1. Today’s Session 1.Quiz 2 is 4/25 during last 45 minutes of class - study guide is on Moodle 2.HW 2 is due 5/2 – see assignment and grading rubric What stage is your group in? Which PSA have you chosen to critique? 3.Student oral presentations – today and 4/25 4.Lecture: women with SUD 5.Role play (if there is time) 1

2. 2 Tuckman Model (1965)

3. 3 Excerpted from http://www.slideshare.net/Torellion/bmp1-forming-storming-norming-performing-12036265 Tips for Teamwork

4. 4 Let’s talk about women with SUD

5. Women are Different from Men l Substance use prevalence, incidence, type l Health and social consequences l Treatment  treatment utilization  pathways to treatment  clinical profile  treatment retention  treatment outcomes

6. A substantial proportion of women are affected by SUD % of US population (SAMHSA, 2013) Per other indices, gender gap is narrowing: (1) alcohol use and abuse rates, (2) nonmedical prescription drug abuse, (3) SUD among youths aged 12 to 17 (Cotto et al., 2010; SAMHSA, 2013).

7. SUD among women has many health and social consequences Heightened risk for morbidity HIV, HCV, cirrhosis, depression Premature mortality Since 2007, more adult women of all ages have died each year from drug overdose than from motor vehicle–related injuries. In 2010, 4 times as many women died from drug overdose as were homicide victims (CDC, 2013). Involvement with criminal justice system ~50-60% of women are under the influence when they commit a crime; >80% of women offenders have a SUD (Bloom & Owen, 2003; Covington & Bloom, 2006). Child health/welfare; intergenerational effects Alcohol and fetal development, child mental health, parental substance abuse raises risk for use during adolescence. Shapes key life events, with possible lifelong effects Risk factor for early parenthood, low educational attainment

8. Mostly based on treatment samples, women more so than men… 1. Traumatic events experience traumatic early life events use substances to alleviate negative feelings Substance use may begin for girls as a maladaptive coping mechanism 2. Social stigma face harsher social stigma for their SUD experience feelings of shame and guilt related to their SUD Once begun, substance use can be a new source of stress for women 8 Childhood adversity may be a key determinant of SUD among women

9. Childhood Adversity & the Stress Process l Childhood adversity may function as an early life origin of SUD l It may be a source of chronic pain l It also may channel people into lower social strata & thereby widens health inequalities l It may create lifelong vulnerability to stress, especially among women Pearlin, 1981, 1989, 2005

10. Why women with SUD do not receive treatment 10 Substance Abuse and Mental Health Services Administration. Substance Abuse Treatment: Addressing the Specific Needs of Women. Treatment Improvement Protocol (TIP) Series 51. HHS Publication No. (SMA) 09-4426. 2009. Rockville, MD: Substance Abuse and Mental Health Services Administration.

11. Underutilization of treatment by women 11 Figure 2. Receipt of and Perceived Need for Substance Use Treatment in the Past Year among Women Aged 18 to 49 Who Needed Treatment: 2004-2006 Substance Abuse and Mental Health Services Administration. The NSDUH report: Substance use treatment among women of childrearing age. Rockville, MD: Office of Applied Studies; 2007.

12. More women than men report chronic pain 12 Munce SE, Stewart DE. Gender differences in depression and chronic pain conditions in a national epidemiologic survey. Psychosomatics. 2007 Sep-Oct;48(5):394-9.

13. Telescoping Telescoping describes an accelerated progression from the initiation of substance use to the onset of dependence and first admission to treatment. Fewer women than men abuse substances or are dependent but women progress more rapidly than men from use to abuse and dependence. Why? What are the implications for treatment?

14. At treatment entry, women tend to have greater severity than men in pre- treatment functioning l addiction severity l co-occurring psychiatric disorders, especially mood & anxiety l lack of employment/vocational skills, lower socioeconomic status l childhood and adult trauma & abuse exposure l parenting responsibilities, involvement with child welfare l interpersonal problems, conflict with family TIP 51: Substance Abuse Treatment for Women at http://media.samhsa.gov/samhsaNewsletter/Volume_18_Number_2/TIP51.aspx http://media.samhsa.gov/samhsaNewsletter/Volume_18_Number_2/TIP51.aspx

15. Women treated for SUD often exhibit more risk factors for SUD than men, and women suffer more SUD-related adverse consequences, and yet women are equally or more likely than men to recover. WHY?? “Gender Paradox” Caveat: findings are mixed… TIP 51: Substance Abuse Treatment for Women at http://media.samhsa.gov/samhsaNewsletter/Volume_18_Number_2/TIP51.aspx http://media.samhsa.gov/samhsaNewsletter/Volume_18_Number_2/TIP51.aspx

16. Men Outnumber Women in Treatment by 3 to 1 Treatment Admissions by Gender and Year Sources: SAMHSA, Office of Applied Studies, Treatment Episode Data Set (TEDS). Highlights 2004; Treatment Episode Data Set (TEDS): 1993-2003.

17. Treatment Components Associated with Better Outcomes for Women l Review of 38 studies with randomized and non-randomized comparison group designs:  child care  prenatal care  women-only admissions  supplemental services & workshops on women’s focused topics  mental health services  comprehensive programming Source: Ashley, Marsden, & Brady, 2003

18. Special Services or Programs for Women l 41% provide domestic violence services (N = 1,946) l 17% provide services for pregnant or postpartum women (N = 807) l 18% provide childcare (N = 855) l 9% provide residential beds for client’s children (N=427) 41% (N = 4,747) N = 11,578 treatment facilities that accept women clients Source: SAMHSA National Survey of Substance Abuse Treatment Services (N-SSATS), 2005

19. DimensionsVariables Treatment Orientation Women as priority or target population, program director’s gender, % women clients, treatment approach (e.g., non-confrontational, empowerment, strengths-based, relational, trauma-informed), % of female staff, staff training & education, cultural competency Women’s Services Prenatal/postnatal services, women-only groups (in mixed-gender settings), parenting training/counseling, trauma/abuse counseling and/or groups General Services Gender-specific assessment, psychiatric consult or on-site MH services, case management, medical, spiritual, educational, vocational, legal/CJS, social services, individual counseling, family therapy, HIV education/prevention, recreational/social, employment/ vocational, 2-step groups, transportation, after-care, housing Children’s Services On-site child care, live-in accommodations for children (in residential settings), age- & number rules regarding children’s participation, counseling services, psychoeducation, educational services, coordination with Child Welfare/Children’s Protective Services Physical Environment Program environment is safe & secure, child care area is clean and well designed, social/recreational spaces, community environment From Generic to Gender-Responsive Treatment Grella, 2008

20. Are Current Evidence-Based Treatments Gender-Responsive? Cognitive Behavioral Therapy Motivational Interventions Contingency Management Trauma-Related Interventions Pharmacotherapy

21. 21

22. Soon after treatment, mothers treated in women-only programs (relative to women in mixed gender programs) had lower rates of … arrest incarceration mental health services utilization 22 …and over 10 years, more of them had “successful outcomes” A study of >4,000 mothers treated for SUD in California and followed for 10 years

23. 23 Hispanic women had similar outcomes as White women despite more severe problems

24. 24 Outcomes were also impacted by perceived neighborhood safety and social involvement

25. Many of these women also had mental illness that went untreated 25

26. 26 Internalizing behaviors were more likely among children of mothers who had depression/anxiety or a severe co-morbid disorder than among children of mothers without these disorders

27. Summary l Treatment environments that address the “whole woman” – i.e., address women’s specific and diverse needs - improve  treatment retention  treatment outcomes  cost-benefits l Yet most women with substance use disorders are treated in programs that are not equipped to treat the whole woman l How can we design treatment settings to be more responsive to women’s needs?

28. Role Play Assess the needs and strengths of this woman with SUD. Design the ideal treatment experience for her. What criteria should be used to know if treatment is “working” for her? Woman with SUD Mental health specialist Social worker Primary care physician SUD treatment counselor