RECOVERY

Behavioral Health is Essential to Health • Prevention Works • Treatment is Effective • People Recover TREATMENTGuidance 

Document for

Supporting 

Women 

in Co-ed 

Settings

Guidance Document for 

Supporting Women in Co-ed Settings 

U.S. Department of Health and Human Services

Substance Abuse and Mental Health Services Administration 

Center for Substance Abuse Treatment 
Acknowledgements

This report was prepared for the Substance Abuse and Mental Health Services Administration 

(SAMHSA) by Advocates for Human Potential, Inc. (AHP), under contract number 283-07-3807, with 

SAMHSA, U.S. Department of Health and Human Services (HHS). Sharon Amatetti, M.P.H., within 

SAMHSA’s Center for Substance Abuse Treatment (CSAT), served as the Government Project Officer. 

Disclaimer

The views, opinions, and content of this publication are those of the authors and contributors and do 

not necessarily reflect the views, opinions, or policies of SAMHSA or HHS. Resources listed in this 

document are not all inclusive; inclusion as a resource does not constitute an endorsement by SAMHSA 

or HHS. This document is intended for information purposes only. 

The people in the photographs that appear on the cover of this document are models and used for 

illustrative purposes only. 

Public Domain Notice

All material appearing in this document is in the public domain and may be reproduced or copied without 

permission from SAMHSA or HHS. Citation of the source is appreciated. However, this publication 

may not be reproduced or distributed for a fee without the specific, written authorization of the Office of 

Communications, SAMHSA, HHS. 

Electronic Access and Copies

This publication may be downloaded or ordered at http://store.samhsa.gov. Or call SAMHSA at 

1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

Recommended Citation

Substance Abuse and Mental Health Services Administration, Guidance Document for Supporting 

Women in Co-ed Settings. HHS Publication No. (SMA) 16-4979. Rockville, MD: Substance Abuse and 

Mental Health Services Administration, 2016. 

Originating Office

Division of Systems Improvement, Center for Substance Abuse Treatment, Substance Abuse and 

Mental Health Services Administration, 5600 Fishers Lane, Rockville, MD 20857. HHS Publication

No. (SMA) 16-4979. Printed 2016. 

HHS Publication Number (SMA) 16-4979 

Printed 2016
Contents

I. INTRODUCTION AND BACKGROUND .............................. 1

Development of this Document .......................................................2

Sex and Gender Differences ............................................................3

II. GUIDANCE STATEMENTS ................................................ 5

Introduction .......................................................................................5

A. Addressing Women’s Unique Needs and Experiences ...............5

B. Gender Dynamics .......................................................................6

C. Trauma ........................................................................................7

D. Physical Health ...........................................................................7

E. Mental Health ..............................................................................8

F. Relationships ...............................................................................8

III. PRACTICES AND STRATEGIES .................................... 10

A. Staffing Issues ..........................................................................10

B. Environment/Facilities ...............................................................13

C. Assessment and Treatment/Recovery Planning ......................15

D. Interventions and Groups ..........................................................22

E. Recovery Support Services .......................................................28

IV. CONCLUSION ................................................................. 33

REFERENCES AND RESOURCES....................................... 34

APPENDIX 1: EXPERT PANEL ............................................. 39

APPENDIX 2: ADDITIONAL STAKEHOLDER INPUT ........... 40

APPENDIX 3: ASSESSMENT TOOL ..................................... 41
Page 1

I. IntRoDUCtIon AnD BACKGRoUnD

In 2013, nearly 566,000 women, 33.7 percent 

of the 1.68 million admissions, entered treatment 

for substance use disorders (SUDs) (Substance 

Abuse and Mental Health Services Administration [SAMHSA]/Center for Behavioral Health 

Statistics and Quality, 2015). Most of these 

women received services in co-ed treatment 

and recovery centers, where men outnumber 

women. Yet women and men with SUDs differ 

from each other in many respects. These 

include sex and gender differences, reasons for 

initiating substance use, consequences of use, 

barriers and motivations for entering treatment, 

and treatment and recovery needs (Brady, 2005; 

Covington, 2007; Greenfield et al., 2007; Grella 

et al., 2005; Fiorentine et al., 1999). 

Data from SAMHSA’s 2013 National Survey 

of Substance Abuse Treatment Services

(N-SSATS) show that less than half (44 

percent) of SUD centers have women-specific 

programming or groups (SAMHSA, 2014b). 

This includes co-ed programs that offer services 

or programs for women, such as womenonly counseling groups. This document’s 

purpose is to offer principles and practices that 

co-ed centers can use to assess and improve 

their programs to better serve women. The 

majority of women entering treatment for an 

SUD have co-occurring mental disorders, 

such as depression, anxiety, posttraumatic 

stress disorder (PTSD), eating disorders, and 

personality disorders (SAMHSA, 2009). Thus, 

throughout this document, “women with SUDs” 

includes women with co-occurring disorders. In 

addition, service recipients are referred to in 

different ways by different provider agencies. 

Throughout this document, women engaged in 

services are referred to as “participants,” which 

includes “clients,” “patients,” and “consumers.” 

SAMHSA has supported the creation of many 

resources focusing on the unique characteristics 

of women with SUDs and effective interventions 

that support their recovery. These resources 

include:

• Treatment Improvement Protocol (TIP) 51: 

Addressing the Specific Needs of Women

• Addressing the Needs of Women and Girls: 

Developing Core Competencies for Mental 

Health and Substance Abuse Service 

Professionals

• Using Matrix with Women Clients: A 

Supplement to the Matrix Intensive 

Outpatient Treatment for People with 

Stimulant Use Disorders

• Family-Centered Treatment for Women with 

Substance Use Disorders—History, Key 

Elements and Challenges

• Guidance to States: Treatment Standards for 

Women with Substance Use Disorders

Since the early 1990s, SAMHSA has supported 

gender-responsive treatment for women through 

the women’s set-aside in the Substance Abuse 

Prevention and Treatment Block Grant. As a 

result, every state has funding for treatment 

to address the needs of pregnant women. 

SAMHSA also funds discretionary grant 

programs for pregnant and parenting women.

Much published research about best practices 

for women is based on studies of participants in 

women-only residential treatment centers with 

comprehensive, gender-responsive, traumainformed, family-centered, and strength-based 

programming. Yet very little published research 

explains how to offer effective, gender-responsive services for women in co-ed settings. It is 

important to ensure that the needs of women 

are not overlooked in these settings. Because 

most women are served in co-ed settings and 

few guidelines or materials exist for supporting 
Page 2

women in co-ed SUD centers, SAMHSA’s Center 

for Substance Abuse Treatment (CSAT) created 

this guidance document.

SEX AND GENDER DIFFERENCES

Nearly all bookstores contain rows of books 

that explore the nature of men, women, and 

relationships. These books explore why men 

and women have trouble understanding each 

other and ways to better communicate (e.g., 

“Why can’t men just listen when I want to talk 

about a problem, instead of telling me how to 

fix it?” or “Why do women always want to talk 

about feelings?”). In their personal lives, people 

often talk about these differences and work to 

better understand the opposite sex. However, 

the design of behavioral health services rarely 

takes sex and gender differences into account. 

Instead, providers too often give the same

services in the same way for men and women. 

DEVELOPMENT OF THIS DOCUMENT 

To guide this project, SAMHSA asked, “Given what we know about high-quality women’s centers, 

what guidance can we provide for serving women in co-ed settings?”

SAMHSA followed a four-step process to gain feedback on draft principles, guidelines, and 

materials for increased use and acceptance by a variety of stakeholders: 

1. Resource and Research Review. SAMHSA conducted a resource and literature review of 

journals and other sources for best practices. Other information about effective programming, 

treatment, and recovery for women in co-ed settings came from the Women’s Services Network 

of the National Association of State Alcohol and Drug Abuse Directors. 

2. Expert Panel. SAMHSA convened an expert panel of 12 nationally known leaders, including 

researchers, treatment and service providers, recovery community representatives, and policy 

experts. The members came from a range of backgrounds and experience, including a mix 

of research/treatment/peer recovery agencies, diverse cultural/geographic demographics, 

and lived experience. The panel members took part in a two-part discussion to share their 

knowledge about best practices in high-quality women’s centers and how these practices 

might apply to co-ed centers. Members discussed their experiences with and uses of research 

about women in co-ed residential and non-residential settings. Their input served as the basis 

for this guidance document. They also provided resources, reviewed drafts, and discussed 

stakeholder comments. (See Appendix 1 for the list of expert panel members.) 

3. Stakeholder Input. SAMHSA asked for stakeholder input from the Women’s Addiction 

Services Leadership Institute (WASLI) network to learn more about treatment and recovery 

service providers’ views on serving women in co-ed settings. Initial input from the WASLI 

network was also used to inform the expert panel. SAMHSA also invited WASLI members 

to review the draft guidance document. SAMHSA staff from other program areas and other 

federal partners provided additional input. Feedback from all stakeholders was woven into 

the final document. (See Appendix 2 for the list of stakeholders.) 

4. Development of Self-Assessment Tool. A self-assessment tool was created for co-ed 

centers after development of the guidance document. The tool can be used to evaluate 

strengths and weaknesses in providing gender-responsive services for women and to find 

ways to improve. A small group of providers in Colorado tested a draft version and offered 

feedback. Their recommendations were used to finalize the tool. (See Appendix 3 for the 

assessment tool.)

Page 2
Page 3

Sex and gender are not the same thing, and 

there are both sex and gender differences that 

influence men and women. 

Sex differences are the biological differences 

between men and women. These include reproductive organs, body size, and bone structure. 

Gender differences refer to ideas about what 

characteristics, roles, and expectations are 

considered masculine or feminine. A person’s 

sense of masculinity or femininity is part of his 

or her identity. People measure their femaleness 

and maleness against certain accepted norms 

and what it means to be a “man” or a “woman” 

in one’s cultural groups. Cultural groups, 

including religion, race, and ethnicity, greatly 

contribute to norms about gender differences 

and gender identity. Yet many women have 

masculine traits, and many men have feminine 

traits, no matter their background, gender 

identity, or sexual orientation. 

No matter what sex a person was assigned at 

birth, that person may identify as a woman, a 

man, a transgender man or woman, gender 

non-conforming, gender fluid, or another gender 

identity. In this document, the term “woman” 

refers to anyone who identifies as female. 

Centers should expect to have transgender 

women in treatment and recovery. If a service 

recipient identifies as a woman, staff should 

treat her as such. 

Examples of Gender and Sex Differences

Women and men have both sex and gender 

differences, but those differences are not 

absolutes. Instead, they tend to occur on two 

bell curves, like those shown in Figure 1. The 

blue (left) curve is men and the red (right) curve 

is women. Traits linked to men and masculinity 

are on the left of the spectrum, and traits linked 

to women and femininity are on the right. As 

one can see, men and women overlap quite a 

bit. For example, men as a whole have more 

physical strength than women, but there are 

women who are physically stronger than most 

men, and men who are physically weaker than 

many women.

Typical gender differences between men and 

women affect how they communicate, make 

decisions, store knowledge, and prioritize. For 

example, women tend to prioritize relationships 

as a means of growth and development. Thus, 

recognizing and understanding the value of 

relationships in women’s lives is important when 

working with them. Women often have “focus 

on children” as their first treatment goal, and “get 

a job” as a lower priority. For men, it is often 

the opposite. They may focus on finding a job 

first and children later. Men may view getting a 

job as the most important and tangible way to 

take care of their children, whereas women may 

focus more on spending time with their children. 

Relationships are important to men, too, but they 

may prioritize them differently or have a different 

viewpoint about them. 

As other examples, when communicating, men 

may focus on “report talk,” which includes talking 

about events and factual information. In contrast, 

women may focus on “rapport talk,” which 

focuses on building a relationship. For example, 

when women get together, their purpose is often 

to talk and share thoughts, feelings, and experiences without a specific agenda. When men 

get together, their purpose is often more “activity 

oriented”—for example, to watch a sporting event 

with a few friends. Also, when women talk about 

the challenges of their day, it is likely that they 

simply want to be heard, because they are in 

the process of thinking through the issues. 

Men are more likely to focus on solving problems 

and sharing challenges in order to talk about 

solutions.
Page 4

But these examples are all generalizations, and 

people fall along the bell curve in terms of both 

gender and sex differences. Some men are 

oriented toward processing emotions or building 

rapport, and some women are oriented toward 

problem solving or reporting facts. No gender or 

sex differences fit all men or all women. 

Gender and Sex Differences in Substance 

Use and the Recovery Process

The National Institutes of Health’s website A to 

Z Guide: Sex and Gender Influences on Health 

(National Institutes of Health, Office of Research 

on Women’s Health, n.d.) provides information 

about research and clinical trials that document 

sex- and gender-based health and disease 

differences between females and males. This 

knowledge can be used to understand differences and improve healthcare services for 

both women and men. Because of sex differences, men and women “may experience the 

same diseases at different rates or with different 

symptoms, or they may experience different 

kinds of illness altogether” (Brittle & Bird, 2007, 

p. 18). This finding holds true with SUDs. 

Women develop SUDs and related medical 

disorders faster than men. This is known as 

the “telescoping effect” (SAMHSA, 2009, p. 

27). For example, “women develop alcoholrelated physical health problems at lower doses 

and over shorter periods of time than do men” 

(SAMHSA, 2009, p. 7). The difference is linked 

to two possible causes. First, women have 

higher body fat and a lower volume of water 

in their bodies, even compared with men of 

the same size. Thus, alcohol is less diluted in 

women’s bodies. Second, women have less of 

the gastric enzyme that metabolizes alcohol, 

which means alcohol remains in women’s bodies 

longer. The combination of higher concentrations of alcohol and longer exposure of organs to 

alcohol’s effects leads to women having greater 

alcohol-related health risks than men (SAMHSA, 

2009, p. 40).

The expert panel stressed that societal expectations about relationships, families, communities, 

and employment also come into play for women 

and men receiving services for SUDs. Power 

differences in society influence who speaks, who 

is silent, and whose voice is heard, along with 

who sets norms and who does not. The panel 

noted that treatment and recovery centers are a 

microcosm of our society. Thus, centers reflect 

the same power dynamics among staff and 

participants. Co-ed treatment settings should 

take these dynamics into account and address 

them when needed.

Despite the differences between men and 

women with SUDs, recovery services and 

training of staff members have been based on 

health research on men’s experiences, ignoring 

sex and gender differences (Bentley, 2005; NIH, 

2009). Going back to Figure 1, when services 

are designed based on the blue (left) curve, 

ignoring the red (right) curve, some women are 

comfortable with these services. Other women 

are able to adapt and still succeed. But many 

women cannot relate and are unable to benefit 

from the services offered. This is why genderresponsive services are needed. 

This document speaks to the needs of women 

with SUDs being served in co-ed centers. It is 

worth noting that gender-responsive services are 

important for men, as well. Programs designed 

for women that do not take men’s needs and 

priorities into account are likely to experience 

poorer engagement and outcomes for male 

participants. However, far fewer men participate in SUD services designed specifically for 

women than the number of women participating 

in general-purpose services, where men significantly outnumber women.

The following guidance statements, and the strategies and practices that flow from them, can help 

improve outcomes for women in co-ed centers.
Page 5

II. GUIDAnCe stAteMents

INTRODUCTION

The expert panel developed guidance statements to offer a general understanding of the 

context and why it is important to address the 

specific needs of women. These guidance 

statements provide information about sex and 

gender differences, women’s experiences, and 

delivery of substance use treatment and recovery 

services. The statements are meant to help 

providers understand how women’s experiences 

impact their recovery, regardless of service 

delivery setting. 

Women are diverse, and their individual 

cultural backgrounds, family histories, and 

life experiences influence their treatment and 

recovery needs. The guidance statements 

are based on experiences and characteristics 

frequently seen among women and will help 

providers better respond to and serve women 

in their centers.

These statements serve as overarching concepts 

that guide the more specific practices and strategies described in the next section. The statements are organized into six primary groups: 

women’s unique needs and experiences, gender 

dynamics, trauma, physical health, mental 

health, and relationships.

A. ADDRESSING WOMEN’S UNIQUE 

NEEDS AND EXPERIENCES

• Effective treatment and recovery 

services for women are personcentered, taking into account gender 

and the priorities, interests, and 

experiences of individual women. 

Women’s pathways to substance use are 

different from those of men. Women also 

have different motivations for treatment, 

treatment barriers, and treatment and 

recovery support needs from men. 

These differences impact women’s 

treatment and recovery process. 

• Providers of effective treatment and 

recovery services consider how the 

treatment environment influences 

women’s treatment experience, 

and they plan accordingly. The 

expert panelists noted that a center’s 

environment is particularly important for 

women. Women thrive in welcoming, 

safe, calm, and well-kept environments. 

Conversely, a chaotic and unattractive 

environment that does not feel safe 

to a woman can be an obstacle to her 

treatment and recovery.

• Effective treatment and recovery 

services are responsive to both 

culture and gender, holding respect 

as a core value. Women’s cultural 

backgrounds shape their world views, 

priorities, values, experiences, gender 

expression, and treatment and recovery 

needs. In culturally competent services, 

staff members are familiar with and 

respectful of the cultural populations 

they are serving. Ideally, staff are also 

culturally representative of the women 

being served. When staff practice cultural 

humility, it means they are aware of 

their own culture and how it influences 
Page 6

their work and world view. This allows 

them to better understand other people’s 

experiences. This approach helps staff 

communicate with women participants in 

a way that is respectful of both gender 

expression and cultural background. 

• Sexuality (including sexual orientation) 

and patterns in a woman’s sexual 

history are important considerations 

in effective treatment and recovery 

planning. Having an SUD can affect 

a woman’s emotional capacity for 

romantic and sexual feelings, and 

her experiences with sex. It also 

influences others’ perceptions of her 

sexuality and sexual history. Lesbian, 

bisexual, and transgender women often 

face discrimination and other unique 

experiences that can affect the recovery 

process. Exploring and establishing 

healthy sexuality, sexual boundaries, and 

relationships is often an important part of 

women’s recovery.

• Effective treatment and recovery 

providers acknowledge that women 

with SUDs are more likely to live in 

poverty than their male counterparts. 

Many women seeking services rely on 

men or other family members for financial 

support. In general, women with SUDs 

have less education and employment 

experience than men with SUDs. They 

often have different obstacles to economic 

well-being and benefit from different 

education and employment services. 

Staff members should be sensitive to and 

respond to the socioeconomic factors that 

shape women’s lives.

B. GENDER DYNAMICS

• Women benefit from support and 

activities that develop their voices and 

self-identities and from sharing their 

stories. Women often enter services for 

SUDs having been silent or silenced by 

others. They may have had few chances 

to think about or express what they want, 

to speak for themselves, or to share 

their personal stories. Having someone 

actively listening to them as they share 

their experiences can be both nurturing 

and empowering. 

• Effective treatment and recovery 

services acknowledge unintended 

biases that favor men. Both staff and 

participants can have biases, which may 

arise in individual counseling, groups, 

and other programming. No matter their 

beliefs about gender roles, female staff 

and participants often defer (consciously 

or unconsciously) to male staff and male 

participants. For example, people often 

listen more closely when men speak 

and respond better to their ideas, even 

when a woman suggested the same 

idea earlier. Also, in co-ed groups, men 

may talk more than women or interrupt 

others who are speaking. Or the women 

may focus too much on helping the men 

open up and responding to their needs. 

Many women with SUDs have had less 

power in life than other women. Many 

also have histories of abuse that make 

them more likely to defer to men. Training 

and clinical supervision can address the 

various types of biases that favor men. 

Staff can adopt strategies to ensure that 

women share their voices and perspectives, and get their needs met. 
Page 7

C. TRAUMA

• Physical and psychological safety 

are of paramount importance when 

treating women with SUDs. Women 

with SUDs have high rates of adverse 

childhood experiences, intimate partner 

violence, and other forms of current and 

past trauma. Women with a history of 

childhood trauma are also more likely to 

have experienced trauma as adults. Both 

the physical setting for treatment and 

recovery services, and interpersonal interactions between staff and female participants, should promote a sense of safety.

• Providers of effective treatment and 

recovery services for women adopt 

and adhere to trauma-informed, 

recovery-oriented principles and 

practices. Trauma-informed and 

recovery-oriented approaches include 

safety, respect, and empowerment, 

all of which are particularly important 

for women. The principles should 

be established, discussed, and built 

into center operations and be visible 

in the organizational culture, staff 

attitudes, service design, and participant 

experiences. 

• Effective treatment and recovery 

services use strength-building 

approaches and avoid punitive 

strategies that further reduce selfefficacy and engagement. Women 

with substance use problems, especially 

women with complex trauma histories, 

often have low self-efficacy and selfesteem. This can impact engagement 

and ongoing recovery. These women 

have often been coerced or forced to do 

things against their will. Thus, making 

choices and having chances for shared 

decision-making, goal-setting, and voicing 

their ideas helps build confidence and 

courage.

• Effective treatment and recovery 

services for women offer an array of 

trauma-specific and trauma-informed 

services that build coping strategies. 

Trauma and violence can have significant 

short- and long-term neurological, biological, psychological, and social effects. 

Trauma histories can have profound 

effects on all aspects of women’s lives, 

including their relationships. Traumainformed staff and trauma-specific interventions help women learn healthier ways 

of coping with the long-term effects of 

trauma, which improves health, healing, 

and recovery.

D. PHYSICAL HEALTH

• Women benefit when their physical 

healthcare needs are addressed and 

integrated into treatment and recovery 

planning. Women with SUDs often have 

a range of health concerns and chronic 

health problems that require prevention, 

primary, gynecological, and other specialized care and wellness services. These 

women may have personal and systemic 

barriers to accessing health and wellness 

services that impede their recovery. 

Navigator services, as well as integrated 

health and behavioral health services, 

help women to overcome obstacles 

and obtain health care, which can also 

improve SUD outcomes. 

• Effective treatment and recovery 

services include a plan to screen for, 

and address, pregnancy and related 

treatment/recovery considerations. 

Pregnancy is a pivotal time in a woman’s 

life and a critical time for addressing 

SUDs and getting support. Pregnant 

women are often motivated to change. 

Though they may still struggle to stop 

their alcohol or drug use, most of them 

care about their unborn children and 

want to deliver healthy babies. Women 

with SUDs benefit from early identification of pregnancy and an informed team 

response that considers symptoms, 
Page 8

pharmacological risks and options, and 

prenatal care. Women with SUDs who 

are pregnant also benefit from learning 

how to lower the risks to their fetuses’ 

health. Risks include miscarriage, 

premature births, fetal alcohol spectrum 

disorder, and neonatal abstinence 

syndrome (NAS). NAS occurs from 

exposure to addictive opiate drugs while 

in the womb. 

E. MENTAL HEALTH

• Women with SUDs have increased 

prevalence of co-occurring mental 

disorders, which can affect SUD 

treatment and recovery outcomes. 

Effective treatment and recovery 

programs ensure that women can access 

screening, assessment, and services 

for mental health conditions, such as 

depression, eating disorders, anxiety, 

and PTSD. These conditions need to 

be addressed for women to fully engage 

in treatment and embrace recovery. All 

of the practices and strategies in this 

guidance document can be helpful when 

serving women with co-occurring mental 

disorders.

• Effective treatment and recovery 

services use an integrated approach 

that addresses both mental and 

substance use disorders at the same 

time. Services include screening, 

assessment, intervention, pharmacological services, cognitive behavioral treatment, and recovery supports. 

Integrated treatment is an evidence-based 

practice proven effective for women. It is 

holistic and uses a collaborative, multidisciplinary team. This collaboration 

allows the treatment team to address both 

substance use and mental disorders at 

the same time—through one team and 

one plan. This increases a woman’s 

chances of recovery from both disorders.

F. RELATIONSHIPS 

• Effective treatment and recovery 

services have highly qualified staff 

members who attend to the therapeutic alliance. Relationships are often of 

primary importance to women. Thus, the 

therapeutic alliance between staff and 

the woman participant is a critical factor 

in treatment and recovery services. A 

therapeutic alliance takes time and effort 

to build, but it is key to creating trusting 

relationships and an environment where 

healing can occur. Having therapeutic 

relationships that offer both boundaries and consistent support creates a 

safe space for women. Through these 

relationships women are able to explore 

their experiences and feelings, learn new 

skills, and share their successes.

• Effective treatment and recovery 

services for women are personcentered and support them within the 

context of their lives. Women have 

many roles and responsibilities, often 

including taking care of children and 

other family members. These responsibilities can be barriers to treatment 

engagement and participation. Women 

often have fewer economic resources 

than men, which can make finding child 

care and support more difficult. Women 

may also attach a higher priority to their 

relationships with others than to their own 

recovery and service needs. Effective 

centers maintain flexibility and offer to 

connect women with resources when 

possible. They also avoid the use of 

punitive or shaming strategies when 

women cannot attend or meet treatment 

expectations.
Page 9

• Effective treatment/recovery services 

provide formal and informal opportunities for women to meet and build 

relationships with each other. Women 

benefit from supportive relationships with 

other women. Effective centers have 

female recovery coaches or peer specialists who can share their experiences and 

support women. Encouraging mutual 

self-help among female participants and 

with other volunteers and community 

members can further build women’s 

recovery capital and engagement. 

Recovery capital includes a woman’s 

internal and external resources to begin 

and sustain recovery. Recovery capital is 

influenced by providers who can support 

a woman’s development of resilience and 

protective factors, wellness, self-efficacy, 

hopefulness about her future, new or 

repaired social networks of family and 

friends, and resources in the community 

to support recovery.

• Effective co-ed treatment and recovery 

services create a venue for women 

to learn about healthy interactions 

and friendships with men, including 

respect, boundaries, and communication. Women with SUDs often have 

histories of poor relationships with men. 

Treatment and recovery centers can 

be safe places for women and men to 

build healthy friendships. Both women 

and men can listen to the struggles of 

the other sex and become more aware 

of their own behavior and expectations. 

Skilled facilitators can address communication dynamics in a safe, respectful 

manner. 
Page 10

III. PRACtICes AnD stRAteGIes

This section presents some of the strategies 

for evaluating an organization’s responsiveness to women and putting new practices into 

place. SUD treatment has evolved over the 

last few decades and will continue to evolve 

as populations change, more becomes known 

about effective interventions, new treatments 

are developed and disseminated, and policy and 

funding requirements shift in ways that impact 

treatment and recovery services. Shifts made 

to integrate the research on sex and gender 

differences into practices and policies for genderresponsive services are an example of this 

change. Many of these practices have been 

put into place in specific programs for women; 

applying this information to co-ed settings is an 

important next step. 

Practices and strategies related to staffing are 

discussed first, then environment and facilities, 

assessment and treatment/recovery planning, 

interventions and groups, and recovery support 

services. The practices described here are 

broad; they can be adapted to meet the specific 

needs of different types of programs or specificsubpopulations of women. 

A. STAFFING ISSUES 

Well-qualified, effective staff and a workable 

staffing plan are the most essential ingredients 

in SUD treatment and recovery services. The 

term “staff” refers to both paid staff and volunteer 

staff in treatment/recovery centers. This includes 

clinicians, counselors, peer specialists, recovery 

coaches, and other professional, paraprofessional, administrative, and support staff. Other 

elements that contribute to a center’s success 

include an organizational culture that supports 

women and offers relevant staff training and 

supervision. Effective supervision is fundamental 

to putting the practices and strategies discussed 

in this document into place. All staff—not just 

clinicians—benefit from supervision.

Staffing Plan

Effective treatment/recovery services for women 

have sufficient staff and a staffing plan that 

allows for strong rapport, therapeutic alliances, 

and true partnerships. These are built through 

consistent interactions between staff and participants. Adequate staffing allows for reasonable 

caseloads, which are needed to build supportive 

therapeutic relationships and let staff be aware 

of participants’ progress and setbacks. Effective 

centers also have sufficient program and clinical 

management, and an array of specialized staff, 

including case managers, housing specialists, 

and peer specialist/recovery coaches—all with 

experience in gender-responsive approaches. 

Hiring professional and paraprofessional staff 

who have specific knowledge and experience in 

gender-sensitive treatment increases a center’s 

ability to reach and retain women in treatment/ 

recovery. Centers are encouraged to ask job 

candidates about gender-specific issues. For 

example, interviewers could ask a candidate 

how his/her experience working with women 

with SUDs differs from his/her experience 

working with men, or about his/her training in 

gender-specific approaches.
Page 11

The expert panel recommended giving priority 

to matching women with female primary 

counselors. Ideally, when assigning counselors, 

centers should consider:

• A woman’s engagement with staff thus far

• The woman’s goals and expectations of 

counselors

• How likely the woman and counselor are 

to create rapport

Matching women with female staff who have 

common experiences and understanding, 

such as similar age and racial/ethnic/cultural 

background, can help build rapport. However, 

a counselor’s perceived empathy is also a key 

factor and may be just as important as gender 

and common life experiences. The use of 

female peer specialists or recovery coaches, 

especially those in long-term recovery, early 

in the treatment/recovery process can be very 

effective in building a woman’s hopeful view of 

the future and building a supportive community. 

Clinical Supervision and Training 

Centers striving to enhance or maintain their 

ability to provide gender-responsive services 

make clinical supervision a priority and ensure it 

happens on a regular basis. Such centers also 

ensure supervisors receive training in effective 

supervision and how to address gender-specific 

issues. Supervisors may need specialized 

training in many other areas, including mental 

health, support of staff with trauma histories, 

prevention of secondary trauma, gender 

dynamics in co-ed groups, trauma-informed 

care, identification and understanding of staff 

members’ biases (e.g., judging women who use 

alcohol or drugs during pregnancy or who stay 

with abusive partners), and gender dynamics in 

co-ed groups. 

During supervisory sessions, supervisors and 

staff may talk about resources and potential 

organizations for collaboration. They can also 

discuss referrals for child care, child welfare, 

reproductive health care, and other services 

necessary for comprehensive support of female 

participants, when the center does not offer 

these services.

Ongoing staff training is also important. It helps 

build staff members’ capacities to serve women 

and should take into account the needs of a 

variety of employees, including both new hires 

and long-term employees. A good place to 

start is with the core competencies described 

in Addressing the Needs of Women and Girls: 

Developing Core Competencies for Mental 

Health and Substance Abuse Professionals

(SAMHSA, 2011). The core competencies can 

be used to inventory staff training needs prior to 

creating a training program. Training strategies 

can include brown-bag lunch sessions, webinars, 

longer in-service training programs, local college 

offerings, and incentives to staff that enroll in 

professional development programs. One helpful 

resource is the online course Introduction to 

Women and SUDs,

1

 developed with SAMHSA 

support.

Beyond initial training, staff need follow-up 

support to effectively apply training content to 

actual work with women participants. Ongoing 

discussions during clinical supervision and 

staff meetings about how to implement what is 

learned from training, clinical supervision, and 

staff meetings will result in better application of 

content. 

Because trauma is so common in women with 

SUDs and has such a profound impact on their 

experience of services, all staff—including 

administrative and support staff—should receive 

training on trauma-informed approaches to 

behavioral health. This may include support 

and training around preventing and addressing 

secondary trauma and creating an environment 

that is trauma informed. For practitioners, an 

important aspect of trauma-informed care is 

recognizing their vulnerability in the work setting, 

including their personal history and potential for 

secondary trauma. This requires appropriate 

and frequent clinical support, mentoring, and 

coaching. 

1

 Introduction to Women with Substance Use Disorders

is offered by the Addiction Technology Transfer Center 

Network’s online distance education program. Continuing 

education hours are available for a nominal fee. 
Page 12

SAMHSA’s Concept of Trauma and Guidance for 

a Trauma-Informed Approach (SAMHSA, 2014c) 

defines a trauma-informed program, organization, or system as one that:

1. Realizes the widespread impact of trauma 

and understands potential paths for 

recovery;

2. Recognizes the signs and symptoms 

of trauma in clients, families, staff, and 

others involved with the system;

3. Responds by fully integrating knowledge 

about trauma into policies, procedures, 

and practices; and

4. Seeks to actively resist re-traumatization. 

The concept document further defines a traumainformed approach as one that follows six key 

principles:

• Safety

• Trustworthiness and transparency

• Peer support

• Collaboration and mutuality

• Empowerment, voice, and choice

• Cultural, historical, and gender issues

Many of these principles are discussed within this 

document. For a more comprehensive understanding, see SAMHSA’s site about traumainformed approaches and interventions at http://

www.samhsa.gov/nctic/trauma-interventions.

To ensure a full understanding of traumainformed approaches, centers can provide staff 

training based on TIP 57: Trauma-Informed Care 

in Behavioral Health Services (SAMHSA, 2014d). 

This publication discusses patient assessment, treatment planning strategies that support 

recovery, and how to build a trauma-informed 

workforce. 

Depending on the level of service, philosophy, 

and evidence-based practices of the center, 

training programs can address other topics, 

such as: 

• The range of women’s experiences 

(e.g., needs of sub groups of women);

• Gender awareness (i.e., understanding the 

economic, status, and power issues facing 

women); 

• Differences between men and women in 

processing and problem-solving; 

• Issues relating to pregnancy and parenting; 

and

• Gender dynamic considerations in group 

facilitation.

Organizational Culture

When the organizational culture respects 

women and actively takes gender into account, 

female participants are more likely to engage 

and actively participate in their treatment/

recovery services. This improves participant 

retention and, ultimately, outcomes. A respectful, gender-responsive culture also creates a 

healthy environment in which staff members 

feel supported as they integrate gender-specific 

content and considerations into service delivery. 

This can help reduce staff turnover, which is 

important because frequent staff turnover can 

negatively affect women in treatment by causing 

instability in relationships. Staff benefit from 

opportunities to discuss, explore, and find ways 

to respectfully and effectively address gender 

dynamics in co-ed settings and relationships. 

Centers can build a culture that supports 

gender-responsive services in many ways. 

They can consider putting some of these 

examples into place:

• Integrate facilitated discussions about 

working with women as part of staff and 

supervision meetings.

• Review outcome data on women’s engagement, retention, and progress and use the 

data to discuss process improvement.
Page 13

• Provide visible leadership opportunities for 

female staff and support them in becoming 

advocates for women’s services. For 

example, centers can create mentoring 

and leadership programs to promote and 

integrate women at all levels of the organization. Doing this sends a positive message 

and provides models for the women 

receiving services.

• Join women’s service provider networks in 

the community. 

• Provide staff with follow-up discussions, 

coaching, and supervision to help build a 

safe and supportive environment for staff 

and women served. 

A culture of support can help staff members keep 

healthy views and attitudes about their work and 

the women they serve. It also helps staff have 

positive outlooks about participants and their 

ability to recover. This support includes understanding participants’ experiences and showing 

respect and empathy. Staff may also need 

practice to shift their views and attitudes about 

women with SUDS from negative judgments to 

more positive approaches. For example, rather 

than viewing a woman as “manipulative,” the 

same behavior can be viewed as “strategic” 

or as “strong survival skills.” 

Putting the above practices and strategies 

into place will help centers build a healthy and 

healing organizational culture and treatment 

setting for women, as well as men. 

B. ENVIRONMENT/FACILITIES

A center’s environment and physical facilities set 

a tone that may impact women’s expectations 

and contribute to their experiences of treatment/

recovery services. When the setting looks 

pleasant, professional, and comfortable, it builds 

a sense of competency, comfort, and promise. 

On the other hand, run-down environments may 

lower expectations and imply a lower level of 

respect. The center’s location, its presentation 

of physical and emotional safety, and general 

warmth can all influence women’s initial perception of the center as a whole. The setting 

should contribute to the treatment environment, 

encourage relationship building, and provide a 

sense of safety.

Physical Environment

A top consideration is whether women can safely 

access the center’s services. Consider the 

following questions.

• If services are offered at night, is parking 

or bus transportation located in a well-lit 

location?

• When women walk to the door, do they pass 

by a group of male smokers, possibly feeling 

exposed, vulnerable, or “on display” as they 

enter the center? 

• Sometimes centers are located in high-risk 

neighborhoods to make access easier 

for people living nearby; in those cases, 

does the inside of the center feel like a 

safe haven? Or does it mirror the negative 

features of the “outside” world from which 

women are seeking respite? 

After talking with various stakeholders (e.g., 

participants, staff, collaborators), centers may 

decide to make physical or administrative 

changes to address physical safety concerns. 

Such changes could include offering group 

transportation, providing safety patrols/escorts to 

parking lots or transportation locations, adding 

more outside lighting, increasing daytime hours, 

or making the inside of the center feel more 

calming and safe.

It is also helpful to consider the type/arrangement 

of furniture and the goals of the center. When 

placing chairs or couches in waiting rooms, group 

rooms, or any group setting, there should be 

enough space allowed to acknowledge personal 

space and provide a sense of security and 

safety. Some of the furniture can be arranged to 

encourage interaction and allow for conversation, 

and other seating can be positioned to allow for 

privacy. 
Page 14

Ideally, centers serving women include a childand family-friendly environment. This can 

involve offering appropriate child care for infants, 

toddlers, and older children who participate 

in family services. Even if a center does not 

offer child care, female participants might bring 

children with them. Accommodations, such as a 

few books, toys, clean floors, and a small area 

for children to play in, build a sense of safety 

and offer a sensitive atmosphere for the woman 

whose child is with her. 

Preferably, co-ed centers provide chances for 

women to “hang out” without men present. A 

dedicated women’s space (e.g., women’s lounge 

area) allows women to gather in a safe space. 

This helps foster connection, interactions, and 

formal and informal recovery supports. This 

space may be a dedicated spot within the center, 

or a location that is used as a “women’s space” 

during certain hours. Centers can consider the 

clientele, neighborhood, and other resources to 

best shape these opportunities. 

More treatment/recovery centers are starting to 

use virtual meeting and counseling spaces and 

other ways for participants to interact through 

private social media venues. With etherapies 

and social media supports, security and monitoring help ensure confidentiality and prevent online 

harassment. Having access to a virtual women’s 

space can also enhance recovery support for 

women while they are not at the center. Such 

spaces can be valuable for women who have 

trouble accessing services in person, such 

as women in rural areas or who have young 

children. 

Personal Safety

Because women with SUDs often arrive at a 

facility worried and vulnerable, centers should 

consider how to create a sense of sanctuary 

within the facility. For example:

• Does the inside environment of the center 

provide a sense of welcome and safety? 

• Does the artwork portray diversity and 

convey a sense of hope or positivity? 

• Does the environment promote a sense 

of well-being and feelings of security and 

comfort for participants and staff?

Signage in the center’s reception area can add to 

or reduce a woman’s sense of safety. Signs that 

are meant to convey rules and guidelines may 

instead make people feel unsafe, uncomfortable, 

or unwelcome. For example, a waiting room 

sign that says “no weapons” generally does not 

make people feel safe or reduce the prevalence 

of weapons. An alternative is to replace the sign 

with calming artwork and have everyone sign 

an acknowledgement of a “no weapons policy,” 

along with the other required paperwork. If 

guidelines about the waiting room are necessary, 

it is helpful to share the content in a way that 

builds community and respect. 

Reception staff also play an important role 

in setting the initial “feel” of the center and 

helping participants feel safe. When a woman 

checks in at the reception desk, greeting her 

with a smile and openness may help her begin 

to let her guard down and feel more comfortable. Centers can offer training for receptionists, intake counselors, and others who meet 

women soon after they enter the center to 

teach them how to recognize deep distress or 

signs of trauma. Protocols can also be set up 

and taught to help support staff reduce participants’ anxieties. Some initial ways to increase 

comfort and feelings of safety are to offer water 

or healthy snacks, point out where the restrooms 

are located, and inform the woman of how long 

she might need to wait. All of this can help a 

woman’s first encounter with the center feel 
Page 15

peaceful and supportive. Creating a sense of 

calm and welcome for male participants also 

improves the overall environment and will impact 

women’s sense of safety.

When participants have a voice in center rules 

and guidelines, it increases their sense of 

safety, belonging, and investment. It also helps 

them feel respected and heard. For example, 

a center may hold group discussions about 

center and group safety, and allow participants to 

help develop guidelines for attire, conduct, and 

communication. This builds a sense of investment, awareness, and empowerment among 

participants. In groups, especially those that 

are co-ed, a lack of community-established 

guidelines can lead to feelings of being unsafe 

or vulnerable. For example, some people may 

wear distracting clothes or make others feel 

uncomfortable by sitting too close to them, using 

profanity or sexual terms, or being too physical 

during interactions. Staff should ask participants 

what makes them feel safe and whether there is 

anything that would help them feel safer. When 

they answer, staff should acknowledge their 

answers and try to accommodate their needs as 

much as possible (e.g., “I need to sit near the 

door,” “I need to sit where I can see everyone 

coming in the door,” or “I need to sit by another 

female participant”). 

C. ASSESSMENT AND TREATMENT/

RECOVERY PLANNING 

Assessment and treatment/recovery planning 

set the foundation for the services a center will 

use to help a woman meet her program participation goals. Treatment/recovery planning may 

occur together or as separate processes. In this 

document, they are discussed together. To learn 

more on assessment, treatment, and recovery 

planning for women, see Guidance to States: 

Treatment Standards for Women with Substance 

Use Disorders (Mandell & Werner, 2008). In 

addition to substance use, participants may 

have many challenges, such as trauma histories, 

single parenting, co-occurring mental disorders, 

or intimate partner violence. The expert panel 

noted that assessment and treatment/recovery 

planning activities that do not address women’s 

experiences or priorities become barriers to 

engagement and activation, which may lead to 

a return to substance use. Patient activation 

refers to a person’s ability to manage his/her 

health and health care. Activation is an important 

element of recovery in that the woman develops 

her capacity to participate in services, make 

decisions, and, ultimately, reduce substance use. 

Centers can promote engagement and activation 

by adopting woman-responsive assessment and 

treatment/recovery planning tools and processes. 

Younger women have very different cultural 

values, relationships, and experiences than do 

older women. A woman’s experiences, needs, 

and priorities are impacted by age, stage of 

life (e.g., adolescence, young adult, parent, 

senior), gender identity, sexual orientation, 

prior participation in treatment/recovery, and 

cultural background. Assessment and treatment/

recovery planning need to identify and consider 

women’s specific needs. Programs need flexibility to respond to the specific treatment/recovery 

needs of women of all ages and diverse cultural 

backgrounds. 

Assessment gathers information about a 

woman’s history of substance use, and associated experiences such as physical health, mental 

health, family, employment, education, and legal 

concerns. The information gathered through 

assessment then informs the treatment/recovery 

plan and services provided. This section 

discusses assessment and then treatment/

recovery planning, followed by a discussion of 

a few essential elements of assessment and 

treatment planning: trauma, mental health, 

physical health, relationships, and intimate 

partner violence.
Page 16

Assessment

In any type of screening or assessment, a center 

should use instruments that have validity for 

women and the subgroups of women it frequently 

treats.2

 Centers can evaluate their assessment 

tool to determine its sensitivity to women’s needs 

and the need for supplemental questions. They 

can consider the areas discussed in the guidance 

statements and whether their assessment 

tool provides enough information to inform the 

treatment/recovery planning for women entering 

the program. Questions to consider include:

• Does it provide enough information to inform 

the woman’s treatment/recovery planning? 

• Does it identify strengths, self-efficacy, and 

recovery capital? 

• Are pregnancy-specific questions available 

and applicable? For example, substance 

use screening tools for pregnant women 

need to be able to assess both use and 

misuse. 

Though a primary goal of assessment is to obtain 

information for developing the treatment/recovery 

plan, it is also a chance to build rapport and trust, 

which can result in improved engagement in 

services and activation. 

The intake interview may be the first time a 

woman has had the chance to talk about herself 

and her experiences. Giving women the chance 

to be listened to, heard, and validated is usually 

of great value to them. An effective assessment 

takes time—sometimes more than one session. 

Ideally, it is an ongoing process. It is vital that 

staff members who conduct assessments avoid 

stereotypes and maintain a non-judgmental 

attitude. 

2

 SAMHSA’s TIP 51: Addressing the Specific Needs of 

Women (2009) discusses the differences between screening 

and assessment, as well as various assessment issues for 

women. 

It is important to conduct assessment interviews in a trauma-informed manner. Discussing 

sensitive personal topics is difficult, especially 

before building trust. Thus, assessment 

questions should be limited to those that will 

impact services or build rapport. 

Most assessments consider substance use and 

treatment history, co-occurring mental disorders, 

family, education, and employment. In each 

area, women may have different experiences 

from men. When asked about their initiation of 

substance use, duration of use, or use patterns, 

some women may describe their use as minimal 

and occurring in isolation. Other women’s use 

may be closely linked to a specific person or 

situational context, while others may have high 

levels of use and dependence. Some women 

may knowingly use substances as a way to 

cope with childhood abuse and other traumas; 

others may not have, or may be unaware of, a 

link to trauma. Some women express tremendous shame, grief, and loss when talking 

about behaviors or situations that occur during 

substance use; others may present as “tough” 

or stoic. 

When getting to know a woman, staff members 

should not make assumptions about her or her 

priorities. For example, the assessment should 

ask about sexual orientation and gender identity, 

rather than assuming all women are heterosexual or cisgender. “Cisgender” is a term for people 

whose gender identity corresponds with the sex 

the person had or was identified as having at 

birth (Merriam Webster, n.d.).
Page 17

Questions about family and education/employment should capture the experiences of women 

with SUDs. Motherhood is an important part of 

many women’s self-identity, but this is not the 

case for all women. Staff should not assume 

every woman wants to be a mother, or that a 

woman wants to parent the children she already 

has. Staff should find out a woman’s feelings 

about parenting, rather than assuming she is 

engaged in motherhood. Some women do not 

have children, and others have not parented 

or been involved with their children. Women’s 

caretaking roles may be incentives or obstacles 

to participation. When assessing a pregnant 

woman, staff should ask about her experience 

and reaction to this pregnancy. Staff should 

also find out the outcome of any past pregnancies and self-care patterns, such as eating 

and sleeping habits and tobacco use. This is 

all valuable information for treatment/recovery 

planning. 

Women often experience poverty or have 

less access to economic resources than 

men. Thus, identifying financial resources and 

healthy survival strategies may be an important 

element in their ongoing treatment/recovery 

planning. Both younger women (under 25) and 

older women (60 and older) may be especially 

dependent upon their families. Employment 

history and experiences can be a source of 

strength or an area of anxiety, depending upon 

a woman’s expectations for herself, and her 

workforce success and experiences.

Women’s reasons for entering treatment and 

priorities for treatment differ. Reasons for being 

in treatment could stem from an arrest, a desire 

to rebuild a relationship or change her life, a child 

welfare case, or an escape from hard life circumstances (e.g., violent relationship, homelessness). Some women may enter treatment only 

as a last resort, perhaps as a result of a court 

order, and may say they “don’t want to be here.” 

No matter what a woman’s reason is for entering 

treatment, centers should offer a safe environment that allows her to be honest about her 

goals and engage in a treatment/recovery plan to 

pursue those goals. 

Treatment/Recovery Planning

A treatment/recovery plan provides concrete 

direction to the woman receiving services and the 

service delivery team. The plan outlines goals 

and activities that help the woman eliminate or 

reduce substance use, develop the skills and 

resources needed for maintaining a healthy 

lifestyle, and work toward other desired goals. 

Individual treatment/recovery plans should reflect 

women’s varying experiences with substance 

use, consequences of substance use, previous 

treatment/recovery efforts, recovery capital, and 

life priorities. 

Treatment/recovery planning is a collaborative process, most often involving the woman 

and a primary counselor. Ideally, the counselor 

engages the woman as an active participant 

in developing her treatment/recovery plan. 

This allows the woman to use her voice, make 

choices, and feel empowered. However, this 

is not always an easy process. A woman who 

“likes” her counselor may seek to please her/him 

and agree with whatever the counselor suggests. 

Other women do not have the hope needed to 

envision a different future for themselves. Some 

may say, “I don’t know” when asked about they 

want to get out of treatment. Some of those 

women may have been silenced or insulted by 

their partners or family for sharing their thoughts. 

This could make them nervous about stating 

their opinions and ideas. Taking the time to build 

rapport, trust, and hope with these women will 

help them begin sharing their ideas and goals. 

Other women are in treatment to fulfil a requirement (e.g., as part of a child welfare case) and 

may not have motivation to address substance 

use. Motivational interviewing and focusing the 

treatment/recovery plan around their current 

priorities or goals may be a good starting point. 

Assessment and Treatment/Recovery 

Planning: Strength-based Approaches

Women may need clear information about the 

treatment/recovery process and about what is 

expected of them while they receive services. 

Asking a woman about potential barriers to 

completing treatment allows on-the-spot problem 
Page 18

solving. Whenever possible, staff members 

should leverage the woman’s strengths, 

passions, and priorities, and integrate them into 

treatment and recovery plans.

Women entering treatment for SUDs often have 

very low self-efficacy and low self-esteem, so it 

is important to help them identify their strengths, 

passions, and priorities. This can be done 

through strength-based assessments. Staff 

should ask a woman to identify positive experiences in her past or activities she enjoys (e.g., 

“What do you like to do in your free time?” “Do 

you like to sing, draw, garden, cook, exercise, 

read, hike, dance, write, etc.?” “Did you have 

a favorite subject in school?” “What do you do 

well?” “What do others say you do well?”). Staff 

should not focus too much on the past, as some 

women may have trouble thinking of interests 

because of their substance use or may feel 

regret about giving up things they once enjoyed. 

A treatment/recovery goal that incorporates 

an interest or strength can be a strong early 

motivator. For example, a woman who likes to 

sing might join a choir to enhance her sense of 

efficacy and growth. A woman who dances may 

join a salsa class to become physically active 

and meet new friends. A woman who likes to 

draw can get a sketch book or share some of 

her art with her counselor or peers. A woman 

who takes pride in doing her children’s hair 

can teach other participants styling techniques. 

These types of goals and activities can help 

motivate women to stay engaged in services 

and address complex problems that take time 

to resolve. Finding strengths and joys can also 

help women explore new recovery opportunities 

and recognize their unique skills. 

Assessment and Treatment/Recovery 

Planning: Physical Health Needs 

Primary health care is a common need for 

women with SUDs. Women often develop 

medical consequences from their substance use 

in fewer years than men (SAMHSA, 2009, p.7). 

Also, women often fail to attend to healthcare 

problems while in active addiction. Screening 

and assessment should consider a woman’s 

health concerns; possibility of pregnancy; and 

need for comprehensive, integrated behavioral, 

reproductive, dental, and primary health care. 

A woman’s history may include risky sexual 

behaviors, partners with irresponsible sexual 

practices, non-consensual sex, sex work, and/

or trafficking. Many women have partners 

who, through violence or intimidation, restrict 

use of safer sex practices. Often women feel 

ashamed or scared to be tested for human 

immunodeficiency virus HIV, viral hepatitis, 

and other sexually transmitted infections. To 

promote a sense of safety, hold all talks about 

recommended testing in a trauma-informed 

and non-judgmental manner. Screening and 

assessment for risks of (HIV) and viral hepatitis 

can help women get early treatment, which 

can dramatically slow disease progression. If 

the woman decides to be tested and tests 

positive for a disease, she will need treatment 

and appropriate counseling, in addition to SUD 

treatment. Addressing her physical health needs 

will be an important element of her treatment/

recovery planning. 

Assessment and Treatment/Recovery 

Planning: Co-occurring Mental Health 

Conditions

Many women entering treatment for SUDs have 

co-occurring mental health conditions, so it is 
Page 19

important to screen for these conditions during 

assessment. Depression, anxiety disorders, 

PTSD, and eating disorders are common 

among women with SUDs. Many women with 

SUDs also have a history of suicidal thoughts 

or attempts. Failure to address co-occurring 

disorders can result in ineffective treatment 

and setbacks after SUD treatment is complete, 

so including integrated treatment in treatment/

recovery planning is of benefit to women. 

Although the prevalence of co-occurring conditions is high, some women have been misdiagnosed with a mental health condition, such as 

mania or borderline personality disorder, when 

clinicians failed to take into account issues such 

as trauma histories, substance use, or intimate 

partner violence. Centers working with women 

should either offer co-occurring services or 

have links with mental health providers who can 

address mental health conditions at the same 

time. Integrated assessment and treatment 

for co-occurring disorders is an evidencebased practice. Addressing both recovery from 

substance use and a mental disorder in the 

same treatment/recovery plan will result in a plan 

that makes sense for both conditions. It also 

prevents the confusion of conflicting recommendations from different providers and the stress of 

having too many treatment/recovery goals. 

Assessment and Treatment/Recovery 

Planning: Trauma Histories

Because the majority of women entering 

treatment have experienced trauma (SAMHSA, 

2009, p.22), trauma-informed assessments are 

important. Many trauma screening tools3

 are 

available to screen for adverse or traumatic life 

experiences. It is important for centers to understand two important factors when screening for 

trauma. First, to reveal traumatic experiences, 

the woman must be engaged in a sensitive and 

caring process that allows her to feel safe and 

comfortable. Second, a woman may not reveal 

3

 See SAMHSA-HRSA Center for Integrated Health Solutions, 

Screening Tools website, listed under “Trauma,” and 

SAMHSA’s TIP 57: Trauma-informed Care in Behavioral 

Health Services (2014), Chapter 4. 

trauma during intake. Thus, a system should 

be in place to screen for trauma post-intake 

and after the development of a trusting relationship with the clinician. All women with SUDs 

should also be assessed for the need for trauma 

services.

Common traumatic experiences among women 

entering SUD treatment include childhood 

abuse, sexual victimization, and intimate partner 

violence (IPV). Assess all intimate relationships 

for IPV, including same-sex relationships. Abuse 

can be physical, sexual, emotional/verbal, or any 

combination of the three. Just because a woman 

is not being physically hurt does not mean she 

is not being abused. Also, women who have 

experienced sex work or human trafficking, 

homelessness, or incarceration typically have 

higher rates of exposure to violence and trauma 

than other women entering treatment. Assessing 

for historical trauma can also help providers 

understand possible causes for depression, 

addiction, and other mental issues (Brave Heart, 

2003). Historical trauma refers to trauma caused 

by widespread events affecting an entire culture 

(SAMHSA, 2014d). Examples of events that 

have led to historical trauma include: slavery 

of African Americans, forced assimilation and 

relocation of Native Americans, the Holocaust, 

and genocidal practices of Hutus in Rwanda and 

Khmer Rouge in Cambodia (SAMHSA, 2014d, 

p. 40). Though further study is needed, historical 

trauma appears to have “repercussions across 

generations, such as depression, grief, traumatic 

stress, domestic violence, and substance abuse, 

as well as signifi cant loss of cultural knowledge, 

language, and identity” (SAMHSA, 2014d, p. 40).

Everyone processes trauma differently. Letting 

women discuss their traumatic experiences in 

a self-paced and respectful way preserves their 

dignity. It also allows them to feel heard and 

validates their feelings. This validation helps 

provide them with a sense of safety and empowerment, which is necessary for healing to begin.
Page 20

Women with trauma histories often use 

substances to cope with and survive traumatic 

experiences, symptoms, and memories. In 

these cases, the underlying trauma needs to 

be addressed. Otherwise she is likely to return 

to substance use after treatment, particularly 

if she returns to a traumatic personal/home 

life. Thus, having access to trauma-specific 

treatment services is vital to long-term recovery. 

Treatment/recovery plans may include traumaspecific interventions, psychiatric evaluation 

and pharmacotherapy, and strategies to build 

awareness of triggers and coping strategies. 

Other helpful services include education about 

self-care, mindfulness, boundary setting, healthy 

relationships, and alternative coping strategies. 

Assessment and Treatment/Recovery 

Planning: Relationships

Relationships are an important aspect of 

women’s lives. Successful assessment and 

treatment/recovery planning often involve strategies for addressing caretaking roles, handling 

relationships with unsupportive family and 

friends, and building new relationships with 

people who are supportive. Women with SUDs 

often report poor relationships with family, 

friends, co-workers, and others, which may be a 

result of addiction or lack of relationship skills. 

Children. Women entering treatment are likely 

to be mothers. For many women, the relationships with their children are their most important 

relationships. Their perception of themselves as 

a mother may have shaped much of their identity 

and given them a sense of purpose. Other 

women may need a safe environment where they 

can talk about their ambivalence toward motherhood. The expert panel noted the importance 

of respect, safety, and support for women who 

do not want to be mothers or do not gain the 

same level of satisfaction and value from their 

mothering role.

Center staff should take the time to learn the 

names and ages of a woman’s children and 

where each one lives, including those who are 

living with others or have been removed from 

her custody. Women who have lost children, 

whether through death, divorce, or loss of 

parental rights, often have tremendous grief that 

is a barrier to recovery. 

Substance use, trauma, and co-occurring mental 

health conditions can affect women’s ability to 

create and maintain a healthy connection to 

their children. Keeping their children’s needs in 

mind while handling the challenges of treatment/

recovery can be hard. These limitations can 

vastly affect a woman’s ability to parent effectively and maintain a mother-child relationship. For 

women whose caretaking role is central to their 

identity, addressing their children’s concerns may 

also be part of their treatment/recovery plan. 

Family Members. When the center includes a 

family counseling group or support programming 

for families, a woman may need help identifying potential “family” members willing to attend 

counseling sessions and support her. She may 

also need help in reaching out to family members 

who may resist participating. Though family is 

often most important for women, men are more 

likely to have a family member who is willing to 

support their recovery efforts and attend family 

sessions. It is also common that, due to a family 

history of substance use and violence, a woman 

may need help figuring out the family member 

best suited to participating and supporting her. 

This may not be her partner, or parent, though 

working on these relationships is likely to be a 

part of her treatment/recovery plan. The most 

appropriate choice may instead be another 

family member or close friend with a healthy, or 

healthier, relationship and lifestyle.
Page 21

Assessment and Treatment/Recovery 

Planning: Intimate Partner Violence

Centers serving women should either develop 

in-house expertise or develop relationships with 

agencies specializing in sexual assault, IPV, and 

other forms of violence. Women may experience IPV regardless of the sex or gender of their 

partner, though women tend to inflict far fewer 

physical injuries then men. In some relationships, both partners are violent or emotionally 

abusive. 

IPV can impact how a woman presents herself 

during treatment, and how she benefits from 

treatment/recovery services. One woman may 

feel shame and appear withdrawn. Another may 

fear that telling staff about the abuse will make 

her ineligible for services unless she leaves her 

partner. Some will keep the IPV a secret, and 

others will feel empowered by entering treatment 

and will choose to leave abusive partners. 

It can be challenging for providers to be both 

family-centered and sensitive to IPV. Until staff 

get to know a woman, including understanding 

her priorities, experiences, and family dynamics, 

it is best to be very cautious about including her 

partner. Sometimes a violent partner appears 

to be the perfect, caring partner, while in reality 

the woman is actually controlled by and fearful of 

that person. It is crucial to interview and assess 

each woman separately from her partner. This 

allows her to independently decide what groups 

or programming she wants to attend and what 

releases she wants to sign for sharing of 

information. 

Women stay in abusive relationships for many 

reasons, such as emotional ties, financial dependence, access to drugs, children, an emotional 

bond to the partner, fear, a belief that they do 

not deserve anything better, and threats of 

worse violence if they leave. When a woman 

chooses to stay in an abusive relationship, it is 

best to honor her choice while also helping her 

develop a safety plan. Center staff should create 

chances for her and other women to:

• Identify signs of unhealthy relationships 

and abuse

• Understand how abusive relationships may 

trigger trauma or substance use

• Practice setting appropriate boundaries

• Share her voice and make choices

• Access resources and ensure safety

A woman who decides to leave an abusive 

relationship may need specialized services. 

Leaving can pose great danger to her life and 

well-being. It is vital to create well-defined 

safety protocols for both the woman and the staff 

members who are working most closely with her. 

Access to Services and Supports

When working with a woman to identify possible 

services and groups, center staff should create 

informal times to talk and build in time for her to 

talk about herself. Peer specialists or recovery 

coaches can also be supportive partners in the 

conversation. Using input from these talks as 

a foundation, center staff should work with the 

woman to identify services and supports that will 

best meet her needs in terms of content, timing, 

and group dynamics (e.g., is she likely to be 

comfortable in a co-ed group?). 

Services and supports will be as varied as the 

women who visit the center. As mentioned 

earlier, many women have co-occurring health 

and mental health conditions. Treatment/

recovery plans should address those health 

conditions and any related goals and link the 

women to needed services. Many women enter 

treatment as a result of a child welfare or court 

case and need support meeting and understanding legal requirements. For example, early 

treatment/recovery goals in such cases may 

include understanding the process and identifying mandates, supports, and strategies for 

handling the situation—emotionally and practically. If a woman has an open child welfare case, 

treatment/recovery planning should prioritize 

issues related to her case. 
Page 22

Assessment and treatment/recovery planning 

have limited value if the center is not equipped 

to help women address problems and priorities 

identified. Centers need to honestly assess their 

ability to meet women’s needs and offer personcentered planning. Some centers may need 

additional training or support to enhance clinical 

expertise in mental health assessment protocols 

or trauma-informed care. Others may choose to 

build relationships with outside service providers. 

Although treatment/recovery plans may link 

directly to participation in specific treatment 

groups or case management services, centers 

should try not to limit treatment/recovery plans 

only to services offered by the center. Holistic 

centers draw on a range of services, and formal 

and informal resources, within the center and 

in the community. For example, many women 

benefit from faith-based programming. Others 

need help accessing health care, child care 

and pre-school programs, or food and housing. 

Treatment/recovery planning may include 

direct support in accessing these resources or 

guidance so the woman can learn to access 

them herself. A woman with low self-efficacy and 

little experience accessing resources may find 

this skill challenging. Treatment/recovery plans 

should allow plenty of time for her to overcome 

her sense of helplessness and become 

empowered.

As her recovery strengthens, a woman may 

develop and maintain her own plan for achieving 

ongoing health, wellness, and positive life goals. 

Or she can create one with the help of a recovery 

coach or peer specialist. Regardless of development approach, these longer-term recovery plans 

might include a woman’s thoughts on contributing to her community, expanding the reach of her 

“voice,” and taking on leadership roles.

D. INTERVENTIONS AND GROUPS

Treatment/recovery planning identifies the 

objectives and priorities for services. It serves 

as a road map for the woman’s journey. Group, 

individual, and family counseling and other interventions are the primary services that support 

the goals of the treatment/recovery plan. This 

section discusses the array of services available 

to women, along with co-ed and women-only 

groups. 

Services Offered

The range of services offered should address the 

physical, financial, emotional, social, cognitive, 

and spiritual needs of the woman, as well as her 

priorities. Many interventions and supports can 

promote wellness, including evidence-based 

practices (EBPs) and curricula that are highly 

effective for women. Before selecting one, clinicians should determine whether it has validity 

with women, as well as men. If possible, clinicians should conduct a trial run in the actual 

service setting. Evaluations of EBPs are often 

based on individual counseling sessions; the 

practices/curricula may not be equally effective 

in co-ed or single-sex group settings. 

Practices the expert panel identified as effective 

for women include the following. 

Motivational interviewing (MI) and motivational enhancement therapy (MET)4

 focus on 

the priorities set by the woman and her unique 

needs and circumstances. The MI approach 

has four principles: expressing empathy and 

avoiding arguing, developing discrepancy, rolling 

with resistance, and supporting self-efficacy and 

strategies for building it. MI and MET both center 

on rapid and internally motivated change (CSAT, 

1999).

Medication-assisted treatment and recovery 

(MATR),

5

 combined with counseling and 

recovery supports, has shown positive impacts 

for opioid-dependent and alcohol-dependent 

women. MATR is strongly indicated for opioiddependent pregnant women. Programs offering 

MATR should set protocols for screening and 

adjusting for pregnancy. Likewise, all centers 

4

 Listed in SAMHSA’s National Registry of Evidence-based 

Programs and Policies (NREPP).

5

 MATR is often referred to as medication-assisted treatment 

(MAT). Information about different types of MATR is found 

at SAMHSA’s Medication-Assisted Treatment website. 
Page 23

serving pregnant women should have a protocol 

for assessment and provision of MATR services 

(CSAT, 2005). 

Centers that do not offer MATR can establish 

a partnership through which to deliver MATR 

treatment/recovery services. This arrangement 

will then provide the best therapeutic option for 

pregnant women and other women needing 

MATR. Centers may also need to work on the 

negative judgment that women engaged in 

MATR may face, particularly in mutual support 

programs. 

Cognitive behavioral therapy (CBT),

6

often used as a part of SUD treatment, is the 

framework for many curricula. CBT can help 

women identify challenging thought patterns 

(e.g., anxiety, negativity, irrationality) that contribute to substance use or addiction and halt the 

cycle of negative thinking. This type of therapy 

can also help women engage in self-care. 

Centers should use CBT topics and curricula 

that support women who lack self-efficacy and 

address issues important to women, such as the 

CBT-based Using Matrix with Women Clients: A 

Supplement to the Matrix Intensive Outpatient 

Treatment for People with Stimulant Disorders

(SAMHSA, 2012c). 

Dialectical behavioral therapy (DBT)7

integrates CBT and mindfulness. DBT was first 

developed to address borderline personality 

disorder, but it has since been used for a variety 

of mental health conditions. DBT is very effective 

in addressing trauma-related symptoms.

Curricula for integrated trauma/substance 

misuse coping skills help women identify 

triggers and develop coping and self-care strategies that reduce substance misuse and other 

problem behaviors. Examples include Seeking 

Safety (Najavits, 2002), Beyond Trauma: A 

Healing Journey for Women (Covington, 2003), 

and The Trauma Recovery and Empowerment 

Model (Harris, 1998). Concurrent Treatment 

6

 Listed in SAMHSA’s NREPP.

7

 Listed in SAMHSA’s NREPP. 

of PTSD and Substance Use Disorders with 

Prolonged Exposure (COPE) focuses on treating 

women with co-occurring PTSD and SUDs (Back 

et al., 2014).

Integrated co-occurring disorder treatment

addresses mental health conditions and 

SUDs within a unified treatment/recovery plan 

(SAMHSA, 2010). The expert panel noted that 

co-occurring disorders should be the expectation rather than the exception and that centers 

should plan for them accordingly. This planning 

includes hiring or training staff members who 

can develop and implement integrated services 

on site. If unified services are not possible, the 

treatment/recovery plan should at least acknowledge the need for coordinated care and support 

access to appropriate mental health providers. 

Other important issues with co-occurring disorder 

services include the following: 

• Some psychopharmacological medications 

used to treat disorders may affect women 

differently than men or have side effects of 

greater concern for women. Prescribing 

practitioners who understand and address 

gender differences can have a positive 

impact on women’s psychiatric care. 

• There are informational and decision aids 

that allow for shared decision-making 

between women and their mental health 

providers. Shared decision-making 

maximizes communication and also enables 

people to actively manage their own health. 

This can be particularly empowering for 

women who have been silent or passive in 

the past and can benefit from a structured 

decision aid (SAMHSA, 2012b).
Page 24

In addition to traditional group counseling and 

educational sessions, other interventions of 

benefit to women include:

• Grief counseling, particularly for women 

who have lost children through death, termination of parental rights, or other ways. 

Significant, unaddressed grief issues can be 

a barrier to recovery.

• Workshops or therapies that allow women 

to develop and express their self-identities, 

self-value, and relationships. Women may 

be particularly receptive to and benefit from 

non-verbal forms of expression, such as art 

therapy, dance, creative writing or journaling, 

and yoga.

• Strength-based case management to 

help women overcome learned helplessness and low self-efficacy while making 

progress toward their recovery plans. 

Identifying small action steps and celebrating each success helps build confidence. 

As successes accumulate, the woman will 

notice her achievements, and her confidence in her ability and problem-solving 

skills will grow. This can be a powerful way 

to build self-efficacy, resilience, and selfdetermination. 

• Communication and assertiveness skills 

workshops designed for women. 

Note: Mutual support programs, many of 

which are backed by research, are described 

in Section III.E. 

Women-Only Groups

Expert panel members agreed that women are 

best served if they attend some women-only 

groups on a regular basis. Thus, co-ed centers 

are most effective when they offer some singlesex groups. Women-only groups provide a 

chance for women to explore recovery topics 

they may be uncomfortable discussing in the 

presence of men. These groups can also help 

build mutual support among women. Men may 

also feel more comfortable in and benefit from 

men-only groups when talking about certain 

topics. Ideally, centers offer many choices of 

co-ed and single-sex groups.

When regularly scheduled women-only groups 

are not an option, centers could consider offering 

one-on-one sessions with a female counselor, 

peer specialist, or recovery coach to talk about 

gender-specific concerns. Centers can also 

make arrangements for women to attend womenonly groups offered by another agency. This may 

mean the content will not be specific to women 

and SUDs (e.g., having a women’s group or 

session focused on eating disorders, HIV prevention, or parenting), but it will create a safe place 

for women to address some of the life challenges 

that could contribute to setbacks. Centers can 

also maximize resources by creating a women’s 

group in conjunction with another agency. 

Centers can invite volunteers and community 

programs to present on parenting, IPV, financial 

concerns for women, juggling home and work, 

and other topics important to women. This 

“normalizes” concerns and shows they affect 

all women. It also encourages participants to 

access community resources to support their 

recovery and personal growth. 

COMBINING CO-ED PROGRAMMING 

WITH INDIVIDUAL THERAPY

“We have women who participate in 

gender-specific, home-based treatment 

[programs], but when they attend an 

intensive outpatient program or a recovery 

group, the groups are primarily co-ed. 

Utilizing more than one program, the 

women have the opportunity to process 

their needs in a safe environment with 

their female therapist and recovery coach 

and/or attend a female-only trauma group 

while also receiving the benefits from the 

additional outpatient programming. Staff 

from both programs also coordinate care.” 

― Provider at a women’s treatment center
Page 25

Topics for Single-Sex Groups

Women often feel uneasy talking about certain 

topics in co-ed groups. Such topics include 

relationships, abuse, body image, anger 

management, economic insecurity, reproductive 

health issues, sexual identity, and co-occurring 

mental disorders (e.g., depression, anxiety, 

PTSD, and eating disorders). 

Sexuality and reproductive choices are important 

topics that are best discussed in a single-sex 

group. Groups that focus on integrated trauma 

and substance use recovery, and coping strategies, are also most often single-sex. Many 

women with SUDs have difficulty with self-care

and benefit from a curriculum focused on taking 

care of their physical and mental health, which 

may be most effective in a women-only group. 

Women may need to develop drug/alcohol 

refusal and interpersonal and life skills that differ 

from those of men entering recovery. Anger 

management, for example, is an important topic 

that is hard to adequately address in a co-ed 

group. This is because women often internalize 

anger or feel shame when they express it. Many 

women need a safe place to share their anger 

and learn how to express it in healthy ways. 

Those who have experienced trauma often have 

displaced anger that needs to be addressed.8

8

 Additional evidence-based curricula can be found at 

SAMHSA’s NREPP. 

Sampling of DiScuSSion TopicS for Women-only groupS

• Trauma, abuse, and violence

• Managing emotions

• Body image

• Self-care/Loving and valuing yourself

• Caregiver roles

• Parenting and child safety

• Pregnancy and substance use

• Women’s sexuality and sexual identity

• Building healthy relationships

• Coping with stress

• HIV/AIDS prevention

• Economic success in recovery

• Pathways to family reunification 

• Stages of violence/abuse

• Weight loss/Eating disorders

• Women’s reproductive health

• Achieving balance

• Overcoming obstacles to recovery

• Women’s mutual support

• Sexism

• Racism and stigma

• Conflict styles/Conflict resolution

• Communication skills

TopicS above Taken from The folloWing curricula:8

• Using Matrix with Women Clients: A 

Supplement to the Matrix Intensive 

Outpatient Treatment for People with 

Stimulant Use Disorders (SAMHSA, 

2012c)

• Boston Consortium Model: TraumaInformed Substance Abuse Treatment 

for Women (Amaro et al., 2005) 

• Women’s Recovery Group 

(Greenfield, 2016) 

• Helping Women Recover: A Program 

for Treating Addiction, Revised Edition

(Covington, 2008) 

• Conflict Resolution for Recovery and 

Relapse Prevention (Moreno-Tuohy, 2011)
Page 26

Likewise, many women need to understand they 

have rights and learn to speak up for themselves 

by developing assertiveness skills. These 

needs are very different from most men’s angermanagement needs. Also, both male and female 

participants may have experienced interpersonal 

violence, which can complicate the dynamics of a 

co-ed anger-management group.

If staff members are uncomfortable discussing 

the above topics in either group or individual 

counseling sessions, professional development 

may be needed to ensure safe and effective 

discussion environments. 

Gender Dynamics in Co-ed Groups

When possible, co-ed groups should be 

somewhat equally balanced between men and 

women. Centers serving many more males 

than females may need to group women to get 

as close to 50 percent as possible. It is best to 

avoid having groups with only one or two women 

among several men.

Many centers operate groups that do not have 

a beginning or an end date. Instead, a rolling 

entry point allows women to enter a group at any 

time. With this in mind, careful planning may 

be needed to welcome new members, establish 

and communicate group guidelines, and make 

an extra effort to accommodate women’s needs 

when the number of women in a group drops to 

just one or two. 

Ideally, co-ed groups have both a male and 

a female facilitator. One may be a recovery 

coach or peer specialist. Effective facilitators 

are trained in group dynamics and skilled in 

engaging diverse participants. They also help 

the group meet its objectives. Facilitators should 

be attuned to possible participant discomfort 

with the group process and aware of cultural, 

age, sexual orientation, and other dynamics that 

can impact group participation and safety. For 

example, facilitators may need to help women 

focus on themselves, rather than on the men in 

the group. This includes identifying caregiving 

differences between men, who tend to “fix,” and 

women, who tend to “nurture.” This focus also 

includes noting the differences between healthy 

and unhealthy caretaking behaviors in groups. 

The facilitators may need to minimize group 

members’ attempts to impress one another. Or 

they might have to balance an individual’s desire 

to share trauma details with the need to minimize 

possible trauma reactions in others. 

When selecting curricula, facilitators should be 

sure they are valid for men and women. They 

should review the curricula, topics, and examples 

and note any gaps or red-flag areas that could 

be problematic. Facilitators may need to be 

prepared and offer other examples as needed. 

When setting up the group, skilled facilitators 

help participants meet for the first time; develop 

group guidelines; and form a group identity, such 

as coming up with a group name. This can help 

participants become more comfortable with each 

other and establish some solidarity. 

Issues of Power in Co-ed Groups

Facilitators need to be aware of gender dynamics 

and power issues that can impact group 

dynamics and participation, such as differences 

in communication styles and assertiveness. The 

group structure and process should also reflect
Page 27

gender differences. Men are often more 

goal-oriented and women more processoriented. Also, women may be more comfortable discussing feelings and exploring ideas 

while men often prefer to report information 

and facts. These gender differences are more 

obvious in co-ed groups than in single-sex 

groups. A skilled facilitator can help participants recognize and process these behaviors, 

and can leverage these differences to support 

the full group.

A highly effective facilitator might address 

power dynamics and use the group experience itself as an example, when appropriate. 

Facilitators should have an array of techniques 

for creating an emotionally safe environment. 

These techniques include getting all group 

members to participate, including those who 

are less likely to jump into a conversation. If 

the facilitator fails to attend to gender issues, 

women may feel marginalized, become quiet, 

or focus on supporting either men or other 

women in the group, rather than on their 

own growth and the development needed for 

lasting recovery.

With a skilled female–male facilitator team, 

co-ed groups can be a safe environment for 

discussing gender dynamics. As the need 

arises, staff can help participants discuss 

gender differences and how they may affect 

participants’ relationships in recovery. Men 

and women both benefit from hearing each 

other speak about needs, frustrations, and 

concerns. 

Co-ed groups offer participants the chance to 

practice listening to one another and talking 

about needs and concerns. For women, 

talking about themselves, their desires, and 

their vulnerabilities may be hard. Out of habit, 

the women may focus on the men in the group 

and try to help them open up and talk about 

their recovery concerns. An effective facilitator will be aware of this and direct a woman’s 

focus back to herself, helping her open up and 

address her recovery concerns. 

Group Guidelines for Leveling 

Gender Dynamics 

Creating group guidelines can help level an 

imbalance of power within co-ed groups. 

Guidelines might include the following: 

• Encourage strength-based self-talk among 

participants

• Avoid self-deprecating statements

• Focus on yourself rather than talking 

about/judging others in the group

• Avoid teasing and sarcasm

• Avoid dominating the group discussion

It is helpful to train facilitators and participants 

on maintaining these guidelines. Provide 

examples of language to use when a line has 

been crossed. The “Ouch Rule,” for example, 

encourages participants to say “ouch” if 

someone says something painful or uncomfortable. The group then stops the conversation 

to address the “ouch.” 
Page 28

Tricia is in a counseling group that often has about six men and usually no other women. 

During the first few sessions, she was an active participant, offering a lot of support to others. In 

the past two sessions, however, she was quieter. She seemed a bit angry and impatient, sitting with 

her hands folded across her chest. Steve, the group facilitator, reported this observation to Joann, 

Tricia’s primary counselor. Rather than waiting for Tricia’s next scheduled meeting in 2 weeks, Joann 

called Tricia to ask if they could schedule a check-in appointment. During this check-in, Joann asked 

Tricia about her impressions of and experiences with the different groups and whether any other 

resources could help her achieve her goals. 

From this conversation, Joann identified two ways the center could improve services for Tricia. First, 

Tricia was feeling dissatisfied with her life. She didn’t want to return to substance use, but felt it was 

her only option. She had gained a lot of weight, was uncertain about her relationship, hated sex, and 

was lethargic and angry. Her children were still in foster care. Tricia didn’t feel like she could speak 

about these issues during the group, as she was the only woman. 

Finding that the only women’s group met at a time that didn’t work for Tricia, Joann scheduled an 

extra 1:1 session with Tricia until a women’s group was available. Joann also worked with Tricia to 

find peer support through child welfare services. During a staff meeting, Joann and Steve brought 

up the need for gender sensitivity and attention to group dynamics. The Program Director developed 

a strategy for tracking groups and clustering female participants together to create more balanced 

groups.

E. RECOVERY SUPPORT SERVICES

Recovery support services promote wellness 

and recovery in part by supporting women as 

they find their voices and self-identity. SAMHSA 

has identified four pillars of recovery supports: 

health, home, purpose, and community 

(SAMHSA, 2012a). For many women with 

SUDs, developing these four pillars involves a 

range of community/ancillary services. As noted 

in the guidance statements, women with SUDs 

often require health, mental health, and additional services to be successful in treatment/recovery 

goals. These women also benefit from recovery 

support services before, during, and following 

SUD treatment. 

This section discusses some of the additional, 

peer support, recovery support, and case 

management services that co-ed centers may 

need to provide to be gender responsive and 

supportive to women. 

Access to Services

Women may need support to access services 

within the center. Early in assessment and 

treatment/recovery planning, counselors can 

work with women to remove barriers to participation and provide resources that will enable 

women to attend groups and center activities. 

Whenever possible, counselors should offer 

an array of groups so women have access to 

programming, despite any changing demands 

and scheduling challenges. Employment is not 

the only limiting feature in a woman’s schedule. 

Women may need to pick up their children from 

school, or tend to their dinner and bedtime 
Page 29

schedules in the early evenings. Lack of safe 

transportation can also make evening sessions 

difficult. When possible, centers should make 

it a priority to create flexible treatment and 

recovery service schedules. Flexible schedules 

help services fit the demands and positive activities of women, minimizing stress and increasing 

opportunities to connect. 

Ideally, programs should offer child care, family 

services, and transportation assistance for 

women who face these potential barriers to 

attendance. When this is not possible, formal 

and informal resources within the community 

may help women overcome service barriers. 

These resources could include referrals to child 

care with sliding-scale fees or programs that 

provide transportation vouchers. 

Peer Supports 

As discussed in the staffing section, recovery 

coaches and peer specialists offer women 

chances to process their experiences, learn, 

and develop a sense of hope and self-efficacy. 

Connecting women in services with female peers 

and recovery coaches promotes rapport and, 

thus, better transmission of strength and hope. 

It can also help prevent uncomfortable gender 

dynamics (e.g., a woman focusing more on the 

feelings of her male recovery coach than her 

own) or possible romantic/sexual feelings within 

the peer relationship, if the woman is heterosexual. 

Many centers offer ongoing services, such as 

post-treatment check-ups and alumni activities. 

These activities help relieve a woman’s feelings 

of isolation, which can contribute to setbacks 

after program completion. Participating in 

co-ed and women-only recreational and social 

events allows women to build relationships while 

engaging in healthy, fun activities. Both co-ed 

and single-sex alumni activities and recovery 

support programming are excellent venues for 

developing healthy relationships. Women and 

men have the chance to practice communication 

skills and learn about differences between men 

and women’s perspectives on relationships and 

communication. These skills will continue to be 

helpful long after treatment is over. Women may 

need support to establish and sustain positive 

healthy relationships with males and females. 

Building such relationships can help women 

create a support network for long-term recovery. 

Educational sessions in self-advocacy and 

understanding rights within the context of the 

center and the larger health system can help 

women become advocates for themselves 

and others while gaining/regaining a sense of 

empowerment. Another way is to offer women 

the chance to participate in volunteer and leadership opportunities. Helping others can build 

self-esteem, a sense of purpose, and solidarity in 

their recovery. Many women lead very full lives 

and have limited time to volunteer in recovery 

support activities. Pressure to volunteer can 

create guilt or raise levels of stress. Thus, center 

staff should be sensitive to women’s commitments and schedules. 

Mutual Support and Self-Help 

Opportunities 

Most communities have a range of in-person 

and virtual self-help programs and meetings. 

In mutual support programs, participants 

support each other’s recovery and share tools 

and techniques that have helped them. Many 

treatment and recovery programs help women 

identify and access mutual support services, as 

well as virtual self-help programs and meetings. 
Page 30

Referrals to community resources might include 

12-step groups, such as Alcoholics Anonymous 

or Narcotics Anonymous, or alternatives, such 

as Women for Sobriety, Rational Recovery, and 

faith-based groups. When referring women 

to mutual support groups, center staff should 

be aware of the many types of meetings and 

options available. Even within one kind of mutual 

support program, participants and tone can vary 

a lot from one meeting to another. 

Within mutual support programs, there are often 

women-only and special topic meetings that 

offer women the chance to discuss important 

gender-specific recovery issues. Center staff 

should encourage and help women to ask others 

about programs they like and to explore different 

options until they find recovery supports that feel 

safe and comfortable to them. 

A woman’s sense of safety and comfort are 

critical to her participation in a mutual support 

program. It is not uncommon for male participants to far outnumber females. Participants 

who lack a healthy respect and boundaries 

for women may say or behave inappropriately 

or not be respectful, making women feel very 

uncomfortable. Women’s experience in these 

settings may range from mild unease to severe 

discomfort. When sexual harassment occurs in a 

mutual support setting, women can feel particularly vulnerable and betrayed. In those cases, it 

is important for the woman’s recovery that she 

have a chance to process the experience and 

her related feelings. Some women with SUDs 

need coaching on protecting themselves while 

in the community, such as not walking alone and 

only going to public venues. Treatment/recovery 

centers can help by encouraging women to 

attend specific meetings or attend together. 

Centers may also decide to provide meetings in 

their facilities or help women to identify womenonly meetings. 

Many virtual self-help meetings are available for 

women who need to be home with children, lack 

transportation, or have busy work schedules. 

Virtual meetings allow women to remain 

connected to a group, which helps them remain 

on their recovery path.

Case Management, Recovery Supports, 

and Ancillary Services

As noted earlier, women often have needs and 

responsibilities beyond SUD counseling and 

services. Failure to meet these needs may result 

in increased stress and lapses in recovery, which 

have a tremendous impact on overall health and 

wellness. Responsive agencies offer access 

to other community services when participant 

needs are beyond their scope of services. 

Specific areas to consider when providing case 

management, care coordination, or other forms 

of advocacy include the following:

• Services to address physical and mental 

health needs. Health screening and access 

to primary care are important for women with 

SUDs, as they tend to have a broad range of 

health concerns. Health education services 

that teach women about their bodies are 

important for women entering recovery. 

Center staff should also remember that 

women with trauma histories often have a 

hard time seeking and following through with 

health care. Staff may need to help them 

identify triggers and find strategies for overcoming them as they access health care. 

Behavioral health staff can also educate 
Page 31

providers of physical health services about 

trauma-informed approaches and how 

to provide services in a trauma-sensitive 

manner. Health services might be needed 

for the following:

– Reproductive health, pregnancy, postpartum care, and family planning

 – Sexually transmitted infections, HIV, and 

hepatitis C prevention and treatment

 – Prevention and treatment of medical conditions, such as hypertension, diabetes, 

cardiovascular diseases, and asthma

 – Mental health services, including behavioral and pharmacotherapy treatment for 

co-occurring mental disorders common to 

women with SUDs

• Services to address family needs. 

Women entering treatment may need 

parenting skills training, trauma-informed 

parenting education, family counseling, 

child development education, access to 

children’s services, and supports for other 

family members’ needs. Women may 

also need help negotiating with the school 

system to support their children through 

special education programs/individualized 

education plans (IEPs), free/reduced price 

school lunch, and parent-teacher conferences. Families may benefit from child care 

referrals/linkages to subsidized programs, 

including Head Start, Early Intervention, 

and other government programs that offer 

sliding-scale fees and child care vouchers. 

Women involved with child welfare agencies 

may have particular needs, including:

 – Parenting education services that are 

trauma-informed, non-judgmental, and 

culturally responsive, and that focus on 

child development. These services help 

reduce family stressors and improve 

parenting. Also, child welfare agencies 

often require these services.

 – Therapeutic parent/child interventions

that are trauma-specific and sensitive 

to the needs of both parent and child, to 

foster healing from past trauma.

 – Family reunification services designed 

to reunite children who have been living 

outside of their home with their families 

and to strengthen families in their own 

homes. Through these services, professionals work with families to make 

sure children are safe within their home. 

Family reunification professionals also 

find and reduce or eliminate risks that 

may cause children to remain out of the 

home.

 – A safe and child-friendly space to have 

supervised visitation and be able to meet 

privately with their child’s caseworker. 

 – Planning and family support programs

that help women learn to build or rebuild 

family connections and cohesion, develop 

family rituals, and participate in recreational and social opportunities. 

• Linkages that address basic needs. 

Though it may be challenging to address 

or make referrals for all women’s needs, it 

is important for centers to understand that 

many women enter and leave treatment 

with very basic needs for food, clothing, and 

shelter. Centers can help women obtain 

services to meet basic needs, including:

 – Income assistance. Women with 

SUDs may qualify for income assistance 

programs such as Social Security Disability Insurance (SSDI), Supplemental 

Security Income (SSI), Temporary Assistance for Needy Families (TANF), or local 

general relief programs. Women may 

need help meeting the documentation and 

application requirements. 

 – Housing and transportation. Referrals 

to subsidized housing programs (e.g., 

local Housing Authority, homeless 

programs) and transportation can support 

women in building lives focused on their 

recovery. 

 – Food and nutrition programs. Women 

may need support in applying for the 

Supplemental Nutrition Assistance 

Program (SNAP, formerly known as food 
Page 32

stamps) or the Special Supplemental 

Nutrition Program for Women, Infants, 

and Children (WIC). They may also be 

interested in learning about nutrition; 

preparation of simple, nutritious meals; 

and access to healthy foods. 

 – Health care. Some women receiving 

SUD services will qualify for Medicaid 

or insurance under the Affordable Care 

Act. They may need help applying 

for insurance and understanding their 

benefits and insurance restrictions.

• Assistance obtaining legal assistance. 

Women who are involved with the criminal 

justice or judicial system must be responsive 

to the demands of probation, parole, and the 

courts. They may need legal help with outstanding warrants, pending charges, or court 

cases. Women may also need legal help for 

non-criminal legal issues, such as resolving 

issues with divorce decrees, mortgages, 

rental disputes, or inheritance; obtaining 

child support; and addressing debt.

• Access to education, employment, and 

career services. Women with SUDs often 

have less experience in the work world than 

men with SUDs. These women may need 

supports related to job readiness, workplace 

negotiation, training, education, and job 

development that take into account their 

skills, resources, interests, and barriers 

to employment. Women with SUDs often 

benefit from education on balancing work, 

family, and self-care and planning for unexpected challenges (e.g., saving paid time off 

from work to care for a sick child, arranging 

alternative child care when a daycare 

provider cancels).

• Help with case management and care 

coordination. Case management and care 

coordination help women access essential 

recovery and community supports while 

managing many demands. These demands 

may stem from multiple service systems, 

such as: 

 – Crisis services (e.g., food, transportation)

 – Child welfare

 – Criminal justice (including probation and 

parole)

 – TANF and welfare programs

 – Educational and employment services 

 – Housing support agencies

 – Children’s services (education, developmental service agencies)

 – Health and mental health service systems

By providing access and referrals to the above 

range of services, centers help women in 

recovery overcome the broader issues and 

barriers they face in daily life. This, in turn, helps 

women maintain abstinence from substance use 

and achieve SAMHSA’s four pillars of recovery: 

health, home, purpose, and community.
Page 33

IV. ConCLUsIon

As noted throughout this document, most women 

receive services in co-ed programs. Because 

women’s needs are unique, developing effective 

co-ed programming with women’s needs in mind 

is of critical importance. Having a better understanding of the needs of women will help support 

gender-responsive efforts of programs that 

generally serve more men than women. Some 

essential ingredients for a center’s success 

include: 

• Leadership support. Senior 

managers of treatment and recovery 

centers can prioritize gender-responsive program development and raise 

the visibility of female staff in leadership positions. 

• Individualized approach to service 

delivery. An individualized approach 

benefits women and men because it 

is more likely to result in better engagement, activation, retention, and 

outcomes. 

• Champions. These are organizational leaders who are committed to 

better addressing the needs of women 

and can support the team through 

resources or clinical supervision. 

• Access. Successful centers minimize 

barriers for women to engage in 

treatment/recovery services. 

• Trauma-informed approach. 

Centers should adopt a traumainformed approach and develop an 

organizational culture, policies, and 

program that demonstrate being 

trauma-informed is a priority. This 

benefits all stakeholders, including 

staff, and is directly linked to healing 

and recovery. 

• Flexibility. Centers need flexibility to 

shift programming and adopt practices 

that will support women. 

• Female peers and community. 

Centers may already have a base 

of female peer specialists, recovery 

coaches, alumni, women currently 

receiving services, and volunteers 

who can establish a community and 

support each other. Centers can 

also identify them through alumni 

communication or meetings and can 

ask women whether they are interested in further engagement before they 

leave treatment or formal recovery 

programming. 

Achieving gender-responsive, culturally 

competent, and trauma-informed services is a 

continuous improvement process. SAMHSA and 

the expert panel hope this document helps co-ed 

centers identify some immediate and longer-term 

steps they can implement to better respond to 

women with SUDs in treatment/recovery. 
Page 34

ReFeRenCes AnD ResoURCeS

Amaro, H., McGraw, S., Larson, M. J., Lopez, L., Nieves, R. L., & Marshall, B. (2005). 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.

Amaro, H., Mangual, S., & Nieves, R. L. (2004). Spirituality and recovery. Boston, MA: Boston 

Consortium of Services for Families in Recovery, Public Health Commission.

Amaro, H., Melendez, M. P., Melnick, S., & Nieves, R. L. (2005). Integrated substance abuse, 

mental health, and trauma treatment with women: A case study workbook for staff training.

Boston, MA: Boston Consortium of Services for Families in Recovery, Public Health Commission.

Amaro, H., & Nieves, R. L. (2004). Economic success in recovery. Boston, MA: Boston Consortium of Services for Families in Recovery, Public Health Commission.

Amaro, H., & Nieves, R. L. (2004). Pathways to family reunification. Boston, MA: Boston Consortium of Services for Families in Recovery, Public Health Commission.

Amaro, H., Nieves, R. L., & Sanders, L. (2004). Women’s leadership training institute. Boston, 

MA: Boston Consortium of Services for Families in Recovery, Public Health Commission.

Amaro, H., & Vallejo, Z. (2008). Moment-by-moment in women’s recovery: A mindfulness-based 

approach to relapse prevention. Boston, MA: Boston Consortium of Services for Families in 

Recovery, Public Health Commission.

Harris, M., Wallis, F., & Amaro, H. (2006). Saber es poder: Modelo de trauma y recuperacion 

para mujeres Latinas. (A Spanish translation and cultural adaptation of Maxine Harris’ Trauma 

Recovery and Empowerment manual). Boston, MA: Boston Consortium of Services for Families 

in Recovery, Public Health Commission.

Back, S. E., Foa, E. B., Killeen, T. K., Mills, K. L., Teesson, M., Dansky Cotton, B., Carroll, K. M., & 

Brady, K. (2014). Concurrent treatment of PTSD and substance use disorders using prolonged exposure 

(COPE): Therapist Guide. U.S.A.: Oxford University Press.

Bentley, K. J. (2005). Women, mental health, and the psychiatric enterprise: A review. Health and 

Social Work, 30(1), 56–63.

Boston Consortium Model: Trauma-informed Substance Abuse Treatment for Women, Intervention 

Summary. (n.d.). Retrieved from SAMHSA’s National Registry of Evidence-based Programs and 

Practices website: http://legacy.nreppadmin.net/ViewIntervention.aspx?id=86

Brady, T. M., & Ashley, O. S. (2005). Women in substance abuse treatment: Results from the Alcohol 

and Drug Services Study (ADSS). (HHS Publication No. [SMA] 04-3968, Analytic Series A-26). Rockville, 

MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies.

Brave Heart, M. Y. H. (2003). The historical trauma response among Natives and its relationship 

with substance abuse: A Lakota illustration. Journal of Psychoactive Drugs, 35(1), 7–13.

The Boston Consortium Model comprises seven separate curricula:
Page 35

Bray, F., & Atkin, W. (2004). International cancer patterns in men: Geographical and temporal 

variations in cancer risk and the role of gender. The Journal of Men’s Health & Gender, 1(1), 38–46.

Brittle, C., & Bird, C. E. (2007). Literature review on effective sex- and gender-based systems/model of 

care. Rockville, MD: Office on Women’s Health, U.S. Department of Health and Human Services.

Center for Substance Abuse Treatment. (2005). Medication-assisted treatment for opioid addiction in 

opioid treatment programs. Treatment Improvement Protocol (TIP) Series 43. (HHS Publication No. 

[SMA] 12-4214). Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved 

from http://store.samhsa.gov/product/TIP-43-Medication-Assisted-Treatment-for-Opioid-Addiction-in-Opioid-Treatment-Programs/SMA12-4214

Center for Substance Abuse Treatment. (1999). Enhancing Motivation for Change in Substance Abuse 

Treatment. Treatment Improvement Protocol (TIP) Series, No. 35. (HHS Publication No. [SMA] 13-4212). 

Rockville, MD: Substance Abuse and Mental Health Services Administration. Retrieved from http://store.

samhsa.gov/shin/content//SMA13-4212/SMA13-4212.pdf

Center for Substance Abuse Treatment. (2008a). Addiction counseling competencies: The 

knowledge, skills, and attitudes of professional practice: Technical Assistance Publication (TAP)

21. (HHS Pub. No. [SMA] 08-4171). Rockville, MD: Substance Abuse and Mental Health Services

Administration. Retrieved from http://store.samhsa.gov/product/TAP-21-Addiction-CounselingCompetencies/SMA14-4171

Center for Substance Abuse Treatment. (2008b). Competencies for substance abuse treatment clinical 

supervisors: TAP 21-A. (HHS Pub. No. [SMA] 08-4171). Rockville, MD: Substance Abuse and Mental 

Health Services Administration. Retrieved from http://store.samhsa.gov/product/TAP-21-ACompetencies-for-Substance-Abuse-Treatment-Clinical-Supervisors/SMA13-4243

Covington, S. S. (2007). A case for gender-responsive drug treatment. Clinical Psychiatry News,

35(8),15. 

Covington, S. S. (2008). Helping women recover: A program for treating addiction (revised ed.). 

Jossey-Bass Publishers. 

Covington, S. S., Burke, C., Keaton, S., & Norcott, C. (2008). Evaluation of a trauma-informed and 

gender-responsive intervention for women in drug treatment. Journal of Psychoactive Drugs, 

40(Suppl5), 387–398.

Fiorentine, R., Nakashima, N., & Anglin, M. D. (1999). Client engagement in drug treatment. Journal of 

Substance Abuse Treatment, 13(3), 199–206. 

Greenfield, S. F. (2016). Treating women with substance use disorders: The Women’s Recovery 

Group manual. New York: Guilford Press. Retrieved from http://www.guilford.com/books/TreatingWomen-with-Substance-Use-Disorders/Shelly-Greenfield/9781462525768

Greenfield, S. F., Brooks, A. J., Gordon, S. M., Green, C. A., Kropp, F., McHugh, R. K., Lincoln, M., 

Hien, D., & Miele, G. M. (2007). Substance abuse treatment entry, retention, and outcome in women: A 

review of the literature. Drug and Alcohol Dependence, 86(1), 1–21. 
Page 36

Greenfield, S. F., Sugarman, D. E., Freid, C. M., Bailey, G. L., Crisafulli, M. A., Kaufman, J. S., 

Wigderson, S., Connery, H. S., Rodolico, J., Morgan-Lopez, A. A., & Fitzmaurice, G. M. (2014). Group 

therapy for women with substance use disorders: Results from the Women’s Recovery Group Study. 

Drug and Alcohol Dependence, 142, 245–253. doi: 10.1016/j.drugalcdep.2014.06.035

Grella, C. E., Scott, C. K., & Foss, M. A. (2005). Gender differences in long-term drug treatment 

outcomes in Chicago PETS. Journal of Substance Abuse Treatment, 28(Suppl1), S3–S12.

Harris, M. (1998). Trauma recovery and empowerment: A clinician’s guide for working with 

women in groups. The Free Press.

Hudson, J. I., Hiripi, E., Pop, H. G. Jr., & Kessler, R. C. (2007). The prevalence and correlates of 

eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348–358.

Kim, J. K., Alley, D., Seeman, T., Karlamangla, A., & Crimmins, E. (2006). Recent changes in 

cardiovas-cular risk factors among women and men. Journal of Women’s Health, 15(6), 734–746.

Mandell, K., & Werner, D. (2008). Guidance to states: Treatment standards for women with substance 

use disorders. Retrieved from the National Association of State Alcohol and Drug Abuse Directors and 

the Women’s Service Network website: http://nasadad.org/2015/07/guidance-to-the-states-treatmentstandards-for-women-with-substance-use-disorders/

Merriam-Webster Dictionary. (n.d.). Cisgender. Retrieved from http://www.merriam-webster.com/dictionary/cisgender

Moreno-Tuohy, C. (2011). Conflict resolution for recovery and relapse prevention. Rockville, MD: 

NAADAC.

Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York, 

NY: Guilford Press.

National Institutes of Health, Office of Research on Women’s Health. (n.d.). A to Z guide: Sex and 

gender influences on health. Retrieved from http://orwh.od.nih.gov/resources/sexgenderhealth/index.asp

National Institutes of Health and Office of Women’s Health, U.S. Food and Drug Administration. 

(2009). The science of sex and gender in human health. [Online course]. Bethesda and Rockville, 

MD. Retrieved from https://www.sexandgendercourse.org/

SAMHSA-HRSA Center for Integrated Health Solutions. (n.d.). Screening tools. Retrieved from 

http://www.integration.samhsa.gov/clinical-practice/screening-tools#TRAUMA

SAMHSA’s National Registry of Evidence-based Programs and Policies. (n.d.). All programs. 

[Website]. Retrieved from http://www.nrepp.samhsa.gov/AllPrograms.aspx

Substance Abuse and Mental Health Services Administration. (n.d.). Medication-assisted Treatment 

(MAT). [Website]. Retrieved from http://www.samhsa.gov/medication-assisted-treatment

Substance Abuse and Mental Health Services Administration. (2009). Substance abuse treatment: 

Addressing the specific needs of women. Treatment improvement protocol (TIP) 51. (HHS Publi-cation 

No. [SMA] 13-4426). Rockville, MD: Author. Retrieved from http://store.samhsa.gov/shin/content//

SMA14-4426/SMA14-4426.pdf
Page 37

Substance Abuse and Mental Health Services Administration. (2010). Integrated treatment for co-occurring disorders: Evidence-based practices KIT. (HHS Pub. No. [SMA] 08-4367). Rockville, MD: Author. 

Retrieved from http://store.samhsa.gov/product/Integrated-Treatment-for-Co-Occurring-DisordersEvidence-Based-Practices-EBP-KIT/SMA08-4367

Substance Abuse and Mental Health Services Administration. (2011). Addressing the needs of women 

and girls: Developing core competencies for mental health and substance abuse service professionals. 

(HHS Pub. No. [SMA] 11-4657). Rockville, MD: Author. Retrieved from http://store.samhsa.gov/shin/

content/SMA11-4657/SMA11-4657.pdf

Substance Abuse and Mental Health Services Administration. (2012a). SAMHSA’s working definition of 

recovery: 10 guiding principles of recovery. [Brochure]. (Publication ID: PEP12-RECDEF). Rockville, 

MD: Author. Retrieved from http://store.samhsa.gov/product/SAMHSA-s-Working-Definition-ofRecovery/PEP12-RECDEF

Substance Abuse and Mental Health Services Administration. (2012b). Shared decision making in 

mental health decision aid: Considering the role of antipsychotic medications in your recovery plan. 

[CD-ROM]. (HHS Pub. No. [SMA]12-4696). Rockville, MD: Author. Retrieved from http://store.samhsa.

gov/product/Shared-Decision-Making-in-Mental-Health-Decision-Aid/SMA12-4696

Substance Abuse and Mental Health Services Administration. (2012c). Using Matrix with women clients: 

A supplement to the Matrix Intensive Outpatient Treatment for people with stimulant use disorders. (HHS 

Pub. No. [SMA] 12-4698). Rockville, MD: Author. Retrieved from http://store.samhsa.gov/shin/content//

SMA12-4698/SMA12-4698.pdf

Substance Abuse and Mental Health Services Administration (2014a). Introduction to women and 

substance use disorders. [Online course]. Rockville, MD: Author. http://www.healtheknowledge.org/

course/info.php?id=44

Substance Abuse and Mental Health Services Administration. (2014b). National Survey of Substance 

Abuse Treatment Services (N-SSATS): 2013. Data on substance abuse treatment facilities. (BHSIS 

Series S-73, HHS Publication No. [SMA] 14-4890). Rockville, MD: Author. Retrieved from http://www.

samhsa.gov/data/sites/default/files/2013_N-SSATS_National_Survey_of_Substance_Abuse_Treatment_

Services/2013_N-SSATS_National_Survey_of_Substance_Abuse_Treatment_Services.html

Substance Abuse and Mental Health Services Administration. (2014c). SAMHSA’s Concept of trauma 

and guidance for a trauma-informed approach. (HHS publication No. [SMA] 14-4884). Rockville, MD: 

Author. Retrieved from http://store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-andGuidance-for-a-Trauma-Informed-Approach/SMA14-4884?WT.mc_id=EB_20141022_SMA14-4884

Substance Abuse and Mental Health Services Administration. (2014d). TIP 57: Trauma-informed care 

in behavioral health services. (HHS Publication No [SMA] 14-4816). Rockville, MD: Author. Retrieved 

from http://store.samhsa.gov/product/TIP-57-Trauma-Informed-Care-in-Behavioral-Health-Services/

SMA14-4816
Page 38

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and 

Quality. (2015). Treatment Episode Data Set (TEDS): 2003–2013. National Admissions to Substance 

Abuse Treatment Services. (BHSIS Series S-75, HHS Publication No. [SMA] 15-4934). Rockville, MD: 

Author. Retrieved from http://www.samhsa.gov/data/sites/default/

files/2003_2013_TEDS_National/2003_2013_Treatment_Episode_Data_Set_National.pdf

Substance Abuse and Mental Health Services Administration, GAINS Center for Behavioral Health and 

Justice Transformation. (n.d.). Fact sheet: Historical trauma. Retrieved from Ohio Mental Health and 

Addiction Services website: http://mha.ohio.gov/Portals/0/assets/Initiatives/TIC/General/Historical%20

Trauma%20SAMHSAs%20Gains%20Center.pdf

Werner, D., Young, N. K., Dennis, K., & Amatetti, S. (2007). Family-centered treatment for women with 

substance use disorders – History, key elements, and challenges. Retrieved from Department of Health 

and Human Services, Substance Abuse and Mental Health Services Administration website: http://www.

samhsa.gov/sites/default/files/family_treatment_paper508v.pdf
A2-39

APPenDIX 1:

Expert Panel to Develop a Co-Ed Guidance Document

The panelists represent a range of backgrounds and experience, including a mix of research/

treatment/peer recovery agencies, and diverse cultural, geographic, and lived experience.

EXPERT PANELISTS

Hortensia Amaro, Ph.D., Associate Vice 

Provost, Community Research Initiatives and 

Dean’s Professor in Social Work and Preventive Medicine, University of Southern California’s 

(USC) School of Social Work

Kimberly Bond, M.Ed., MFT, President and 

CEO, Mental Health Systems, Inc.

Shelly F. Greenfield, M.D., M.P.H., Chief 

Academic Officer, Chief of the Division of 

Women’s Mental Health, Director of Clinical 

and Health Services Research and Education, 

Division on Alcohol and Drug Abuse, McLean 

Hospital; Professor of Psychiatry, Harvard 

Medical School

Christine E. Grella, Ph.D., Professor, Department of Psychiatry and Biobehavioral Sciences; 

Co-Director UCLA Integrated Substance Abuse 

Programs (ISAP)

Beverly J. Haberle, M.H.S., LPC, CADC,

Executive Director, The Council of Southeast 

Pennsylvania, Inc.

Karen Mooney, M.S.W., LCSW, CACIII,

Manager, Women’s Substance Use Disorder 

Programs, Office of Behavioral Health, Colorado 

Department of Human Services

Jeanne Obert, M.A., M.S.M., LMFT, Executive 

Director, Matrix Institute on Addictions

Eva Petoskey, M.S., Program Director,

Inter-Tribal Council of Michigan, 

Anishnaabek Healing Circle Access 

to Recovery (ATR)

Kathleen M. Reynolds, L.M.S.W., ACSW,

Vice President, Health Integration and 

Wellness Promotion, National Council for 

Behavioral Health

Madalynn Rucker, M.A., Executive Director,

ONTRACK Program Resources

Cynthia Moreno Tuohy, NCAC II, CCDC 

III, SAP, Executive Director, NAADAC, 

The Association for Addiction Professionals

Becky Vaughn, M.S.Ed., Vice President,

Addiction Services, National Council for 

Behavioral Health

SAMHSA

Sharon Amatetti, M.P.H., Women’s Issue 

Coordinator and Project Officer, Center for 

Substance Abuse Treatment

ADVOCATES FOR HUMAN 

POTENTIAL, INC.

Deborah (Deb) Werner, M.A., Project Director

Fran Basche, M.A., Task Co-Lead

Sarah Farmer, M.A., Task Co-Lead

Sherri Downing, M.A., Reviewer

Nailah Harrell, M.S., Reviewer

Natasha Zaretskaya, Research Assistant
A3-40

APPenDIX 2:

Additional Stakeholder Input 

To learn more about treatment and recovery service providers’ perspectives and women in 

recovery, SAMHSA solicited stakeholder input from the Women’s Addiction Services Leadership 

Institute (WASLI) network to inform the expert panel discussions. These stakeholders, as well as 

SAMHSA staff from other program areas and other federal partners, reviewed the document, and 

their feedback on the draft was integrated into the final document. 

Lonnetta Albright, B.S., CPEC, Executive 

Director, Great Lakes ATTC – University of Illinois 

at Chicago

Mary Blake, C.R.E., Public Health Advisor,

Center for Mental Health Services, Substance 

Abuse and Mental Health Services 

Administration

Julie Cushman, LLMSW, ACSW, CAAC,

Associate Executive Director, Home of New 

Vision 

Susan Dargon-Hart, M.S.W., Director of 

Behavioral Health, Casa Esperanza 

Wendi Davis-Cox, M.S.W., LCSW, Addiction 

& Recovery Services Program Director, Weber 

Human Services

Francine Feinberg, Psy.D., LCSW, Consultant,

Former Executive Director, Meta House

Martha Kurgans, LCSW, Program Specialist/

Women’s Services Coordinator, Virginia Department of Behavioral Health & Developmental 

Services

Christina MacFarlane, M.S.W., LSCSW, LAC-T,

Co-Occurring Program Supervisor, Area Mental 

Health Center

Mary M. McCann, LCSW, CAC III, State Project 

Officer, Center for Substance Abuse Treatment, 

Substance Abuse and Mental Health Services 

Administration

Samia Dawud Noursi, Ph.D., Deputy 

Coordinator, Women and Sex/Gender 

Differences Research Program, National Institute 

on Drug Abuse, National Institutes of Health

Jennifer A. Oppenheim, Psy.D., Public Health 

Advisor, Center for Mental Health Services, 

Substance Abuse and Mental Health Services 

Administration

Deirdre Pearson, M.S.W., LCSW, CSAC,

Program Manager, Women’s Substance Use 

Disorder Services, Richmond Behavioral Health 

Authority

Carol G. Renard, CAP, ICADC, Director of 

Program and Staff Development, WestCare 

Foundation 

Mary Roberson, Ed.D., LCPC, CSADC,

Executive Director, Nicasa

Jessica Tytel, M.P.H., Senior Advisor for 

Planning and Evaluation, Office on Women’s 

Health, U.S. Department of Health and Human 

Services

Susan Winslow, M.S.W., LICSW, Human 

Services Manager, Ramsey County Mental 

Health

Cathy Worthem, M.S.W., LMSW, CAADC, 

CCS, ADS, Program Manager, Arbor Circle
A3-41

APPenDIX 3:

Self-Assessment for Treating Women with 

SUDs in Co-Ed Settings

This self-assessment tool helps providers detect 

strengths and potential growth areas in the 

delivery of gender-responsive co-ed services. It 

follows the sections of the Guidance Document 

for Treating Women in Co-ed Settings. Please 

read through the guidance document before 

filling this out; it will help you better understand 

the questions and terms.

You can complete this self-assessment for 

your overall center or a specific program in 

your center. Some sections may be helpful in 

evaluating a specific service team or yourself. 

Before starting the assessment, decide whether 

you are filling it out for your whole agency, a 

physical center, a specific program, or a staffing 

team. Then choose a small group of people 

to complete the survey. You can work on the 

survey as a group or have people complete it 

alone. Afterward, discuss each item as a group 

and come to an agreement on the response. 

After you finish, some questions at the end will 

help you develop an improvement plan.

Self-Assessment Checklist for:

_______________________________________________________________________________________

(Identify whether you are reviewing your whole agency, physical center, a specific program, 

or a staff cluster.)

For each statement, think about how your activities, policies, and staff training address it and how 

often it occurs. Then assign a score of U, A, or C.

U = Unable (Do not do this, or do it very rarely.)

A = Aware (Do this some of the time.)

C = Committed (Do this most of the time.)

You may also want to note your strengths, challenges, or improvement ideas while filling in 

the checklist. This will be helpful when you create a plan of action. 
A3-42

unDerSTanDing anD applicaTion of The guiDance STaTemenTS

aDDreSSing Women’S unique neeDS anD experienceS

Consider each statement below and assign a score based on your assessment.

We offer person-centered services, taking gender and the priorities, interests, and experiences of each 

woman into account.

We respect the cultural diversity of women and know cultural background and experience shape a woman’s 

world view, priorities, values, experiences, and treatment and recovery needs.

We recognize sexuality (including sexual orientation) and patterns in a woman’s sexual history as important 

elements to consider when developing a treatment and recovery plan.

We know and take into consideration that women with SUDs often live in poverty and must rely on men or 

other family members for financial support.

TOTALS ON ADDRESSING WOMEN’S UNIQUE NEEDS

# of Unable =  # of Aware =  # of Committed = 

genDer DynamicS

Consider each statement below and assign a score based on your assessment. 

We offer support and activities that help develop women’s voices and self-identities and allow them to share 

their stories.

We recognize that staff and people in treatment and recovery may have subconscious and unintended 

biases, which result in women deferring to men.

We encourage staff to address their own personal beliefs and judgments through training and clinical 

supervision.

We address patterns of client and staff bias when they arise in client feedback, individual counseling, 

groups, supervision, case management, and other programming.

TOTALS ON GENDER DYNAMICS

# of Unable =  # of Aware =  # of Committed = 

SCORE

(U, A, or C)
A3-43

SCORE

(U, A, or C)

Trauma

Consider each statement below and assign a score based on your assessment.

We ensure the physical and psychological safety of women who are being served.

Our services are trauma informed. 

We avoid punitive actions that can reduce a woman’s self-efficacy and engagement with staff and groups.

Our services follow recovery-oriented principles and practices.

TOTALS ON TRAUMA

# of Unable =  # of Aware =  # of Committed = 

phySical healTh

Consider each statement below and assign a score based on your assessment.

We take into account a woman’s health concerns and the need for comprehensive, integrated behavioral and 

primary health care, and we address health in treatment and recovery planning.

We address a woman’s need for reproductive health care and have a plan in place to screen for, and 

address, pregnancy and related treatment/recovery considerations.

We educate women about their risks for sexually transmitted infections (STIs), HIV, and viral hepatitis and 

offer testing and early intervention and treatment services as needed.

We ensure that all conversations about health and recommended testing are held in a trauma-informed, 

nonjudgmental manner that promotes a sense of safety.

TOTALS ON PHYSICAL HEALTH

# of Unable =  # of Aware =  # of Committed = 
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SCORE

(U, A, or C)

menTal healTh

Consider each statement below and assign a score based on your assessment.

We understand the prevalence and signs of psychiatric disorders and common mental health problems 

among women with SUDs and know how these disorders can affect recovery.

We help women access screening, assessment, and services for a variety of mental disorders.

We help women access screening, assessment, and services for anxiety.

We help women access screening, assessment, and services for PTSD.

We help women access screening, assessment, and services for eating disorders.

We help women access screening, assessment, and services for depression.

We are sensitive to the needs of women with co-occurring disorders and make accommodations 

when needed.

We use an integrated approach to mental health and substance use recovery.

TOTALS ON MENTAL HEALTH

# of Unable =  # of Aware =  # of Committed = 
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SCORE

(U, A, or C)

relaTionShipS

Consider each statement below and assign a score based on your assessment.

We ensure that staff members are qualified and able to build therapeutic alliances.

We offer person-centered services and support women within the context of their life circumstances, roles, 

and responsibilities.

We offer formal and informal chances for women to meet and build relationships with each other.

We create venues for women to learn more about healthy relationships, respect, boundaries, and 

communication.

TOTALS ON RELATIONSHIPS

# of Unable =  # of Aware =  # of Committed = 
A3-46

cenTer/program pracTiceS & STraTegieS

SpecializeD STaff/STaffing STraTegieS

Consider each statement below and assign a score based on your assessment.

We have adequate program and clinical management, as well as an array of specialized staff 

(including counselors, clinicians, case managers, and peer specialists/recovery coaches) with 

experience in gender-responsive approaches.

We match women with female primary counselors and recovery coaches/peer mentors with some common 

experiences and understanding (e.g., similar age, cultural background), unless contraindicated.

We have staff members who communicate well with women in terms of understanding each woman’s 

expression of gender, cultural background, and sexual orientation or identity.

Our staff members are culturally competent and practice cultural humility.

We have female peer specialists or recovery coaches.

TOTALS ON SPECIALIZED STAFF/STAFFING STRATEGIES

# of Unable =  # of Aware =  # of Committed = 

Supervision/Management

Consider each statement below and assign a score based on your assessment.

We prioritize clinical supervision by making sure it happens often and regularly. 

We have supervisors with specialized training, including those who can support staff in addressing trauma 

and preventing secondary trauma.

We have supervisors who can work with staff members to identify and understand their own biases 

(e.g., judging women who use alcohol or drugs during pregnancy or who stay with abusive partners).

continued on next page

SCORE

(U, A, or C)
A3-47

We have supervisors who are trained to address gender dynamics in co-ed groups.

Staff—including administrative and support staff—receive ongoing training about trauma-informed 

approaches.

We offer training and follow-up support to apply training content to actual work with women (e.g., ongoing 

discussions of the implementation process during clinical supervision and staff meetings).

TOTALS ON SUPERVISION/MANAGEMENT

# of Unable =  # of Aware =  # of Committed = 

organizaTional culTure

Consider each statement below and assign a score based on your assessment.

We have an organizational culture that respects women and takes gender into account.

We consistently review outcome data by gender and look at women’s engagement, retention, and progress 

so we can discuss ways to improve.

We provide leadership opportunities for female staff members and support them in becoming advocates for 

women’s services.

We take part in women’s service provider community networks.

We give staff members opportunities for discussions, coaching, and supervision that help build a safe and 

supportive setting that prevents secondary trauma and encourages self-care.

TOTALS ON ORGANIZATIONAL CULTURE

# of Unable =  # of Aware =  # of Committed = 

SCORE

(U, A, or C)
A3-48

Environment/Facilities

Consider each statement below and assign a score based on your assessment.

We have a welcoming, safe, calm, and appealing physical environment.

Women can safely access our center, and we have ways to provide safe access (e.g., near bus stops, 

well-lit parking lots and streets, group transportation, escorts to parking lots). 

Furniture is set up in a way that encourages engagement or offers privacy.

We offer a child- and family-friendly setting.

We have a women’s space (e.g., women’s lounge area) that allows a safe space for connection, interaction, 

and formal and informal recovery support. 

We have friendly reception staff members who make women feel welcome and who are trained to recognize 

and respond when someone is in deep distress.

We allow participants to have a voice in center rules and guidelines, and they are encouraged to state 

what helps them feel safe.

TOTALS ON ENVIRONMENT/FACILITIES

# of Unable =  # of Aware =  # of Committed = 

SCORE

(U, A, or C)
A3-49

Assessment and Treatment/Recovery Planning

Consider each statement below and assign a score based on your assessment.

We use screening and assessment tools that have validity for women and the subgroups of women often 

seen in the center.

Our assessment interviews are conducted in a trauma-informed manner.

Staff who conduct assessments avoid stereotypes and maintain a nonjudgmental attitude.

We regularly evaluate our assessment and treatment/recovery planning protocols to think about whether 

they address women’s experiences and responsibilities. 

We provide women with ongoing screening and assessment for psychiatric disorders and other mental 

health problems.

We have protocols for screening, assessment, and prioritization for pregnant women. 

We help women identify strengths, passions, priorities, and unique abilities, and we integrate these into 

treatment/recovery plans.

We work with women early in the treatment/recovery process to detect barriers to participation and potential 

resources that will help them attend groups and center activities.

We have in-house expertise or partnerships with agencies that offer services for women who have 

experienced sexual assault, intimate partner violence, or other forms of violence.

continued on next page

SCORE

(U, A, or C)
A3-50

SCORE

(U, A, or C)

When a woman includes her partner in her treatment plan, we interview her away from her partner so 

she can decide what groups or programming she wants to attend or what information-sharing releases 

she wants to sign, without her partner’s influence.

We address co-occurring physical health and mental health issues and integrate physical health and mental 

health goals into treatment/recovery plans.

TOTALS ON ASSESSMENT AND TREATMENT/RECOVERY PLANNING

# of Unable =  # of Aware =  # of Committed = 

Interventions/Groups

Consider each statement below and assign a score based on your assessment.

In co-ed groups, we group women together, so they make up as close to 50 percent of the group 

as possible. 

For co-ed groups, we have one male and one female facilitator.*

Our facilitators* are trained in group dynamics, able to help diverse groups of people engage with each other, 

and able to ensure that women fully participate.

Our facilitators* are aware of group gender dynamics and power issues and can create a safe environment for 

discussing gender dynamics.

We offer participants the chance to practice communication skills, including actively listening and 

communicating their needs and concerns.

continued on next page
A3-51

Our groups have guidelines (ideally developed by participants) that address gender dynamics, safety, 

and respect. 

We offer women-only groups that enable women to discuss sensitive topics.

When there are no women-only groups, we offer other ways for women to build relationships with other 

women and individual counseling on sensitive topics.

We provide or offer links to medication-assisted treatment and recovery (MATR) services, along with 

counseling and recovery supports, especially for pregnant women who are opioid dependent.

We use evidence-based practices (e.g., motivational interviewing, cognitive behavioral therapy) and curricula 

that have validity with women and the subgroups of women served.

TOTALS ON INTERVENTIONS/GROUPS

# of Unable =  # of Aware =  # of Committed = 

* Facilitators may include therapists, counselors, group leaders, peer specialist/recovery coaches, health

educators, or anyone leading group services.

SCORE

(U, A, or C)
A3-52

SCORE

(U, A, or C)

Recovery Support Services

Consider each statement below and assign a score based on your assessment.

We help women identify barriers to participation and community resources that may help them overcome 

these service barriers (e.g., referrals to child care resources, referral programs).

We offer child care at our organization while women are attending treatment.

We offer flexible scheduling for services and programming.

We offer ongoing services and connections (e.g., alumni activities) upon program completion.

We help women identify and access safe mutual support services in their communities that are welcoming 

to women.

We offer case management and care coordination, or advocacy services, to address women’s additional 

needs (e.g., services to address basic or family needs, legal assistance, educational and career services).

We are sensitive to and prioritize a woman’s need to work with child welfare services, especially if she has 

an open reunification case. 

TOTALS ON RECOVERY SUPPORT SERVICES

# of Unable =  # of Aware =  # of Committed = 
A3-53

SUMMARIZE YOUR FINDINGS:

In which areas did you score the most Cs (Committed)?

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In which areas did you score the most As (Aware)? 

_______________________________________________________________________________________

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In which areas did you score the most Us (Unable)? 

_______________________________________________________________________________________

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ACKNOWLEDGE STRENGTHS AND IDENTIFY IDEAS FOR IMPROVEMENT:

Looking at your assessment and your scores, complete the table below to help evaluate your ability to 

meet the needs of women in your center.

STRENGTHS WEAKNESSES

OPPORTUNITIES CHALLENGES
A3-54

What are some of the areas in which you are doing well? What has led to your success 

in these areas?

What are some actions you can put into place now to improve your center’s 

responsiveness to female participants? For example:

• Get the light fixed in the parking lot.

• Identify women-only 12-step meetings in your community.

• Rearrange furniture in the reception area and make the area look more welcoming.

What are some actions you can take in the next few months? For example:

• Improve linkages between substance use and mental health services, so all women entering an

SUD program are screened for psychiatric disorders.

• Hold staff discussions about gender dynamics in the program and groups.

• Evaluate women’s engagement, retention, and completion data, and their satisfaction surveys.

• Evaluate the research about the validity of specific curricula and practices utilized at the center

and identify necessary process improvements.

What are some longer-term steps your center can take? Work as a team to develop a 

plan for how to prioritize and address them. For example:

• Implement a training program on gender dynamics and facilitating co-ed groups.

• Expand opportunities for women-only groups and informal opportunities for women to build

relationships with each other in the center.

• Build relationships with intimate partner violence prevention and intervention services, and

expand mutual referrals and supports.

• Hire staff who possess core competencies for working with women.
SMA 16-4979

First Printed 2016