Women Substance Misuse and Mental Health - Essay Example

Women Substance Misuse and Mental Health Historically, alcoholism and other drug use disorders have been conceptualized as problems οf men, and the study οf addictive behaviour in men has shaped the field's understanding οf the etiology, course, and treatment οf these disorders. Consequently, because women have been substantially underrepresented in most studies exploring outcomes οf different treatments for substance abuse, the effects οf different intervention approaches on women's outcomes are far less understood than they are for men. Because οf the significant behavioural, social, and emotional differences between treatment-seeking substance-abusing men and women, the findings from intervention studies that have focused largely or exclusively on alcoholism in men may not generalize to alcoholic women. (CCETSW 2000) For example, comparisons οf men and women entering treatment for alcoholism indicate that women (a) tend to do so earlier in the course οf their problem drinking (i.e., they exhibit a shorter average progression from drinking to being intoxicated regularly to first seeking treatment); (b) are younger, poorer, and more likely to have children; (c) receive less emotional support from their intimate partners and family members; and (d) have a higher prevalence οf psychiatric disorders, such as depression and anxiety. It is not surprising that several studies have also found differences in treatment response and outcomes for male and female patients. For example, one οf the few significant predictors οf post treatment outcomes to emerge from Project MATCH, the most comprehensive alcoholism treatment outcome study conducted to date, was gender; women had a significantly higher percentage οf days οf abstinence from alcohol after treatment than men. Similarly, Sanchez-Craig, Leigh, Spivak, and Lei (1999) reported that alcoholic women had greater reductions in heavy and problem drinking after brief outpatient treatment than men. Moos, Finney, and Cronkite (1990) found that women seeking help for alcoholism were more successful in medically oriented treatment programs, whereas men were more successful in peer-group-oriented programs. In their review οf the literature examining gender and alcoholism treatment, Hodgins, el-Guebaly, and Addington (1997) concluded that women tend to respond better to less structured interventions than do men. Interpersonal conflict and relationship factors appear to play a particularly important role in the drinking behaviour οf women. For example, Allan and Cooke (1985) found that, compared with men, women were more likely to drink in response to current life stressors and life events, such as marital discord, divorce, and children leaving the home. Consistent with these findings, Lutz (1991) found that, in contrast to alcoholic men, women were more likely to cite relationship problems as a primary motivational influence on becoming and remaining sober. An investigation by Connors, Maisto, and Zywiak (1998) revealed that women were significantly more likely than men to report conflict with their intimate partner as a primary relapse precipitant. Because family and relationship factors appear to play a critical role in the maintenance and exacerbation οf drinking problems as well as relapses after treatment, interventions specifically designed to address both relationship and drinking problems concurrently seem likely to have significant benefit for female alcoholic patients. A family-based treatment approach for alcohol use disorders that has significant empirical support is behavioural couples therapy (BCT). Studies conducted over the last 3 decades have found consistently that BCT is associated with positive outcomes for alcoholic couples and their families across multiple domains οf functioning, including reductions in drinking, improvements in relationship adjustment, reductions in intimate partner violence, and fewer emotional and behavioural problems οf the couples' children (for a review, see Fals-Stewart, O'Farrell, Birchler, Cordova, & Kelley, 2005). Unfortunately, investigations οf BCT that have appeared in the literature to date have relied almost exclusively on data from male patients. The few BCT studies that included female alcoholic patients had too few female patients to examine the comparative efficacy οf BCT for male and for female patients. It is interesting to note that, contrary to speculation that marital and family-based treatments for female patients with alcohol use disorders may be effective, some have argued that these interventions for alcoholic female patients may actually be no more effective than conventional, individual-based alcoholism treatment. In their influential review οf family therapies for alcoholism, Edwards and Steinglass (1995) reported that studies that have found family treatment superior to control treatments in reducing alcohol consumption had a substantially smaller proportion οf female participants (average οf 6% οf participants) than investigations that have found no differences in drinking outcomes between a family treatment and a control treatment (average οf 30% female participants). They argued that in studies “with a preponderance οf male alcoholics, marital or family therapy may be more likely to yield positive results; family therapy for female alcoholics may lose its edge over individual treatment” (p. 502). Conversely an investigation by Winters, Fals-Stewart, O'Farrell, Birchler, and Kelley (2002) indicated that BCT may be a comparatively effective intervention for substance-abusing women. Among female drug-abusing patients and their nonsubstance-abusing male partners, those who were randomly assigned to receive BCT had significantly better 12-month follow-up outcomes, in terms οf improved relationship adjustment and reduced substance use, than female patients who received individually based cognitive–behavioural treatment. Because the significant minority οf the drug-abusing female participants also met criteria for current alcohol dependence (i.e., 24%) and because there are similarities between drug- and alcohol-abusing populations in general, these findings suggest that BCT may, in fact, be an effective intervention for alcoholic women. However, what is needed is an investigation focusing exclusively on the efficacy οf BCT for alcoholic women. Thus, the purpose οf this paper is to examine the work οf a voluntary organisation drug and alcohol team offering one to one support in harm reduction, relapse prevention and to refer to community substance misuse teams and community mental health teams. (Tew 2004) The paper will also examine the comparative effects οf BCT on the outcomes οf married or cohabiting alcoholic female patients and their nonsubstance-abusing spouses or intimate partners. We hypothesized that participants who received BCT would report lower frequency οf alcohol use and higher relationship satisfaction than those who participated in other interventions (i.e., individual-based treatment [IBT] or a partner-involved psycho educational attention control treatment [PACT] condition) during treatment and during a 12-month follow-up period. Although drinking behaviour and relationship satisfaction are the primary outcomes οf interest, we also examined the comparative effects οf BCT on other significant areas οf broad psychosocial adjustment (e.g., physical health, social responsibilities, interpersonal relationships). (Trevithick 2005) In addition, we examined the effects οf BCT on partner violence, which is a highly significant public health concern for alcoholic women and has been found to be a prevalent problem among alcoholic patients and their partners. We also explored whether BCT had differential treatment effects on relationship functioning when it was actively being delivered. Because BCT was the only intervention used in this investigation that focused extensively on relationship enhancement, we expected that participants receiving BCT would report greater improvements in relationship satisfaction during treatment than those in other interventions. (DH 2002) Although drinking behaviour and relationship satisfaction were the primary targets οf the BCT intervention, the comparatively positive results for BCT were observed in other significant areas οf psychosocial adjustment. In particular, women who participated in BCT reported fewer total negative consequences as a result οf drinking during the year after treatment, particularly in terms οf interpersonal, intrapersonal, and social responsibility consequences, than women who participated in IBT or PACT. Despite these differences favouring BCT, it is also important to note that there were not differences among the conditions in terms οf female participants receiving formal treatment for alcoholism during the 12-month post intervention phase. (Adams 2002) Partners who received BCT versus those who received IBT or PACT reported fewer days containing episodes οf partner violence, in terms οf both male-to-female and female-to-male physical aggression. Because partner violence is a significant and prevalent problem among alcoholic dyads in general, identification and use οf interventions that serve to reduce partner violence in this population, as well as substance use, may be particularly important. The present investigation is the first to demonstrate greater reductions in partner violence among alcoholic women who received BCT compared with other treatments. Considered from a treatment process perspective, our findings indicate that the effect οf BCT was as intended and anticipated, resulting in accelerated increases in levels οf relationship happiness during the weeks when it was being delivered compared with IBT or PACT. Moreover, by the end οf treatment, couples who received BCT had higher levels οf dyadic adjustment than those who received IBT or PACT. Contrary to our expectations, we did not find differences among female patients in the three conditions in terms οf PAD during the intervention phase οf the investigation. This finding is inconsistent with the results οf other BCT studies with alcohol- and substance-abusing patients, which have typically found that patients who participate in BCT with their partner report fewer days οf substance use during treatment than patients in other treatment conditions. In this paper, all οf the interventions were fairly effective in reducing reported drinking during treatment, with most patients in all conditions reporting abstinence or very low levels οf drinking. In Winters et al.'s investigation, differences in substance use and dyadic adjustment between the two treatments (i.e., BCT and IBT) diminished over the course οf the 12-month follow-up period; in contrast, in this paper, group differences in these domains οf functioning increased during post treatment follow-up. It is not clear why the effects οf BCT were more robust over time in the paper than in the Winters et al. investigation, particularly given that the BCT treatments provided in the two studies were very similar (i.e., each used the same BCT therapy manual). However, certain differences in socio demographic and relationship characteristics οf participants in the respective studies suggest some plausible explanations for differences in outcome over the post treatment period. (Thompson 2006) In particular, the female participants and the couples in the Winters et al. (2002) study appeared to be more globally distressed than those who participated in the present investigation. Dyads in the Winters et al. study had much lower levels οf dyadic adjustment and were οf lower socioeconomic status, and the female partners typically had multiple current substance use diagnoses. Consequently, the patients in the Winters et al. study often presented with a more formidable, multifaceted set οf problems and thus were more difficult to treat in general than those who participated in the current investigation. Our clinical impression is that we used more session time in the Winters et al. study to address significant relationship and substance use crises that arose during the previous week and to diffuse high levels οf partner conflict than we used for the couples in the paper. Although the content οf the manualised BCT sessions was the same in both studies, more session time was used with alcoholic women and their partners for introducing, building, and practicing couples-based skills to enhance their relationship and build couple-based support for sobriety. Thus, it is plausible that the alcoholic women and their partners had more opportunity to learn, develop, and strengthen these skills during treatment, which, in turn, might have eroded more slowly after treatment. In this paper, we included a couples-based attention control condition, which reduces the likelihood that the positive effects οf BCT we observed were due simply to increased attention to the dyad or the male partner. In contrast to the Winters et al. study, we collected information on partner violence in the current investigation and observed important group differences (favouring BCT over IBT or PACT) in these behaviours. Because the vast majority οf treatment programs in Britain have a disease model orientation toward alcoholism and thus provide some form οf 12-step facilitation treatment, the findings οf the paper are likely to be more generalisable to community-based alcoholism treatment. Our investigation is marked by several other important strengths in general, including (a) use οf discriminable treatments with extensive, well-developed manuals; (b) high levels οf adherence and competence οf treatment delivery by counselors; (c) high levels οf participation in scheduled therapy sessions by participants in all treatment conditions; (d) high levels οf participation by partners in scheduled assessments οf treatment response and outcome, including few dropouts during the post treatment follow-up period; and (e) use οf psychometrically sound measures οf drinking, dyadic adjustment, and so forth. With these strengths noted, certain limitations οf the paper should also be highlighted. Most important, we excluded female alcoholic patients whose male partner met criteria for a current alcohol or substance use disorder. Other studies have found that either the majority or a significant minority οf married or cohabiting female alcoholic or substance-abusing patients entering treatment are involved with substance-abusing romantic partners. Thus, the nature οf our sample limits the generalizability οf our findings. Clearly, partner-involved interventions for dyads in which both partners misuse psychoactive substances need to be developed and evaluated to avail couples therapies to these dyads, although some researchers have argued that such an intervention needs to be substantially different than BCT, perhaps incorporating motivational interviewing methods or contingency management. An effective couples therapy approach for these couples not only would serve the needs οf many female patients initially entering treatment but would also have the effect οf reaching substance-abusing individuals (i.e., female patients' intimate male partners) who might not otherwise seek help. Alcoholism and drug abuse are among the most pressing public health concerns in the United Kingdom, often culminating in considerable negative consequences not only for those afflicted but also for their families and the communities in which they live. Although significant progress has been made in developing, evaluating, and subsequently improving treatments for these disorders, most interventions for substance abuse have evolved from treatment models developed and designed to address the substance use and associated behaviours οf men. However, in large part because οf significant behavioural, emotional, and socio demographic differences between treatment-seeking substance-abusing men and women, it has long been recognized by both clinicians and investigators that men and women have different treatment needs (Straussner & Zelvin, 1997). For example, in comparison with their male counterparts, substance-abusing women who enter treatment (a) tend to do so earlier (i.e., after a briefer period οf regular drug use); (b) are younger, poorer, and more likely to have children (e.g., Weisner & Schmidt, 2002); (c) receive less emotional support from their intimate partners and family members; (d) tend to be less involved in criminal activity but are more likely to be referred by social services; and (e) are more likely to meet criteria for generalized anxiety disorder and major depression but are less likely to meet diagnostic criteria for antisocial personality disorder (e.g., Grella & Joshi, 1999). Given these and other differences between male and female substance-abusing patients, it is not surprising the results οf the few available studies suggest male and female substance-abusing patients respond differently to certain types οf treatment. For example, Sanchez-Craig, Leigh, Spivak, and Lei (1999) reported women had greater reductions in heavy and problem drinking after brief outpatient treatment for alcohol misuse than did men. Moos, Finney, and Cronkite (1990) found women problem drinkers were more successful in medically oriented treatment programs, whereas men were more successful in peer-group oriented programs. Fiorentine, Nakashima, and Anglin (1999) reported female substance-abusing patients respond more favourably to an empathic counselling style, whereas men appear to respond better to a more utilitarian approach. Such findings suggest results from substance-abuse-treatment outcome studies that have relied mostly on data from male participants may not generalize to female substance-abusing patients. Unfortunately, it has been far more the norm than the exception that the vast majority οf substance-abuse-treatment outcome studies have largely or exclusively used male substance-abusing patients as participants. Because women have been substantially underrepresented in most clinical trials exploring various treatments for substance abuse, the effects οf different intervention approaches on women are far less understood than they are for men. Because οf the significant role οf family relationships in the etiology and maintenance οf substance use among women and their influence on treatment motivation, several clinical investigators have argued that involving family members may be a particularly important aspect οf the treatment for substance-abusing women (e.g., Enders & Mercer, 1993). Unfortunately, as with the majority οf substance-abuse-treatment outcome studies, investigations with BCT that have appeared in the literature to date have relied almost exclusively on data from male substance-abusing patients. Furthermore, there is some evidence that couples in which female partners abuse drugs are different along several dimensions οf functioning than are those in which male partners abuse drugs. For instance, in comparison with dyads in which only male partners abuse drugs, couples in which only female partners abuse drugs reported lower levels οf relationship satisfaction and were less committed to their relationships. Additionally, the substance-abusing partners in the male-only substance-abusing couples tended to have more significant problems in multiple areas οf functioning (e.g., more frequent substance use, more drug-related arrests, more drug-related hospitalizations) than their counterparts in the female-only substance-abusing dyads. Thus, it is not clear whether the positive outcomes observed when treating married or cohabiting male substance-abusing patients with BCT would be similar with couples with substance-abusing female partners. Although some authors have called for controlled trials to examine the efficacy οf behaviourally oriented couples therapy with female substance-abusing patients (e.g., McCrady & Raytek, 1993), no such studies have appeared in the literature to date. The few studies οf BCT that have included female alcoholic patients (e.g., Longabaugh, Wirtz, Beattie, Noel, & Stout, 1995; McCrady et al., 1991) had too few female patients to examine the efficacy οf BCT for male and for female patients. A very recent shift in research on treatment οf the substance-abusing client has been toward the investigation οf the effectiveness οf client–treatment matching strategies (e.g., Mattson et al., 1994). Although many therapy approaches have been found to be effective in the treatment οf substance abusers, few treatments have demonstrated any differential effectiveness when evaluated across undifferentiated, heterogeneous groups οf substance abusers. The notion οf treatment matching posits that therapeutic impact can be increased among clients who are appropriately matched to treatments, relative to clients who are not so matched. This was the design used in the recent Project MATCH, a multisite collaborative trial οf client–treatment matching. Little support for the matching hypothesis has thus far been accumulated through Project MATCH, in that few individual-difference variables have proven useful in predicting differential responsiveness to the treatments investigated. However, a major criticism οf the Project MATCH findings is that the therapies chosen did not specifically target the different therapy needs οf individual substance-abusing clients. All therapies investigated in Project MATCH were generic therapies that were designed to target pathological features common to all alcoholics. Moreover, the particular motivations οf different subtypes οf substance abusers were not specific targets οf intervention. Motivational theories οf substance abuse vulnerability generally propose that individual differences in personality produce different susceptibilities to the reinforcing properties οf drugs οf abuse (Pihl & Peterson, 1995). Conrod et al. recently found support for the validity οf the motivational hypothesis by demonstrating that substance-abusing women, classified according to specific personality profiles (i.e., anxiety sensitivity, introversion–hopelessness, impulsive sensation seeking, nonimpulsive sensation seeking), manifest distinct patterns οf addictive and nonaddictive psychopathology and coping skills deficits. Specifically, a profile characterized by elevated anxiety sensitivity was associated with higher rates οf simple phobia, somatization disorder, and anxiolytic substance dependence; whereas introversion–hopelessness was associated with elevated rates οf social phobia, major depression, and opioid substance dependence. Impulsivity was associated with a higher incidence οf antisocial personality disorder and stimulant substance dependence. Unlike these three profiles, a nonimpulsive sensation-seeking profile was associated with alcohol dependence exclusively and no other distinct concurrent psychopathology profile. Finally, a fifth profile, labelled low personality risk, characterized by relatively low scores on all four identified personality dimensions, was associated with lower rates οf comorbid psychopathology and milder substance abuse patterns relative to the other four profiles. These findings highlight the importance οf developing intervention strategies that differentially target subtype-specific motivational, personality, and coping skills profiles. Lacking in particular are targeted strategies for female substance abusers considering the current research indicating that the psychosocial and health consequences οf substance abuse may be more costly for women than men. The goal οf the present study was to conduct a preliminary test οf the effect οf matching motivation-specific cognitive–behavioural interventions to different personality and motivational profiles for substance abuse. Interventions were developed to target four different profiles: anxiety sensitivity, introversion–hopelessness, impulsivity, and sensation seeking. These interventions were also designed to be brief (90 min) as the literature strongly suggests that brief interventions can be very effective in changing drinking patterns and related problems. Bien, Miller, and Tonigan (1993) proposed that an active component οf successful brief interventions for alcohol abuse is the persuasiveness οf individualized feedback. Therefore, the current interventions involved providing clients with personalized feedback on their results from an extensive personality and motivational assessment. Furthermore, emerging studies on the treatment οf nonaddictive disorders indicate that successful cognitive–behavioural therapies for emotional disorders can lead to reductions in anxiety sensitivity in anxiety patients, depressive cognitions in depressed patients, and impulsivity in adolescents with externalizing disorders. Therefore, our interventions also included cognitive–behavioural skills training that targeted coping skills specifically relevant to each personality profile. (DH 2002) Considering the demonstrated effect οf assessment and motivational interviewing on alcohol- and drug-related behaviour (e.g., Bien et al., 1993), we tested the proposed intervention strategy against the effects οf a comparison intervention in which clients were presented with a film designed to enhance motivation for change and then were encouraged to discuss their reactions to the film with a therapist. Furthermore, the issue οf motivation specificity was critical in the current intervention strategy because we hypothesized that interventions that target the profile-specific motivations for substance misuse and related coping would prove more effective in reducing substance dependence than would exposure to general motivational and cognitive–behavioural principles. Therefore, the second comparison intervention involved motivational and coping skills training that was similar to the matched intervention but that targeted a personality profile that necessarily did not match the client's actual profile. Although our findings suggest that differences in drinking and dyadic adjustment outcomes favoured BCT over IBT and PACT throughout the post treatment follow-up, the positive outcomes observed at the end οf treatment gradually declined over time. Although decay οf treatment effects is the norm rather than the exception in substance abuse treatment outcome studies and treatment outcome studies in general, more attention needs to be given to developing and using methods to maintain gains over a longer period οf time after BCT is completed. Recognizing this problem, some investigators have sought methods to increase the durability οf the treatment effects. For example, with alcoholic couples who receive BCT, it appears that adding post treatment relapse prevention sessions is effective in sustaining therapy gains after treatment. Certain methodological limitations should also be noted. Participants were included who met criteria for either alcohol abuse or alcohol dependence, which yielded a somewhat heterogeneous sample. We also had a moderate number οf missing data; although the imputation method used to deal with missingness was rigorous and has many advantages over other commonly used approaches (e.g., listwise deletion, mean substitution), it does introduce a degree οf uncertainty into the results versus use οf actual data collected from participants. Given positive outcomes across multiple domains οf functioning, BCT appears to be a very promising intervention for women seeking alcoholism treatment who are involved with nonsubstance-abusing partners. Conclusion The physical consequences οf both alcohol and substance use are serious for women. Alcohol is the third leading cause οf death among women aged 35—55 years, and women who drink heavily are at higher risk than their male counterparts for rapid development οf liver disease and for death due to cirrhosis. Women experience the adverse effects οf drinking—liver, cardiovascular, and gastrointestinal disease—more quickly, and at lower drinking rates, than do men, a phenomenon known as "telescoping". Reproductive consequences οf alcohol and other drug use include an increased risk for amenhorrhea, spontaneous second trimester abortions, breast cancer and sexually transmitted diseases including HIV infection. Alcohol use, while less sensational than drug use, is much more prevalent than other substances in general, and more prevalent among individuals with severe mental illness in particular. (Webber 2000) Significant gains have been made since the absence οf research in women's health care was first identified as a barrier to effective treatment οf women. Women diagnosed with severe mental illness speak with increased candour about their experiences, prompted by the attention and respect that consumer voices have gained. Information and innovative treatment models are emerging from both the mental health and the addiction treatment sectors that raise the next level οf questions. Will the current rise in heroin use exacerbate the already alarming increase in HIV infection among women? Although crack cocaine use has diminished among the general population, will its use continue or spread among severely mentally ill women? (Tew 2004) We need to know more about the social networks οf dually diagnosed women: To what degree do they support recovery or promote relapse? Does the woman with a severe psychiatric diagnosis experience violence and victimization differently from the woman with a less serious psychiatric disability? How do early and ongoing experiences οf violence and abuse affect the course οf treatment for both severe psychiatric disorders and co-occuring addictive disorders? With respect to services, we must ask to what degree existing models adequately address the broad range οf service needs οf dually diagnosed women: To what degree, and how, do these models achieve linkage with community-based supports? To what extent are they willing to accept responsibility for women with severe psychiatric diagnoses? And what treatment components are effective in promoting recovery for dually diagnosed women? However, these questions may be rendered moot by present political circumstances. 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Ideas in Action: The Mental Health Dimension in the New Social Work Degree: Starting a Debate" Social Work Education Vol 23, No 2 April 2004 pp 231-240 Thompson, Neil (2006) Promoting Equality: Challenging Discrimination and Oppression (2nd edition) Trevithick, Pamela., (2005) Social Work Skills: A Practice Handbook Webber, R., Wright, P. and Chauhan, B. (2000) Mental health teaching and learning within qualifying level social work education. London: CCETSW Weisner, C., & Schmidt, L. (2002). Gender disparities in treatment for alcohol problems. 1872–1876. Read More