Based on TIP 51 

Substance Abuse Treatment: 

Addressing the 

Specific Needs 

of Women

KAP Keys

For Clinicians

Knowledge Application Program

KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

Substance Abuse Treatment:

Addressing the Specific 

Needs of Women

A Treatment

Improvement

Protocol

TIP

51
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

2

Keys were developed to accompany the Treatment 

Improvement Protocol (TIP) series published by the Substance 

Abuse and Mental Health Services Administration (SAMHSA). 

These Knowledge Application Program (KAP) Keys are based 

entirely on TIP 51 and are designed to meet the needs of 

the busy clinician for concise, easily accessed “how-to” 

information.

TIP 51 draws on the systemic framework of Bronfenbrenner’s 

ecological theory* and the Center for Substance Abuse 

Treatment’s Comprehensive Substance Abuse Treatment 

Model for Women and Children (see Appendix B in TIP 51 

for more information on this model). It is based on clinical 

practice and research centered on women. It is not derived 

primarily by comparing women with men. The knowledge, 

models, and strategies presented in the complete TIP 

are grounded in women’s experiences and their unique 

biopsychosocial and cultural needs.

For more information on the topics in these KAP Keys, readers 

are referred to TIP 51.

Introduction

TIP 25, Substance Abuse Treatment and Domestic Violence

SMA 12-4076

TIP 42, Substance Abuse Treatment for Persons With 

Co-Occurring Disorders SMA 13-3992

TIP 48, Managing Depressive Symptoms in Substance Abuse 

Clients During Early Recovery SMA 13-4353

TIP 56, Addressing the Specific Behavioral Health Needs of 

Men SMA 13-4736

Other TIPs that are relevant to these KAP Keys:

*Bronfenbrenner, U. (1989). Ecological systems theory. Annals of Child 

Development, 6, 187–249. 
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

3

• Acknowledge the importance and role of socioeconomic

issues and differences among women.

• Promote cultural competence specific to women.

• Recognize the role and significance of relationships in women’s lives.

• Address women’s unique health concerns.

• Endorse a developmental perspective.

• Attend to the relevance and influence of various caregiver

roles that women often assume throughout the course of

their lives.

• Recognize that ascribed roles and gender expectations

across cultures affect societal attitudes toward women who

abuse substances.

• Adopt a trauma-informed perspective.

• Use a strengths-based model for women’s treatment.

• Incorporate an integrated, multidisciplinary approach to

women’s treatment.

• Maintain a gender-responsive treatment environment across

settings.

• Support the development of gender competence specific to

women’s issues.

Gender-Responsive Treatment 

Principles
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

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Women’s Biopsychosocial Uniqueness

Biological and Psychological

1. Women have different physical responses to substances.

2. Women with substance use disorders have greater susceptibility to as well as earlier onset of serious medical problems 

and disorders.

3. Women who abuse substances have specific health issues 

and medical needs related to gynecology.

4. Pregnancy is a significant concern when treating women who 

have substance use disorders.

5. Women who abuse substances are more likely than other 

women to have co-occurring disorders, including mental and 

substance use disorders.

6. Women who have substance use disorders are more likely to 

have been physically or sexually traumatized and subjected 

to interpersonal violence.

Social

1. Significant relationships and family histories play integral 

roles in the initiation, patterns of use, and continuation of 

substance abuse for women.

2. Significant relationships and adult family members may substantially influence women’s behavior associated with treatment seeking, support for recovery, and relapse.

3. For women, pregnancy, parenting, and child care influence 

alcohol and drug consumption and increase the likelihood of 

entering and completing substance abuse treatment.

4. Women are more likely to encounter obstacles across the 

continuum of care as a result of caregiver roles, gender 

expectations, and socioeconomic hardships.

5. Despite the unique challenges they face, women are more 

likely to engage in help-seeking behavior and to attend treatment after admission.

6. Women report more interpersonal stressful life events.

7. Women often take different paths in accessing treatment for 

substance use disorders.

8. Women have unique client–counselor expectations and relational needs related to treatment.

9. Women are uniquely discriminated against with regard to 

substance abuse.

Developmental

1. Women have unique life-course issues and events (e.g., 

pregnancy; menopause; often having the primary responsibilities of providing care to parents, parents-in-law, and 

dependent children).
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

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Risk Factors of Initiation

Risk Factors Associated With Initiation of 

Substance Use and the Development of 

Substance Use Disorders Among Women

1. Women are affected by familial substance abuse as much as

men; the prevalence of substance use disorders is 10 to 50 

times higher among women with a parent who abuses substances than among women whose parents do not. 

2. Women who are dependent on substances are more likely to

have a history of overresponsibility in their family of origin.

3. Adverse childhood experiences significantly increase the likelihood of early initiation of use among women.

4. Women who are dependent on illicit drugs are more likely

than men who are dependent on illicit drugs to have partners who use illicit drugs.

5. Premorbid personality risk factors lay the foundation for substance abuse among women (e.g., anxiety, difficulty in regulating affect and behavior, low self-worth).

6. A history of traumatic events including, but not limited to,

sexual and physical assaults, childhood sexual and physical 

abuse, and domestic violence are significantly associated 

with initiation of substance use and the development of substance use disorders among women.

7. Women are more likely than men to have co-occurring mental and substance use disorders.

8. For women, anxiety disorders and major depression are

associated with substance use, abuse, and dependence and 

are the most common co-occurring diagnoses. Other common mental disorders in women with substance use disorders are eating disorders and posttraumatic stress disorder 

(PTSD), a common result of violence and trauma.
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

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Six Patterns Associated With Women’s 

Substance Use

1. Narrowing of the Gender Gap: In comparing men’s and 

women’s rates of alcohol use across 10 years, there is evidence of the gender gap narrowing.

2. People of Introduction and Relationship Status: Women 

are more likely to be introduced to and initiate alcohol and 

drug use through significant relationships.

3. Drug Injection and Relationships: Even though women are 

less likely to inject drugs than men, research suggests that 

women move from other modes of use to injecting at a faster rate than men. 

4. Earlier Patterns Foreshadow Later Problems: Drinking low 

to moderate levels of alcohol in early adulthood is a predictor of later heavy drinking and alcohol-related substance use 

disorders among women. In addition to amount of alcohol 

intake, frequency of use is associated with increased risk of 

alcohol dependence.

5. Responsibilities and Pattern of Use: Women are more likely 

to alter their pattern of use temporarily in response to caregiver responsibilities.

6. Progression and Consequences of Use: Women experience 

an effect called telescoping, whereby they progress faster 

than men from initial use to alcohol and drug-related consequences even when using a similar or lesser amount of substances.
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

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Screening

The most important things to screen for when working with 

women include:

• Substance abuse.

• Pregnancy.

• Immediate risks related to serious intoxication or withdrawal.

• Immediate risks for self-harm, suicide, and violence.

• Past and present history of violence and trauma, including

sexual victimization and interpersonal violence.

• Past and present mental disorders, including PTSD and other

anxiety disorders, mood disorders, and eating disorders.

• Health conditions, including, but not limited to, HIV/AIDS,

hepatitis, tuberculosis, and sexually transmitted diseases

(STDs).
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

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Screening and Assessment Considerations

•	How screenings and assessments are conducted is as important as the information gathered. Screening and assessment 

are often the initial contact between a woman and the treatment system. They can either help build a trusting relationship or create a barrier to engaging in further services.

•	Self-administered tools may be more likely to elicit honest 

answers; this is especially true regarding questions related to 

drug and alcohol use.

•	Face-to-face screening interviews have not always been successful in detecting alcohol and drug use in women, especially if the counselor is uncomfortable with the questions.

•	Routinely, substance abuse screening and assessment tools 

are less likely to identify women as having substance abuse 

problems than they are to identify men as having substance 

abuse problems.

•	Screening and assessment instruments should be examined 

to determine if they were developed using female populations. If not, counselors need to explore whether or not there 

are other instruments that may be more suitable to address 

specific evaluation needs.
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

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Mental Health Screening for 

Women

• Women need to be routinely screened for depressive, eating,

and anxiety disorders, including PTSD.

• Women tend to report higher levels of anxiety and somatic

symptoms associated with depression than men.

• Gathering explicit details about traumatic experiences may

make women uncomfortable. This information does not need

to be addressed early on in treatment.

• For some women, drugs have had a secondary effect and

purpose (i.e., weight management). Be aware that weight

gain during recovery can be a concern and a relapse risk factor for women; clinical and health psychoeducation and intervention surrounding body image, weight management, nutrition, and healthy lifestyle habits are essential ingredients in

treatment for women.

• Bulimia nervosa is the most common eating disorder among

women in substance abuse treatment. Counselors should

become knowledgeable about the specific behavioral patterns associated with this disorder (e.g., compensatory and

excessive exercise for overeating, routine pattern of leaving

after meals, persistent smell of vomit on the woman’s breath

or in a particular bathroom, taking extra food from the dining

room, hoarding food).

• Be aware that women with bulimia nervosa are usually of

normal weight.
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

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As with any treatment, the focus should be on the whole person. The following services and programmatic considerations 

are recommended by the TIP 51 consensus panel and reinforced by some State standards. These services may be warranted across the continuum of care, beginning with early 

intervention and extending to continuing care services.

Medical Services

 ̈	Gynecological care

 ̈	Family planning

 ̈	Prenatal care

 ̈	Pediatric care

 ̈	HIV/AIDS services

 ̈	Treatment for infectious diseases, including viral hepatitis

 ̈	Nicotine cessation treatment services

Health Promotion

 ̈	Nutritional counseling

 ̈	Educational services about reproductive health

 ̈	Wellness programs

 ̈	Education on sleep and dental hygiene

 ̈	Education about STDs and other infectious diseases (e.g., 

viral hepatitis, HIV/AIDS)

 ̈	Preventive healthcare education

Psychoeducation

 ̈	Sexuality education

 ̈	Assertiveness skills training

 ̈	Education on the effects of alcohol and drugs on prenatal 

and child development

 ̈	Prenatal education

Gender-Specific Needs

 ̈	Women-only programming (e.g., is the client likely to benefit 

more from a same-sex versus mixed-gender program due 

to trauma history, pattern of withdrawal among men, and 

other issues?)

 ̈	Services (including health services) specific to lesbian and 

bisexual women

Cultural and Language Needs

 ̈	Culturally appropriate programming

 ̈	Availability of interpreter services or treatment services in 

native language

Services and Programmatic 

Considerations: A Checklist

Continued on next page
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

11

Life Skills

 ̈	Money management and budgeting

 ̈	Stress reduction and coping skills training

Family and Child-Related Services

 ̈	Childcare services, including homework assistance in conjunction with outpatient services

 ̈	Children’s programming, including nurseries and preschool 

programs

 ̈	Family treatment services, including psychoeducation surrounding addiction and its impact on family functioning

 ̈	Couples counseling and relationship enrichment recovery 

groups

 ̈	Parent/child services, including age-appropriate programs 

for children and education for mothers about child safety; 

parenting education; nutrition; children’s substance abuse 

prevention curriculum; and children’s mental health needs, 

including recreational activities, school, and other related 

activities

Comprehensive Case Management

 ̈	Linkages to welfare system, employment opportunities, and 

housing

 ̈	Integration of stipulations from child welfare, Temporary 

Assistance for Needy Families, probation and parole, and 

other systems

 ̈	Intensive case management, including case management 

for children

 ̈	Transportation services

 ̈	Domestic violence services, including referral to safe houses

 ̈	Legal services

 ̈	Assistance in establishing financial arrangements or accessing funding for treatment services

 ̈	Assistance in obtaining high school equivalency credentials 

or further education, career counseling, and vocational 

training, including job readiness training to prepare women 

to leave the program and support themselves and their 

families

 ̈	Assistance in locating appropriate housing in preparation for 

discharge, including referral to transitional living or supervised housing

Services and Programmatic 

Considerations: A Checklist

Continued on next page
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

12

Mental Health Services

 ̈	Trauma-informed and trauma-specific services

 ̈	Eating disorder and nutrition services

 ̈	Services for other co-occurring disorders, including access 

to psychological and pharmacological treatments for mood 

and anxiety disorders

 ̈	Children’s mental health services

Disability Services

 ̈	Resources for learning disability assessments

 ̈	Accommodations for specific disabilities

 ̈	Services to accommodate illiteracy

Staff and Program Development Considerations

 ̈	Strong female role models in terms of both leadership and 

personal recovery

 ̈	Peer support

 ̈	Adequate staffing to meet added program demands for 

women and children

 ̈	Staff training and gender competence in working with 

women

 ̈	Staff training and program development centered on incorporating cultural and ethnic influences on parenting styles, 

attitudes toward discipline, children’s diet, level of parenting 

supervision, and adherence to medical treatment

 ̈	Flexible scheduling and staff coordination 

 ̈	Adequate time for parent–child bonding and interactions in 

daily program schedule

 ̈	Administrative commitment to addressing the unique needs 

of women in treatment

 ̈	Staff training and administrative policies to support the 

integration of treatment services with clients on methadone 

maintenance

 ̈	Culturally appropriate programming that matches specific 

socialization and cultural practices for women 

Services and Programmatic 

Considerations: A Checklist
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

13

Improving Transitions and Retention Rates for Women

Programs that maintain relationships or connections with 

women throughout their treatment and during step-down 

transitions from more intensive to less intensive treatment appear paramount in maintaining high levels of 

retention. Using supportive telephone calls to maintain 

contact with women between residential and outpatient 

addiction treatment is an effective strategy.

Women-Specific Predictors of Relapse and Reactions to 

Relapse

Relapse Risks Unique to Women

Women are more likely to relapse if they report or display:

• Interpersonal problems and conflicts.

• Low self-worth that is connected to intimate relationships.

• Severe untreated childhood trauma.

• Strong negative affect.

• Symptoms of depression.

• Greater difficulty in severing ties with other people who use.

• Failure to establish a new network of friends.

• Lack of relapse prevention coping skills.

Women’s Reactions to Relapse

During or after relapse, women are more likely than men to:

• Relapse in the company of others and particularly with

female friends or a significant other.

• Escalate use after initial relapse, which is associated with

greater severity of childhood trauma.

• Seek help.

• Experience slightly shorter relapse episodes.

• Report depressed mood.

Women-Specific Predictors of Relapse and 

Reactions to Relapse 
KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

14

 ̈	Be culturally informed and knowledgeable.

 ̈	Be trauma informed, and have awareness of the prevalence 

and impact of trauma on women’s lives.

 ̈	Understand the psychological growth and development of 

women.

 ̈	Recognize the centrality of relationships for women, particularly parenting and social roles and the socialization process.

 ̈	Be knowledgeable about the physiology of women as it 

relates to substance use and abuse.

 ̈	Understand the etiology of substance abuse in women.

 ̈	Be familiar with the co-occurring disorders that commonly 

occur in women.

 ̈	Understand the context of abuse and patterns of use for 

women.

 ̈	Identify the consequences of substance abuse (e.g., legal, 

general health, infectious diseases, influence of and effects 

on family and relationships, psychological).

 ̈	Understand the treatment and recovery experience of 

women.

 ̈	Identify family dynamics (e.g., family of origin, parenting, 

child development).

 ̈	Be familiar with women’s processes of recovery.

 ̈	Be knowledgeable about the following:

– Relapse prevention for women. 

– Relapse triggers, such as family reunification.

– Recovery resources. 

– Maintaining a safe place for the client. 

 ̈	Understand issues related to sexuality, sexual orientation, 

and gender identity for women and their relationship to substance abuse.

 ̈	Know confidentiality rules and guidelines.

Clinical Knowledge Checklist for Treating 

Women Who Have Substance Use Disorders
Easy Ways To Obtain Free Copies of 

All TIP Products

1. Call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) 

(English and Español), 

2. Visit SAMHSA’s Publications Ordering Web page at 

http://store.samhsa.gov

Do not reproduce or distribute this publication for a fee 

without specific, written authorization from the Office of 

Communications, Substance Abuse and Mental Health 

Services Administration, U.S. Department of Health and 

Human Services.

Ordering Information

TIP 51 

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

KAP Keys Based on TIP 51

Substance Abuse Treatment: Addressing 

the Specific Needs of Women

HHS Publication No. (SMA) 14-4844

First Printed 2014

Reprinted 2014