Substance Abuse in Women:
Clinical & Program Issues in the
Community & Criminal Justice
System
Joan E. Zweben, Ph.D.
Executive Director, EBCRP
Clinical Professor of Psychiatry; UCSF
ADP Conference
October 13, 2010
Introduction
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1970’s – first focus on gender
disparities and women’s issues
90% of articles on gender published
since 1990 (Back, 2007)
24% of substance abuse treatment
facilities now provide specific programs
or groups for women
(SAMHSA Facility Locator, 2007)
Epidemiology
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Prevalence of AOD disorders greater in
men
Gender differential is higher for alcohol
use disorders than drug use disorders
Prescription drug abuse and tobacco use
in women only slightly less than men
For adolescents, the gap disappeared for
alcohol, marijuana, cocaine and cigarettes
Minority Women and Alcohol
Use
Drinking patterns influenced by:
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Religious activity
Genetic risk/protective factors
Level of acculturation to U.S. society
Historical, social and policy variables
(Collins & McNair, 2002)
African American Women
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Relatively high rates of abstention and
low rates of heavy drinking among
black women
Most over 40 did not consume alcohol
High participation in religious activities
is a protective factor
(Collins & McNair, 2002)
Asian American Women
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Regardless of national origin, Asian American women
have low rates of alcohol use and problem drinking
Facial flushing response (occurring in 47-85% of
Asians) is a protective factor
ALDH2-2 leads to perspiration, headaches,
palpitations, nausea, tachycardia, and facial flushing
Women report being more embarrassed than the men
do
Acculturation promotes increased drinking (e.g.,
Japanese women)
(Collins & McNair, 2002)
Native American Women
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Availability of distilled spirits, its use outside
specific cultural contexts, and modeling of
heavy drinking by Europeans promoted binge
drinking
Tribal policies about drinking on the
reservation are influential
High density of alcohol outlets in poor urban
communities
Marketing of high alcohol content to Native
Americans (Crazy Horse)
(Collins & McNair, 2002)
Latinas
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Often did not drink, or drank small
amounts in country of origin, but
drinking patterns changed more
dramatically than male counterparts
More research on Mexicans than Puerto
Ricans or Cubans
After three generations, the drinking
patterns of Mexican-American women
are similar to other U.S. women
(Collins & McNair, 2002)
Older Women
Risk Factors:
 Longer life expectancies
 Many losses
 Live alone longer
 Less likely to be financially independent
 More susceptible to the effects of
alcohol, particularly as they age
(Blow & Barry, 2002)
Women in the Military
Women Veterans of Iraq & Afghanistan:
 Review of records from Defense Medical
Surveillance System indicated 17.4%
received specific mental health
diagnosis (overall rate, 12%)
 22% suffered from military sexual
trauma, compared with 1% of men
(Susan Storti, NIDA Conference 2010)
Diagnostic & Screening Issues
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Women tend to seek treatment at
mental health or primary care clinics
Both substance abuse and psychiatric
conditions are often undetected
A single question about last episode of
drinking can increase detection in
primary care settings
Psychosocial Influences
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Women more likely to have role models in
nuclear families and/or spouses who are
alcohol dependent
Weight control is important factor in tobacco
smoking
Relapse factors: women more likely to cite
interpersonal and other stressors; men more
likely to report external temptations
Medical Comorbidity
Biological Factors
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Alcohol
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Enzymes – lower concentration of gastric
dehydrogenase
Higher fat/water ratio
Drugs
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Hormone fluctuation during menstrual
cycle
Gender differential in brain activation by
stress and drug cues
Alcohol
Course of Illness
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Increased vulnerability to adverse
consequences
“Telescoped” course
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Females advance more rapidly from use to regular
use to first treatment episode
Severity generally equivalent to males despite
fewer years and smaller quantities
Biological and psychosocial factors contribute
to this outcome
Biological Factors
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Alcohol: differences in bioavailability
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Enzymes – lower concentration of gastric
alcohol dehydrogenase (enzyme that
degrades alcohol in the stomach)
Higher fat/water ratio (smaller volume of
total body water so alcohol is more
concentrated)
Breast Cancer
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Moderate consumption elevates the risk (linear
relationship between #drinks and risk)
Occurs with all forms of alcohol
Does alcohol raise estrogen levels?
Metabolism of ethanol leads to the generation of
acetaldehyde (AA) and free radicals. Acetaldehyde is
carcinogenic (e.g., GI tract cancers)
Research areas: specific drinking patterns, body mass
index, dietary factors, family hx breast cancer, use of
HRT, tumor hormone receptor status, immune
function status
(10th Special Report to Congress: Alcohol & Health)
Psychiatric Comorbidity
Psychiatric Comorbidity
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More likely in girls and women:
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Anxiety disorders (especially PTSD)
Depression
Eating disorders
Borderline personality disorders
Onset more likely to precede the onset of the
substance use disorder
More likely in boys and men:
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Antisocial personality disorder
Conduct disorder
PTSD
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Convergence of trauma, PTSD and
SUDS particularly important
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Early life stress, esp sexual abuse, more
common in girls
Higher risk of alcohol dependence in
women exposed to violence in adulthood
AOD use elevates risk for victimization
Uncontrollable stress increases drug selfadministration in animals
Treatment Issues
Gender Differences in
Treatment I
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Women less likely to enter treatment
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Sociocultural: stigma, lack of partner/family
support
Socioeconomic: child care, pregnancy, fears about
child custody
Children are a big motivator to enter
treatment or avoid it
Availability of appropriate treatment for cooccurring disorders is important
Gender Differences II
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Few differences in retention, outcome,
or relapse rates
If there are differences, women have
better outcomes
Show greater improvement in other
domains (e.g., medical), shorter relapse
episodes, more likely to seek help
following a relapse
Gender Differences III
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No strong evidence that gender-specific
treatments are more effective, but there are
few controlled trials
Residential programs that include children
have better retention rates
Gender is not a specific predictor overall, but
specific treatment elements improve
outcomes for various subgroups
(Greenfield et al 1006)
Key Services to Improve
Outcomes for Women
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Child care
Prenatal care
Supplemental services addressing womenfocused topics (e.g., trauma history)
Mental health services; psychotropic meds
Transportation
Women-only groups
Employment services (jobs with decent pay)
Documented
Improvements
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Length of stay; treatment completion
Decreased use of substances
Reduced mental health symptoms
Improved birth outcomes
Employment
Self-reported health status
HIV risk reduction
(Ashley et al 2003; Greenfield et al, 2007)
Readiness to Change: Start
Where the Woman Is
Domestic violence
 Emotional problems
 Substance abuse
 HIV risk behaviors
Rapidly address what the woman
indicates as high priority, and build a
bridge to the other problems
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(Brown et al, 2000)
Treatment Culture
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Female role models at all levels of
hierarchy
Positive male role models available
Forthright feedback but not aggressive
confrontation
Monitor the intensity, especially for
women who are more disturbed
Sexual boundary issues
Women-Only vs Mixed Gender
Programs
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Most consistent difference: provision of
services related to pregnancy and parenting
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Parenting classes
Children’s activities
Pediatric, prenatal, post-partum services
Also more likely to assist with housing,
transportation, job training, practical skills
training
(Grella et al, 1999)
Women-Only Groups
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Foster greater interaction, emotional
and behavioral expression
More variability in interpersonal style
Women in mixed groups engage in a
more restrictive type of behavior; men
show wider variability (and interrupt
women more).
(Hodgkins et al, 1997)
Relapse Issues for
Women
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Untreated psychiatric disorders,
especially depression and trauma
sequelae (PTSD)
Intimate partner
Underestimating the stress of
reunification or ongoing parenting
Isolation; poor social support
High level of burden
Seeking Safety:
Early Treatment Stabilization
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25 sessions, group or individual format
Safety is the priority of this first stage tx
Treatment of PTSD and substance
abuse are integrated, not separate
Restore ideals that have been lost
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Denial, lying, false self – to honesty
Irresponsibility, impulsivity – to commitment
Seeking Safety: (2)
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Four areas of focus:
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Cognitive
Behavioral
Interpersonal
Case management
Grounding exercise to detach from emotional
pain
Attention to therapist processes: balance
praise and accountability; notice therapists’
reactions
Seeking Safety (3):
Goals
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Achieve abstinence from substances
Eliminate self-harm
Acquire trustworthy relationships
Gain control over overwhelming symptoms
Attain healthy self-care
Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002; www.seekingsafety.org)
Women in the
Criminal Justice
System
Epidemiology
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Women are the fastest growing
segment of the CJ population in all
components since 1990s
Majority are nonviolent offenders
Most are minority, esp black and
Hispanic
Variety of medical problems, more
severe than age matched counterparts
Children at High Risk
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Most women offenders have children
Disproportionately linked to race
Family disorganization, financial hardship,
exposure to abuse and trauma often predated
incarceration
No reliable research to support the view that
these children are more likely to be
incarcerated as adults
Did have problematic school behavior and
deviant peer influences
Family Contact
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Family contact in prison is associated
with lower rates of post release
recidivism
Telephone restrictions significantly
reduce family contact
Budget cuts have led to reduced visiting
hours
Criminogenic Factors Targeted
to Improve Outcomes
Antisocial values
 Criminal peers
 Dysfunctional families
 Substance abuse
 Criminal personality
 Low self-control
Substance abuse treatment alone is not
enough.
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Treatment In Custody
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S. Covington manuals specific for this
population
Gender-responsive treatment showed
better outcomes (Messina et al, JSAT 2010)
Community based continuing care
improves outcomes
Safety issues: women victimized by
other inmates and custodial staff
Treatment in the Community
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Re-entry courts as an alternative
sanction
Second Chance, PROTOTYPES, intensive
tx that addresses COD
Complex problems of women parolees
often not addressed
Barriers to Effective Treatment
in the Community
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Laws and regulations are designed for
high risk inmates
Difficult to get approval for educational
activities outside the program
Computer access restricted
Exploitative requirements for telephone
access
Prohibitions/restrictions on medications
Recommendations
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Select appropriate evidence-based practices; avoid
“pick from this list” approach
Beware of rigid adherence to a model or EBP at the
expense of individualized treatment planning
Carefully investigate whether appropriate services are
available
Eliminate barriers to medication use for psychiatric or
addictive disorders
Acknowledge that tx requires building capacity for
independence; avoid excess restrictions not required
for public safety
References
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Covington, S. (1999). Helping Women Recover. San Francisco:
Jossey Bass.
Covington, S. (2000). Helping women to recover: Creating
gender-specific treatment for substance-abusing women and
girls in correctional settings. In M. McMahon (Ed.), Assessment
to Assistance: Programs for Women in Community Corrections
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(pp. 171-233). Latham, Maryland: American Correctional
Association.
Messina, N., Grella, C. E., Cartier, J., & Torres, S. (2010). A
Randomized Experimental Study of Gender-Responsive
Substance Abuse Treatment for Women in Prison. Journal of
Substance Abuse Treatment, 38(2), 97-107.
Zweben, J. E. (2011). Women's Treatment in Criminal Justice
Settings. In C. Leukefeld, J. Gregrich & T. P. Gullotta (Eds.),
Handbook on Evidence-Based Substance Abuse Treatment
Practice in Criminal Justice Settings. New York, NY: Springer.
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