Women Substance Misuse and Mental Health - Essay Example

Running Head: Women Substance Misuse and Mental Health Women Substance Misuse and Mental Health of the of the institution] Women Substance Misuse and Mental Health Historically, alcoholism and other drug use disorders have been conceptualized as problems f men, and the study f addictive behaviour in men has shaped the field's understanding f the etiology, course, and treatment f these disorders. Consequently, because women have been substantially underrepresented in most studies exploring outcomes f different treatments for substance abuse, the effects f different intervention approaches on women's outcomes are far less understood than they are for men. Because f 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 f men and women entering treatment for alcoholism indicate that women (a) tend to do so earlier in the course f 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 f 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 f the few significant predictors f 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 f days f 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 f 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 f 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 f 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 f functioning, including reductions in drinking, improvements in relationship adjustment, reductions in intimate partner violence, and fewer emotional and behavioural problems f the couples' children (for a review, see Fals-Stewart, O'Farrell, Birchler, Cordova, & Kelley, 2005). Unfortunately, investigations f 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 f 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 f 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 f female participants (average f 6% f participants) than investigations that have found no differences in drinking outcomes between a family treatment and a control treatment (average f 30% female participants). They argued that in studies "with a preponderance f 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 f improved relationship adjustment and reduced substance use, than female patients who received individually based cognitive-behavioural treatment. Because the significant minority f 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 f BCT for alcoholic women. Thus, the purpose f this paper is to examine the work f 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 f BCT on the outcomes f 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 f 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 f interest, we also examined the comparative effects f BCT on other significant areas f broad psychosocial adjustment (e.g., physical health, social responsibilities, interpersonal relationships). (Trevithick 2005) In addition, we examined the effects f 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 f the BCT intervention, the comparatively positive results for BCT were observed in other significant areas f psychosocial adjustment. In particular, women who participated in BCT reported fewer total negative consequences as a result f drinking during the year after treatment, particularly in terms f 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 f 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 f partner violence, in terms f 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 f 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 f BCT was as intended and anticipated, resulting in accelerated increases in levels f relationship happiness during the weeks when it was being delivered compared with IBT or PACT. Moreover, by the end f treatment, couples who received BCT had higher levels f 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 f PAD during the intervention phase f the investigation. This finding is inconsistent with the results f 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 f substance use during treatment than patients in other treatment conditions. In this paper, all f the interventions were fairly effective in reducing reported drinking during treatment, with most patients in all conditions reporting abstinence or very low levels f 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 f the 12-month follow-up period; in contrast, in this paper, group differences in these domains f functioning increased during post treatment follow-up. It is not clear why the effects f 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 f 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 f dyadic adjustment and were f 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 f 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 f partner conflict than we used for the couples in the paper. Although the content f 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 f 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 f treatment programs in Britain have a disease model orientation toward alcoholism and thus provide some form f 12-step facilitation treatment, the findings f 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 f discriminable treatments with extensive, well-developed manuals; (b) high levels f adherence and competence f treatment delivery by counselors; (c) high levels f participation in scheduled therapy sessions by participants in all treatment conditions; (d) high levels f participation by partners in scheduled assessments f treatment response and outcome, including few dropouts during the post treatment follow-up period; and (e) use f psychometrically sound measures f drinking, dyadic adjustment, and so forth. With these strengths noted, certain limitations f 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 f married or cohabiting female alcoholic or substance-abusing patients entering treatment are involved with substance-abusing romantic partners. Thus, the nature f our sample limits the generalizability f 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 f many female patients initially entering treatment but would also have the effect f 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 f men. However, in large part because f 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 f 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 f the few available studies suggest male and female substance-abusing patients respond differently to certain types f 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 f 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 f different intervention approaches on women are far less understood than they are for men. Because f the significant role f family relationships in the etiology and maintenance f 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 f the treatment for substance-abusing women (e.g., Enders & Mercer, 1993). Unfortunately, as with the majority f 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 f 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 f 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 f 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 f 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 f 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 f BCT for male and for female patients. A very recent shift in research on treatment f the substance-abusing client has been toward the investigation f the effectiveness f client-treatment matching strategies (e.g., Mattson et al., 1994). Although many therapy approaches have been found to be effective in the treatment f substance abusers, few treatments have demonstrated any differential effectiveness when evaluated across undifferentiated, heterogeneous groups f substance abusers. The notion f 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 f 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 f the Project MATCH findings is that the therapies chosen did not specifically target the different therapy needs f 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 f different subtypes f substance abusers were not specific targets f intervention. Motivational theories f substance abuse vulnerability generally propose that individual differences in personality produce different susceptibilities to the reinforcing properties f drugs f abuse (Pihl & Peterson, 1995). Conrod et al. recently found support for the validity f 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 f addictive and nonaddictive psychopathology and coping skills deficits. Specifically, a profile characterized by elevated anxiety sensitivity was associated with higher rates f simple phobia, somatization disorder, and anxiolytic substance dependence; whereas introversion-hopelessness was associated with elevated rates f social phobia, major depression, and opioid substance dependence. Impulsivity was associated with a higher incidence f 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 f comorbid psychopathology and milder substance abuse patterns relative to the other four profiles. These findings highlight the importance f 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 f substance abuse may be more costly for women than men. The goal f the present study was to conduct a preliminary test f the effect f 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 f successful brief interventions for alcohol abuse is the persuasiveness f 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 f 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 f 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 f 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 f 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 f treatment gradually declined over time. Although decay f 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 f time after BCT is completed. Recognizing this problem, some investigators have sought methods to increase the durability f 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 f 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 f uncertainty into the results versus use f actual data collected from participants. Given positive outcomes across multiple domains f 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 f both alcohol and substance use are serious for women. Alcohol is the third leading cause f death among women aged 35-55 years, and women who drink heavily are at higher risk than their male counterparts for rapid development f liver disease and for death due to cirrhosis. Women experience the adverse effects f drinking-liver, cardiovascular, and gastrointestinal disease-more quickly, and at lower drinking rates, than do men, a phenomenon known as "telescoping". Reproductive consequences f 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 f research in women's health care was first identified as a barrier to effective treatment f 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 f 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 f 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 f violence and abuse affect the course f 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 f service needs f 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. The research and practice that have been developed to delineate and address domestic violence, sexual abuse, and addiction-particularly as they affect women at our extreme economic margins-are likely to be undermined by current and impending budget cuts. It would be tragic indeed, for the individuals most directly involved as well as for the society as a whole, if our emerging knowledge about women with co-occurring addictive and mental disorders is never to have the opportunity to shape future practice. References Adams, R, Dominelli L, Payne M. (eds) (2002) Critical Practice in Social Work Basingstoke, Palgrave Allan, C. A., & Cooke, D. J. (1985). Stressful life events and alcohol misuse in women: A critical review. Journal f Studies on Alcohol, 46, 147-152. Bien, T. H., Miller, W. R., & Tonigan, J. S. (1993). Brief interventions for alcohol problems: A review. Addiction, 88, 315-336. 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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