Sud Women

Quick Guide
For Clinicians
Based on TIP 51
Substance Abuse Treatment:
Addressing the
Specific Needs

Addressing the Specific
Needs of Women
Of WomenA Treatment
Improvement
Protocol
TIP
51
Wo
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
W
Center for Substance Abuse Treatment
SPECIFIC
www.samhsa.gov NEEDS
Contents
Why a Quick Guide? ....................................................... 2
What Is a TIP?................................................................. 3
Introduction .................................................................... 5
Gender-Responsive Treatment Principles .................... 7
Women’s Biopsychosocial Uniqueness ......................11
Factors That Protect Against the Development
of Substance Abuse and Dependence ....................... 21
Patterns Associated With Women’s
Substance Use .............................................................22
Physiological Effects of Substances
in Women......................................................................25
Characteristics of Treatment Admissions
Among Women .............................................................28
Screening and Assessment of Substance
Abuse Among Women..................................................30
At-Risk Screening for Drug and Alcohol
Use During Pregnancy .................................................34
Treatment Engagement, Retention,
and Planning ................................................................36
Predictors of Relapse and Reaction to
Relapse Among Women...............................................49
Treatment Considerations for
Diverse Populations .....................................................50
Treatment Outcomes—Did You Know?........................56
Quick Guide
For Clinicians
Based on TIP 51
Addressing the Specific Needs
of Women
This Quick Guide is based entirely on information contained in

TIP 51, published in 2009. No additional research has been
conducted to update this topic since publication of TIP 51.
Substance Abuse Treatment: Addressing
2 the Specific Needs of Women
WHY A QUICK GUIDE?

This Quick Guide accompanies the treatment
improvement guidelines set forth in Substance
Abuse Treatment: Addressing the Specific
Needs of Women, number 51 in the Treatment
Improvement Protocol (TIP) series. It summarizes
the how-to information in TIP 51 pertinent to
behavioral health counselors and clinicians, focus-
ing on tools, techniques, and concerns related to
providing services to women with substance use
disorders in behavioral health settings.
Users of this Quick Guide are invited to consult

the primary source, TIP 51, for more information
and a complete list of resources for addressing the
needs of women who have substance use disor-
ders. To order a copy or access the TIP online, see
the inside back cover of this Guide.
DISCLAIMER: The opinions expressed herein are

the views of the consensus panel members and
do not necessarily reflect the official position of
the Substance Abuse and Mental Health Services
Administration (SAMHSA) or the U.S. Department
of Health and Human Services (HHS). No official
support of or endorsement by SAMHSA or HHS for
these opinions or for the instruments or resources
described are intended or should be inferred. The
guidelines presented should not be considered
substitutes for individualized client care and treat-
ment decisions.
What Is a TIP? 3
WHAT IS A TIP?
The TIP series provides professionals in behavioral
health and related fields with consensus-based,
field-reviewed guidelines on behavioral health
topics of vital current interest. The TIP series is
published by SAMHSA and has been in production
since 1991.
TIP 51, Substance Abuse Treatment: Addressing

the Specific Needs of Women:
• Discusses women’s patterns of substance
use across a continuum from initiation of use
through recovery.
• Identifies the physiological effects of alcohol,
drugs, and tobacco on women.
• Focuses on specific screening, assessment, and
treatment engagement, placement, and planning
processes that support the unique constellation
of women’s issues.
• Highlights women’s prevention issues and treat-
ment needs across specific population groups
and treatment settings.
• Synthesizes current knowledge, including sci-
ence-based and best practices, to best address
the biopsychosocial factors that influence treat-
ment engagement, retention, and outcomes
among women.
• Provides an overview of administrative consider-

ations to support gender-responsive treatment
for women.
Other TIPs of interest to readers include:

• TIP 25: Substance Abuse Treatment and
Domestic Violence
• TIP 36: Substance Abuse Treatment for Persons
With Child Abuse and Neglect Issues
• TIP 42: Substance Abuse Treatment for Persons
With Co-Occurring Disorders
• TIP 43: Medication-Assisted Treatment for Opioid
Addiction in Opioid Treatment Programs
• TIP 48: Managing Depressive Symptoms in
Substance Abuse Clients During Early Recovery
Note: You may download TIPs and related products for free through the
SAMHSA Store at http://store.samhsa.gov.
Introduction 5
INTRODUCTION
Guidelines for Readers
This Quick Guide draws on ecological theory and

the Center for Substance Abuse Treatment’s
(CSAT’s) Comprehensive Substance Abuse
Treatment Model for Women and Children (see
Appendix B in the complete TIP). It is based on
clinical practice and research centered on women.
Rather than primarily comparing women with men,
the knowledge, models, and strategies presented
are grounded in women’s experiences and their
unique biopsychosocial and cultural needs.
The consensus panel recognizes that the reali-

ties of substance abuse treatment will sometimes
preclude implementing the wide array of services
and programs recommended in this Quick Guide.
Nevertheless, by presenting a variety of tech-
niques for addressing the specific treatment needs
of women, the panel hopes to increase sensitivity
to these needs and options for improving treat-
ment.
Terminology
Gender. This term is used not just as a biologi-

cal category, but also as a social category; society
or culture shapes the definition of gender and
shapes the socialization of each woman.
Gender-responsive. The content, delivery, and

cultural orientation of gender-responsive (or
woman-centered) services address the needs and
characteristics of each woman. Particular consid-
eration is given to the selection and development
of the treatment setting and environment, staff,
program components, and administrative and
clinical policies and procedures. Overall, gender-
responsive services reinforce healthy attitudes,
behaviors, and lifestyles while appreciating the
unique challenges and strengths of each woman.
Substance abuse. The term “substance abuse”

refers to both substance abuse and substance
dependence (as defined by the Diagnostic and
Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision, American Psychiatric
Association, 2000).
Gender-Responsive Treatment Principles 7
GENDER-RESPONSIVE TREATMENT
PRINCIPLES
The principles articulated by the consensus panel
are derived from research that highlights the dis-
tinctive characteristics and biopsychosocial issues
associated with women in general and specifically
with women who have substance use disorders.
These principles are as follows:
• Acknowledge the importance and role of
socioeconomic issues and differences among
women. Women’s substance use and abuse
should be framed in their socioeconomic con-
texts, including, but not limited to, employment,
educational status, transportation, housing, lit-
eracy levels, and income.
• Promote cultural competence specific to
women. Treatment professionals must under-
stand the worldviews and experiences of women
from diverse ethnic and cultural backgrounds,
as well as the interactions among gender, cul-
ture, and substance use, to provide effective
substance abuse treatment. Effective treatment
depends equally on attention and sensitivity to
the vast diversity among the female population,
including overlapping identities of race, class,
sexual orientation, age, national origin, marital
status, disability, and religion.
• Recognize the role and significance of relation-
ships in women’s lives.
• Address women’s unique health concerns.

Women possess distinctive risk factors associ-
ated with onset of use, have greater propensity
for health-related consequences from drug
and alcohol consumption, exhibit higher risks
for infectious diseases associated with drug
use, and display greater frequency of various
co-occurring disorders. Women who abuse sub-
stances are more likely to encounter problems
associated with reproduction, including fetal
effects from substance use during pregnancy,
spontaneous abortion, infertility, and early onset
of menopause.
•Endorse
a developmental perspective. Generally,
women experience unique life-course issues. One
should consider age-specific and other develop-
mental concerns starting with the assessment
process and proceeding through continuing care
and long-term recovery. Specific to women who
abuse substances, these life-course issues, along
with developmental milestones, influence their
patterns of use, engagement in treatment, and
recovery. Substance use and abuse affect women
differently at different times in their lives.
• Attend to the relevance and influence of vari-
ous caregiver roles that women often assume
throughout the course of their lives. Regardless
of substance abuse, women are more likely to
assume primary caregiving responsibilities for
their children, grandchildren, parents, and other
Gender-Responsive Treatment Principles 9
dependents. These roles may heavily influence a

woman’s willingness to seek help for substance
abuse and also may interfere with her ability to
fully engage in the treatment process or to com-
ply with treatment recommendations.
• Recognize that ascribed roles and gender
expectations across cultures affect societal
attitudes toward women who abuse substanc-
es. Whether or not a woman neglects her role as
a caregiver, engages in alcohol or drug-induced
sexual activity, continues to use despite pregnan-
cy, or uses sex to secure her next supply of drugs
or alcohol, women with substance use disorders
experience significant prejudice due to societal
attitudes and stereotypes of women who drink
and use drugs.
• Adopt a trauma-informed perspective. Current
and past violence, victimization, and abuse
greatly affect many women who abuse alco-
hol and drugs. Substance abuse treatment
approaches need to help women find safety,
develop effective coping strategies, and recover
from the effects of trauma and violence.
• Use a strengths-based model for women’s
treatment. A strengths-based approach builds
on the woman’s strengths and uses available
resources to develop and enhance resiliency
and recovery skills, deepen her sense of compe-
tence, and improve the quality of her life. These
strengths may include personality traits, abilities,
knowledge, cultural values, spirituality, and other

assets; resources may involve supportive rela-
tionships and environments as well as profes-
sional support.
• Incorporate an integrated and multidisciplinary
approach to women’s treatment. Treatment
needs to integrate current knowledge, research,
theory, experience, and treatment models
from diverse disciplines critical to understand-
ing women and substance abuse treatment.
Treatment providers must network and collabo-
rate with other agencies to provide comprehen-
sive case management and treatment planning
to address the complexity of biopsychosocial and
cultural issues that women may exhibit through-
out treatment.
• Maintain a gender-responsive treatment envi-
ronment across settings. Women with sub-
stance use disorders are more likely to remain
in treatment settings that feel familiar and safe,
include their children, use proactive case man-
agement, and foster supportive relationships
across the continuum of care.
• Support the development of gender com-
petence specific to women’s issues among
clinicians, administrators, and other staff.
Administrative commitment and vigilance will
ensure that staff members receive gender-
specific training and supervision to promote the
development of gender competence in providing
services for women.
Women’s Biopsychosocial Uniqueness 11
WOMEN’S BIOPSYCHOSOCIAL
UNIQUENESS
Women with substance use disorders have unique
biopsychosocial needs that should be addressed
if their treatment is to be successful. The following
information highlights these biological, psychologi-
cal, social, and developmental factors.
Biological and Psychological
Women’s physical responses to substances differ

from those of men.
• Women have different physical responses to
substances and typically display a quicker pro-
gression from initial use to the development of
health-related problems.
• Women become intoxicated after drinking small-
er quantities of alcohol than men. Women who
drink are affected more by alcohol consump-
tion due to higher blood alcohol concentrations,
proportionately greater body fat, and less body
water to dilute alcohol.
• Women develop substance use disorders and
health-related problems in less time than do
men, and this effect is known as telescoping.
Women with substance use disorders have

greater susceptibility to as well as earlier onset
of serious medical problems and disorders.
• From moderate to heavy use, drug and alcohol
consumption increase specific health risks and
physical disorders among women.
• Alcohol consumption increases risk for breast
and other cancers, osteoporosis in premeno-
pausal women, peripheral neuropathy, and cog-
nitive impairment.
• Women develop cirrhosis and heart muscle and
nerve damage with fewer years of heavy drinking
than do men.
• Illicit drug use is associated with greater risk for
liver and kidney diseases, bacterial infections,
and opportunistic diseases.
Women who abuse substances have gynecologi-

cal health issues and medical needs.
• Routine gynecological care is fundamental to
the prevention or early detection of a variety of
serious health problems among women with sub-
stance use disorders, including cervical, breast,
and other cancers; HIV/AIDS; and other infec-
tious diseases.
• Evidence supports the disruption substances
cause in reproductive processes, such as the
roles heavy alcohol use plays in infertility and
drug use plays in menstrual cycles.
• In substance abuse treatment, many young and

low-income women have never had a gynecologi-
cal examination. Moreover, women over 40 with
substance use disorders are less likely to have
received a mammogram than other women of
similar age.
In treating women of childbearing age who have

a substance use disorder, pregnancy is a signifi-
cant concern.
• Women who are abusing or are dependent on
alcohol or other drugs may not realize they are
pregnant.
• Women may mistakenly associate early signs of
pregnancy as symptoms related to use of or with-
drawal from substances.
• Often, women who are pregnant and using alco-
hol and illicit drugs do not begin prenatal care
until well into their pregnancies, yet adequate
prenatal care often defines the difference
between routine and high-risk pregnancy and
between good and bad pregnancy outcomes.
• Numerous medical concerns can result from
substance use during pregnancy as well as from
detoxification and the medications used to treat
substance use disorders.
Women who abuse substances are more likely

than other women to have co-occurring disor-
ders.
• Women with substance use disorders are more
likely to meet diagnostic criteria for mood disor-
ders specific to depressive symptoms, agorapho-
bia with or without panic attacks, posttraumatic
stress, and eating disorders.
Women who have substance use disorders are

more likely to have been physically or sexually
traumatized and subjected to interpersonal vio-
lence.
• A high proportion of women with substance use
disorders have histories of trauma, often perpe-
trated by persons they both knew and trusted.
These women may have experienced sexual or
physical abuse or domestic violence, or they may
have witnessed violence as children.
• Women who have been abused as children are
more likely to report substance use disorders as
adults.
• Physical and sexual dating violence are signifi-
cant predictors of substance use.
• A reciprocal relationship exists between sub-
stance abuse and domestic violence; rates for
one are higher in the presence of the other.
Social
Significant relationships and family history play

integral roles in the initiation, pattern of use,
and continuation of substance abuse for women.
• Women with alcohol use disorders are more like-
ly than men to report having had alcohol-depen-
dent parents, other alcohol-dependent relatives,
and dysfunctional family patterns.
• Women are more likely to be introduced to and
initiate alcohol and drug use through significant
relationships, including boyfriends, spouses,
partners, and family members.
• Women whose partners abuse substances
exhibit greater substance use themselves, and
they also have a higher incidence of substance
use disorders.
• Women with substance use disorders are more
likely to have intimate partners who also have
substance use disorders.
Significant relationships and adult family mem-

bers may substantially influence women’s behav-
ior associated with treatment seeking, support
for recovery, and relapse.
• Women may have less support from family/part-
ners than do men for seeking treatment.
• Women with alcohol problems are more likely to
be left by their partners at the time of entry into
treatment.
• Women’s partners are less likely to stay with

them after completion of treatment.
• Women are more likely to relapse due to inter-
personal problems and conflicts, and relapse is
more likely to occur in the presence of an unsup-
portive significant other.
For women, pregnancy, parenting, and child care

influence alcohol and drug consumption and
increase the likelihood of entering and complet-
ing substance abuse treatment.
• For many women, including those with substance
use disorders, use of alcohol, tobacco, and/or
illicit drugs significantly decreases after becom-
ing aware of their pregnancy.
• It is common for women who abstained from
alcohol, drugs, and tobacco during pregnancy to
return to use after childbirth.
• If they are able to have their children in treat-
ment, women are more likely to enter treatment,
participate and stay in the program, and main-
tain abstinence.
• Women who are with their children in treatment
have better treatment outcomes in major life
areas than women who are without their children
in treatment.
• Women in recovery see the support of their chil-
dren as an essential ingredient for their recovery.
Women are more likely to encounter obstacles

across the continuum of care as a result of care-
giver roles, gender expectations, and socioeco-
nomic hardships.
• Beyond pregnancy, women often assume many
other caregiver roles that can significantly inter-
fere with treatment engagement and regular
attendance at treatment services.
• Of women who receive substance use treatment,
about one third cannot cover treatment costs
due to inadequate or nonexistent health insur-
ance.
• Many female clients need transportation assis-
tance; affordable, safe housing; and onsite child
care and other services for their children.
Despite the unique challenges they face, women

are more likely to engage in help-seeking behav-
ior and to attend treatment after admission.
• Women with alcohol use disorders as well as
drug use disorders of marked severity are at
least as likely as men to initiate treatment.
• Once women are admitted to substance abuse
treatment, they are at least as likely as men to
participate and stay in treatment.
Women report more interpersonal stressful life

events.
• Women report more interpersonal stress,
whereas men report more legal and work-related
stress.
• During the week prior to relapse and on the ini-

tial day of relapse, women report interpersonal
problems and negative affect as key stressors.
Women often take different paths in accessing

treatment for substance use disorders.
• Women are more likely than men to seek out
physical and mental health treatment, including
substance abuse treatment.
• Among women with substance use disorders,
the most frequent source of referral to treatment
is through self-referral; the next most frequent
source is referral via the criminal justice system
and other community referrals, including child
protective services.
Women have unique client–counselor expecta-

tions and relational needs in treatment.
• Women are more likely to view relationship build-
ing as an essential treatment ingredient.
•Women
are more likely to stay in treatment lon-
ger if they receive more intensive and individual
care, can maintain their parenting role while in
treatment, and stay within the same treatment
services or maintain a connection with treat-
ment providers throughout the continuum of
services, including continuing care.
Women face unique types of discrimination relat-

ed to substance abuse.
• Women who report not receiving or not perceiv-
ing a need for treatment attribute social preju-
dice as the primary reason.
• Some women fear negative consequences,
including mandatory involvement with child pro-
tective services, loss of child custody, or other
legal consequences if their substance abuse
becomes known.
Developmental
Women experience unique life-course issues and

events. Changes in physiology, emotional and
social development, and cognitive capacity, as well
as changes in social roles and expectations, have
all been associated with substance abuse and its
treatment.
Identity and gender expectations: The younger

years
• During adolescence and young adulthood, young
women are likely to face greater gender-based
sociocultural expectations.
• The need to balance career endeavors—educa-
tion, training, and employment—with caregiver
responsibilities involving a woman’s parents as
well as her children is a major developmental
task that is undertaken by women more often
than men.
Caring for parents and partners

• More than 60 percent of caregivers are female.
• About 80 percent of informal elder care falls on
family caregivers, and these caretaking responsi-
bilities can last 10 years or more.
• Obstacles exist for women with substance use
disorders—balancing the need to care for their
parents and the need for their own substance
abuse treatment.
• Women are more likely than men to outlive their
partners.
The later years

• Substance abuse and dependence may exacer-
bate postmenopausal risks for coronary heart
disease, osteoporosis, and breast cancer in
women.
• Alcohol problems are ordinary events among the
elderly, and estimates of the prevalence of heavy
drinking or alcohol abuse range from 2 to 20
percent for this population.
• The etiology of elder substance use disorders is
multifaceted, and spousal loss is one commonly
cited factor.
Factors that Protect Against the Development
of Substance Abuse and Dependence 21
FACTORS THAT PROTECT AGAINST THE

DEVELOPMENT OF SUBSTANCE ABUSE
AND DEPENDENCE
Partners
A good marriage can be protective against the
development of alcohol abuse in women with a
familial history of alcohol abuse.
Religious and Spiritual Practices

Higher levels of personal devotion, religious affili-
ation, and religious beliefs may reduce the risk for
substance use and dependence among women.
Parental Warmth
Women who come from families that have high
parental warmth are less likely to initiate use,
abuse substances, or become dependent on alco-
hol or drugs.
Coping Skills
Engaging in problem-solving skills, mobilizing sup-
port from others, and learning to cope with one’s
feelings are key protective ingredients.
PATTERNS ASSOCIATED WITH

WOMEN’S SUBSTANCE USE
• Women are affected by familial substance abuse
as much as men; the prevalence of alcohol
dependence among women whose parents use
substances is from 10 to 50 times higher than
prevalence among women who do not have a
parent who abuses substances.
• Women who grew up in families where they took
on adult responsibilities as children, including
household duties, parenting of younger children,
and emotional support of parents, are more
likely to initiate drug and alcohol use.
• Women with partners who have alcohol-related
problems are more likely to report mental health
problems, including mood, anxiety, and quality-
of-life problems, as well as substance use disor-
ders.
• Women who are dependent on illicit drugs are
more likely than their male counterparts to have
partners who also use illicit drugs.
• Female adolescents and women struggling with
either issues or prejudice surrounding sexual
orientation are at greater risk of initiating and
maintaining drug and alcohol use.
• Some women continue using alcohol and illicit
drugs to have an activity in common with their
partners or to maintain their relationships.
Patterns Associated With Women’s Substance Use 23
• Women are at risk of contracting HIV/AIDS and

hepatitis from sharing needles or having sexual
relations with men who inject drugs or have sex
with men.
• A history of adverse childhood experiences and
other traumatic events (e.g., sexual and physical
assault, childhood sexual and physical abuse,
domestic violence) is significantly associated
with initiation of substance use and the develop-
ment of substance use disorders among women.
Trauma is both a risk factor for and a

consequence of substance abuse. Women
with histories of trauma may be using
substances to self-medicate symptoms. Thus,
interventions should be immediately put
into place to help build coping strategies to
manage strong affect, including relaxation
and other anxiety management skills. Start
skills-building immediately rather than
waiting for an incident to occur. It is far
more difficult to manage symptoms when
they are heightened than when they are
at lower levels of intensity.
• Women are more likely than men to have

co-occurring mental and substance use disor-
ders.
• Anxiety disorders and major depression, the

most common co-occurring diagnoses, are posi-
tively associated with substance use, abuse, and
dependence among women.
• Women are more likely to be introduced to and
initiate alcohol and drug use through significant
relationships, including boyfriends, spouses,
partners, and relatives.
• Even though women are less likely to inject
drugs than men, they accelerate to injecting at
a faster rate than men, and they are more likely
than men who inject drugs for the first time to
be introduced to this form of administration by a
sexual partner.
• Drinking low to moderate levels of alcohol in
early adulthood is a predictor of later heavy
drinking and alcohol-related substance use dis-
orders among women. Frequency of use appears
positively associated with risk of alcohol depen-
dence.
• Women are likely to curtail use of or establish
abstinence from alcohol and illicit drugs while
pregnant, even though they are as likely to
resume use later on.
• Women experience an effect called telescoping,
whereby they progress faster than men from ini-
tial use to alcohol- and drug-related consequenc-
es, even when using a similar or lesser amount
of substances.
Physiological Effects of Substances in Women 25
PHYSIOLOGICAL EFFECTS OF
SUBSTANCES IN WOMEN
Physiological Effects of Alcohol Consumption
Women experience negative physical consequenc-

es and complications from alcohol sooner and at
lower levels of consumption than men. Evidence
suggests that women progress significantly faster
in developing dependence, organ damage, and
diseases, even with much lower levels of alcohol
consumption. Women are more likely to die many
years earlier from alcohol abuse and dependence.
Following is a selection of disorders and diseases

associated with alcohol use among women.
Liver and other gastrointestinal disorders
• Fatty liver
• Alcohol hepatitis
• Cirrhosis
• Liver cancer
• Ulcers/gastritis
• Pancreatitis
• Diabetes
Heart-related conditions
• High blood pressure (hypertension)
• Cardiomyopathy
• Stroke
• Arrhythmia
Nutritional deficiencies
• Malnutrition
• Vitamin and mineral deficiencies
Reproductive consequences
• Fetal alcohol spectrum disorders (FASDs)
• Low birth weight
• Miscarriage
• Painful/irregular menstruation
• Underproduction of hormones
Cancers
• Breast
• Throat and mouth
• Stomach and colon
FASDs
Maternal alcohol use during pregnancy contrib-
utes to a wide range of effects on exposed off-
spring known as FASDs. FASDs are characterized
by abnormal facial features, growth deficiencies,
and central nervous system problems. Symptoms
can include hyperactivity and attention problems,
learning and memory deficits, and problems
with social and emotional development. Despite
alcohol-related birth defects being completely
preventable, FASDs are the most commonly
known nonhereditary causes of developmental
disabilities.
Physiological Effects of Substances in Women 27
Bone diseases
•Osteoporosis

Cognitive and other neurological effects
•Brain
shrinkage
•Peripheral
neuritis/neuropathy
•Dementia

•Wernicke’s
encephalopathy
•Korsakoff
syndrome
•Cerebellar
degeneration
Infections (greater susceptibility, faster
progression)
•HIV/AIDS

•Tuberculosis

•Pneumonia

Physiological Effects of Drug Use
Research, although limited, suggests that women

may be more vulnerable to the physiological effects
of licit and illicit drugs and points to the existence of
a gender-based vulnerability to the adverse conse-
quences of substance dependence. Women report
more severe psychiatric, medical, and employment
complications than men, and there is evidence that
women who use injection drugs are more suscep-
tible to medical disorders and conditions. Similarly,
women who use cocaine, heroin, or injection drugs
have a heightened risk of developing herpes, pul-
monary tuberculosis, and/or recurrent pneumonia.
CHARACTERISTICS OF TREATMENT
ADMISSIONS AMONG WOMEN
• Women are less likely to report alcohol as their
primary substance of abuse than men. Although
alcohol is still the primary substance of abuse,
women are more likely than men to be in treat-
ment for drug use.
• Women who enter treatment are more likely to
identify stress factors as their primary problem
rather than substance use.
• Women exhibit more severity of and problems
related to substance use upon entering sub-
stance abuse treatment, including medical and
psychological problems.
• Women constitute about 30 percent of admis-
sions for substance abuse. Depending on treat-
ment level, admission rates vary from 29 percent
in hospital inpatient facilities to 39 percent in
outpatient methadone programs.
• Women are admitted in notable proportions for
all types of prescription and over-the-counter
drug abuse: 47 percent for prescription narcot-
ics, 44 percent for prescription stimulants, 50
percent for tranquilizers, 51 percent for seda-
tives, and 42 percent for over-the-counter medi-
cations.
• Approximately 4 percent of women admitted to
substance abuse treatment are pregnant at the
time of admission.
Characteristics of Treatment Admissions Among Women 29
Note to Clinicians
For a woman entering treatment, the tendency
to focus on problems or stressors other than her
substance abuse is quite normal:
Women are socialized to assume more caregiv-
er roles and to focus attention on others. Even
if a woman has not appropriately cared for oth-
ers (such as her children) during her addiction,
it does not mean that she will not see this as
an important issue immediately upon entering
a detoxification or treatment program. Instead
of assuming that the female client’s worries
and her tendency to be other-focused is a det-
riment or an issue of resistance for treatment,
clinicians should use her concerns as a means
of motivation throughout treatment.
Depending on the specific drug class, some
women may have considerable concerns
regarding potential weight gain if they enter
treatment and establish abstinence. Among
women, weight loss is more likely to be seen
as a major benefit in continuing drug use.
In assessing risk factors or potential triggers
for relapse, note that the initial reasons for use
may be the same as reasons for relapse, even
if initial use occurred many years ago. More
times than not, women generally will underes-
timate the risks associated with these issues.
For example, women who initiated use due to
a relationship will often deny that relationships
are a current risk factor.
SCREENING AND ASSESSMENT OF

SUBSTANCE ABUSE AMONG WOMEN
How screenings and assessments are conducted
is as important as the information gathered.
Screening and assessment are often the initial
contact between a woman and the treatment sys-
tem. They can either help build a trusting relation-
ship or create a deterrent to engaging in further
services.
• Self-administered tools may be more likely to
elicit honest answers, especially regarding ques-
tions related to drug and alcohol use.
• Face-to-face screening interviews have not
always been successful in detecting alcohol and
drug use in women, especially if the counselor is
uncomfortable with the questions.
• Substance abuse screening and assessment
tools, in general, are not as sensitive in identify-
ing women with substance abuse problems.
• Screening and assessment instruments should
be examined to determine if they were devel-
oped using female populations. If not, counsel-
ors need to explore whether or not there are
other instruments that may be more suitable to
address specific evaluation needs.
• Because women are more likely to experience
greater consequences earlier than men, using an
instrument that highlights specific consequences
of use is crucial.
Screening and Assessment of Substance Abuse Among Women 31
Trauma-Informed Screening and Assessment

Often, clients who have posttraumatic stress
disorder (PTSD) have a difficult time distinguish-
ing between past feelings of danger associated
with trauma(s) and their current surroundings
when discussing trauma-related material during
interviews and counseling. Therefore, counselors
must remember that discussing the occurrence
or consequences of traumatic events and sub-
sequent PTSD symptoms can feel as unsafe and
dangerous to clients as if the event were occur-
ring now. Although the counselor should try not to
encourage avoidance or reinforce the belief that
discussing trauma-related material is dangerous,
sensitivity is needed when gathering information
about a woman’s history of trauma.
Initial questions about trauma should be general

and gradual. Although ideally, the counselor will
allow the client to control the level of disclosure,
it is important to mediate the level of disclosure.
At times, clients with PTSD just want to gain relief;
they disclose too much, too soon, without having
established trust, an adequate support system, or
effective coping strategies. Preparing a woman to
respond to trauma-related questions is important.
By taking the time with the client to prepare and
explain how the screening is done and the poten-
tial need to pace the material, the client has more
control over the situation. Overall, she should
understand the screening process, why the spe-
cific questions are important, and that she can
choose not to answer or to delay her response.
From the outset, counselors need to provide trau-
ma-informed education and guidance.
Culturally Responsive Screening and

Assessment
Foremost, use instruments that have been
adapted and tested on women in specific cul-
tural groups and special populations.
Even though a woman may speak English well,
she may have trouble understanding the sub-
tleties of questions on standard assessment
tools.
Acculturation levels can affect screening and
assessment results. A single question may
need to be replaced with an indepth discussion
with the client or family members to under-
stand substance use from the client’s point of
view.
Interviews should be conducted in a client’s
preferred language by trained staff members or
an interpreter from the woman’s culture.
It is important to remember that many instru-
ments have not been tested on women across
cultural groups and that caution should be
taken in interpreting the results. Counselors
need to discuss the limitations of instruments
they use with clients.
The most important domains in which to conduct

screening when working with women include:
Substance abuse.
Pregnancy considerations.
Screening and Assessment of Substance Abuse Among Women 33
• Immediate risks related

to serious intoxication or Assessment is only
withdrawal. as good as the
• Immediate risks for self- ability to follow
harm, suicide, and vio- through with
lence. recommendations
•Past
and present mental
disorders, including PTSD and other anxiety
disorders.
• Past and present history of violence and trauma,
including sexual victimization and interpersonal
violence.
• Health screenings, including HIV/AIDS, hepatitis,
tuberculosis, and sexually transmitted diseases.
For detailed information on screening and assess-

ment tools that can address each of these
domains, see pages 60 through 81 in the com-
plete TIP.
AT-RISK SCREENING FOR DRUG AND

ALCOHOL USE DURING PREGNANCY
• In screening women who are pregnant, face-to-
face screening interviews have not always been
successful in detecting alcohol and drug use.
• Self-administered tools may be more likely to
elicit honest answers; this is especially true
regarding questions related to drug and alcohol
use during pregnancy.
• Although questions regarding past alcohol and
drug use or problems associated with self,
partner, and parents will help identify pregnant
women who need further assessment, counsel-
ors should not underestimate the importance of
inquiring about previous nicotine use to identify
women who are at risk for substance abuse dur-
ing pregnancy.
• There are other factors that are associated with
at-risk substance abuse among women who are
pregnant, including moderate to severe depres-
sion, living alone or with young children, and liv-
ing with someone who uses alcohol or drugs.
At-Risk Screening for Drug and Alcohol Use During Pregnancy 35
Note to Clinicians
Because timely treatment for HIV/AIDS can
virtually eliminate the chance of a pregnant
woman passing the infection to her fetus, all
women with substance use histories should
have an HIV/AIDS evaluation at the first sign of
any possible pregnancy.
Methadone maintenance treatment has been
recommended as the only treatment for the
management of opioid dependence during
pregnancy because, when methadone is pro-
vided within a treatment setting that includes
comprehensive care, obstetric and fetal com-
plications (including neonatal morbidity and
mortality) can be reduced.
Counselors should be sensitive to female cli-
ents who are pregnant and help them manage
the additional stresses, demands, and guilt
that pregnancy can cause in a woman already
struggling with a substance use disorder.
TREATMENT ENGAGEMENT,
RETENTION, AND PLANNING
Barriers to Treatment Engagement
Women have identified multiple factors as barriers

to entering treatment, to engaging and continuing
with treatment services across the continuum of
care, and in maintaining connections with com-
munity services and mutual-help groups that sup-
port long-term recovery. At the outset, barriers
may exist on several levels. Following are some
examples of the types of barriers women may
encounter.
Intrapersonal (individual factors)
• Anticipation of not being able to use substances
to cope with stress, to manage weight, or to deal
with symptoms associated with mental disorders,
which creates considerable apprehension in
making a commitment to treatment
• Feelings of guilt and shame regarding use and
behavior associated with use
• Fear of losing custody of children upon admitting
the substance problem or seeking treatment
• Difficulties in accessing treatment, securing
appropriate services, and coordinating medical
and substance abuse treatment needs
Treatment Engagement, Retention, and Planning 37
Interpersonal (relational issues)

• Women are usually the primary caregivers of
children as well as of other family members; they
are often unable or not encouraged to enter and
remain in treatment.
• Women are particularly vulnerable to losing their
partner upon entering treatment.
Structural (program characteristics)
• Few treatment facilities offer groups or programs
for pregnant or postpartum women.
• Few residential programs allow mothers to have
their children with them, and outpatient pro-
grams often do not provide services for children
or child care.
• Few programs can simultaneously combine the
necessary prenatal care with substance abuse
treatment and services for older children.
• Women may have to travel with their children
and use public transportation to reach treatment
agencies; this can be a hindrance for women
in rural areas and for those who have limited
income.
Sociocultural
• Women are more likely to gain awareness of
substance abuse treatment and to initiate con-
tact with treatment providers if outreach services
are implemented.
• Women worry about being viewed as irrespon-

sible or neglectful “bad mothers” if they admit to
substance abuse or dependence; this fear can
interfere with help-seeking behavior.
• Women in some cultural groups experience more
negative attitudes toward their substance use in
general and may have more difficulty engaging
in help-seeking behavior and treatment services
based on gender roles and expectations.
Systemic (larger systems, policies, and laws)
• Many women in need of treatment are involved
in multiple social service systems; services may
be fragmented, requiring a woman to negotiate
a maze of service agencies to obtain assistance
for housing, transportation, child care, substance
abuse treatment, vocational training, education,
and medical care.
• In entering treatment, women sometimes risk
losing public assistance.
• Women who have substance use disorders often
fear legal consequences.
Treatment Engagement: Three Core

Strategies
The following strategies are particularly successful

when working with women.
Strategy 1: Provide out-

reach services The barriers
• Identify a woman’s most that exist before
treatment are
urgent concerns and
often the same
address those first, until obstacles that
she is ready to take on interfere with
other issues. successfully
• Programs that address completing
domestic violence, HIV/ treatment or
AIDS, or crisis intervention maintaining
can be a vital conduit for abstinence.
helping women take the
first step in connecting to substance abuse ser-
vices.
• Empathize with her fears and resistances while
helping her follow through on commitment.
• Help women negotiate the human service sys-
tem, particularly when the decision to seek treat-
ment is stymied by the lack of adequate, appro-
priate, or accessible programs.
Strategy 2: Conduct pretreatment intervention
groups
• Prevent more significant alcohol- and drug-relat-
ed consequences through early identification
and intervention.
• Provide personalized or structured feedback to
clients about their alcohol and drug use.
• Offer information about available treatment ser-
vices and treatment processes.
• Use strategies that enhance motivation,

decrease alcohol and drug use, and address cer-
tain psychosocial barriers.
Strategy 3: Offer comprehensive case
management
• Bridge the gap between services and agencies
via comprehensive case management.
• Match services to the client’s needs rather than
forcing the client to fit into the specific services
offered by an agency.
• Serve several functions and provide an array of
services for the client, including outreach, needs
assessment, planning, resource identification,
service linkages, monitoring and ongoing assess-
ment, and client advocacy.
• Know that women assigned to intensive case
management have significantly higher levels of
substance abuse treatment initiation, engage-
ment, and retention; high alcohol and drug absti-
nence rates; and longer lengths of abstinence.
They also tend to access a greater variety of
services.
For a complete list of services needed in women’s

substance abuse treatment, see Figure 5-3 on
page 93 of the complete TIP.
Treatment Retention
Women who are in treatment for substance use

disorders are more likely to benefit from:
• Supportive therapies rather than other types of
therapeutic approaches.
•A therapist’s warmth, empathy, ability to stay con-
nected during treatment crises, and skillful man-
agement of countertransference during therapy.
• A treatment environment that is supportive, safe,
and nurturing.
• A therapeutic relationship of mutual respect,
empathy, and compassion.
• Recognition that for parents, especially women,
children’s safety often is a chief concern and a
principal barrier to treatment engagement and
retention. Even if women do not have custody of
their children, they often are the ones who con-
tinue to care for them.
• Less aggressive treatment approaches based on
awareness, understanding, and trust.
• Therapeutic styles focused on the treatment
goals that are important to the client (this may
mean addressing issues of food, housing, or
transportation first).
The type of confrontation used in traditional

programs tends to be ineffective for women
unless a trusting therapeutic relationship
has been developed.
• Therapeutic styles that facilitate the client’s

awareness of the differences in the way
her life is now and the way she wants it to be.
• A view of treatment as a collaboration of equal
partners—the therapist is the expert on what has
helped other people, and the client is the expert
on what will work for herself.
• Women-only groups that specifically
provide more gender-responsive services.
•Access
to various ser-
vices in one location.
•Greater
intensive care Although many
(specifically residential women find
treatment). women-only groups
•Treatment
services beneficial, some
that include individual may express hostility
counseling. toward other women
•The
ability to keep their in such groups or
children with them treatment programs;
while in treatment. they may see other
•Relationships
or con- women as a threat
nections that are to their relationships
maintained throughout and engage in
treatment and during competitive behavior
step-down transitions in the group process,
from more to less or they may project
intensive treatment. their internalized
•A
counselor’s confi- negative stereotypes
dence in their prog- of women onto other
ress. group members.
Note to Clinicians
Women appear more likely to attend continuing
care, yet they often express feelings of discon-
nection with the new treatment provider and
struggle to manage the added demands and
expectations of child care while attending less
intensive treatment.
Women are more likely to engage in continu-

ing care if the primary treatment they received
involved specialized programming for women.
Treatment Planning Considerations
Involving intimate partners in treatment

In deciding whether or not to involve a woman’s
partner in treatment, primary consideration should
be given to her safety and to the partner’s willing-
ness to participate in treatment. If the client does
not feel safe involving her partner, the emphasis
should change to safety
planning.
The following important issues should also be

assessed to determine participation and level of
treatment involvement and to establish an appro-
priate treatment plan:
Is there a history of violence in the relationship?
Is there a history of substance use in the rela-
tionship?
• How influential has this partner been regarding

the client’s continued drug and alcohol use?
•Does
the partner see the client’s alcohol and/or
drug use as a problem needing treatment?

•How often are substances used during sexual inti-
macy or other activities with each other?
•Has
the client left prior treatment experiences
prematurely due to this relationship?
•What
is the partner’s attitude toward alcohol and
drug use?
•Are
there potential barriers that limit physical
attendance, such as distance from program,
transportation, work schedule, financial resourc-
es, childcare responsibilities, or similar concerns?
•Are
there any known mental health issues with
the partner or client that have affected or will
affect the relationship?
•Has
the partner ever threatened to leave, with-
draw financial support, or dispute the custody of
the children?
•Is
there a current commitment to maintaining the
relationship?
Parenting and relationship-building skills devel-
opment: Psychoeducational and clinical factors
Combining behavioral training with attachment-
based parenting interventions appears to be ben-
eficial. This strengths-based relational approach to
parenting assumes maternal assets already exist
that can be identified and built on and that the
emotional quality of the parent–child relationship
is equally important in improving that relationship

and the psychological adjustment of the child.
Topics for parenting skills and relationship building
include:
•Age-
and developmentally-appropriate behavioral
expectations for children.
•Children’s
emotional, physical, and developmen-
tal needs.
•Parenting
styles and other childrearing prac-
tices, including attachment-oriented approaches
defined as enhancing the parent’s ability to accu-
rately perceive and sensitively respond to the
emotional needs reflected in her child’s behavior.
•Strategies
to improve nurturing that begin with
helping mothers find a way to nurture themselves
as an important step in learning how to nurture
their children.
•Constructive
discipline strategies without corporal
punishment.
•Anger
management strategies to assist parents in
learning how they can appropriately manage their
strong feelings.
•Appropriate
parent–child roles, including model-
ing opportunities.
•Integration
of culturally congruent parenting prac-
tices and expectations.
Addressing co-occurring disorders
• Provide women who have co-occurring disorders
with comprehensive coordinated services using
an integrated treatment model.
Screen and assess for trauma as a standard

practice for women in treatment for substance
use disorders.
View services as long term, suggesting a range of
continuing care services and peer support, such
as 12-Step programs, group therapy, or women’s
support groups.
Attend to a client’s reaction to medication and
compliance, particularly when she is treated for
mental illness.
Note to Clinicians
Often, clinicians fear that addressing trauma-
related issues is counterproductive and may pro-
duce deleterious effects on women in substance
abuse treatment. However, data support the
safety of integrated, trauma-focused interven-
tions for women in substance abuse treatment
programs and show no differences in adverse
mental disorder and substance abuse symptoms
or events compared with standard care. Although
the selection of services and the planning for
how to deliver trauma-informed services is impor-
tant in maintaining integrity of care for clients,
integrated, trauma-focused interventions are not
only a viable option, but also an essential compo-
nent of treatment for women with substance use
disorders.
Women with substance use and eating disorders

Severe binge eating is consistently associated
with alcohol consumption, and dieting and purging
are associated with stimulant and sleeping pills/
sedative use. Approximately 17 percent of women
seeking treatment for either anorexia nervosa or
bulimia nervosa have a lifetime drug use disorder.
Overall, research indicates that substance abuse

is accompanied more often by bulimia and bulimic
behaviors than by anorexia. Nearly one third of
women with a history of bulimia also have a histo-
ry of alcohol abuse, and 13 percent have a history
of alcohol dependence.
Attitudes toward dieting among young women may

be related to increased susceptibility to alcohol
and drug use. This is both a health issue and
a relapse risk, because some women may use
cocaine or amphetamines (or both) to manage
their weight. Additionally, the tendency to overeat
affects many women in early recovery. Compulsive
or binge eating bears a similarity to abuse of sub-
stances other than food and is correlated with
depression, thoughts of suicide, and childhood
sexual abuse. Women engaging in binge eating
sometimes use food as a substitute for alcohol
and drugs; others may overeat to compensate for
the stress they experience in early abstinence.
Elements of the eating disorder may take the

place of relapsing to the drug of choice.
Advice to Clinicians:
Women With Eating Disorders
Substance abuse counselors may want to con-
sider these steps in addressing eating disorders:
Include an eating history as part of comprehen-
sive assessment.
Refer the client for medical evaluation.
Ask the client what happens as a result of the
disordered eating behaviors. Does she feel
in control, more relaxed, or numb? Approach
eating disorders as a response to emotional
discomfort.
Educate the client about eating behaviors as a
legitimate health concern.
Develop integrated services, and coordinate
necessary services and referrals (including a
referral to a provider who specializes in eating
disorder treatment).
Offer nutritional counseling and psychoeduca-
tion on eating disorders and disordered eating.
Institute routine observations at and between
meals for disordered eating behaviors.
Recommend the use of support groups that
are designed specifically for the given eating
disorder.
Teach coping skills using cognitive–behavioral
therapy, and include anxiety management
training.
Predictors of Relapse and Reaction to Relapse Among Women 49
PREDICTORS OF RELAPSE AND

REACTION TO RELAPSE AMONG WOMEN
Relapse Risks Unique to Women
Women are more likely to relapse if they report or

display:

•Interpersonal problems
and conflicts. Be aware that

•Low self-worth connected weight gain during
to intimate relationships. recovery can be a

•Severe untreated child- major concern and
hood trauma. a relapse risk

•Strong negative affect. factor for women.

•More symptoms of
depression.

•Greater difficulty in severing ties with other peo-
ple who use substances.

•Difficulty establishing a new network of friends.
•Lack
of relapse prevention coping skills.
Women’s Reactions to Relapse
Women are more likely than men to exhibit the fol-

lowing behaviors during or after relapse:
•Relapsing
in the company of others (particularly
with female friends or a significant other).
•Escalating
use after initial relapse that is positive-
ly associated with severity of childhood trauma.
•Seeking
help.
• Experiencing slightly shorter relapse episodes.
• Reporting depressed mood.
TREATMENT CONSIDERATIONS FOR

DIVERSE POPULATIONS
Hispanic/Latina Women
• Conduct initial assessment to determine level of

acculturation.
• Provide opportunities to identify and express
feelings about heritage and self-perception.
• Encourage exploration of strengths in their
cultural backgrounds, histories, and heritages,
including opportunities to explore old and new
ways to incorporate spirituality into their lives.
• Develop opportunities to build alliances and rela-
tionships with women (including staff and other
clients) from other groups and cultures.
African American Women
• Incorporate a strengths-based approach rather

than relying on a traditional deficit model.
• Use an Afrocentric perspective, when appropri-
ate and welcomed, to provide a framework for
recovery.
• Provide trauma-informed services that encom-
pass the impact of cumulative stress from his-
torical trauma, including the experience of preju-
dice and discrimination, to specific trauma.
• Involve family members and community to build
a network of safety and support.
Treatment Considerations for Diverse Populations 51
• Recognize the relevance of spirituality for the cli-

ent and encourage involvement, when appropri-
ate, to enhance or secure recovery.
Asian American and Pacific American Women
• Address the importance of ethnic heritage and

assess the level of acculturation at the begin-
ning of treatment to avoid making assumptions
regarding cultural values, family structure, gen-
der roles, and styles of communication.
• Incorporate drug and alcohol education to
reduce the stigma attached to substance abuse
and dependence.
• Approach treatment from the vantage point of
promoting overall health rather than focusing
solely on substance abuse; include a holistic
connection between body, mind, and spirit.
Reframe the presenting problem by emphasizing
the positive aspects of change.
• Provide a nurturing environment that does not
encourage cultural and gender-related tenden-
cies toward self-blame.
• Develop trust and build a therapeutic alliance to
help decrease internalized feelings of guilt and
shame.
• Honor the importance of family as the focal
point, and acknowledge that maintaining family
honor, obligations, and responsibilities is central
to women.
• Focus on problem-solving, goal-oriented, and

symptom-reduction strategies to circumvent the
likely shame associated with delving into past
alcohol or drug use behavior.
• Explore the history of trauma and the potential
for posttraumatic stress. Many older immigrant
Asian American women have been exposed to
losses, torture, and other types of war-related
trauma.
Native American Women
• Assess for a history of traumatic events, includ-

ing sexual and physical abuse, and a diagnosis
of PTSD.
• Provide trauma-informed services that encom-
pass the impact of cumulative stress from his-
torical trauma to specific trauma.
• Recognize that the role of “helper” may extend
beyond substance abuse counseling to seeking
advice for other health concerns, for other fam-
ily members, or for other life circumstances or
stressors.
• Acknowledge the importance of family history
and extended family members, and, as appropri-
ate, involve family members during treatment.
• Explore beliefs regarding healing and knowl-
edge of cultural practices. Do not assume that
a Native American woman follows traditional
practices.
• Understand and acknowledge the specific Tribe’s

cultural values, beliefs, and practices, including
customs, habits, gender roles, rituals, and com-
munication styles.
Lesbian and Bisexual Women
• Explore coping style and enhance coping skills

needed to manage stress associated with self-
disclosure and the “coming out” process, to deal
with attitudes from others regarding sexual orien-
tation, and to address feelings of alienation from
family members who reject the client’s sexual
orientation.
• In addition to appropriate family members, con-
sider friends as a vital component of treatment
and support structure. Lesbians generally receive
greater support from friends than from family.
Social support from family and friends will likely
enhance psychological well-being.
• Assess for interpersonal violence. Rates of part-
ner violence or abuse among lesbian women are
similar to those among heterosexual women,
and partner abuse often is accompanied by alco-
hol use. Assess for history of traumatic events,
including sexual and physical abuse and a diag-
nosis of PTSD.
Older Women
• Introduce coping strategies, including relaxation

methods, to enhance feelings of self-efficacy in
handling life stressors.
• Incorporate counseling services that address
issues of grief along with substance abuse treat-
ment as needed.
• Use additional resources to reinforce the need
for and support of treatment including, but not
limited to, extended family members, healthcare
providers, faith-based services, and so forth.
• Incorporate behavioral activation therapy to help
address depressive symptoms. This behavioral
approach helps clients recognize the connec-
tions among life stressors, mood, and less
effective coping behaviors. It encourages and
provides strategies for monitoring mood and
daily activities with an emphasis on strategies to
increase the number of enjoyable activities.
• Recognize and address the potential losses
associated with changes in caregiver roles.
Women in Rural Areas
• Screen for co-occurring disorders, and refer as

needed.
• Obtain a history of traumatic events, including
sexual abuse.
• Incorporate screening procedures to aid in

appropriate referral to other health and social
services.
• Explore potential reluctance in seeking help out-
side of the client’s immediate community.
• Assess for a history of interpersonal violence,
and recognize that rural women have often
reported learning that violence toward women is
acceptable.
• Explore beliefs and attitudes toward alcohol and
drug use.
TREATMENT OUTCOMES—
DID YOU KNOW?
• Gender is not a significant predictor of treatment
outcome. Once in treatment, women are as likely
as men to complete treatment and have good
treatment outcomes.
• One year after discharge from treatment, women
have abstinence rates and overall quality of life
similar to those seen in men.
• For women with posttraumatic stress reactions,
literature supports the relationship between the
receipt of integrated trauma-informed treatment
services and positive treatment outcomes.
• For women, participation in 12-Step programs
and involvement in social networks that support
recovery are important ingredients in maintaining
abstinence for 5 or more years.
• There appears to be a stronger association
between treatment participation and posttreat-
ment outcomes among women.
• Treatment completion and length of stay in resi-
dential treatment are important factors in estab-
lishing positive posttreatment outcomes among
women.
• In residential treatment for pregnant and parent-
ing women and their children, longer length of
stay is associated with increased abstinence,
improved employment and income, decreased
Treatment Outcomes—Did You Know? 57
arrests and depressive symptoms, and more
positive attitudes toward parenting.
• Relapse rates in women who complete treatment

for substance use disorders are not significantly
different from those seen in men.
• Women show greater increases than men in
employment, recovery-oriented social support
systems, and participation in mutual-help groups.
Ordering Information
TIP 51 Substance Abuse Treatment:
Addressing the Specific Needs RI
Women
Other TIP 51–Related

Products Substance Abuse Treatment:
Addressing the Specific
KAP Keys for Clinicians Needs of Women
A Treatment
Quick Guide for Improvement
Protocol
Administrators TIP
51
Consumer Brochure
Wo
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
W
Center for Substance Abuse Treatment
SPECIFIC
www.samhsa.gov NEEDS
Do not reproduce or distribute this publication for a fee without

specific, written authorization of the Office of Communications,
Substance Abuse and Mental Health Services Administration,
U.S. Department of Health and Human Services.
Two Ways to Obtain FREE Copies

of all TIPs Products:
1. Call SAMHSA: 1-877-SAMHSA-7

(1-877-726-4727; English and Español)
2. Visit the SAMHSA Publications Ordering Web page:

http://store.samhsa.gov
Other HHS products that are relevant
to this Quick Guide:
TIP 25: Substance Abuse Treatment and Domestic

Violence (SMA 12-4076)
TIP 36: Substance Abuse Treatment for Persons With

Child Abuse and Neglect Issues (SMA 12-3923)
TIP 42: Substance Abuse Treatment for Persons With

Co-Occurring Disorders (SMA 13-3992)
TIP 43: Medication-Assisted Treatment for Opioid

Addiction in Opioid Treatment Programs
(SMA 08-4214)
TIP 48: Managing Depressive Symptoms in

Substance Abuse Clients During Early Recovery
(SMA 13-4353)
See the inside back cover for ordering informa

tion for all TIPs and related products.
HHS Publication No. (SMA) 13-4789

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Quick Guide

Substance Abuse Treatment:

Why a Quick Guide? ....................................................... 2

Gender-Responsive Treatment Principles .................... 7

Women’s Biopsychosocial Uniqueness ......................11

Factors That Protect Against the Development

of Substance Abuse and Dependence ....................... 21

Patterns Associated With Women’s

Substance Use .............................................................22

Physiological Effects of Substances

Characteristics of Treatment Admissions

Among Women .............................................................28

Screening and Assessment of Substance

Abuse Among Women..................................................30

At-Risk Screening for Drug and Alcohol

Use During Pregnancy .................................................34

Treatment Engagement, Retention,

and Planning ................................................................36

Predictors of Relapse and Reaction to

Relapse Among Women...............................................49

Treatment Considerations for

Diverse Populations .....................................................50

Treatment Outcomes—Did You Know?........................56

This Quick Guide is based entirely on information contained in

WHY A QUICK GUIDE?

Users of this Quick Guide are invited to consult

DISCLAIMER: The opinions expressed herein are

TIP 51, Substance Abuse Treatment: Addressing

• Provides an overview of administrative consider-

Other TIPs of interest to readers include:

This Quick Guide draws on ecological theory and

The consensus panel recognizes that the reali-

Gender. This term is used not just as a biologi-

Gender-responsive. The content, delivery, and

Substance abuse. The term “substance abuse”

• Address women’s unique health concerns.

dependents. These roles may heavily influence a

knowledge, cultural values, spirituality, and other

Biological and Psychological

Women’s physical responses to substances differ

Women with substance use disorders have

Women who abuse substances have gynecologi-

• In substance abuse treatment, many young and

In treating women of childbearing age who have

Women who abuse substances are more likely

Women who have substance use disorders are

Significant relationships and family history play

Significant relationships and adult family mem-

• Women’s partners are less likely to stay with

For women, pregnancy, parenting, and child care

Women are more likely to encounter obstacles

Despite the unique challenges they face, women

Women report more interpersonal stressful life

• During the week prior to relapse and on the ini-

Women often take different paths in accessing

Women have unique client–counselor expecta-

Women face unique types of discrimination relat-

Women experience unique life-course issues and

Identity and gender expectations: The younger

Screen and assess for trauma as a standard