Charleston Area Medical Center, Charleston, WV, USA
AddictionsWomen-specific issuesStrategies for addictions therapy
A myth exists in the world of women’s fashions called “one size fits all.” Every woman alive knows there is no article of clothing that will truly fit all sizes. Sadly, the approach to the treatment of addictions has historically been a “one size fits all” approach. The opportunity exists to recognize the unique circumstances of women dealing with addiction issues and the treatment modalities that will most effectively treat their disease. The motivation needed to move women towards recovery as well as the approach to treatment differs from that of men . Recognizing these differences and directing care appropriately is a competency to be embraced by all providers.
Despite progress of the Women’s movement a gender bias persists in Western culture. The role of nurturer continues to be perceived primarily as that of the female’s responsibility. This bias transfers to the stigma women with addiction issues experience. The mantra is that because a female has potential to procreate, the capacity to nurture should/could protect women from engaging in behaviors that are counterintuitive to nurturing. Traditional households where the women continue to be the primary caretakers of children will perpetuate these stereotypes . As much as the glass ceiling has been pushed and the percentage of “June Cleaver’s” home vacuuming in her pearls has been replaced with significant numbers of professional women, the stereotype persists that the female is responsible for familial unity and sustainment of all things protective.
The state of Tennessee’s legislation in 2013 making it possible for a woman to be charged with aggravated assault if she tests positive for drugs during her pregnancy is being debated heavily in the literature as discriminatory and showing little insight into the complexity of substance abuse .
These beliefs perpetuate the shame that women feel and exacerbates the secrecy and hesitancy to seek treatment thus resulting in lower numbers of women engaged in recovery . The result is that women find creative ways to hide their substance use and when at long last they are confronted, they often fail to disclose. Women too can discriminate against other women in this same manner. Pregnant women attending AA or NA meetings have found themselves shunned. Belittling comments even amongst the recovery community have differentiated the recovering addict from the “bottom feeding” addict who will use even though she’s pregnant .
A woman willing to engage in treatment often is met with substantial barriers that may tax her already poor distress tolerance skills and reinforce her perception of failure. Historically, the large percentage of women working in service line business and industry have been employed by companies that offer minimal to no benefits. Even with the passing of the mental health parity law in 2008 discrimination against mental health and substance abuse issues has persisted.
The scheduled times of 12-step meetings, lack of child care at meetings or for appointments with mental health and substance abuse professionals and geographic constraints, and transportation issues are all potential barriers for women receiving treatment. A lack of public service information regarding the resources for treatment, coupled with the shame and stigma described previously, compile the roadblocks for women desiring help .
The distinct correlation between women suffering from addiction issues and those living as victims of intimate partner violence is well documented. Controlling partners and partners who have substance abuse issues themselves can prevent women from seeking treatment. The absence of intimate partners, the partner’s level of drug or alcohol use, and the heightened anxiety experienced in the family system in the absence of the female who is participating in treatment are found to be influential in the decision to seek help by the woman with substance abuse issues .
An ongoing debate exists amongst providers regarding the most effective treatment approaches for clients dealing with addiction issues. Time demands, philosophical approaches, organizational hierarchies, and provider bias all have the potential to impact the method of treatment that will be applied. When self-disclosure and screening questionnaires are stand-alone tools for diagnosing substance abuse issues, a high percentage of at risk patients will be missed . Recognizing cues, discrepancies, and early warning signs of substance abuse has become a crucial skill of the effective, thorough diagnostician.
The clinician, who desires to be thorough in identifying and treating the female patient effectively, must be aware of their own biases and preconceived notions. A patient seeking treatment that appears affluent or well educated is less likely to be considered as someone with a potential addiction issue . Use of universal drug and alcohol screening in private practice is much less prevalent than that in clinic-based practices. In part this has contributed to the false assumption that the more influential, financially stable, or well educated a patient is, the more unlikely it is that she will be engaged in illicit activities.
The use of validating messages can be a first step towards building a therapeutic relationship with the female client struggling with substance issues. If the school of thought that the substance abuse is symptomatic of larger issues is correct, identifying and treating those issues, most notably, a history of trauma is imperative if intervention is going to be effective . The female client who has never developed a sense of self, or who has surrendered that sense of self due to abuse or neglect; who has little to no concept of belonging and who has had few opportunities for success, are going to find treatment interventions overwhelming. Something as simple as referring to a “class” they need to attend may conjure up images of school failure that the client has experienced and thus sabotage treatment before it’s begun.
Considering the individual needs of the client and designing intervention accordingly will promote the greatest opportunity for success. Assessing the educational level of the patient, her distress tolerance and coping skills, social situation, economic factors, and support systems should be considered when creating a treatment plan for women with substance abuse issues.
The utilization of Motivational Interviewing has increased significantly in the area of substance abuse treatment over the past decade. The premise of MI is that by appealing to the client’s intrinsic motivation the clinician will guide the client to the desired change. Reflective listening, the use of affirmations and eliciting from the client, and goals that she would wish to accomplish are tools of MI that are believed to help accomplish sobriety .
Traditional 12-step programs such as Alcoholics Anonymous and Narcotics Anonymous have been recommended in the addictions world for years. The philosophy of the 12-step programs is that by utilizing support groups, adopting and “working” the various steps of the program and abstaining from all use of alcohol or drugs the participant will be “in recovery.” The belief is that one is never “recovered” from the addiction, but rather must persist in these behavioral changes to continue to “recover” .
Cognitive Behavioral Therapy , a model of therapy that examines the relationship between the client’s thoughts, feelings, and behaviors is also the foundation of numerous treatment programs for substance abuse issues. By changing her thought from, “I am a victim to my disease of drug abuse,” to “I can choose to overcome my drug abuse,” the client can change her feelings from that of victim to that of someone who is empowered and thus change behavior and become clean or sober. Opponents of these concepts will argue that disbelief in free-will disrupts the CBT potential and addicts will use this as a scapegoat for needing to control their own destiny .
An emerging thought in the treatment of addictions is to neither dismiss the disease model vs. free will debate but to recognize that there exists a shared governance. Rather than viewing addiction as a disease where a patient’s predisposition or chemical makeup dooms them to a world of abusing drugs and alcohol, that addiction is viewed similarly to Type II Diabetes. A client’s choices may still influence whether they develop an addiction by the behavior in which they choose to engage .
Dialectical Behavior Therapy , a form of Cognitive Behavioral Therapy was introduced in the late 1980s as a treatment for clients with Axis II Diagnoses, primarily Borderline Personality Disorder. As the psychotherapy began displaying positive results in this patient population, transference of the concepts to other psychiatric illnesses, including addiction, was implemented. Consistent success has been demonstrated using DBT for the treatment of women with drug dependence . The structure and reinforcement of the DBT model provides a community to the recovering woman that models healthy communication and social dynamics that may be unknown to them outside the treatment arena.
Contingency management or incentive programs have been supported in emerging evidence as an effective approach to the treatment of women suffering from addiction. This approach is seen as a way to facilitate recovery and provide a positive experience for the patient . Clients participating in such programs articulate positive responses when interviewed regarding their perceptions of the incentive program. Likewise, acceptance by the provider of the concept of contingency management appears to have an impact on the outcome .
A relatively new approach to treatment is that of incorporating a realization of one’s health—an intrinsic connection to health and wellness—into the treatment model. Coined Health Realization the goal is to teach the client a set of principles that focuses on the understanding of the principles of Consciousness, Thought, and Mind from a model developed by Mills and Pransky. Rather than focusing on disorders or disease models, Health Realization which has been used in other arenas for over 30 years, has been incorporated into substance abuse programs to reduce depression and anxiety and improve personal relationships and improved self-esteem . This model has been used primarily in in-patient treatment models and thus consideration for a client needing an outpatient modality of treatment should be directed to a therapist or mental health professional who has specific credentials in this treatment methodology.
Regardless of the treatment model selected for female clients, the literature repeatedly supports that the interventions that approach the patient’s treatment from a systemic model are the most effective. Involving the client’s family, community, or identified source of support in treatment provides the link and validation that are significant to female clients . Furthermore, the interaction with other women facing the same crisis is also believed to be a guiding principle in successful treatment .
There is no “one size fits all” and the clinician must invest time to connect with the client to determine a modality that is most suited for that client. Utilizing multidisciplinary team approaches to the client’s treatment provides the clinician with a multitude of resources to hopefully treat the client holistically. It cannot be emphasized enough that diagnosing and providing treatment for client’s with a history of trauma is crucial to positive outcomes. Otherwise, only the symptoms are being addressed and we have failed to reach the core of the patient’s need.
Lastly, awareness of one’s own biases in the treatment of the female patient suffering from addiction or substance abuse issues is warranted. Because addictions affect such a significant percentage of people, it is likely that the provider has personal experience either directly or indirectly with someone suffering from a dependency or addictive disorder. Differentiating personal feelings from professional judgment can become difficult if the provider has not processed through their own issues with addiction. This becomes compounded further when the addict is a woman because it again is in conflict with our stereotype of females as the nurturers of our society. This bias does not bypass female providers. Counterproductive attitudes of female providers have been documented to impede effective treatment of the client .
The National Institutes of Health estimated in the beginning of the new millennium that of the 294 billion estimated cost of substance abuse, 12 billion dollars a year is spent on the treatment of addictions . Though that amount is a statistically small percentage of the estimated cost given the high incidence of recidivism, the question exists of how effective is our approach. While this debate is likely to go on for decades, one statistic is irrefutable; not providing any treatment or intervention will lead to even greater health care issues and a continued threat to our public health. We have a unique opportunity in treating women to attempt to steer them towards a model of health and wellness that will ultimately impact their family and community. Providers can no longer ignore the issue of substance abuse and addiction amongst their patients. They have a duty and obligation to educate themselves about effective treatment options and in a nonjudgmental, compassionate manner work with their patients to create an effective treatment plan.
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