One dozen considerations when working with women in substance abuse groups.
Abstract: Women and men have different histories, presentations, and behaviors in substance abuse groups. Twelve considerations are offered for the beginning group leader when encountering women with substance abuse issues. These include understanding sexism, what brings women to treatment, and how women behave in group treatment. Implications for clinical practice with women in single-gender and mixed-gender groups are included.

Keywords--addiction, gender, group treatment, women's substance abuse
Article Type: Report
Subject: Women (Drug use)
Women (Health aspects)
Substance abuse (Care and treatment)
Substance abuse (Health aspects)
Substance abuse (Analysis)
Authors: Bright, Charlotte Lyn
Osborne, Victoria A.
Greif, Geoffrey L.
Pub Date: 03/01/2011
Publication: Name: Journal of Psychoactive Drugs Publisher: Taylor & Francis Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Taylor & Francis Ltd. ISSN: 0279-1072
Issue: Date: March, 2011 Source Volume: 43 Source Issue: 1
Product: Product Code: 8000143 Alcohol & Drug Abuse Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers SIC Code: 8093 Specialty outpatient clinics, not elsewhere classified
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 287390915
Full Text: Gender differences in the prevalence and consequences of substance use are well-documented. The National Institute on Alcohol Abuse and Alcoholism estimates that of the 15.1 million people who abuse alcohol or are dependent on alcohol, approximately six million--40%--are women (Grant et al. 2004). While rates of substance abuse are higher for males 17 and older than for females, among 12- to 17-year-olds the rates are slightly higher for females (SAMHSA 2009). Women are also more likely than men to abuse prescription drugs (Simoni-Wastila & Strickler 2004). Women tend to develop health problems related to alcohol and drug use disorders more severely than men (Bradley et al. 1995), lose control over alcohol more quickly than men (Randall et al. 1999), and experience social-role problems such as fulfilling family and work obligations.

In a recent article published in this journal, Greif (2009a) discussed the importance of considering men's unique life circumstances and treatment needs when they enter a psycho-education, support, or psychotherapy group where substance abuse is the focus. This article examines the flip side of that coin by describing, for beginning group leaders, what they should consider when working with women in substance abuse groups. (For our purposes, substance abuse refers to alcohol, illegal, and prescription drugs that are misused and impair daily living.) The following 12 considerations may be useful to treatment providers in establishing such an environment.

FEMALE DEVELOPMENT

Taking care of self and others are often ideals by which females are raised (Gilligan 1993a). Coupled with these ideals are women's needs to integrate equality and respect with connection and relationship (Gilligan 1993b). As male development is more centered on individual achievement than on conflicting goals of caring for others and oneself, moral development may be more challenging for girls than it is for boys (Gilligan 1993a) and saying "no" may carry more emotional weight. Women may abuse substances in an attempt to build or maintain relationships.

While this orientation is not without complications, a spirit of caretaking is highly congruent with the use of group treatment modalities. Group work, based on fostering healthy connections and recognizing mutual experiences, can be quite therapeutic for women (Covington & Surrey 1997). The treatment process can further conform to female development by emphasizing that "recovery is an ongoing process" (Grant 2006: 186), rather than simply an endpoint or target.

WOMEN'S STYLES OF INTERACTING

Related to the above are women's styles as compared with men's styles. Women place a greater emphasis on communicating with friends and men on engaging in activities (Greif 2009b). In mixed-gender groups, there may be more competition when compared with single-gender women's groups and communication may be more male dominated (Walker 1981). If women are good listeners, they may not assert their points of view, while men, in turn, may be accustomed to talking rather than listening. A dynamic can therefore occur in group sessions in which men dominate discussions.

This pattern can become a focus of discussion as group behavior often mirrors what happens outside of the group. The purpose of most groups is to help group members make the link between their behavior in and out of the group so they can change maladaptive ways of interacting outside of the group. If, for example, women are subservient to men outside of the group, this can be addressed within the group when similar behavior is displayed.

SEXISM AND RELATIONSHIPS WITH MEN

Sexism reflects a power imbalance between men and women in society (DeVault 1996). The persistence of sex roles and gendered stereotypes are theorized to be instrumental in the development of substance abuse as escapism (Briggs & Pepperell 2009). Furthermore, gendered assumptions about appropriate behavior for women (including acting as a wife and/or mother), coupled with societal disapproval of women's use of substances, may simultaneously aggravate the behavior and prevent help-seeking (Angove & Fothergill 2003).

The dynamics of substance abuse among women are colored, in part, by the nature of their relationships with men. For example, women may initiate substance abuse because of the influence of their male partners (Bright, Ward & Negi In press). Intimate partner violence may also play a role in the development of substance abuse among women.

In a group setting, the leader must be attuned to the assumptions that arise about what women (or men) should do or how they should behave in relation to their parenting, work, and caretaking roles. How the group discusses a mother's relationship with her children sends a signal about what other roles she should be occupying. Is it acceptable, for example, to miss a group session because a child is ill or an elderly family member needs help? Substance abuse treatment should broach gender stereotypes, acknowledge oppression, and advocate for equality. It can also consider the role that relationships with men play in women's patterns of use.

STRESS AND COPING

Women and men use substances for different reasons, with women more likely to self-medicate or use substances to ease stress or pain (Jamison et al. 2010). While there is no conclusive evidence on causal linkages to substance abuse, researchers have suggested that certain socioenvironmental factors are at play. These include attempting to fulfill gendered social roles, having a history of abuse and traumatization, and experiencing relationship problems (Colman & Widom 2004). In addition, women who misuse alcohol tend to have few social supports (Haseltine 2000).

If the reasons for substance abuse differ between men and women, the topics that are discussed in the group must span the different paths that the group members have traveled to treatment. Focusing too much on the social, traditionally male context of drug use or downplaying early experiences as reasons for using drugs may reinforce the tendency of women to take a backseat in discussions.

COMORBID MENTAL ILLNESS

Comorbid mental health issues are also evident in women's substance use patterns. Women may use substances as a way of managing mental disorders like anxiety or depression (Greenberger 1998). In a study by Peindl and colleagues (1998), women who met criteria for alcohol dependence had greater histories than men of psychiatric disorders and earlier onset of mental illness.

If the focus of the group is substance abuse, a careful assessment should be made so that other co-occurring issues are unearthed which may affect treatment. Some groups may become so focused on reducing substance abuse, especially if professional success for the group leader is linked to a reduction in abuse, that they do not focus on the whole person and other psychiatric/emotional needs are overlooked.

TRAUMA

Abuse and trauma are highly associated with later adult substance misuse (Clark & Foy 2000). Women who experienced physical or sexual abuse in childhood also tend to have higher comorbidity of post-traumatic stress disorder (PTSD) and depression with alcohol misuse (Back et al. 2003). Women may abuse substances after experiencing traumatic events (including sexual assault) as a form of self-medication of negative affect (Kilpatrick & Williams 1997).

This requires the leader to be extremely sensitive around the issue of trauma in a mixed-gender group for two reasons. First, it is a highly explosive topic for the individuals in the group as they may not only be confronting their own history for the first time but they may also be traumatized by the stories of other group members. Second, women have often been abused as children or adults by men or boys. A dynamic may be established in the group where the men and women do not know how to react to each other if past (and present) perpetrators have been male. Consistent with a model of group work that is transparent, the leader can comment on this dynamic by saying, "Many of you are talking about men as perpetrators. Does anyone want to comment on how that might play out in this group?"

STIGMA

Substance abuse has traditionally been more stigmatized for women than for men (Jersild 2001). Public drinking behavior is often deemed "unladylike" or unfeminine (Brienza & Stein 2002), and women may be considered less fit to be a wife or mother when they abuse substances (Greenfield & Grella 2009). Although many women who use are in relationships with men who also use, the reality is that women are more likely to risk losing their relationships if they enter treatment (Greenfield & Grella 2009).

Stigma is an important topic for substance abuse groups. Not only is it linked to women's roles, it is tied to confidentiality and secrets. Asking women if they feel comfortable talking about their substance abuse problems outside of the group and if not, why not, is one way to begin looking at how stigma is shaped by society as well as by gender.

INTERSECTION OF RACE, CLASS, AND GENDER

Substance-abusing women have been found to have lower educational and employment levels than substance-abusing men (Wong et al. 2002). Women of color are at elevated risk, moreover, for specific problems including injecting intravenous drugs and mortality related to overdose (Allen 1995). Women in treatment will likely espouse a number of identities, many of them associated with marginalization or oppression, defining themselves based on gender and ethnicity but also based on class, ability, age, and sexual orientation. A focus on gender to the exclusion of other identities can therefore be alienating to women in substance abuse groups. Rather, the diversity of women's experiences must be recognized, and this intersectionality of identity should be considered a strength (Davis 2008).

MOTHERHOOD

Family structures and women's roles have changed dramatically in recent years, as women increasingly are members of the workforce, often as primary breadwinners in their households (Marks 2006). Even so, women remain responsible for the majority of child care, and women who are parents regularly consider that role as central to their identity (Arendell 2000). Women in substance abuse treatment report that motherhood is essential to their self-image and recognize that their drug or alcohol use can directly or indirectly harm their children (Baker & Carson 1999). Women may resist treatment because of a fear of losing custody of their children (Ayyagar et al. 1999).

Group treatment for women can recognize the importance of the mother role. If the mother is worried about losing custody or has lost it, discussion will need to center on concrete steps to improve her situation. A loss of custody should not mean a loss of motherhood, which is dynamic and lifelong. The group leader should be attuned to metaphors about nurturing and responsibility and use these to emphasize mothers' abilities. In addition, agencies should provide concrete assistance in the form of prenatal health care, parenting education, and childcare. Residential programs should offer live-in options for children in order to effectively serve women who are their primary caregivers (Brady & Ashley 2005).

SCREENING AND REFERRAL

Women are less likely than men to be screened for substance misuse. Women tend to seek mental health help from their primary care physicians (Green 2006) and it is well established that physicians are not consistent in screening for or detecting substance misuse in patients, particularly women (Brienza & Stein 2002). Men are more likely to be referred to treatment via the criminal justice system or their employers (involuntary referrals) whereas women are more likely to be referred via the social services or mental health systems, or with the assistance of a family member or friend urging them to seek help (voluntary referrals) (Schmidt & Weisner 1995).

The relevance of this last point is that, depending on the group and its purpose, the entry into substance abuse as well as into the group may be different between some women and some men. Women's topics of interest and personal histories can vary a great deal from men's. Finding common threads among the different group members can be challenging, yet all can be addressed through the common theme of needing to change their substance abuse.

LOGISTICAL OBSTACLES TO TREATMENT ENTRY

When women are referred for substance abuse treatment, they are less likely than men to actually enter into treatment. Reasons for this include logistical barriers such as childcare challenges, transportation issues, or lack of insurance or insufficient funds to pay out of pocket (Green 2006; Brady & Ashley 2005). In order to be accessible to lower-income women, substance abuse treatment groups should consider operating on a sliding-fee scale, accepting Medicaid, and providing transportation and childcare during group sessions. Additionally, women's experiences of poverty and resource-related challenges may be appropriate topics for discussion during group sessions.

SINGLE AND MIXED-GENDER TREATMENT APPROACHES

Women-focused, or gender-specific, treatment can be considered for many reasons. Some factors related to substance use disorders are either more prevalent among women, or specific to women, as discussed previously. Therefore, programs that are holistic in the sense of incorporating childcare, parenting classes, GED classes, job skills or employment enhancement, and specialized mental health treatment for trauma and comorbid mental illness are well suited for women who have substance use disorders. Programs solely for women focus on gender-specific content, allow clinician-client gender matching (services for women provided by women counselors), and provide a secure and comfortable environment, which is especially crucial for women who have been abused in childhood or adulthood by men (Greenfield & Grella 2009). Because women tend to have more comorbid mental health issues (see above), single-gender groups can incorporate treatment for those disorders as well. Similarly, women with substance use disorders are more likely than men to be in relationships with a partner who also abuses or is dependent on substances, and in which they may be experiencing violence in the home (Greenfield & Grella 2009).

It is important, however, not to assume that women are a homogenous group. Women with substance use disorders are demographically and psychosocially heterogeneous, from various socioeconomic, racial/ethnic, educational, marital status, sexual orientation, and age backgrounds. Additionally, not all women have comorbid mental health disorders, or if they do have mental health challenges, they may be very diverse in nature. Women also may not have had the same past experiences, including similar victimization or trauma histories.

Some research has found single-gender groups to be better than mixed-gender treatment with regard to women's sobriety (Green et al. 2004), although one recent randomized study of women-only and mixed-gender programs reveals no differences in treatment outcomes (Kaskutas et al. 2005). Women who have PTSD or have experienced sexual abuse appear to benefit more from single-gender programs (Hien et al. 2004). Mixed-gender groups, furthermore, may be the established modality within an agency. Regardless of whether a group leader treats women in single- or mixed-gender groups, it behooves him or her to attend to and plan for women's specific issues regarding treatment entry, presentation, and behavior in groups.

CONCLUSION

The considerations described here are not exhaustive, as treating substance abuse in women (or men) is an extremely complex undertaking. The purpose is to alert beginning substance abuse group leaders about some of the issues that may arise both before a woman arrives for treatment and what she may experience once in the group. Treatment can occur in single- or mixed-gender environments, using approaches ranging from self-help to court-mandated residential placement. Not all issues discussed above will be equally relevant for all treatment providers. Nevertheless, this discussion is intended to support treatment providers as they plan and implement services for women struggling with substance abuse.

DOI: 10.1080/02791072.2011.566503

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Charlotte Lyn Bright, M.S.W., Ph.D., Assistant Professor, University of Maryland School of Social Work, Baltimore, MD.

Victoria A. Osborne, M.S.W., Ph.D., Assistant Professor, University of Missouri School of Social Work and Program in Public Health, Columbia, MO.

Geoffrey L. Greif, D.S.W., LCSW-C, Professor, University of Maryland School of Social Work, Baltimore, MD.

Please address correspondence and reprint requests to Charlotte Lyn Bright, 525 W. Redwood St., Baltimore, MD 21201; Phone: 410.706.3605; email: cbright@ssw.umaryland.edu
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