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Need for Services Research

on Treatment for

Drug Abuse in Women

Jacqueline Wallen, Ph.D., M.S.W.

INTRODUCTION

In a 1990 report on treatment for drug abuse, the Institute of Medicine (IOM) argued for the critical importance of health services research

as a basis for building drug abuse treatment systems (Institute of Medicine 1990). In the same report, a need for research on women in treatment was identified, particularly women in the childbearing years and

women with children. This concern relates to the objectives set for

women in Healthy People 2000 (U.S. Department of Health and Human

Services 1990), including abstinence from alcohol, tobacco, and other

drugs during pregnancy. Other objectives in Healthy People 2000 require

a better understanding and monitoring of services offered to women in

treatment for drug abuse. These services include prenatal care, maternal

health and nutrition during pregnancy, and family planning. Understanding the extent to which women in drug abuse treatment are currently able to obtain services that address their needs, and how financial

and other factors influence the services they receive once they have

sought treatment, is especially important in view of current debates over

which drug abuse treatment services should be covered by public and

private third-party payers.

Debates over health care reform concern policymakers at both the

Federal and State levels. Central to these debates is an understanding

of services currently provided for women and how they are being used.

Little research has been conducted on how women use drug abuse treatment services or on how health insurance coverage affects the kinds of

services women receive after they enter treatment. The 1990 IOM report portrayed treatment for drug abuse as a two-tiered system consisting

of a public and a private sector. The two tiers have different types of

clients and offer different kinds of services. Although relatively little

research has been done to document these differences, the IOM report

suggested that clients in the public sector have a longer history of
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drug-taking, have taken more drugs, are less likely to be employed, have

more major social deficits, and are more likely to have records of criminal activity than clients in the private sector. Thus public sector clients

require more services. However, in contrast to private facilities, public

facilities have less capacity and offer fewer services.

Because the drug abuse treatment system was largely developed at a

time when most patients were men, there is concern that this system is

not sufficiently responsive to women’s economic, social, and emotional

issues (Kumpfer 1991; Wallen 1990, pp. 103-109). In 1984 the U.S.

Congress mandated that at least 5 percent of the block grant funds for

alcohol and other drug abuse services be used to support new or expanded services for women (Institute of Medicine 1990). Because little

research has been conducted on the services received by women in treatment, the extent to which these women receive services that address

their special needs is not known. The Institute of Medicine (1990)

reported that only about one-third of the more than 80,000 women

in drug abuse treatment were in programs that had special services for

women. A recent California study (Soman et al. 1996) found that

although California increased funding for treatment services for drugaddicted women and their children in the early 1990s, there are still

wide gaps between the kinds of services that are appropriate for drugaddicted women and their children and the kinds of services that are

provided in the treatment system.

In addition to the scarcity of information about services provided

to women in drug abuse treatment, relatively little is known about the

characteristics and treatment needs of women in drug abuse treatment.

Research on women’s use of drug abuse treatment services has rarely

studied a range of treatment settings and populations. Instead, studies

generally have been confined to a single type of treatment or a particular

population of women. As a result, findings are inconsistent and conflicting because different populations and settings are related to different

treatment needs and different patterns of utilization.

CHARACTERISTICS OF

WOMEN IN TREATMENT

Characteristics of women in treatment, such as race and ethnicity,

age, income, pay source, number of children, previous treatment history,

medical and psychiatric comorbidities, types and amounts of drugs used,
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and severity of drug problem (including polydrug use), reflect differences

in access to treatment among different subpopulations of women and are

important predictors of women’s treatment needs (Harrison and Belille

1987; Root 1989; Lex et al. 1988, p. 53). Research suggests that many

women in treatment face other serious problems in addition to addiction,

including unemployment, problems with the legal system, health problems, and homelessness (Gehshan 1993). Several studies of women in

treatment for drug abuse have shown that they have high rates of previous

sexual and physical abuse (e.g., Nelson-Zlupko et al. 1995; Wallen 1992).

Many drug-abusing women are of childbearing age and may be mothers

who have custody of their children. Reviews of the literature on addicted

mothers indicate that these mothers are concerned about the well-being

of their children and feel inadequate as parents (Luthar and Walsh 1995).

Women in treatment often cite concern about their children as a primary

motivation for entering treatment (Colten 1980, pp. 1-18). Yet information on women in treatment that includes a broad range of treatment programs is lacking. Studies of treatment populations have focused disproportionately on individuals receiving inpatient treatment and those using

public facilities and typically do not distinguish between men and women

in treatment (Institute of Medicine 1990). Comparisons of men and

women that do exist suggest that research investigating the characteristics

of women in treatment, both as a subgroup of the treatment population

and in comparison to men, is needed across a broad spectrum of treatment

settings.

PATHWAYS TO TREATMENT FOR WOMEN

Research findings concerning how women arrive in treatment are often conflicting, probably because studies were conducted in different settings with different populations of women. Some studies on women and

alcoholism treatment show that women are more likely than men to be

self-referred to treatment, whereas others show the opposite (Beckman

and Amaro 1984, pp. 15-24). It is also not clear what role family factors

and life stress factors play in treatment-seeking on the part of women

(Amaro et al. 1987; Weisner and Schmidt 1993). Women are entering

drug abuse treatment in increasing numbers, and there is evidence that

a greater proportion now come to treatment through the criminal justice

system (Institute of Medicine 1990). Women in general (Beckman and

Amaro 1986), and African-American women in particular (Amaro et al.
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1987), are less likely than men to have health insurance coverage for

substance abuse treatment. Women also are more likely to have family

responsibilities that interfere with treatment (Beckman and Amaro

1986). Inadequate child care may pose a significant barrier to treatment

for many women (Institute of Medicine 1990; Chatham 1990, pp. 3-14)

and may prevent women from seeking treatment until their symptoms

have become severe (Institute of Medicine 1990). Lack of child care is

one of the most frequently reported barriers to treatment among women

(Blume 1988; Wilsnack 1991). Zimmerman (1988) found that, along

with lack of child care, pregnancy was an obstacle to treatment; however, differences in the kind of treatment sought by women with and

without children have not been examined systematically. In addition,

few studies have compared women in treatment with women who have

similar drug problems but are not in treatment to learn what characteristics are associated with entry into treatment.

Research is needed to examine how women in treatment came to

be there, identify differences among subpopulations of women in the

route by which they entered treatment, and compare women with drug

problems who are in treatment with women who have drug problems in

the general population. Such research will enhance the understanding

of barriers to treatment for women.

COMPARISON OF TREATMENT SETTINGS

Different treatment settings provide different services. In a study

of substance abuse treatment programs, Gehshan (1993) found that

most programs offer individual and group counseling and information

about addiction, aftercare, and relapse prevention. Many offer medical

detoxification. What differentiates programs, according to Gehshan,

are the ancillary and medical services offered, including transportation

to appointments, job training and placement, primary medical care,

educational programs, help with housing, prenatal and obstetric and

gynecologic care, child care, family planning, legal assistance, and

medical care for infants and children. However, comparisons of different

kinds of facilities have rarely examined the extent to which they offer

services specifically related to women’s needs, such as child care or

family programs. Only two studies that specifically examined womenonly programs were found in a review of the literature (Copeland and

Hall 1992; Hearn 1989). Another study examined the extent to which
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female-sensitive treatment services (defined as a high ratio of female

to male clients; availability of a female counselor; and availability of

employment, health, and relationship counseling) were received by

women in several different types of New York City opiate abuse treatment programs (Hanke and Faupel 1993). This study found that,

overall, residential programs were somewhat more female-sensitive

than detoxification, outpatient, or methadone treatment programs,

but the programs were not compared with respect to other characteristics

such as public v. private ownership. More research comparing the

kinds of services available to women in different treatment settings

is needed to clarify the gaps in available services.

SERVICES USED BY WOMEN

Relatively little is known about the services received by women in

treatment for drug abuse. For example, how do the services received by

women in inpatient treatment compare with those received by women

in outpatient treatment? How do services received in public facilities

differ from those received in private facilities? Moreover, it is not clear

how often specialized programs attract the kinds of women they were

designed to serve. For example, a study of 92 programs for pregnant

women found that although 94 percent of the programs claimed to serve

pregnant women, 70 percent had served fewer than 5 such women in the

past year. Interviews with women who had used the programs indicated

that these programs had no provisions for child care or transportation

and that they provided no special facilities for women (Rovner 1993,

p. 5). A number of recent studies of treatment outcomes for women

with children confirm the importance of including children in their

mothers’ treatment programs (Goldberg 1995). Poor women, especially,

often require comprehensive programs that deal not just with substance

abuse but also with housing, contraception, educational issues, and

medical and counseling needs (Goldberg 1995). One small study of

34 women in substance abuse treatment indicated that relationships

(to children, husbands or partners, and others) were of central concern

to these women, who also indicated a preference for discussing these

issues in groups with other women (Kauffman et al. 1995). An even

smaller study of 24 women, carried out by the same group of researchers,

found that only about half the women’s treatment experiences had included the option of women-only groups. Opportunities for discussion
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about reproductive health and sexuality were less common, and parenting

education, help obtaining child care, and onsite child care were the least

common (Nelson-Zlupko et al. 1996). Further research is needed on the

services received by women, using larger samples that permit comparison

among subpopulations of women and across a variety of treatment settings.

SUMMARY

A solid body of research is needed that shows who the women in drug

abuse treatment are, how they get there, and what services they receive in

treatment. Relatively little is known about how the services received by

women differ from one treatment setting to another, or whether programs

designed to facilitate access to treatment for particular subpopulations of

women accomplish this goal. Because of the current high priority given

to attracting and retaining women in treatment for drug abuse and to

preventing drug abuse by women in the childrearing years, research on

women’s use of drug abuse treatment services would be particularly timely

and could serve as a foundation for future research on treatment utilization and treatment outcomes.

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Beckman, L.J., and Amaro, H. Personal and social difficulties faced by males and

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AUTHOR

Jacqueline Wallen, Ph.D., M.S.W.

Associate Professor

Department of Family Studies

University of Maryland

1204 Marie Mount Hall

College Park, MD 20742

(301) 405-4008 (Tel)

(301) 314-9161 (Fax)

jw127@umail.umd.edu (E-mail)