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Behavioral Therapies for

Female Drug Users: An

Efficacy-Focused Review

Karla Moras, Ph.D.

INTRODUCTION

This chapter summarizes current knowledge about the efficacy

of behavioral therapies for women who abuse substances. Herein, the

term “behavioral therapies” is synonymous with “psychosocial therapies.” It refers to all nonpharmacological interventions, such as contingency management methods and skills training from behavior therapy

(Childress et al. 1985), cognitive therapy (e.g., Beck et al. 1993),

and interpersonal psychotherapy (e.g., Rounsaville and Carroll 1993,

 pp. 319-352). Information in the chapter is derived primarily from a

review of the clinical and empirical literature on opiate and cocaine

abuse.1 A focal question guided the review: Do female substance

abusers require gender-specific therapies? The chapter also provides

an overview of current directions in the development of behavioral

therapies for women who are substance users. Some additional directions are suggested.

An extensive literature now exists on behavioral therapies for

female substance users. It has increased exponentially since about 1960

(Davidson and Bemko 1978). However, the relevant literature consists

largely of clinical observations with suggested treatment approaches,

descriptive information on existing treatment programs, and epidemiological data. Although many behaviorally oriented therapy programs

for women have been implemented in the United States, almost no

efficacy data on them have been published. Few results are available

from studies that specifically were designed to either evaluate the

efficacy of behavioral interventions developed for female substance

abusers or examine gender differences in the efficacy of existing nongender-specific treatments.2,3

The lack of relevant efficacy data is a major limitation. Treatment

efficacy studies are important tools for systematically identifying therapies that might merit widespread implementation. Efficacy studies are
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those in which experimental methods are used to obtain answers to

questions such as: Does a therapy have desired effects, is it more efficacious than alternative therapies, and what are the characteristics of

the individuals for whom it is most efficacious? Full efficacy studies

require at least two treatment conditions, including a nontreatment or

minimum-treatment control condition. The control condition tests

whether the particular treatment is associated with greater change than

naturally occurs with the passage of time, with typical fluctuations in

symptom severity, or with life experiences that individuals of the type

being treated can have. Efficacy studies also require random assignment

of patients to study treatments and intent-to-treat analyses to reduce

problems in interpreting findings caused by patient dropout (e.g.,

Howard et al. 1990, pp. 66-79).

Unfortunately, the majority of therapy outcome studies for substance

use disorders are missing some of the crucial elements of efficacy studies.

Thus, although many outcome studies exist, few conclusive findings on

effects attributable mainly to the treatments of interest have been

generated. This is particularly true for substance use treatments that

have been recommended for women.4

WHAT ARE BEHAVIORAL THERAPIES?

Behavioral therapies consist of verbal and behavioral interventions

derived from theories and findings from psychology (e.g., from behavior

theory, social learning theory, and cognitive theory). Behavioral therapies, sometimes the sole treatments for substance use disorders, are also

often combined with pharmacological agents. For example, treatment

programs for heroin addiction in the United States often combine methadone with behavioral contingency methods to help reduce the use of

ancillary substances such as cocaine. Some of the most common types of

behavioral treatments applied to substance use are listed in table 1.

Table 1 lists the types of behavioral interventions for which at least

some efficacy data are available. The therapies listed do not include

those that have been hypothesized to be most efficacious for female

drug abusers. Rather, they are the ones that most frequently have been

examined in efficacy or partial efficacy studies.
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TABLE 1. Behavioral treatments commonly applied to substance

use disorders

Treatment Reference

Behavior change techniques Childress et al. 1985; Higgins et al. 1993; Stitzer et al.

1992; Onken et al. 1993

Cognitive therapy Beck et al. 1993

Family or couples therapy Szapocznik et al. 1988

Interpersonal psychotherapy Rounsaville and Carroll 1993, pp. 319-352

Relapse prevention Carroll et al. 1994a, 1994b; Rawson et al. 1993,

pp. 92-115; Wells et al. 1994

Skills training Childress et al. 1985; Wells et al. 1989

TREATMENT-RELEVANT SUBTYPES

OF FEMALE SUBSTANCE ABUSERS

The phrase “female substance abusers” suggests that women who

use substances constitute a homogeneous class. However, like their male

counterparts, female substance users can be subtyped on several dimensions. Examples are pattern of drug use (e.g., type and number of drugs

abused, frequency of drug use, chronicity); degree of impairment in social

roles associated with drug use; and socioeconomic, marital, and parental

status. Subtyping on these dimensions creates groups such as single,

employed professional women who use crack cocaine on weekends v.

unemployed, poor, single mothers who are chronic intravenous heroin

users and who also frequently use cocaine. The literature indicates that

several potentially treatment-relevant subtypes of female substance

abusers can be distinguished. That is, at least some subtypes are likely to

be differentially responsive to existing and proposed therapies. For

example, some subtypes are likely to need specialized therapy programs to

achieve clinically significant improvement; others may not need genderspecific therapies.

At least six potentially treatment-relevant subtypes of female substance users can be identified: (1) pregnant females (further distinguished as teens or adults), (2) intravenous drug users, (3) adolescent

polydrug users, (4) single professionals, (5) housewives, and (6) seniors.

The first three subtypes currently receive the most attention in the

opiate, cocaine, and alcohol use literature. They also are the focus of

more federally funded behavioral treatment research than the subtypes of

single professionals, housewives, and seniors.
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The research focus on pregnant drug users is justified in part by

their prevalence, as well as by the obvious social impact of their drug use.

One estimate is that 105,000 pregnant women per year need substance

use treatment, although fewer than one-third of that number receive it

(Institute of Medicine 1990, pp. 154-155). Single professionals, housewives, and seniors receive scant attention in the clinical and research

literature on substance use (but see Barry 1986, pp. 65-69).

Cultural, ethnic, and racial backgrounds are other potentially

treatment-relevant characteristics of female drug users that often are

noted in the substance use literature (e.g., Moise et al. 1982).

FINDINGS ON GENDER DIFFERENCES

ASSOCIATED WITH DRUG USE TREATMENTS

Treatment-Seeking

Female substance users are said to be proportionately less likely

to seek treatment for their drug use than male substance abusers (e.g.,

Reed 1985). In an epidemiological review published in 1980, Ferrence

(1980) concluded that the percentages of women with substance use

problems who sought treatment were notably below estimated prevalence rates. In contrast, a more recent review of treatment studies

published between 1984 and 1989 concluded that women are not

proportionately underrepresented in studies of opiates, cocaine, or

alcohol (Toneatto et al. 1992). However, Toneatto and colleagues used

Ferrence’s (1980) gender ratios to compare study samples, a procedure

that might underestimate the current prevalence of some types of substance use among women. On the other hand, Carroll and Rounsaville

(1992) compared a rather large sample of treatment-seeking (n=89) and

non-treatment-seeking (n=89) cocaine abusers on several dimensions.

No gender differences were found between the two groups, and both

groups were predominantly male (67 to 69 percent).

To the extent that some differential treatment-seeking by gender

exists, what might contribute to it? Experts suggest or provide evidence

on several variables, including sexism of programs (e.g., predominantly

male treatment staff) (Reed 1985; Toneatto et al. 1992) and shame about

substance use. Socioeconomic and racial background are also thought

to contribute to some women’s seeking treatment less frequently (Marsh

and Miller 1985). Another explanation is that mothers avoid treatment
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because their children might be taken from them (Marsh and Miller

1985). Shame also might inhibit mothers and pregnant users from

seeking treatment because of the inconsistency of their drug use with

societal expectations for responsible parenting (Kumpfer 1991).

Child Care

Wellisch and Steinberg (1980) found that female drug abusers are

just as likely to have children as women who do not use drugs. Expectably, a woman’s child care responsibilities can interfere with treatment

program attendance, particularly programs that require extensive time

commitments (Marsh and Miller 1985). Some evidence supports this

supposition (e.g., Reed et al. 1982, pp. 477-531). Thus, treatment

programs for women should include child care arrangements (e.g.,

Finkelstein 1994).

Depression, Anxiety, and Self-Esteem

Several studies have shown that female substance users as a group

have lower self-esteem than male substance users, but not necessarily

lower self-esteem than women who have psychiatric disorders other than

drug abuse (e.g., Beckman 1978). Another common finding is that

female drug users are more likely than their male counterparts to have

depression and/or anxiety symptoms or diagnoses (e.g., Blume 1986;

Colten 1980, pp. 7-36; Griffin et al. 1989). However, the results of a

study of mood and anxiety disorder diagnoses using the criteria of the

Diagnostic and Statistical Manual of Mental Disorders, Third Edition,

Revised (American Psychiatric Association 1987) suggest that gender

differences in depression and anxiety among substance users might be

more complicated and less robust than prior studies indicated. In a

sample of 50 male and 50 female substance-using inpatients, Brady and

colleagues (1993) found that female substance users as a group were

significantly more likely than male substance users to have an anxiety

disorder, but not more likely to have a mood disorder. However, significant gender differences in comorbid anxiety disorders were not found

among patients whose primary substance of abuse was cocaine.

Epidemiological findings consistently have indicated that depression

is more common among women than men in non-substance-abusing

populations in the United States (e.g., Culbertson 1997; Kessler et al.
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1994; Weissman and Klerman 1977; Weissman and Paykel 1974).

Female-to-male ratios have tended to range from about 2:1 to 4:1,

and recent cross-cultural evidence suggests that a gender difference is

more likely to exist in more developed cultures (Culbertson 1997).

Thus, the findings for depression among substance-using women might

not be linked to drug abuse. However, depression also could be a risk

factor for substance use if some women are motivated, in part, to use

drugs because of negative affect states, including feelings of worthlessness

and hopelessness.

Polysubstance Use:

A Non-Gender-Specific Finding

One robust, treatment-relevant but non-gender-specific finding is

that many individuals who abuse opiates or cocaine concurrently abuse

other drugs. For example, cocaine abusers often abuse alcohol (e.g.,

Higgins et al. 1994; Means et al. 1989), and heroin abusers often also

abuse cocaine (e.g., Condelli et al. 1991; Stitzer et al. 1992).

Employment Options, Rehabilitation

Success, and Poverty

Providers in treatment programs for women who chronically engage

in the most dangerous forms of drug abuse (e.g., intravenous heroin use)

have found rehabilitation efforts to be handicapped by some women’s

lack of marketable skills. This is less frequently a problem for men.

(Men, however, might encounter another type of job-related problem.

Platt and Metzger [1987] speculated that high rates of relapse by men

who successfully complete opiate treatment programs might be attributable in part to a “relapse potentiation” effect of completing a program

only to find themselves in unrewarding, low-status, low-paying jobs.)

For female substance users, a correlate of lack of marketable job skills

is poverty. The prevalence of poverty, in turn, supports recommendations

such as providing transportation to treatment programs. However, this is

not necessarily a gender-specific need.

Sexual Abuse

Some data indicate that (1) female substance users report higher

rates of sexual abuse than males (Rohsenow et al. 1988; Wallen 1992)
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and (2) sexual abuse increases the risk for substance use disorders, as

well as for other psychiatric disorders such as depression (Winfield et al.

1990). Data on sexual abuse are cited to support the idea that prevention efforts focused on sexual and physical abuse of girls could reduce

the risk of substance use disorders among women (e.g., Goldberg 1995).

It should be noted, however, that high rates of reported sexual abuse

were found among both teenage boys (42 percent) and teenage girls

(71 to 90 percent) in an inpatient substance use treatment program

(Rohsenow et al. 1988).

Gender Differences in Biological Effects of Drugs

Although not obtained from treatment efficacy studies, evidence

shows that women’s bodies respond differently than men’s to at least

some substances. For example, Jones and Jones (1976, pp. 103-136)

reported that a dose of ethanol produces higher blood alcohol levels in

women than in men. Frezza and associates (1990) reported that women

metabolize only about one-quarter of the amount of alcohol metabolized

by men, resulting in more absorption. In a small sample study of cocaine

effects (n=7 males; n=7 females), Lukas and colleagues (1996) found

that peak plasma levels were higher in males and that peak levels in

females differed by phase of menstrual cycle.

Evidence also shows that drugs have differential gender effects at

more molar biologic levels. For example, women who abuse alcohol are

twice as likely as men who abuse alcohol to develop cirrhosis of the liver

(Lex 1991, pp. 225-296).

TREATMENT IMPLICATIONS OF

GENDER DIFFERENCE FINDINGS

What do these findings and speculations on gender differences

imply about treatments for female substance users? Five implications

for modifying existing therapies and/or developing new ones for women

are discussed below. More extensive discussions of all the topics except

biological factors can be found in the literature on treatments for female

substance users.
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Gender-Specific Treatments Might Be Needed for

Some Subtypes of Women Substance Users

As previously noted, no clear research evidence shows the need for

gender-specific treatments for female substance users. However, some

findings are consistent with the possibility that gender-specific interventions might be valuable for subtypes of female users. For example,

substance use treatment programs that target women who have difficulty

coping with social role responsibilities (e.g., nonabusive parenting,

financially supporting children) and that include interventions to build

necessary coping and other skills (e.g., parenting skills, ability to find

and access helpful community resources) might be more likely than

current non-gender-specific programs to attract certain subtypes of

female substance users.

Behavioral Treatments Might Be

Differentially Efficacious for Some Women

To the extent that the depression, anxiety, and self-esteem problems

of some female drug abusers are reactions to environmental, social, or

intrapsychic variables, behavioral therapies are likely to be important

components in treatment programs.

Women’s Health Concerns as Indications

for Gender-Specific Treatments

The fact that drug use treatment often is needed by pregnant women

is one of the more compelling reasons to develop nonpharmacological

treatments for drug abuse. Also, the known and unknown teratogenic

effects of substance use (e.g., Jessup and Green 1987) make the development of efficacious treatment programs for pregnant substance users

crucial from a public health perspective.

Recognizing facts of the foregoing type, NIDA spearheaded treatment and evaluation efforts for pregnant and postpartum substance

users in its Perinatal-20 Treatment Research Demonstration Program

(Rahdert 1996). Twenty demonstration projects were initiated during

1989 and 1990. Effectiveness reports are expected soon. One descriptive study from Perinatal-20 indicated that some pregnant substance

users have intellectual limitations and high rates of psychiatric
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comorbidity (Haller et al. 1993). Such data suggest that both behavioral

interventions (e.g., skills training) and cognitive therapy (e.g., for

anxiety and depression) might be required to achieve clinically significant effects with some types of pregnant substance users.

Gender Differences in Biological Effects

Of Drugs Should Inform Treatments

Evidence on any gender differences in biological reactions to substances (e.g., rates and doses at which physiological dependence on

different substances occurs) could be important to incorporate into

behavioral therapies. For example, some biological evidence suggests

that differential risk exists for men v. women for serious medical complications secondary to drug abuse. Including information of that type in

behavioral treatments would enable women to make better risk-informed

decisions about their substance use behaviors (Fischhoff and Downs

1997; Moras 1997).

Comprehensive Treatment Programs for

Some Subtypes of Female Substance Users

Gender differences in characteristics such as employability, the

likelihood of being the primary parenting figure, self-esteem, and

comorbid psychiatric symptoms have led to a national focus on developing comprehensive treatment programs for some subtypes of female drug

abusers.

Among the recommended components of comprehensive treatment

programs are the following: prenatal and neonatal care, family involvement, parenting skills, vocational training, employment counseling,

medical services, and HIV risk protection. Programs for women with

such components are widely and enthusiastically recommended in the

substance use treatment literature (e.g., Hagan et al. 1994; Kumpfer

1991; Marsh and Miller 1985; Wald et al. 1995; Zankowski 1988).

Rationales for most of the components are likely to be evident from the

material presented so far in this chapter (see Goldberg 1995). However,

multicomponent treatment strategies previously were tried for alcohol

dependence, with disappointing results (e.g., Miller and Hester 1986).
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EFFICACY FINDINGS

What is known from existing studies about the efficacy of behavioral

therapies for female substance users?

Low Percentages of Women

in Treatment Study Samples

In most studies of major drugs of abuse (opiates and cocaine), women

constitute 30 percent or less of the sample (e.g., Carroll et al. 1994a).

In contrast, gender representation in nicotine treatment studies tends

to favor females (estimated average of 60 percent women in samples)

(Toneatto et al. 1992). The gender distributions in studies of major

drugs of abuse are generally consistent with the estimate that 30 percent

or fewer of substance users in treatment are women (National Institute

on Drug Abuse 1989).

As noted previously, whether women are underrepresented in substance use studies is debatable; however, the most widely quoted study

of behavior therapies for opiate addiction was an all-male sample treated

at a Veterans Administration hospital (Woody et al. 1983, 1987).

Underrepresentation aside, the small numbers of women in studies

have direct implications for finding gender differences in the effects

of behavioral therapies, if clinically meaningful differences do exist

(see next paragraph).

Gender Differences in Treatment Efficacy

Not Reported or Examined

Although gender differences in the efficacy of behavioral substance

use treatments rarely have been reported, the question rarely has been

examined. For example, in their review of treatment studies published

from 1984 to 1989, Toneatto and colleagues (1992) found that outcomes

by gender were reported in only 13 percent of the alcohol treatment

studies and 23 percent of the studies of other drugs of abuse (not further

defined). The lack of outcome analyses by gender in the relatively

recent studies reviewed by Toneatto and coworkers (1992) reflects a

longstanding pattern.

One problem that contributes to the lack of gender difference

analyses is that the relatively small numbers of female participants do

not allow gender effects to be examined in statistically reliable ways
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(with adequate statistical power). Thus, investigators generally do not

report analyses for gender effects even in studies regarded as among the

best available (e.g., Carroll et al. 1994a).

The fact that women historically have participated at lower rates

than men in substance use treatment studies can be evidence for gender

differences in efficacy when the substance use problem being treated is

equally prevalent among men and women who reside in the vicinity of

a treatment program. In such circumstances, differential participation

rates are an index of the treatment’s acceptability. If women who qualify

for treatment do not enter it at the same rate as men do, the treatment is

less acceptable to women. Because treatment cannot be efficacious for

that proportion of a relevant population who reject it outright, different

rates of treatment participation by men and women, when the prevalence of the substance use disorder under treatment is comparable by

gender, can be interpreted as evidence for differential efficacy by gender.

Unfortunately, information of the type needed to evaluate acceptability

by gender rarely is included in study reports.

High Dropout Rates

High dropout rates are a robust finding in treatment studies of

substance abuse (Stark 1992). High attrition often is found early in

the treatment engagement phase (e.g., the time between evaluation

for participating in a treatment study and the beginning of treatment).

For example, Gawin and Kleber (1984) reported a 54-percent dropout

rate before beginning treatment for cocaine users who were accepted for

treatment. On the other hand, Carroll and coworkers (1994a) reported

a low pretreatment dropout rate (13 percent) in a study of cocaine users,

but the percentage of patients who were offered treatment and who

completed it was also quite low (35 percent).

As suggested by Carroll and colleagues’ (1994a) 35-percent finding,

high attrition also typically is found for individuals who start substance

use treatment. Stark’s (1992) review of substance use studies conducted

primarily in the 1980s indicated high dropout rates among substance

users who entered treatment. For example, Gossop and associates

(1987) reported that 83 percent of the outpatients in an opioid detoxification program did not complete it. Similarly, Silberfeld and Glaser

(1978) reported 83 percent attrition by alcohol or narcotic users from

an outpatient program.
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Somewhat surprisingly, Stark (1992) concluded that although

dropout rates from substance use treatment programs are high, they “do

not differ dramatically” from treatment studies of non-substance-using

psychiatric patients. This conclusion is inconsistent with the fact that

dropout from efficacy studies of treatments for mood and anxiety disorders tends to be 35 percent or less (e.g., Elkin et al. 1989).

Although gender differences have been reported in dropout rates

in some substance use studies (e.g., Agosti et al. 1991), gender typically

has not been examined as a dropout predictor. The review by Toneatto

and colleagues (1992) found that only 10 percent of alcohol studies and

18 percent of studies of other drugs reported dropout by gender.

The existing attrition figures indicate that substance use treatments

can be vastly improved for both males and females.

Few Efficacy Data on Gender-Specific

Treatment Programs for Women

Only one study of a gender-specific intervention was found in which

randomized assignment was used. Dahlgren and Willander (1989)

reported that female alcohol users assigned to a treatment program for

women had better outcomes than those in a mixed-gender program.

In another alcohol use treatment study in which randomization was

not used, no advantages were found for women-only compared to mixedgender programs (Copeland and Hall 1992; Copeland et al. 1993).

However, Copeland and coworkers (1993) also reported that the

women-only program attracted some women who were demographically

different from those in the mixed-gender program. This finding suggests

that the availability of some types of women-only programs might

expand the population of female substance users who will at least enter

treatment.

Bartholomew and colleagues (1994) examined an assertiveness

and sexuality treatment module for women in outpatient methadone

maintenance programs. Unfortunately, the methodological problem

of no randomized assignment, leading to confounding through selfselection bias, does not allow conclusions to be drawn about the value

of adding the gender-specific module to the standard, mixed-gender

program.
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Few Efficacy Data on Comprehensive

Treatment Programs for Women

Comprehensive treatment programs for female substance users that

include components like those described previously (e.g., prenatal and

neonatal care) were evaluated in NIDA’s Perinatal-20 demonstration

projects. Outcome data are not yet published from these projects, but a

large number of efficacy data are not expected. Most of the projects were

not designed to generate efficacy findings, and those that were included

only partial efficacy research methods. However, the demonstration

projects will yield information on implementation feasibility of some

comprehensive treatment programs for pregnant substance users, the

acceptability of the programs to targeted recipients, and effectiveness.

One study examined a non-gender-specific, semicomprehensive

treatment program that offered additional services to both male and

female substance users. McLellan and associates (1993) reported improved outcomes on some variables when adjunctive interventions were

used for specific problems, but no gender differences were reported.

Only one randomized study of a comprehensive treatment program

for women was found (Carroll et al. 1995). It was a small study of

20 pregnant, opiate-addicted women who received either standard

treatment (methadone maintenance, weekly group counseling, and

urine drug screenings three times per week) or “enhanced” standard

treatment (standard treatment plus weekly prenatal care, weekly relapse

prevention groups, contingency awards for drug abstinence, and child

care during treatment visits). The comprehensive program was not

associated with better substance use outcomes, but it was associated

with longer gestations and infants with higher birth weights.

Effectiveness of Behavioral Therapies

The strongest efficacy evidence for existing behavioral therapies

for substance use is for contingency management techniques (e.g.,

Higgins et al. 1993; Silverman et al. 1996; Stitzer et al. 1992) derived

from behavior theory and the principles of operant conditioning discovered by B.F. Skinner. For example, the introduction of contingency

management techniques in methadone maintenance clinics repeatedly

has been found to reduce the use of other drugs (e.g., Stitzer et al. 1992).

In such contingency management programs, individuals in treatment for
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heroin addiction are given privileges such as taking home 3 days of

methadone doses when their urine tests negative for other substances

of abuse. The reward is not having to come to the clinic daily. Some

impressive results have been reported with contingency management

techniques. For example, in a small study (n=38) Higgins and coworkers

(1993) found that 68 percent of cocaine-dependent participants in a

treatment program that offered rewards for cocaine-negative urine

specimens achieved 8 weeks of continuous abstinence from cocaine.

The comparable figure was 11 percent for those who received only drug

counseling. No gender differences have been found in the efficacy of

contingency management methods.

A persistent limitation of contingency management is that the

behavior change does not continue when the reward system is withdrawn (Childress et al. 1985; Stitzer et al. 1992). Also, even when a

contingency management system is maintained, abstinence effects

can diminish. For example, in the Higgins and colleagues (1993) study,

42 percent of the contingency management patients achieved 16 weeks

of continuous abstinence, compared with the 68 percent who achieved

8 weeks of continuous abstinence.

Few true efficacy findings on the other major, non-gender-specific

behavioral therapies used in the United States for substance use disorders (see table 1) have been reported. One notable exception is the

study by Carroll and associates (1994a, 1994b) in which relapse prevention was compared with medication for cocaine use and which included

a pill placebo control condition. In general, findings from efficacy

studies or partial efficacy studies that do not include a control condition

(e.g., Carroll et al. 1991; Wells et al. 1994) often indicate some reduction in drug use but tend to be disappointing in terms of the amount of

reduction and the percentage of treated individuals who achieve clinically significant improvement (e.g., the Woody and coworkers [1983]

findings for cognitive-behavioral therapy plus group drug counseling

and the Carroll and colleagues [1991] findings for interpersonal psychotherapy).

High Relapse Rates and Relapse Prevention

All treatments for substance use tend to be associated with high

posttreatment relapse rates (DeLeon 1993). High rates of relapse are

found across drugs of abuse, including nicotine, and in general do
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not differ by gender. One underutilized, potentially valuable research

topic is gender differences in reasons for relapse (e.g., Saunders et al.

19935).

High rates of relapse contributed to the development and widespread use of relapse prevention treatment strategies (e.g., Marlatt and

Gordon 1985; Rawson et al. 1993, pp. 92-115) in substance use treatment programs. As noted (e.g., Carroll et al. 1994a), relapse prevention

interventions also have been tested in efficacy or partial efficacy studies.

However, studies of relapse prevention strategies are not fully consistent

with the connotation of the term “relapse prevention,” which suggests

that recovery has been achieved and that the intervention is intended to

prevent recurrence. Semantics aside, findings for relapse prevention

treatments tend to indicate that benefit is achieved and also that

substantial room exists for better efficacy (e.g., percentage of those

treated who achieve a recovery criterion). For example, in a small study

(n=42) of cocaine abusers, Carroll and colleagues (1991) found that

57 percent attained 3 weeks or more of continuous abstinence and

43 percent met a criterion of recovery at the end of a 12-week treatment

program. In a later study, Carroll and colleagues (1994b) also found

some evidence that gains attained during acute treatment were maintained (i.e., findings consistent with the connotation of relapse prevention) in a 1-year followup of relapse prevention and pharmacotherapy

for cocaine abuse. Treatment gains were maintained and even increased

to some extent for the relapse prevention-alone condition. Gender

differences in the efficacy of relapse prevention treatments have not

been reported.

Few Methodologically Sound Studies

As noted earlier, substance use treatment outcome studies often

have methodological weaknesses that reduce the conclusiveness of

any efficacy data provided. Methodological improvements are clearly

evident in the newest studies. However, consumers of existing studies

need to be mindful of a few common methodological limitations, in

addition to those described above. For example, study therapists often

do not receive extensive training in the specific treatments being

tested. The conduct of the therapies is not clearly and comprehensively articulated in written manuals that are used to train therapists.

Manuals and training are important because they help standardize the
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implementation of study therapies and ensure their quality. In addition,

no attempts are made to ensure that therapists adhere to the designated

interventions. Thus, neither the integrity of the treatments nor the

competence with which they are delivered is ensured. When evidence

for a therapy’s efficacy is not found, limitations of the foregoing type

reduce the reliability of the conclusion that it is not efficacious. Such

weaknesses mean that it cannot be determined whether the treatment

of interest was tested.

SUGGESTED DIRECTIONS FOR

TREATMENT RESEARCH AND DEVELOPMENT

FOR FEMALE SUBSTANCE USERS

Adolescent Polydrug Users

Some evidence exists that women who are chronic substance users,

and whose lives reflect extensive functional impairment, manifest certain

patterns of substance use in adolescence. One group that is at high risk

of developing chronic substance use is adolescent polydrug users. Thus,

focusing treatment development efforts on this group could help reduce

the frequency of chronic, severe substance use and social dysfunction

among adult women. Female adolescent polydrug users, particularly

pregnant females, already are targeted in NIDA-funded research. The

potential of sexual abuse prevention efforts for girls to reduce risk for

later substance abuse is discussed above.

Self-Esteem and Life Options

Interventions that focus on self-esteem enhancement and life

options “training” could be beneficial adjuncts to treatment programs

for adolescent polydrug abusers as well as to prevention efforts focused

on adolescent girls. Life options training might consist of several

components such as helping girls to (1) become aware of options

that are realistically available to them, (2) learn the steps needed

to successfully pursue options of the most personal interest, and

(3) learn to seek and use social supports and community resources

to help sustain the behaviors needed to achieve their goals.
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Interventions for Depression and Anxiety

The potential importance of including behavioral therapies with

demonstrated efficacy for depression and anxiety in treatment programs

for female substance users is discussed above.

Comprehensive Treatment Programs

The rationales in the literature for comprehensive, multimodule

treatment programs for female substance abusers, particularly those who

are mothers or who are pregnant, are compelling (but also recall the

caveat from the alcohol treatment research literature). However, conducting efficacy studies of such programs is extremely challenging (e.g.,

Rahdert 1996). One novel methodological suggestion is that marked

heterogeneity in psychosocial development among women who need

comprehensive programs indicates that individualized outcome assessment

methods should be used to evaluate efficacy. Such methods should take

into account differences in reasonable outcome expectations across

individuals (Hagan et al. 1994).

Costs of comprehensive treatment programs affect the decisions of

the public policymakers who determine whether efficacious programs

may be implemented. Thus, including cost-effective methodologies is

important for studies of comprehensive programs.

Efficacy Studies

This chapter views efficacy studies as critical for obtaining reasonably

conclusive findings about which treatments are most likely to produce

desired outcomes in treatment-relevant subtypes of female substance users.

Thus, conducting efficacy trials designed to examine therapies that have

been recommended for various subtypes of female substance users, and

that compare the efficacy of those therapies with other available therapies, is recommended.

Survey Studies of Women’s Treatment

Preferences and Experiences

Survey methods are a potentially useful research strategy to aid in

developing efficacious treatments for female substance users. For example,

Burman (1993) collected data on women’s views of various treatments.
214

One interesting suggestion was that some treatment programs might be

more efficacious if women-only and mixed-gender treatment components were provided in a “staged” sequence; for example, an initial

women-only phase focused on selected issues, followed by mixed-gender

treatment components that address other issues. The potential value of

survey research designed to obtain patients’ perceptions of efficacious

features of therapies also is illustrated by Lovejoy and associates (1995).

Unfortunately, women were underrepresented in the respondent sample.

Education of Medical Practitioners

The overprescription of psychotropic medications, particularly

those associated with physiological dependence, has not been discussed

in this chapter (see Marsh and Miller 1985; Kandel et al., this volume).

One potentially useful and efficient intervention for prescription drug

abuse by housewives and other working women is education of medical

practitioners. Education efforts could include federally initiated dissemination of information to practitioners about prescription patterns that

demonstrate overprescription to women of medications with abuse

potential. The American Psychiatric Association might support Staterequired participation in continuing education courses on this topic.

In conjunction with educational interventions, contingency management methods might be initiated for practitioners; for example,

(1) the creation of incentives to refer women with ongoing anxiety

or depression symptoms to mental health professionals for behavioral

interventions and (2) censure for prescribing psychotropic medications

for women beyond specified durations, unless the patient is also concurrently in a behavioral therapy program and the prescriber can verify that

both treatment providers agree that continuation of the medication is

indicated. The implementation of measures such as the latter is, of

course, dependent on the availability of affordable and convenient

behavorial therapy.

Concurrent with interventions for practioners, public health information campaigns could be targeted to women and their significant

others about overprescription of medications for women for symptoms

that might be efficaciously treated by behavioral interventions.
215

CONCLUSION

The development and evaluation of treatments for female substance

users clearly merits the attention of researchers and mental health

professionals. As we approach the 21st century, essentially no data

exist on the efficacy of existing and proposed treatments for distinctive

subtypes of female substance users. The lack of controlled data is in

marked contrast to a large literature that includes compelling arguments

for gender-specific treatments for at least some subtypes. Existing

efficacy studies provide little evidence for gender differences in the

effects of non-gender-specific treatments. However, for reasons discussed

in this chapter, the lack of evidence cannot be understood as evidence

for lack of gender differences. Much work remains to systematically test

the extensive existing recommendations for gender-sensitive therapies.

Perhaps one benefit of the women’s movement in the United States in

the past 35 years is that it has become politically safer to suggest that at

least some women differ from men in ways that might merit gendersensitive therapies. Thus, it can be hoped that the rate of the needed

treatment research on and development of gender-specific interventions

will increase exponentially in the years to come. Such activity would

mirror the markedly accelerated focus on women in the drug abuse

literature since 1960.

NOTES

1. PsychLit and MEDLINE databases were used for the literature

search. The search was limited to publications from 1980 through

the first 6 months of 1996. Many keywords and permutations were

used (e.g., substance use treatment and outcome and gender; drug

treatment and outcome and gender; substance use and gender).

Relevant references also were found in the reference lists of articles

located by the search. A second source was used specifically for

information on efficacy findings for the treatment approaches listed

in table 1. The source was unpublished literature reviews obtained

in 1994 for NIDA by Lisa Onken and Jack Blaine of NIDA’s Treatment Research Branch in the Division of Clinical Research. The

reviews evaluated the state of outcome findings and other knowledge

of the most commonly used behavioral treatments for drug abuse and

identified promising and needed directions for research.
216

2. “Efficacy” studies are contrasted with effectiveness studies in treatment outcome research (Blaine et al. 1994, pp. 593-624). Efficacy

studies use experimental methods (e.g., randomization, control of

confounding variables such as changes associated with the passage

of time) to determine whether a treatment is associated with statistically significant benefits compared with putatively inactive treatments. Effectiveness studies are conducted in naturalistic settings,

with less use of experimental controls to estimate a treatment’s

effects when it is performed in “real life” conditions (e.g., by all

therapists in a setting, including those who might not be particularly

committed to the treatment approach). Effectiveness studies are

the expected next steps in evaluating treatments that have demonstrated efficacy.

3. Efficacy studies also are distinguished from evaluation research,

which is similar to effectiveness research. The results of evaluation

studies of woman-focused treatments are not reviewed in this chapter. Marsh and Miller (1985) reviewed that evaluation research.

They observed, however, that limited data are available from evaluation research treatments for female substance users. The paucity

of studies mirrors the situation with efficacy studies.

4. For a concise review of gender difference findings in substance use

research, see Greenfield (1996, pp. 299-321). Note, however, that

Greenfield’s summary of treatment outcome and other findings is

not limited to efficacy studies.

5. Saunders and associates (1993) actually examined predictors of

relapse, not drug users’ stated reasons for relapse.

REFERENCES

Agosti, V.; Nunes, E.; Stewart, J.W.; and Quitkin, F.M. Patient factors related to

early attrition from an outpatient cocaine research clinic: A preliminary

report. Int J Addict 26(3):327-334, 1991.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders, Third Edition, Revised. Washington, DC: American Psychiatric

Association, 1987.

Barry, P.P. Gender as a factor in treatment of the elderly. In: Ray, B.A., and

Braude, M.C., eds. Women and Drugs: A New Era for Research. National

Institute on Drug Abuse Research Monograph 65. DHHS Pub. No.

(ADM)86-1447. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1986.
217

Bartholomew, N.G.; Rowan-Szal, G.A.; Chatham, L.R.; and Simpson, D.D.

Effectiveness of a specialized intervention for women in a methadone

program. J Psychoactive Drugs 26:249-255, 1994.

Beck, A.T.; Wright, F.D.; Newman, C.F.; and Liese, B.S. Cognitive Therapy of

Drug Abuse. New York: Guilford Press, 1993.

Beckman, L.J. Self-esteem of women alcoholics. J Stud Alcohol 39:491-498,

1978.

Blaine, J.D.; Ling, W.; Kosten, T.R.; O’Brien, C.P.; and Chiarello, R.J.

Establishing the efficacy and safety of medications for the treatment of drug

dependence and abuse: Methodologic issues. In: Prien, R.F., and Robinson,

D.S., eds. Clinical Evaluation of Psychotropic Drugs: Principles and Guidelines.

New York: Raven Press, 1994.

Blume, S.B. Women and alcohol. J Am Med Soc 256:1467-1469, 1986.

Brady, K.T.; Grice, D.E.; Dustan, L.; and Randall, C. Gender differences in

substance use disorders. Am J Psychiatry 150:1707-1711, 1993.

Burman, S. Chemically-dependent women in treatment: A study of the

experiences in and responses to different treatment models. Dissertation

Abstr Int 54(November):1973-A, 1993.

Carroll, K.M.; Chang, G.; Behr, H.; and Clinton, B. Improving treatment

outcome in pregnant, methadone-maintained women: Results from a

randomized clinical trial. Am J Addict 4:56-59, 1995.

Carroll, K.M., and Rounsaville, B.J. Contrast of treatment-seeking and

untreated cocaine abusers. Arch Gen Psychiatry 49:464-471, 1992.

Carroll, K.M.; Rounsaville, B.J.; and Gawin, F.H. A comparative trial of

psychotherapies for ambulatory cocaine abusers: Relapse prevention and

interpersonal psychotherapy. Am J Drug Alcohol Abuse 17:229-247, 1991.

Carroll, K.M.; Rounsaville, B.J.; Gordon, L.T.; Nich, C.; Jatlow, P.; Bisighini,

R.M.; and Gawin, F.H. Psychotherapy and pharmacotherapy for ambulatory

cocaine abusers. Arch Gen Psychiatry 51:177-187, 1994a.

Carroll, K.M.; Rounsaville, B.J.; Nich, C.; Gordon, L.T.; Wirtz, P.W.; and

Gawin, F.H. One-year follow-up of psychotherapy and pharmacotherapy for

cocaine dependence: Delayed emergence of psychotherapy effects. Arch

Gen Psychiatry 51:989-997, 1994b.

Childress, A.R.; McLellan, A.T.; and O’Brien, C.P. Behavioral therapies for

substance abuse. Int J Addict 20:947-969, 1985.

Colten, M.E. A descriptive and comparative analysis of self-perceptions and

attitudes of heroin-addicted women. In: Addicted Women, Family Dynamics,

Self-Perceptions and Support Systems. DHHS Pub. No. (ADM)80-762.

Washington, DC: U.S. Govt. Print. Off., 1980.

Condelli, W.S.; Fairbank, J.A.; Dennis, M.L.; and Rachal, J.V. Cocaine use by

clients in methadone programs: Significance, scope, and behavioral

interventions. J Subst Abuse Treat 8:203-212, 1991.
218

Copeland, J., and Hall, W. A comparison of women seeking drug and alcohol

treatment in a specialist women’s and two traditional mixed-sex treatment

services. Br J Addict 87:499-504, 1992.

Copeland, J.; Hall, W.; Didcott, P.; and Biggs, V. A comparison of a specialist

women’s alcohol and other drug treatment service with two traditional

mixed-sex services: Client characteristics and treatment outcome. Drug

Alcohol Depend 32:81-92, 1993.

Culbertson, F.M. Depression and gender. Am Psychol 52:25-31, 1997.

Dahlgren, L., and Willander, A. Are special treatment facilities for female

alcoholics needed?: A controlled two-year follow-up study from a

specialized female unit (EWA) versus a mixed male/female treatment

facility. Alcoholism Clin Exp Res 13:499-504, 1989.

Davidson, V., and Bemko, J. International review of women and drug abuse.

J Am Med Womens Assoc 33:507-518, 1978.

DeLeon, G. What psychologists can learn from addiction treatment research.

Psychol Addict Behav 7:103-109, 1993.

Elkin, I.; Shea, M.T.; Watkins, J.T.; Imber, S.D.; Sotsky, S.M.; Collins, J.F.;

Glass, D.R.; Pilkonis, P.A.; Leber, W.R.; Docherty, J.P.; Fiester, S.F.; and

Parloff, M.B. National Institute of Mental Health Treatment of Depression

Collaborative Research Program: General effectiveness of treatments. Arch

Gen Psychiatry 46:971-982, 1989.

Ferrence, R.G. Sex differences in the prevalence of problem drinking. In:

Kalant, O.J., ed. Alcohol and Drug Problems in Women: Vol. 5. Research

Advances in Alcohol and Drug Problems. New York: Plenum, 1980.

Finkelstein, N. Treatment issues for alcohol- and drug-dependent pregnant and

parenting women. Health Soc Work 19:7-15, 1994.

Fischhoff, B., and Downs, J. Accentuate the relevant. Psychol Sci 8:154-158,

1997.

Frezza, M.; di Padova, C.; Pozzato, G.; Terpin, M.; Baraona, E.; and Lieber, C.S.

High blood alcohol levels in women: The role of decreased gastric alcohol

dehydrogenase and first-pass metabolism. N Engl J Med 322:95-99, 1990.

Gawin, F.H., and Kleber, H.D. Cocaine abuse treatment: Open pilot trial with

desipramine and lithium carbonate. Arch Gen Psychiatry 41:905, 1984.

Goldberg, M.E. Substance-abusing women: False stereotypes and real needs.

Soc Work 40:789-797, 1995.

Gossop, M.; Johns, A.; and Green, L. Opiate withdrawal: Inpatient versus

outpatient programs and preferred versus random assignment to treatment.

Br Med J 293:103-104, 1987.

Greenfield, S.F. Women and substance use disorders. In: Jensvold, M.F.;

Halbreich, U.; and Hamilton, J.A., eds. Psychopharmacology and Women:

Sex, Gender, and Hormones. Washington, DC: American Psychiatric Press,

1996.
219

Griffin, M.L.; Weiss, R.D.; Mirin, S.M.; and Lange, U. A comparison of male

and female cocaine abusers. Arch Gen Psychiatry 46:122-126, 1989.

Hagan, T.A.; Finnegan, L.P.; and Nelson-Zlupko, L. Impediments to

comprehensive treatment models for substance-dependent women:

Treatment and research questions. J Psychoactive Drugs 26:163-171, 1994.

Haller, D.L.; Knisely, J.S.; Dawson, K.S.; and Schnoll, S.H. Perinatal substance

abusers: Psychological and social characteristics. J Nerv Ment Dis 181:509-

513, 1993.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Foerg, R.E.; and Badger, G.J. Alcohol

dependence and simultaneous cocaine and alcohol use in cocainedependent patients. J Addict Dis 13:177-189, 1994.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Hughes, J.R.; Foerg, F.; and Badger, G.

Achieving cocaine abstinence with a behavioral approach. Am J Psychiatry

150:763-769, 1993.

Howard, K.I.; Cox, W.M.; and Saunders, S.M. Attrition in substance abuse

comparative treatment research: The illusion of randomization. In: Onken,

L.S., and Blaine, J.D., eds. Psychotherapy and Counseling in the Treatment of

Drug Abuse. National Institute on Drug Abuse Research Monograph 104.

DHHS Pub. No. (ADM)90-1722. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1990.

Institute of Medicine. A study of the evaluation, effectiveness, and financing of

public in a private drug treatment system. In: Gerstein, D.R., and Harwood,

H.J., eds. Treating Drug Problems, Volume 1. Washington, DC: National

Academy Press, 1990.

Jessup, M., and Green, J.R. Treatment of the pregnant alchohol-dependent

woman. J Psychoactive Drugs 19(2):193-203, 1987.

Jones, B.M., and Jones, M.K. Women and alcohol: Intoxication, metabolism,

and the menstrual cycle. In: Greenblatt, M., and Shuckit, M.A., eds.

Alcohol Problems in Women and Children. New York: Grune and Stratton,

1976.

Kessler, R.C.; McGonable, K.A.; and Zhao, S. Lifetime and 12-month

prevalence of DSM-III-R psychiatric disorders in the United States: Results

from the National Comorbidity Survey. Arch Gen Psychiatry 51:8-19, 1994.

Kumpfer, K.L. Treatment programs for drug-abusing women. Future Children

1:50-60, 1991.

Lex, B.W. Gender differences and substance abuse. In: Mello, N.K., ed.

Advances in Substance Abuse: Behavioral and Biological Research, Vol. IV.

London: Jessica Kingsley, 1991.

Lovejoy, M.; Rosenblum, A.; Magura, S.; Foote, J.; Handelsman, L.; and

Stimmel, B. Patients’ perspective on the process of change in substance

abuse treatment. J Subst Abuse Treat 12:269-282, 1995.
220

Lukas, S.E.; Sholar, M.B.; Lundahl, L.H.; Lamas, X.; Kourie, E.; Wines, J.D.;

Kragie, L.; and Mendelson, J.H. Sex differences in plasma cocaine levels

and subjective effects after acute cocaine administration in human

volunteers. Psychopharmacology 125:346-354, 1996.

Marlatt, G.A., and Gordon, J.R. Relapse Prevention: Maintenance Strategies in the

Treatment of Addictive Behavior. New York: Guildford, 1985.

Marsh, J., and Miller, N. Female clients in substance abuse treatment. Int J

Addict 20:995-1019, 1985.

McLellan, A.T.; Arndt, I.O.; Metzger, D.S.; Woody, G.E.; and O’Brien, C.P.

The effects of psychosocial services in substance abuse treatment. JAMA

269:1953-1959, 1993.

Means, L.B.; Small, M.; Capone, D.M.; Capone, T.J.; Condren, R.; Peterson,

M.; and Hayward, B. Client demographics and outcome in outpatient

cocaine treatment. Int J Addict 24(8):765-783, 1989.

Miller, W.R., and Hester, R.K. The effectiveness of alcoholism treatment: What

research reveals. In: Miller, W.R., and Healther, N., eds. Treating Addictive

Behaviors: Processes of Change. New York: Plenum Press, 1986.

Moise, R.; Reed, B.G.; and Ryan, V. Issues in the treatment of heroin-addicted

women: A comparison of men and women entering two types of drug abuse

programs. Int J Addict 17:109-139, 1982.

Moras, K. Potential applications of behavioral decision research to treatments

for drug abuse, related risky behaviors, and other problems: A comment on

Fischhoff and Downs. Psychol Sci 8:159-161, 1997.

National Institute on Drug Abuse. Highlights From the National Drug and

Alcoholism Treatment Unit Survey (NDATUS). Rockville, MD: the

Institute, 1989.

Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds. Behavioral Treatments for Drug

Abuse and Dependence. National Institute on Drug Abuse Research

Monograph 137. DHHS Pub. No. (ADM)93-3683. Washington, DC: Supt.

of Docs., U.S. Govt. Print. Off., 1993.

Platt, J.J., and Metzger, D.S. Cognitive interpersonal problem-solving skills and

the maintenance of treatment success in heroin addicts. Psychol Addict

Behav 1:5-13, 1987.

Rahdert, E.R., ed. Treatments for Drug-Exposed Women and Children: Advances in

Research Methodology. National Institute on Drug Abuse Monograph 166.

DHHS Pub. No. (NIH)96-3632. Washington, DC: Supt. of Docs., U.S.

Govt. Print. Off., 1996.

Rawson, R.A.; Obert, J.L.; McCann, M.J.; and Ling, W. Neurobehavioral

treatment for cocaine dependency: A preliminary evaluation. In: Tims,

F.M., and Leukefeld, C.G., eds. Cocaine Treatment: Research and Clinical

Perspectives. National Institute on Drug Abuse Research Monograph 135.

Pub. No. (ADM)93-3639. Washington, DC: Supt. of Docs., U.S. Govt.

Print. Off., 1993.
221

Reed, B.; Laud, J.; Hartman, A.; and Harding, L. Working with the child

welfare system to obtain needed services for drug dependent women and

their children. In: Reed, B.; Beschner, G.; and Mondanaro, J., eds.

Treatment Services for Drug Dependent Women, Volume 2. National Institute

on Drug Abuse. DHHS Pub. No. (ADM)81-1177. Washington, DC: Supt.

of Docs., U.S. Govt. Print. Off., 1982.

Reed, B.G. Drug misuse and dependency in women: The meaning and

implications of being considered a special population or minority group.

Int J Addict 20:13-62, 1985.

Rohsenow, D.J.; Corbett, R.; and Devine, D. Molested as children: A hidden

contribution to substance abuse. J Subst Abuse Treat 5:13-18, 1988.

Rounsaville, B.J., and Carroll, K. Interpersonal psychotherapy for patients who

abuse drugs. In: Klerman, G.L., and Weissman, M.M., eds. New Applications

of Interpersonal Psychotherapy. Washington, DC: American Psychiatric

Press, 1993.

Saunders, B.; Baily, S.; Phillips, M.; and Allsop, S. Women with alcohol

problems: Do they relapse for reasons different from their male

counterparts? Addiction 88:1413-1422, 1993.

Silberfeld, M., and Glaser, F.B. Use of the life table method in determining

attrition from treatment. J Stud Alcohol 39:1582-1590, 1978.

Silverman, K.; Higgins, S.T.; Brooner, R.K.; Montoya, I.D.; Cone, E.J.; Schuster,

C.R.; and Preston, K.L. Sustained cocaine abstinence in methadone

maintenance patients through voucher-based reinforcement therapy. Arch

Gen Psychiatry 53:409-415, 1996.

Stark, M.J. Dropping out of substance abuse treatment: A clinically oriented

review. Clin Psychol Rev 12:93-116, 1992.

Stitzer, M.L.; Iguchi, M.Y.; and Felch, L.J. Contingent take-home incentive.

J Consult Clin Psychol 60:927-934, 1992.

Szapocznik, J.; Perez-Vidal, A.; Brickman, A.L.; Foote, F.H.; Santisteban, D.;

Harris, O.E.; and Kurtines, W. Engaging adolescent drug abusers and their

families in treatment: A strategic structural systems approach. J Consult

Clin Psychol 56:552-557, 1988.

Toneatto, A.; Sobell, L.C.; and Sobell, M.B. Gender issues in the treatment of

abusers of alcohol, nicotine, and other drugs. J Subst Abuse 4:209-218,

1992.

Wald, R.; Harvey, S.M.; and Hibbard, J. A treatment model for women

substance users. Int J Addict 30:881-888, 1995.

Wallen, J. A comparison of male and female clients in substance abuse

treatment. J Subst Abuse Treat 9:243-248, 1992.

Weissman, M.M., and Klerman, G.L. Sex differences and the epidemiology of

depression. J Health Soc Behav 26:156-182, 1977.
222

Weissman, M.M., and Paykel, E.S. The Depressed Woman: A Study of Social

Relationships. Chicago: University of Chicago Press, 1974.

Wellisch, D.K., and Steinberg, M.R. Parenting attitudes of addict mothers. Int J

Addict 15:809-819, 1980.

Wells, E.A.; Catalano, R.F., Jr.; Plotnick, R.; Hawkins, J.D.; and Brattesani,

K.A. General vs. drug-specific coping skills and post-treatment drug use

among adults. Psychol Addict Behav 3:9-21, 1989.

Wells, E.A.; Peterson, P.L.; Gainey, R.R.; Hawkins, J.D.; and Catalano, R.F.

Outpatient treatment for cocaine abuse: A controlled comparison of relapse

prevention and 12-step approaches. Am J Drug Alcohol Abuse 20:1-17,

1994.

Winfield, I.; George, L.K.; Swartz, M.; and Blazer, D.G. Sexual assault and

psychiatric disorders among a community sample of women. Am J

Psychiatry 147:335-341,1990.

Woody, G.E.; Luborsky, L.; McLellan, A.T.; O’Brien, C.P.; Beck, A.T.; Blaine,

J.; Herman, I.; and Hole, A. Psychotherapy for opiate addicts: Does it help?

Arch Gen Psychiatry 40:639-645, 1983.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O’Brien, C.P. Twelve-month

follow-up of psychotherapy for opiate dependence. Am J Psychiatry

144:590-596, 1987.

Zankowski, G.L. Responsive programming: Meeting the needs of chemically

dependent women. Alcohol Treat Q 4:53-66, 1988.

AUTHOR

Karla Moras, Ph.D.

Assistant Professor of Psychology and Psychiatry

Center for Psychotherapy Research

University of Pennsylvania

3600 Market Street, Seventh Floor

Philadelphia, PA 19104-2640

(215) 349-5219 (Tel)

(215) 349-5171 (Fax)

moras@landru.cpr.upenn.edu (E-mail)