Introduction:
In working with women that are chemically dependent, there is significant anecdotal evidence that most of the women that we work with experience co-ocurring chemical dependency as well as other mental health issues. We also know from anecdotal evidence that most of the women that we work with have experienced some form of trauma in her lifetime. In order to best serve the clients that we work with, we are constantly reading journals and articles to educate ourselves. The focus of this literature review will be to look at what is already known about women’s issues in chemical dependency as well as what is being done currently to address this problem. The articles will address background regarding the problem of high recidivism rates for chemically dependent women, variables, and treatments that are currently used to address the problem. Covington (2008) chronicles the history of substance abuse treatment. Covington explains that throughout the history of substance abuse treatment, counselors focused only on addiction and assumed that other issues would resolve themselves throughout the recovery process, or would be dealt with by another mental health professional at a later time.
The Covington (2008) article reports that research demonstrates that addiction treatment services for women need to be based on an integrated and women-centered approach that acknowledges their psychosocial needs. Covington believes that the most important factors in developing effective services for women is understanding their life experiences and the impact of living as a female in a male based society and acknowledging this. Covington goes on to identify common themes in the lives of addicted women. These include: shame and stigma, physical and sexual abuse, relationship issues including; fear of losing children, fear of losing partner, needing a partner’s permission to obtain treatment; treatment issues including: lack of services for women, not understanding women’s treatment, long waiting lists, and lack of childcare services; and lastly, systemic issues including: lack of financial resources, lack of clean sober housing, and poorly coordinated services (p. 378).
Covington (2008) identifies that the addiction treatment field considers addiction a progressive and chronic disease, yet its treatment practices are more aligned with those of an acute care medical model than the chronic disease care model. Covington recommends a recovery model that is more in line with disease management approaches to other chronic health problems, focusing on quality-of-life outcomes as defined by the individual and family. She further recommends offering a broader range of services earlier with pre-treatment (recovery priming), recovery mentoring through primary treatment, and would extend services and treatment well beyond the traditional medical services model with post-treatment recovery support services (p.379).
In her article, Covington (2008) reports that women are likely to experience these co-occurring disorders: dissociation, depression, post-traumatic stress disorder, eating disorders, anxiety disorders, and personality disorders including borderline personality disorder. Covington cites mood and anxiety disorders at the top of the list. She goes on to identify that women are more often diagnosed with borderline personality disorder than men and that one would see borderline personality disorder when viewed through the lens that considers abuse and trauma that is often associated with borderline personality disorder. She also responds to this in identifying that borderline personality disorder will likely be changed to complex PTSD in the upcoming DSM V.
The Covington 2008 article cites Dr. Judith Herman who defines trauma as a “disease of disconnection” (p. 381). She presents a three stage model for trauma recovery 1.) safety; 2.) rememberance and mourning; and 3.) reconnection. Covington brings in Herman’s work that emphasizes that a trauma survivor who is working on safety issues needs to be in an all women’s recovery group until she begins stage three, reconnection (p.382). She also explains that a woman who is stabilized in her addiction treatment may begin stage two trauma; the work of remembrance and mourning. She reports that the third stage of trauma work, reconnection which focuses on developing a new self and a new future, might not begin until a woman has been in recovery from addiction for two or more years, depending on each individual situation.
Covington (2008) advises that women need to be educated in trauma, as they often do not know what it is or that they have been abused, nor do they understand PTSD. She reports that they need to have their reactions normalized; meaning that what they do behaviorally is often a response to an abnormal situation. Finally, they need to develop coping skills such as deep breathing and other grounding exercises to help themselves cope with the trauma they experienced.
Another article that addresses abuse and trauma is an article by McDevitt-Murphy et al. (2009). In their article the authors study the co-occurrence of substance use disorders (SUDs) and post-traumatic stress disorder (PTSD) longitudinally over four years. The study looked at the relationships between PTSD and SUDs and identified 6 classes of people within that study. The six classes identified were low SUD-low PTSD (62.4%), low SUD-high PTSD (7.7%), high SUD-high PTSD (3.8%), high SUD-low PTSD (17.5%), low SUD-increasing PTSD (1.8%), and low SUD-decreasing PTSD (6.8%). The subjects with a lifetime history of PTSD at baseline had much higher rates of SUDs (alcohol and drugs) than subjects without PTSD.
McDevitt-Murphy et al. (2009) cites findings from the National Comorbidity Survey that suggests lifetime comorbidity of 51.9% for PTSD and alcohol use disorders (AUDs) and 34.5 % for PTSD and drug use disorders (DUDs). For women, the study shows lifetime comorbidity rates of 27.9% for AUDs and 26.9% for DUDs. The study states that these rates are even higher among people that seek treatment. The evidence also shows that people with both PTSD and SUDs display a much more severe and persistent course of both disorders, with more substance related problems and more psychological distress.
The McDevitt-Murphy et al. (2009) article states that patients with comorbid PTSD-AUD rely on maladaptive coping strategies more than alcohol abusers with other psychiatric disorders and they tend to show less improvement than patients with AUDs alone following traditional substance use treatment, they also have a shorter latency to relapse among substance abusers. One study cited showed higher levels of PTSD were associated with a higher risk of relapse in response to negative affect.
The McDevitt-Murphy et al. (2009) study had a sample size of 668 participants. Exclusion criteria for the study included current psychosis, current intoxication or withdrawal, ages older than 45 or younger than 18, IQ less than 85, or confusional state due to organic disorders. The participants were selected based on meeting the diagnostic criteria for one of four personality disorders of interest: schizotypal, borderline, avoidant, or obsessive compulsive. There were 245 men and 423 women in the study.
The McDevitt-Murphy et al. (2009) results showed that, patients with PTSD had higher rates (61.8%) of SUDs than patients without PTSD (46.2%).The study further found that within the low SUD-low PTSD group, the majority of participants were assigned to the avoidant group (25.3%), or the obsessive-compulsive group (27.9%). Within the high SUD-high PTSD group, a majority of participants were assigned to the borderline group (65.4%). The study also looked at the age of first trauma. The study found that the low SUD-low PTSD class had less than 20% of participants with borderline personality disorder and the high SUD-high PTSD group having more than half borderline participants. The groups with higher rates of PTSD also reported substantially younger ages of first trauma.
If we look at trauma further and explore some of the differences in the etiology of different trauma types, it may help to understand some of the behaviors one might encounter in working with clients with subsequent personality disorders. Kaehler and Freyd (2009) address issues related to borderline personality disorder.
Kaehler and Freyd (2009) identify that borderline personality disorder (BPD) has been identified as originating from both insecure attachment styles and trauma. They suggest that Betrayal Trauma Theory (BTT) states that survivors of trauma may be unaware of betrayal in order to maintain necessary attachments to primary caregivers.
Kaehler and Freyd (2009) report that 75% of people diagnosed with borderline personality disorder (BPD) are women and 80% of people seeking treatment for BPD are women. The authors report that patients with BPD frequently display either fearful or unresolved attachment styles. They further identify fearful attachment style as a mistrustful attachment style whereby the person longs for intimacy, however is fearful of being hurt or rejected. Unresolved attachment style (with preoccupied features) is identified as an attachment style whereby the person seeks intimate relationships, but is sensitive to perceived dependency.
The Kaehler and Freyd (2009) article cites one threat to the development of a secure attachment style is parental maltreatment. The authors cite one study that found attachment-anxiety to be directly correlated with childhood sexual abuse (CSA). And attachment avoidance was found to be associated with all types of childhood maltreatment. The authors estimate that CSA is estimated to be as high as 75% in patients diagnosed with borderline personality disorder. It is further suggested that CSA may be an etiological precursor to developing borderline personality disorder. The article cites physical abuse, emotional abuse, and neglect as being frequently associated with the development of borderline personality disorder.
The Kaehler and Freyd (2009) article cites maltreatment rates as high as 90% in patients diagnosed with borderline personality disorder. The article goes on to report that attachment relationship functions as a key survival function of its own, protection. The betrayal trauma theory (BTT) uses this premise to account for why people need to isolate specific knowledge that may threaten survival. The authors define a betrayal trauma as a trauma involving a violation by someone that would be seen as necessary for survival (pg. 262) such as a violation by a primary caregiver. The BTT suggests that in order to maintain a necessary attachment to a primary caregiver, a survivor of primary caregiver maltreatment must remain oblivious to that betrayal.
Kaehler and Freyd (2009) maintain that normally it would be good to be able to detect betrayal in order to prevent future betrayals; but if detecting that betrayal would result in immediate violation of the attachment with a primary caregiver, a person may find it more adaptive to remain unaware of that violation. This can be found in the phenomenon of dissociation, which is a feature of the DSM criteria for borderline personality disorder (BPD).
Kaehler and Freyd (2009) explain that childhood trauma and dissociation in BPD are not really clear. The article cites different studies: one found that childhood trauma and dissociation in BPD were not related; another article found that although total childhood trauma and dissociation were not significantly associated, emotional neglect was. Another study they cited in the article found four risk factors for dissociation in BPD patients: inconsistent treatment by a primary caregiver, sexual abuse by a primary caregiver, witnessing sexual violence as a child, and date rape in adulthood. This particular study identified that instead of being an intrinsic component of BPD, dissociation and BPD may share childhood trauma as an etiological factor (pg. 262), and may be considered separately.
The Kaehler and Freyd (2009) study assessed borderline personality traits using a 53 item self-report inventory, the Borderline Personality Inventory (BPI) and the Brief Betrayal Trauma Survey (BBTS), a 12 item self- report questionnaire. This inventory looks at the betrayal level- low (e.g. natural disasters), medium (e.g. being attacked by someone not relationally close), or high (e.g. being attacked by someone relationally close), as well as the age that the trauma occurred.
Kaehler and Freyd (2009) found that borderline characteristics were significantly associated with high betrayal trauma and medium betrayal trauma, but not low betrayal trauma. The article goes on to describe possible limitations to the study, including that the sample consisted of undergraduate students, which the authors report could be a highly resilient population compared with a group that might be found in a typical clinical setting. They also report that the majority of the participants were White.
The Kaehler and Freyd (2009) article concludes with ideas for future studies including examining the age at which the trauma occurred in a more diverse sample, also exploring trust and awareness of betrayal in patients diagnosed with borderline personality disorder (BPD). Also, they would like to study memory impairment in people diagnosed with BPD.
One idea that Covington discusses in the first article is the idea of shame and its recurrent theme in addicted women. Another article that looks at shame is Rahm and Ringsberg’s article ‘disgust, disgust beyond description’- shame cues to detect shame in disguise, in interviews with women who were sexually abused during childhood (2006)
In this article Rahm and Ringsberg (2006) discuss shame and its recurrent theme in context of sexually abused women. The article aims at exploring one, whether and how women that were sexually abused in childhood verbally express shame- both covert and overt shame; and second, if shame was present, describes the extent of the shame expressed by the women. This was a qualitative approach using semi-structured interviews. The interviews were analyzed for verbal expressions of shame by identifying code words and phrases. These code words and phrases were sorted into six shame indicator groups and further categorized into different aspects of shame.
Rahm and Ringsberg (2006) start out with an introduction explaining shame and the difference between shame and guilt. The article explains that feelings of shame are experienced on a continuum whereby someone that is in deep humiliation for a long duration risk chronic feelings of shame which then may lead to pathologically low self-esteem, tendencies toward isolation, as well as social phobias. The article goes on to explain overt versus covert shame. Overt shame is described as giving rise to physical expressions of shame such as sweating, blushing, as well as certain behaviors such as breaking eye contact, putting hands in front of the face and various hiding behaviors. Covert shame is described as being more constant and more difficult to identify.
Rahm and Ringsberg (2006) cite Gottschald and Gleser (1969) as having developed a content analysis scale for the identification and quantification of linguistic expressions of various psychological states in order to detect deeper layers of meaning in the content of the text. According to these authors, shame can be identified through the use of key words or phrases that indicate shame. Rahm and Ringsberg (2006) indicate that this scale was further developed by Retzinger (1991) who discovered that these key words and phrases can be categorized into six groups indicating different qualities of shame. The author goes on to state that being sexually abused in childhood is taboo and shameful, so is the feeling of shame itself. The author cites Scheff (1990) who says that the feeling of shame is repressed and denied because it is mentally painful and threatens social bonds. The article goes on to claim that sexual abuse may be an under-reported public health problem because the subject itself is taboo and that to help victims recover it is key to set words to the taboos. It includes talking about the abuse as well as detecting the underlying processes including shame that can prevent recovery.
Rahm and Ringsberg (2006) discuss the meaning of the concept of shame so that there would be no linguistic or conceptual misunderstandings. The method was a qualitative approach with semi-structured interviews was used in data collection to ensure that unforeseen aspects might also be revealed because the concept of shame is so complex and involves many factors. Data was analyzed from both a qualitative approach- identifying the spoken expressions for shame and then categorizing them into different aspects of shame. It was quantitative in that frequency of key words and phrases were counted.
In the Rahm and Ringsberg (2006) study, ten women were chosen from three separate self-help groups for women based on self reports of sexual abuse during childhood. The subjects were Swedish born and Swedish speaking. The interviews that took place before the groups started were informal and between 1.5-2.0 hours in length. The informants chose the interview location. The interviews focused on four topics: one, current physical and mental health; two, relationships with original and present family members; three, relationships with other relatives and friends; and four, childhood and the circumstances under which the sexual abuse occurred. These issues were discussed in all interviews and the interviewees were also free to introduce issues that were of concern to them.
In the Rahm and Ringsberg (2006) study, interviews were taped and transcribed verbatim. The analysis was conducted in five steps. First, interviews were read several times in order to grasp the content. Second, they were qualitatively analyzed for verbal expressions of shame. Third, key words and phrases were sorted into six groups. Fourth, the code words in each indicator group were then sorted according to different aspects of shame. Fifth, the code words and phrases were counted.
Rahm and Ringsberg (2006) found that the informants had many shared experiences in that they felt alienated. This was expressed as feeling betrayed, feeling alone, or feeling like an outsider. Rahm and Ringsberg cited several examples of how this feeling was expressed. The informants also had the shared feelings of inadequacy. This was described in feeling powerless, feeling unworthy, or feeling worthless. The indicator group “hurt” was described with key words such as “offended,” “wounded,” “sensitive,” and “defeated.” This group included being hypersensitive and being stigmatized. Another part of experiences included being or feeling confused. Key words and phrases here included feelings of emptiness, being stunned, and/or losing control in a way that makes you dazed. There was only one aspect of this, turning off. The women described their feelings during and in relation to the abuse as though they turned the feelings off. Another category “uncomfortable” The study found that key words and phrases were not as frequently mentioned during the interviews. These included feelings of feeling awkard and feeling frightened. The last category accounted for was “ridiculous.” Key words here included funny, silly, odd, and different. The main idea here was feeling different.
In the Rahm and Ringsberg (2006) article, the data clearly showed that the women studied verbally expressed unacknowledged overt and covert shame. Key words and phrases were identified and categorized into the various aspects of shame. The study showed that the effect of shame was present and had influenced the lives of the interviewees. Mental health was negatively affected, as was their relationships with themselves and others. A few of the interviewees had attempted suicide.
Some limitations of Rahm and Ringsberg (2006) are that it is very hard to quantify a verbally expressed feeling. Although we can express with words, the magnitude of how someone feels something is very subjective. It also seems that the sample size was rather small. Considering that these were likely long interviews, it may be unreasonable to ask for a sample size of 200 or more participants. It would seem that the point is made and clearly supported that shame is present in various forms in the lives of women that were sexually abused as children. It appears to be something that they still deal with. It would have been nice to compare this with a population of non-sexually abused women. There may also be a certain amount of shame, as it seems that this is a universal human emotion. The interview questions would have to be structured differently to exclude childhood sexual abuse. It would be interesting to include some type of magnitude scale (0-10) to help the interviewees identify the magnitude to which these emotions negatively affected them.
One article that discusses specifically substance use after treatment with women and girls is Gil-Rivas, Grella, and Prause’s article. The Gil-Rivas, Grella, and Prause (2009) study looked at anxiety/depressive symptoms and lifetime and recent trauma exposure against substance use after residential treatment among individuals with co-occurring disorders. Data was collected at the beginning of treatment as well as six months after and 12 months following treatment. The study began with 402 participants and ended with 322 where the researchers were able to obtain complete data.
The Gil-Rivas, Grella, and Prause (2009) article explains that a large number of adults entering treatment for substance use disorders (SUDs) have at least one co-occurring disorder. It is reported that following treatment, many of these individuals return to substance use, experience employment and social problems, and report significant distress and psychiatric symptoms. The article cites another study that suggested that individuals with SUDs and other Axis I disorders likely have a greater sensitivity to anxiety states and a propensity to use avoidance as a coping mechanism, which may motivate them to use substances to alleviate these symptoms. The substance use in turn contributes to higher states of perceived stress which maintains the symptom-use cycle.
The Gil-Rivas, Grella, and Prause (2009) article reports that a history of violent victimization during childhood increases the likelihood for further victimization and to psychological and physiological reactions to stressors later in life. The article goes on to state that trauma exposure during childhood may cause difficulties in expressing and managing emotions, behavioral regulation, and may cause disruptions in social development. These individuals are likely to struggle with managing negative affective states. This population is also more likely to experience the likelihood for further trauma due to mental health issues, poor social functioning, unstable housing, poverty, and/or cognitive deficits. This is even more common for women who appear to experience more trauma and violent victimization than their male counterparts.
The Gil-Rivas, Grella, and Prause (2009) article found that 98.5% of participants experienced at least one lifetime trauma exposure event. The study also found that employment the year preceding the first interview proved to be a protective factor, the authors postulate that this might be indicative of better cognitive and social functioning as well as provide for greater access to resources which may facilitate efforts to maintain abstinence. The study also found that women were more likely to report substance use over the follow up interviews than men.
The Gil-Rivas, Grella, and Prause (2009) article reports that women are more likely to use alcohol in response to alcohol related cues when experiencing negative affective states compared with men. It also reports that women are more likely to enter treatment with more severe psychosocial difficulties compared with men. Latino participants were less likely to use substances compared with White participants; also supervised housing during the follow-up was associated with lower risk for substance use.
The Gil-Rivas, Grella, and Prause (2009) study found that higher levels of anxiety/depressive symptoms were associated with higher substance use during the follow-ups. Trauma exposure during the follow up period was also associated with an increase in substance use. The study found that ongoing anxiety and depressive symptoms rather than the presence of a PTSD diagnosis is more likely to contribute to substance use following treatment.
The Gil-Rivas, Grella, and Prause (2009) article concludes with ideas for future directions including the idea that researchers and treatment providers would serve patients better by routinely assessing trauma exposure during and post-treatment. It also recommends relapse prevention efforts including: skills training geared to helping individuals identify internal and external cues for use, how to identify and manage negative affective states, learn skills to effectively manage psychiatric symptoms, as well as teach individuals to identify, anticipate and avoid situations that may lead to further trauma exposure. The article recommended the Seeking Safety trauma curriculum citing it as having the most empirically supported data and that substance abuse treatment needs to incorporate mental health, substance abuse, and trauma concurrently. The article further identifies that efforts to promote long-term abstinence need to address poverty, unemployment, safe and supervised living situations, and the development of supportive social relationships.
One model that addresses how women develop relationally is the relational model of psychological development. In their book Wilsnack and Wilsnack (1997) explore in one chapter the relational model of women’s psychological development and its implications in substance abuse treatment. The chapter begins with a brief discussion of traditional theories of development whereby children move from childlike dependence to mature independence. The authors contrast this to the relational model, which views development as growth towards connection rather than individuation.
Wilsnack and Wilsnack (1997) then explore the Stone Center Relational Model. This model, the authors state, was built on the early work of Jean Baker Miller. This model posits that for women, the primary motivation throughout the lifespan is toward establishing connections with others. This model states that healthy connections with others are creative, mutual, energy-releasing, and empowering for the people involved and that this is fundamental to women’s psychological well-being. This model further claims that pathologies can be traced to disconnections or violations within relationships. The authors explain that these could be at the personal/family level or at sociocultural levels.
The next section of the chapter directly addresses substance use. Wilsnack and Wilsnack (1997) cite Miller, who is said to have described a relational paradox- “when a woman cannot move a relationship toward mutuality, she begins to change herself to maintain the relationship” (pg. 336). The authors list five patterns of relational disconnection that may foster substance abuse and increase relapse in women. These are: nonmutual relationships; effects of isolation and shaming; limiting relational images; abuse, violation, and systemic violence; and distortion of sexuality. (pg. 338) The authors propose that rather than honing in on women’s pathological or problematic orientation towards caretaking or maintenance of relationships, the focus should be on failures of mutuality in relationships as a source of problems.
Wilsnack and Wilsnack (1997) cite many authors who suggest that women who are at high risk for drug abuse are frequently socially isolated, single parents, unemployed, recently separated, divorced, or widowed. They explain that psychological isolation occurs when there is a breakdown of the relational context to validate and respond to a woman’s experience or her attempts at connection.
Wilsnack and Wilsnack (1997) report that by age 18, 38% of all female children in this country have been sexually abused in comparison to seven percent of male children. The rate of abuse in alcoholic families is even higher. The risk of being abused as an adult is much higher for women that have an alcoholic partner than for those that do not have an alcoholic partner. Other studies have shown that between 70 and 80 percent of husbands that batter their wives use alcohol, according to the authors. They go on to explain that women who have been abused are at greater risk to abuse substances. One study that the authors cite found that 70% of battered women are frequent drinkers.
Wilsnack and Wilsnack (1997) contend that women survivors of childhood molestation, battering, and rape are teaching us about the impact of such trauma on relational development. When early parental relationships are abusive- all future relationships are impacted. The authors found sexual dysfunction to be the best single predictor of female’s chronic problems with alcohol over a five year study period. Women use chemicals to numb out, to self-medicate the pain of the abusive experience. This often creates more sexual dysfunction since chemicals decrease physiological sexual arousal.
Wilsnack and Wilsnack (1997) explain that dissociation is a defense mechanism used by people that have been abused. Alcohol and drugs recreate the dissociative experience. When we are dissociated, we are not connected. Also discussed in this section is the strong sex-alcohol connection in advertisements. The authors explain that other studies have found that alcohol is the drug of choice for seductive and aphrodisiac purposes despite evidence that it actually takes away from the sexual experience.
In the next section, Wilsnack and Wilsnack (1997) discuss implications for treatment including self- help groups. They discuss the strengths and weaknesses of these. The strengths are said to be that these groups provide a forum for connection to happen, and it is free and easily accessible. The weaknesses are that these groups are not designed to address issues of rape, battering, and other traumas that often keep women from achieving long term sobriety. The authors also cite the language used in the Big Book as not female friendly and somewhat outdated.
Wilsnack and Wilsnack (1997) also discuss the concept of codependency. They criticize the idea of codependency because the definition is so vague yet so inclusive, that almost everyone in the culture fits the criteria. Since women in our culture are expected to be the primary caretakers of others and relationships, co-dependency tends to be gender-linked. Instead of affirming and revisioning women’s potential strengths in relationships and validating their need for connection, the codependency concept pathologizes this relational orientation and puts women in a cultural double bind.
Many treatment models use a nonmutual and hierarchical and anti-relational model, explain Wilsnack and Wilsnack (1997). Women’s unique patterns of substance abuse and psychological recovery have not been the basis of the design of these programs. The authors argue that developing effective treatment services for women requires more than merely adding new components or staff trainings to existing programs. They believe not only do we lack treatment programs designed specifically for women, but the programs are designed specifically for men and then women are expected to fit in. Findings show that when men and women are grouped together, the women help facilitate the men’s talking about their experiences more and the women share their feelings and experience less than when they are in an all female group.
Wilsnack and Wilsnack (1997) state that specialized treatment programs are the preferred treatment setting. They believe that programs that are built on the relational model are extremely effective and powerful. Programs are most successful when the relational model provides the underlying treatment philosophy, shapes staff and client relationships and is reflected in staff interactions and decision-making.
The Sepulveda, 2010 article addresses the issue of substance abuse, dependency and incarcerated women. This article reiterated some of the trauma issues discussed in other articles and also highlighted that although women often develop substance abuse and dependency at faster rates than men, they also tend to have a greater awareness of their substance related issues. The female inmates also reported a greater use of coping mechanisms including seeking sober support, accepting responsibility, and escaping than their male counterparts. The article emphasized the need to focus on these positive protective factors women tend to have.
The Sepulveda, 2010 article also identifies risk factors including residing in neighborhoods with high rates of drug use, living with partners that are involved in illegal activities, combined with female specific stressors as critical barriers to these women’s recovery from substance abuse/dependence and incarceration.
Another article that addresses treatment interventions is the Amaro, McGraw, Larson, Lopez, and Nieves, et al. 2004 article. This article chronicles the development of a comprehensive trauma-specific model for women with alcohol and drug addiction in an urban, poor, and culturally diverse population with co-occurring mental health issues and a history of sexual and/or physical abuse.
The Amaro, McGraw, Larson, Lopez, and Nieves, et al. 2004 article chronicles that challenges that were faced in terms of coordination and communication across various sectors of providers (mental health, alcohol and drug, and domestic violence providers). The intervention developed included implementation of the TREM (Trauma, Recovery and Empowerment) curriculum as well as various skills building groups developed by the consortium including a women’s leadership training program, economic success in recovery, pathways to reunification and recovery, and family nurturing.
Amaro, McGraw, Larson, Lopez, and Nieves, et al. 2004 found that their intervention worked best when implemented in an inpatient or intensive outpatient setting. They had much less success in retention of participants in the methadone and other more loosely structured programs.
The APA has come up with specific guidelines for psychological practice with women and girls. This is discussed in the American Psychological Association (2007) article “Guidelines for psychological practice with girls and women.”
In this article The American Psychological Association (APA) (2007) discusses social differences and stressors for women as well as guidelines for psychological practice with women and girls. The article aims to articulate guidelines that will enhance gender and culture sensitive psychological practice with women and girls from various social backgrounds. The article begins with an identification of the problem citing that women and girls of many different social backgrounds have encountered extreme changes and complexities in regards to education, work, health, personal relationships, as well as reproductive and caregiving roles. The article explains that although women have had an increase in equality, they have also gained an increase in the amount of stressors that they experience. The stressors cited include: interpersonal victimization and violence, unrealistic media images, oppression and discrimination, limited economic resources, devaluation, role overload, relationship disruptions and work inequalities.
The APA (2007) article cites some statistics. Women are twice as likely as men to experience depression; girls are seven times more likely than boys to experience depression. Women that are subject to discrimination are even more likely to experience depression. Women and girls are approximately nine times more likely to have eating disorders than males. Women are two to three times more likely to experience anxiety disorders than men. The article explains that abuse and violence in the US may play a part in the development of these dysfunctions. The article also states that many people in the psychology field believe that women’s issues were resolved in the 1970’s and 80’s but that there is compelling evidence and need for psychologists to gain guidance in helping women for a few reasons. One, to avoid harm. Two, to improve research, consultation, teaching, and counselor training: And three, to develop and enhance treatment efforts, teaching, research, prevention, and all other areas that may help women and girls.
The APA (2007) article states that psychology as a field was criticized in the 1960’s and 1970’s for its biases with regards to race, class, gender, ethnicity, and sexual orientation. The article goes on to discuss bias in diagnosis and treatment. It explains that gender bias has become less covert, but is still observable and influential. The article gives the example of inappropriate use and overuse of certain diagnoses histrionic and borderline personality disorders, depression, somatization disorder, dissociative disorders, agoraphobia, and premenstrual dysphonic syndrome.
The APA (2007) article goes on to say that the specific needs and problems of girls and women may get overlooked and underdiagnosed because girls are more likely than boys to internalize problems or to express problems with less overt symptoms. The article cites the example that girls with attention deficit disorder tend to exhibit fewer disruptive behaviors, but have been found to suffer from more severe cognitive disabilities.
The APA (2007)article also discusses that there may be a problem in conceptualization of diagnosis because of sampling biases. The article cites another study that identified potential gender sampling biases associated with diagnostic categories of histrionic personality disorder, somatization disorder, conduct disorder, gender identity disorder, as well as dependent personality disorder. The article states that problems in diagnosis and treatment occur when the literature on a particular problem is based on mainly men or boys or mainly women and girls, or predominantly one ethnic group.
The APA (2007) article states that addiction and alcohol dependence research has often been based on male samples and generalized to all clients. The article goes on to state that women and girls metabolize alcohol differently, experience impairment with less alcohol consumption and are at greater risk of dying from alcohol related accidents. The article also states that women are less likely than men to seek help in addiction specific settings. The APA (2007) article explains that it is very important to consider how a person’s social background may affect the expression of a disorder. It also gets more in depth in regards to trauma. The article explains that the majority of PTSD diagnoses fall on women, however the construct of PTSD as we know it was based on data obtained from male combat veterans. The article explains that many women and girls are diagnosed with other axis I and axis II disorders when they experience trauma features that do not fit the traditional PTSD profile and that their diagnoses are often considered more stigmatizing and more chronic as in the example of borderline personality disorder or schizophrenia.
The APA (2007) article also discusses trauma further in that it is important to consider in more detail because of the high proportion of women (69%) that are exposed to traumatic stressors including sexual abuse and partner abuse. The article also reports that women are more than twice as likely to develop chronic PTSD symptoms following a traumatic event as well as lifetime risks for suicidal and self destructive behaviors, panic and anxiety attacks, eating disorders, substance use disorders, sexual adjustment disorder, and somatization disorder.
The APA (2007) article also explains that practitioners need to take into account external stressors and the context from which a woman or girl comes from rather than focusing too much attention on internal or intra-psychic factors inappropriately and/or detrimentally, including not considering discrimination or oppression. The article further calls on the most blatant example of gender bias and abuse whereby a practitioner violates the most important boundary and engages in sexual relationships with clients. The APA article states that despite clear ethical guidelines in this area, sexual relationships still occur and research demonstrates that these relationships most often occur with white, middle aged men having sex with younger female clients. The article explains that this not only interferes with therapy, but further victimizes the women and girls, rendering them more vulnerable to traumatization.
The APA (2007) article further delves into women with disabilities, and explains that an individual can be both an oppressor, member of an oppressed group, and both oppressor and oppressed at the same time which contributes to the stress that individuals experience. It also discusses contemporary social issues including the increase in global terrorism, violence and war where women are more vulnerable to rape, assault, and poverty; the media culture portraying women as thin, white, sexualized and victimized; changes having to do with a woman’s reproductive changes; and the increasing lifespan of an aging population consisting mainly of women.
The APA (2007) article concludes with an explanation of the history and development of the guidelines. The rationale was that gender socialization and traditional roles related to sexuality and gender are reinforced through differential treatment between boys and girls and may also be re-enacted without awareness or conscious intention. It explains the process by which these guidelines were developed. It included three task forces that were responding to early concerns about women’s rights, issues, and discrimination. This was the continuation of work that had begun in earlier conferences. It started with brainstorming and a sharing of dreams for this project with a final goal of producing an integrated document that honored gender and culture.
References:
Amaro, H, McGraw, S, Larson, M, Lopez, L, & Nieves, R. (2004). Boston consortium of services for families in recovery: a trauma informed intervention model for women's alcohol and drug addiction treatment. Alcoholism Treatment Quarterly, 22(3/4), 95-119.
American Psychological Association. (2007). Guidelines for psychological practice with girls and women. American Psychologist, 62(9), 949-979.
Covington, S. (2008). Women and addiction: a trauma-informed approach. Journal of Psychoactive Drugs, 5(Nov), 377-385.
Gil-Rivas, V, Grella, C, & Prause, J. (2009). Substance use after residential treatment among individuals with co-occurring disorders: the role of anxiety/depressive symptoms and trauma exposure. Psychology of Addictive Behaviors, 23(2), 303-314.
Kaehler, L, & Freyd, J. (2009). Borderline personality characteristics: a betrayal trauma approach. Psychological Trauma:Theory, Research, Practice, and Policy, 1(4), 261-268.
McDevitt-Murphy, M, Grilo, C, McGlashan, T, Skodol, A, Shea, M, Yen, S, Sanislow, C, Gunderson, J, & Markowitz, J (2009). Trajectories of ptsd and substance use disorders in a longitudinal study of personality disorders. Psychological Trauma: Theory, Research, Practice, and Policy, 1(4), 269-281.
Rahm, GB, Renck, B, & Ringsberg, KC. (2006). 'disgust disgust beyond description'-shame cues to direct shame in disguise, in interviews with women who were sexually abused during childhood. Journal of Psychiatric and Mental Health Nursing
Ramo, D, & Brown , S. (2008). Classes of substance abuse relapse situations: a comparison of adolescents and adults. Psychology of Addictive Behaviors, 22(3), 372-279. and Mental Health Nursing, 13, 100-109.
Sepulveda, V. (2010). Substance abuse, chemical dependency and incarcerated womnen: possible barriers to treatment and suggestions for counselors. The Wisconsin Counseling Journal, 24, 3-8.
Wilsnack, S. & Wilsnack, R. (1997) Gender and alcohol: individual and social perspectives. New Brunswick, N.J.: Rutgers Center of Alcohol Studies
Literature Reviews for your consideration
-By Jennifer Nyakundi
