Journal of Substance Abuse Treatment 23 (2002) 41 – 48

Regular article

Women in addictions treatment: comparing VA and community samples Tania M. Davis, Ph.D.a,b,*, Kelly M. Carpenter, Ph.D.a, Carol A. Malte, M.S.W.a, Molly Carney, Ph.D.c, Sharon Chambers, C.S.W., C.D.C.d, Andrew J. Saxon, M.D.a,b a

VA Puget Sound Health Care System Center of Excellence in Substance Abuse Treatment and Education, Seattle, WA 98108, USA b Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195, USA c Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA 98105, USA d Residence XII Chemical Dependency Treatment for Women, Kirkland, WA 98034, USA Received 10 September 2001; received in revised form 19 February 2002; accepted 28 February 2002

Abstract Despite increasing awareness of gender issues in substance use treatment, women with substance use disorders (SUD) and gender-specific treatment remain understudied. This study examines differences, including identification of comorbid issues and patients’ perceived treatment needs, between women in different SUD treatment settings: an intensive VA outpatient program (VA; N = 76) and a private residential/ outpatient program (Residence XII; N = 308). In both settings the Addiction Severity Index (ASI) was administered at intake; ASI data were collected from retrospective chart review. Results support previous findings that women entering SUD treatment endorse high rates of psychiatric and medical comorbidity, and past abuse. Women in VA SUD treatment experienced more impairment on indices of medical, psychiatric, and employment issues whereas the private agency sample had higher alcohol and family/social composite scores. The differences between and similarities among the two treatment groups have implications for design of women-specific SUD treatment programs. D 2002 Elsevier Science Inc. All rights reserved. Keywords: Women; Addictions treatment; Gender-specific treatment; Veterans; Psychosocial issues

1. Introduction Although recent trends have promoted awareness of gender issues in substance use treatment, women with substance use disorders (SUD) and gender-specific treatment services remain relatively understudied (Smith & Weisner, 2000; Stein & Cyr, 1997). Although SUD, with the exception of nicotine dependence, occur more often in men (Anthony, Warner, & Kessler,1994; Weisner & Schmidt, 1992), women have high rates of severe negative consequences of their substance use (Conte, Plutchik, Picard, Galanter, & Jacoby, 1991; Cornelius et al., 1995; Gomberg, 1989; Hanna & Grant, 1997; Helzer & Pryzbeck, 1988; Lindberg & Agren, 1988; Mann, Batra, Gunthner, & Schroth, 1992; Miller, Lestina, & Smith, 2001). Women also * Corresponding author: VA Puget Sound Health Care System — Seattle Division (S116ATC), 1660 S. Columbian Way, Seattle, WA 98108, USA. Tel: +1-206-7642608; fax: +1-206-7642293. E-mail address: [email protected] (T.M. Davis).

report shorter progressions from first drug use to dependence (Anglin, Hser, & McGlothin, 1987; McCance-Katz, Carroll, & Rounsaville, 1999; Westermeyer & Boedicker, 2000) and develop the same number of symptoms as men do but in a shorter period of time (Piazza, Vrbka, & Yeager, 1989). Despite the severity of substance abuse complications in women, they continue to utilize SUD treatment in somewhat lower numbers than do men. In fact, in a review of treatment in 1997, the Substance Abuse and Mental Health Services Administration estimated approximately 30% of females (compared to 35% of males) who needed drug treatment received it (Substance Abuse and Mental Health Services Administration, 1997). One possible explanation for this situation is that many women face unique barriers to treatment. For example, women tend to perceive more personal and social difficulties in entering treatment than do men (e.g., childcare issues, fear/mistrust of authority) (Watkins, Shaner, & Sullivan, 1999), and they report greater social costs of having entered treatment (e.g., opposition from family or friends) (Beckman & Amaro, 1986). Thus, it

0740-5472/02/$ – see front matter D 2002 Elsevier Science Inc. All rights reserved. PII: S 0 7 4 0 - 5 4 7 2 ( 0 2 ) 0 0 2 4 2 - 8

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T.M. Davis et al. / Journal of Substance Abuse Treatment 23 (2002) 41–48

appears many women are not accessing treatment and the women who do enter treatment differ from women who do not (e.g., they may suffer more severe consequences of use or have the ability to circumvent barriers to treatment). When compared to men, women who do enter treatment are more likely to be younger (Grella & Joshi, 1999; RowanSzal, Chatham, Joe, & Simpson, 2000), to be single parents or responsible for child care (Grella & Joshi, 1999; RowanSzal et al., 2000), to have been married (Grella & Joshi, 1999), and to be unemployed or to have employment or financial problems (Beckman & Amaro, 1986; Brown, Alterman, Rutherford, Cacciola, & Zaballero, 1993; McCance-Katz et al., 1999; Schneider, Kviz, Isola, & Filstead, 1995; Rowan-Szal et al., 2000). Additionally, women tend to endorse more medical problems (Brown et al., 1993), psychological symptoms (Brown et al., 1993; Dansky, Byrne, & Brady, 1999; Grella & Joshi, 1999; Davis & DiNitto, 1996; McLellan et al., 1992; Schneider et al., 1995), family/social issues (Brown et al., 1993; Davis & DiNitto, 1996), and fewer legal problems (Brown et al., 1993; Schneider et al., 1995). Lastly, women in treatment are likely to report a history of sexual victimization (Miller, Downs, & Testa, 1993; Rohsenow, Corbett, & Devine, 1988; Root, 1989). Such findings have led many investigators to believe female-specific social factors are key to both treatment-seeking and program development for women. Although these characteristics of treatment-seeking women in general have been identified, little research to date has attempted to describe subpopulations of women who access different treatment forums or to relate female client factors and perceived needs to outcome (Comfort & Kaltenbach, 2000), data that may serve to promote treatment access for nontreatment-seeking female substance abusers. Another possible influence on women’s treatment utilization is the type of treatment itself. Historically, substance abuse treatment has been male-oriented with treatment designed for and primarily utilized by men (Marsh, D’Aunno, & Smith, 2000). The literature conveys mixed results in regard to differential outcomes for women and men in mixed gender programs, with some studies suggesting both sexes have equivalent outcomes and others that women have poorer outcomes (McCaul, Svikis, & Moore, 2001; Mertens & Weisner, 2000; Mulvaney et al., 1999; Toneatto, Sobell, & Sobell, 1992). Other studies comparing mixed-gender to female-only addictions treatment have found improved retention and outcomes for women in female-only treatment programs (Copeland, Hall, Didcott, & Biggs, 1993; Dahlgren & Willander, 1989). The discrepant findings related to treatment outcome for women may be a result of different characteristics of the women who utilize different facilities/modalities, as well as a lack of identification of gender-appropriate outcome variables. Many agencies have responded to the above information by developing gender-specific programming (Comfort & Kaltenbach, 2000). As a preliminary step toward identifying the characteristics and perceived needs of female clients

who utilize these gender-specific treatment programs, this retrospective study was conducted to describe and compare the patients from two community-based women’s addictions treatment programs: an intensive outpatient program at a large VA hospital (VA) and a private pay residential and intensive outpatient program. We conducted this study with the assumptions heterogeneity exists among female client populations and facilities do in fact treat different populations of women. However, given the exploratory nature of the analysis, no specific hypotheses are presented. It is hoped the identification of female patients’ perceived needs and increased understanding of the nature of comorbid issues in subpopulations of women will enhance treatment development and contribute to better overall treatment of women with SUD.

2. Method 2.1. Participants Participants were women attending addictions treatment at one of two women’s treatment programs: an intensive outpatient program at a large VA and a residential/ intensive outpatient program at a community treatment center (Residence XII). The VA sample includes 76 women seen consecutively in the outpatient women’s addictions program from 1997 to 2000. The Residence XII sample consists of 308 women seen consecutively in residential treatment between 1999 and 2000. The average lengths of stay for these respective programs is 238 and 21 days, respectively. 2.2. Procedure The fifth edition of the Addiction Severity Index (ASI) (McLellan et al., 1992) was administered as part of the routine intake procedure by clinical staff in both treatment settings, and data were collected from a retrospective chart review. Data regarding the number of women discharged prior to the ASI administration are unavailable. The ASI is a widely used instrument that addresses seven problem areas and provides composite scores for each area, with higher scores indicating more severe problems. This study was approved by the Institutional Review Board at the University of Washington. 2.3. Treatment programs The VA program is an intensive outpatient program available to eligible veterans free of charge. It is not known how many of these women have private insurance although the authors’ experience suggests very few have non-VA healthcare options. The Residence XII program is primarily a residential program paid for by patients’ health insurance or private pay. In addition, Residence XII has two beds paid

T.M. Davis et al. / Journal of Substance Abuse Treatment 23 (2002) 41–48 Table 1 Demographic characteristics Variable Age (mean ± SD) Race (%) Black White Other Marital status (%) Never married Married/widowed Divorced/separated Living situation (%) With partner/ family/friends Alone Unstable/controlled environment Employment pattern last Full time Part time Student/service Retired/disability Unemployed

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2.4. Analyses

Residence XII (N = 38)

VA (N = 76)

t (df ) or X2(df )a

38.2 ± 10.2

41.4 ± 8.6

-2.76 (133.2)

4.0 89.7 6.3

21.1 64.5 14.5

33.61 (2)x

27.3 39.3 33.4

22.4 18.4 59.2

18.61 (2)y

87.0

61.8

11.7 1.3

31.6 6.6

27.23 (2)x

39.5 14.5 1.3 18.4 26.3

34.37 (4)x

three years (%) 61.1 19.5 2.6 3.3 13.5

a

Comparisons were made by independent t-tests or the chi-square test, as appropriate. y Significant at .01 level after Bonferroni correction. x Significant at .001 level after Bonferroni correction.

for with state funding for women who cannot pay for their own treatment. Both the VA and the Residence XII programs treat women with a variety of SUD and both use a variety of treatment modalities (e.g., group, individual, and family psychotherapy, addictions education, and skills training) in attempts to be flexible and to address gender-specific issues. Both sites offer individualized treatment and longterm continuing care and endorse a biopsychosocial treatment philosophy. Although psychiatric medication management is offered at both locations, the VA program offers more comprehensive psychiatric care with psychiatrists and psychologists on staff. The VA program also offers methadone maintenance treatment, which is not offered at Residence XII.

Prior to analyses, the number of days between the admission date and the interview date was examined in order to ensure similarity in the definition of the ‘‘past 30 days’’ period. The lag to ASI administration was greater for the VA group (Residence XII mean ± SD = 4.3 days ± 3.1; VA = 11.1 days ± 20.9, t[75.8] =
2.80, p = .007), indicating this group of VA women was in treatment for a larger segment of the ‘‘past 30 days.’’ Therefore, whenever possible ‘‘lifetime’’ data are reported. We conducted chi-square analyses to examine differences in categorical variables and t-tests to examine differences in continuous variables. Due to the large number of family-wise comparisons made, significance levels reflect a Bonferroni correction for the number of nonindependent comparisons. Corrected significance levels are as follows: .05 level corrected to .0007, .01 level corrected to .0001, and .001 level corrected to .00001. In cases where unequal variance between groups was detected by Levene’s test, we reported the t-value adjusted for the inequality. The continuity corrected chisquare value is given in all appropriate cases. In some instances data are reported regarding differences between groups where the differences did not attain statistical significance but appeared to be of clinical or administrative interest. Variance in sample size among analyses is related to missing data. All analyses were conducted using Statistical Package for the Social Sciences for Windows Version 10.1 (2000).

3. Results 3.1. Demographics As indicated in Table 1, Residence XII women were more likely to be married or widowed, while VA clients were more likely to live alone or in an unstable or controlled environment. The ethnic distribution was more diverse in the VA sample.

Table 2 ASI composite scores Residence XII

VA

Composite score

N

Mean ± SD

N

Mean ± SD

t (df )

Medical Employment Alcohol Drug Legal Family/social Psychiatric

307 301 306 285 298 286 303

0.242 ± 0.310 0.382 ± 0.281 0.524 ± 0.283 0.153 ± 0.142 0.089 ± 0.169 0.372 ± 0.212 0.369 ± 0.231

71 76 67 68 69 70 74

0.425 ± 0.371 0.620 ± 0.297 0.283 ± 0.238 0.128 ± 0.133 0.163 ± 0.211 0.246 ± 0.225 0.423 ± 0.260

-3.86 (93.8)* -6.51 (375)x 6.48 (371)x 1.33 (351) -2.69 (89.2) 4.40 (354)x -1.73 (375)

* Significant at .05 level after Bonferroni correction. Significant at .001 level after Bonferroni correction.

x

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T.M. Davis et al. / Journal of Substance Abuse Treatment 23 (2002) 41–48

Fig. 1. Percent of clients endorsing use (lifetime). * c2 [1, N = 364] = 14.72, p = .0001, significant at .01 level after Bonferroni correction.

3.2. Medical Generally, VA clients were more likely to receive a pension for medical disability (Residence XII = 1.9%; VA = 22.4%; c2 [1, N = 384] = 41.59, p < .00001), although they did not endorse significantly higher rates of chronic medical problems (Residence XII = 39.1%; VA = 53.9%; c2 [1, N = 383] = 4.93, ns). The ASI medical composite scores were significantly higher for the VA sample (Table 2). 3.3. Education/employment Employment patterns over the past three years are presented in Table 1. Residence XII clients were signifi-

cantly more likely to report working full time, while VA clients were more likely to report being unemployed or disabled/retired. The groups were similar in terms of total months of education (Residence XII mean ± SD = 163.90 ± 28.98; VA mean ± SD = 166.59 ± 24.25) and in having a transferable profession, trade, or skill (Residence XII = 83.4%; VA = 73.7%). In the 30-day period prior to the interview, the Residence XII sample reported more days of employment (Residence XII mean ± SD = 11.5 ± 11.4; VA = 5.9 ± 9.9, t[128.6] = 4.30, p < .0001) and more employment earnings (Residence XII mean ± SD = $1025.7 ± $2069.8; VA = $297.9 ± $603.4, t[369.5] = 5.28, p < .00001) than did the VA sample. VA women reported receiving more money from welfare (Residence XII mean ± SD = $12.3 ± $65.1; VA = $53.3 ± $144.8, t[82.6] =
2.41, ns) and pen-

Fig. 2. Psychiatric symptoms endorsed (lifetime). Please note that the categories above represent patient self-report of symptoms, not formal diagnoses. * c2 [1, N = 381] = 11.46, p = .0007, significant at the .05 level after Bonferroni correction. y c2 [1, N = 380] = 17.37, p = 3.1e
5, significant at the .01 level after Bonferroni correction. x c2 [1, N = 381] = 12.66, p = .0004, significant at the .05 level after Bonferroni correction.

T.M. Davis et al. / Journal of Substance Abuse Treatment 23 (2002) 41–48

sions (Residence XII mean ± SD = $83.7 ± $376.5; VA = $462.3 ± $1082.5, t[78.4] =
2.99, ns) than did the Residence XII group. VA clients had significantly higher ASI employment composite scores (Table 2) than did Residence XII clients. 3.4. Alcohol/drug use As presented in Fig. 1, lifetime rates of use of specific substances were similar for both groups except that VA clients had a higher rate of heroin use. The samples did not differ significantly in numbers of lifetime SUD treatment episodes (Residence XII mean ± SD = 1.29 ± 2.25; VA mean ± SD = 1.66 ± 2.53, t[382] =
1.24, ns). The Residence XII sample scored significantly higher on the ASI alcohol composite score; ASI drug composite scores were not significantly different (Table 2). 3.5. Legal involvement

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Table 3 Patient severity ratings Residence XII

VA

N

N

Percent yes

Percent yes

Patient ratings of distress (considerable or extreme) Medical problems 308 23.1 76 32.9 Employment problems 307 30.3 76 28.9 Alcohol problems 307 65.5 76 31.6 Drug problems 308 43.2 76 35.5 Legal problems 308 15.6 76 19.7 Family problems 308 58.8 75 30.7 Social problems 308 42.9 66 39.4 Psychiatric problems 306 60.5 76 59.2

X2 (df ) 2.65 (1) 0.01 (1) 27.49 (1)x 1.17 (1) 0.49 (1) 18.02 (1)y 0.14 (1) 0.00 (1)

Patient ratings of treatment importance (considerable or extreme) Medical problems 307 14.7 76 43.4 29.33 (1)x Employment problems 305 18.0 76 26.3 2.14 (1) Alcohol problems 308 79.5 76 48.7 28.20 (1)x Drug problems 308 53.6 76 52.6 0.00 (1) Legal problems 307 5.5 76 14.5 5.92 (1) Family problems 307 59.6 74 32.4 16.67 (1)y Social problems 304 45.7 68 27.9 6.48 (1) Psychiatric problems 306 64.7 76 64.5 0.00 (1)

Generally, VA clients endorsed higher rates of lifetime criminal convictions (Residence XII mean ± SD = 0.3 ± 1.0; VA = 1.1 ± 2.2, t[82.1] =
3.23, ns), higher rates of current treatment admission being prompted by the legal system (Residence XII = 8.1%; VA = 22.4%; c2 [1, N = 383] = 11.21, ns), and higher rates of current parole or probation (Residence XII = 12.3%; VA = 21.1%; c2 [1, N = 384] = 3.14, ns). Such differences are reflected in the higher ASI legal composite score for the VA sample, although this difference also was not statistically significant (Table 2).

receipt of a pension (Residence XII = 1.3%; VA = 25.0%; c2 [1, N = 383] = 56.48, p < .00001 level) and of having been hospitalized (Residence XII = 29.5%; VA = 43.4%; c2 [1, N = 384] = 4.75, ns) for a psychiatric condition. VA ASI psychiatric composite scores were not significantly higher than those of the Residence XII sample (Table 2).

3.6. Family/social relationships

3.8. Patient severity ratings

Residence XII clients endorsed a greater number of close, meaningful relationships with family members and friends in their lifetimes (Residence XII mean ± SD = 4.3 ± 1.3; VA = 3.1 ± 1.7, t[99.9] = 5.99, p < .00001) and more days of family problems in the past 30 days (Residence XII mean ± SD = 4.9 ± 8.4; VA = 2.6 ± 7.3, t[123.6] = 2.32, ns). Both groups endorsed high rates of lifetime verbal abuse (over 80% for both groups), physical abuse (over 65% for both groups), and sexual abuse (over 50% for both groups), with no significant group differences. Residence XII clients received significantly higher ASI family/social composite scores than did the VA sample (Table 2).

As shown in Table 3, Residence XII patients were more likely to report considerable or extreme distress in the areas of alcohol and family problems. Following from this, Residence XII clients endorsed higher rates of considerable or extreme treatment need in the areas of alcohol and family problems. The VA sample was more likely to rate treatment need as considerable or extreme for medical problems, although ratings of distress in this area did not differ significantly between the two groups. The majority of both groups rated the need for drug and psychiatric treatment as considerable or extreme.

y x

Significant at .01 level after Bonferroni correction. Significant at .001 level after Bonferroni correction.

4. Discussion 3.7. Psychiatric symptomatology As presented in Fig. 2, both samples reported high rates of psychiatric symptoms and psychopharmacologic treatment. VA clients were more likely to endorse experiencing anxiety symptoms, hallucinations, and trouble understanding, concentrating and remembering in their lifetimes. In addition, the VA group indicated a greater likelihood of

Results from the present study indicate women entering SUD treatment endorse high rates of medical complications, employment difficulties, family/social concerns, psychiatric disturbance, and abuse. These findings are consistent with past research (Brown et al., 1993; Dansky et al., 1999; Davis & DiNitto, 1996; Grella & Joshi, 1999; McCanceKatz et al., 1999; Miller et al., 1993; Rohsenow et al., 1988)

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and suggest our samples are similar to women who enter SUD treatment in general. Our results also indicate, in comparison to a sample from a private treatment agency, women entering SUD treatment at a VA program appear to be more severely impaired on a variety of indices, including medical, psychiatric, and employment, while Residence XII women reported more family and alcohol problems. Moreover, perceptions of distress and treatment needs appear to vary among subpopulations of women. The greater medical and employment impairment in the VA sample may be due in part to the fact most of the Residence XII patients have insurance or are able to pay privately for their treatment. Individuals with health insurance are likely to be higher functioning as insurance indicates they are maintaining either employment or a stable marital relationship with someone maintaining employment. The VA sample reported higher rates of many lifetime psychiatric symptoms. That no group differences were found on the ASI psychiatric composite score may be accounted for by the high rating of psychiatric treatment need in both groups and the fact ASI composite scores do not include lifetime variables. Moreover, nearly 65% of women in both samples rated psychiatric treatment as considerably or extremely important, and the majority of women endorsed a history of abuse, a finding consistent with the literature showing a relationship between trauma and substance abuse in women (Simpson & Miller, in press). The private treatment sample did appear to be more severely impaired than the VA women in the areas of alcohol use and family/social relationships. Women with more stability (e.g., medical, social, legal, employment, housing), as in the community sample, may rate alcohol problems as interfering more with their functioning. With regard to the family/social composite, many VA women have little or no family/social contact at all, as evidenced by the VA sample endorsing significantly fewer close, personal relationships with immediate family/friends and being more likely to report living alone and in unstable conditions. Thus, when asked to rate their level of family problems, they would rate it as low (no family = no problem), which may have contributed to misleadingly low scores on this measure. Further similarities and differences are seen in the women’s ratings of distress and treatment importance. While the majority of women in both samples rated drug and psychiatric treatment as considerably or extremely important, the samples differed in their perceived treatment needs beyond these two areas. A low percentage of the Residence XII sample reported a high level of treatment need in the medical, employment and legal areas as compared to the VA sample. Rather, they endorsed high rates of need in the areas of alcohol use and family/social problems, although a substantial minority of VA clients did rate treatment as considerably or extremely important in these areas as well.

Several possible limitations to this study should be addressed. First, the ASI was the only measure available for analysis and this instrument may not assess some variables relevant to women’s specific treatment needs (Comfort & Kaltenbach, 2000). For example, the ASI does not fully assess for pregnancy-related medical issues or parenting and childcare responsibilities. Therefore, despite the differences noted between these samples in areas of concern and perceived treatment needs, there may be additional needs not identified here. A second limitation is, as clinical practice varied between the two settings, the VA sample completed the ASI later in treatment than the Residence XII group. This difference between groups affects all items concerning ‘‘the past 30 days.’’ Therefore, interpretations of composite scores and recent problems should be made with caution. Lastly, the present study was exploratory and retrospective in nature. However, the purpose of this study was to make a preliminary examination of differences between clinical samples of women in different community-based settings and to provide direction for further, prospective research. The findings noted have implications for the design of women-specific SUD treatment programs. The study clearly shows women in clinical samples are far from uniform in their treatment needs and their perception of need. Since most women seeking SUD treatment have experienced abuse, a component of women-specific SUD treatment clearly should focus on trauma. Moreover, most women in SUD treatment have serious psychiatric symptoms that warrant attention. However, our study suggests SUD programs for women also may need to tailor services to their specific subpopulation. For example, the content of family/ social treatment for VA clients may focus on assertiveness and social skill development in order to increase and maintain their social networks and family connections whereas specific family counseling may be more important to women in private treatment who have contact with family members but experience conflict. Conversely, legal, housing, and employment assistance would meet crucial needs of the VA sample but would be unnecessary for many in the private treatment sample. The differences in problem severity and treatment needs found between women in these two different SUD programs offer one potential explanation for discrepancies in efficacy of women-specific vs. generic SUD treatment described in prior research (McCaul et al., 2001; Mertens & Weisner, 2000; Mulvaney et al., 1999; Toneatto et al., 1992). Accruing evidence points to the value of providing treatments that meet the specific needs of individual patients (McLellan et al., 1997). It is conceivable some prior studies of ‘‘women-specific’’ treatment included generic components that, while appropriate, did not address the needs of some women in those treatments. The increasing development of more gender-specific treatment programs necessitates continued examination of patient characteristics and comorbid problems in order to create more comprehensive treatment

T.M. Davis et al. / Journal of Substance Abuse Treatment 23 (2002) 41–48

packages that address women’s needs and their perception of these needs, as well as to identify gender-appropriate outcome variables.

Acknowledgments This research was presented in part as a poster presentation at the annual conference of the American Psychological Association in August, 2001. Views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, the University of Washington, the Alcohol and Drug Abuse Institute, or Residence XII Chemical Dependency Treatment for Women.

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