapsychic processes. Case vignettes illustrate how interventions into three domains (1) the characteristics of the pregnancy, (2) the characteristics of the mother, and (3) the characteristics of the environment can increase the strength of the maternal-fetal bond, resulting in a decrease in alcohol and drug abuse during pregnancy

Variation in suicidality among substance-abusing women: the role of childhood adversity.

The relationship of early adversity to suicidality in later life has been noted in diverse populations. Here we report such a relationship for a sample of African American women who smoke crack cocaine. This article is a secondary analysis of data from women (mean age = 31 years; range, 19-48) who were recruited from treatment settings (n = 152) or informal community contacts (n = 56). The present analyses focused on measures related to investment in self-preservation and development, particularly suicidal ideation and attempts. Multiple regression analyses were used to model the effect of early stress (sexual abuse, parental loss, and parental impairment) on the primary outcome measures (suicidality total, age at first consensual sexual relations, and years of education). Suicidality was associated with childhood adversity (sexual abuse, loss of mother). Of those who had experienced early sexual abuse, 42% had attempted suicide, compared to 19% of those who had not been sexually abused.

Posttraumatic Stress Disorder Symptoms and Situation-Specific Drinking in Women Substance Abusers

Posttraumatic stress disorder (PTSD) and alcohol use disorders are frequently comorbid conditions (Stewart, 1996). Alcohol use may serve a “negatively-reinforcing” function among traumatized individuals with PTSD (Stewart, 1996; Stewart, Conrod, Pihl, & Dongier, 1999a; Stewart, Pihl, Conrod, & Dongier, 1998). As such, the heavy drinking behavior of those with PTSD should be relatively situation-specific (i.e., more frequent in “negative” discriminative contexts than in other types of contexts). To test this “situational-specificity” hypothesis, a lifetime measure of trauma exposure (Everstine & Everstine, 1993), the PTSD Symptom Self-Report Scale (Foa, Riggs, Dancu, & Rothbaum, 1993), and the 42-item Inventory of Drinking Situations (Annis, Graham, & Davis, 1987) were administered to a community-recruited sample of 294 adult women substance abusers. PTSD symptoms were significantly positively correlated with frequency of heavy drinking in negative situations, but unrelated to frequency of heavy drinking in positive and temptation situations. At the level of specific drinking situations, PTSD symptoms were significantly positively correlated with frequency of heavy drinking in the negative situations of Unpleasant Emotions, Physical Discomfort, and Conflict with Others. PTSD symptoms were unrelated to frequency of heavy drinking in the positive situations of Pleasant Times with Others and Social Pressure to Drink, or in the temptation situations of Testing Personal Control and Urges and Temptations. Additionally, PTSD symptoms were significantly negatively correlated with frequency of heavy drinking in positive situations involving Pleasant Emotions. Anxiety sensitivity (fear of anxiety-related sensations; Peterson & Reiss, 1992), but not Neuroticism (tendency to experience negative affect; Costa & McCrae, 1992), mediated the observed associations between PTSD symptoms and situation-specific heavy drinking in negative contexts in general, and Conflict with Others and Physical Discomfort situations in particular. Implications for designing potentially more effective interventions for women with comorbid PTSD-alcohol use disorders are discussed.

Substance Abuse in African American Women

Limited attention to ethnicity in research on substance abuse and women has resulted in assumptions that may not fit the experience of women of color. This study employed a combined quantitative and qualitative design to investigate substance abuse in African American women ages 21 to 48. Life experiences of women with histories of chemical dependence were compared with women who were maintaining a nonabusing lifestyle. Variables examined were history of parental substance abuse and child abuse, exposure to racism and traumatic events, and social support and spirituality. The substance abusing and nonabusing women were distinguished from each other in the areas of spirituality and family connectedness. Although all participants reported high violence exposure and personal losses, significantly more substance abusing women reported being battered, experiencing homelessness, and more traumatic events. Participants described multiple experiences with racism, though their descriptions of their responses to these experiences suggested different styles of coping. Findings have significant implications for prevention of substance abuse, particularly in the areas of religious involvement, family support, and the development of active problem-solving strategies.

Drug-Using Women's Communication with Social Supporters about HIV/AIDS Issues

Communication about health issues such as HIV/AIDS is essential for people, especially women, to obtain the social support they need either to prevent illness or manage it. This article compares the kinds of HIV-related issues that HIV positive and HIV negative substance-abusing women (N=211) in New York City talk about with various types of supporters. Despite the stigma associated with AIDS and their unconventional lifestyles, both groups of women talked to a broad spectrum of supporters about a variety of HIV-related issues, though this was more the case for HIV positive women. Although the main topic that both groups discussed with their supporters was their HIV status, the women also talked about risk reduction, their supporters' HIV status, HIV testing, how to live with AIDS, information about HIV/AIDS, and the emotional impact of AIDS (e.g., fear of infection, reactions to learning test results, and the impact of knowing others who have died from the disease).