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Section 21
The Impact of Women’s Family Status on Completion of Substance Abuse Treatment

Question 21 | Test | Table of Contents

A growing literature suggests that women continue to be the "second sex" in substance abuse treatment theory development, diagnostics,  access to treatment, and delivery of substance abuse services. Studies show that men are nearly 10 times as likely to enter treatment than women, have longer lengths of stay, and have greater rates of treatment completion. Research suggests that at least some of the gender differences in treatment outcomes are due to differences in family roles that can hinder a woman's ability to access, enter, and complete drug abuse treatment.

Ingersoll, Lu, and Haller studied 64 predominantly polysubstance abusing (86%) perinatal women admitted for the first time to intensive outpatient treatment. They found that having fewer children increased the probability of women staying in treatment longer even among those who relapsed during treatment. Although the female-specific treatment program they studied included medical care and ancillary services for women and their dependent children, having more children tended to undermine treatment completion for women substance abusers. In a five-year review of outcomes for postpartum female substance abusers in mixed-sex treatment programs in which women-only support groups were available, Strantz and Welch also found that the fewer children a woman has, the longer she is likely to stay in voluntary day treatment. However, the number of children was negatively associated with length of stay for women in both court-mandated or voluntary outpatient treatment. Problems associated with child care were greatest for women with three or more dependent children. Women who retained custody of their infants stayed longer in the intensive day treatment program, particularly if they had fewer other dependent children.

A study of 172 outpatients (40% women) in alcoholism treatment found that contradictory factors predicted failure to complete treatment. While having no dependents discouraged women from initiating or completing outpatient treatment, the same women were more likely to complete inpatient treatment. An Australian study found that the fewer dependents a woman had, the more likely she was to return to heavy drinking, but no similar relationship between number of dependents and treatment outcomes was observed among men.

In addition to having children, being pregnant can make it more difficult for women to get and complete substance abuse treatment because many facilities do not have the means to support pregnant women in their care. For example, a study of 163 pregnant and postpartum women found that those who were younger and who referred themselves to treatment were more likely to fail to complete treatment even though these women sought treatment initially. Many have suggested that women-only treatment programs are the best way to address the special needs of women, particularly those who are pregnant, postpartum, or who have a history of being sexually abused. There is some evidence that women-only treatment programs can be more effective. One study found that women in women-only treatment were more than twice as likely to complete treatment than women in mixed-gender programs. The women in the women-only programs were more likely to be younger, pregnant, and homeless. The researchers concluded that if the treatment environment is more focused on the special needs of women substance abusers, women who otherwise are at a greater risk of dropping out can complete treatment at higher rates.

Asking for help for substance abuse can put women in jeopardy of losing custody of their children. For many states, habitual or addictive use of alcohol or drugs is evidence of child abuse and neglect. Although there have been changes in some state policies regarding separation of families when parents enter treatment, the presumption of abuse and neglect triggers assessment and frequent placement of dependent children with other family members or in foster care settings, particularly for single mothers who abuse alcohol or drugs.

The law's tragic effect is that children of substance abusers are subject to permanent removal from their families as a result of their parents' efforts to recover from addiction. Instead of strengthening and keeping families together, the law serves to tear families apart. (p. 339)

Because substance abuse is more likely to be detected among participants in social service programs for economic aid and child care, many of the children who are placed in foster care come from disadvantaged households headed by single, unemployed mothers. These women have limited social and economic resources to help them recover and care for their children. A few states have revised their definitions so that addicted parents who voluntarily participate in a program of recovery are not automatically presumed guilty of child abuse or neglect unless there is additional evidence to support abuse or neglect charges. Here, the decision by child protective service agencies to leave children with their parents often is determined by whether there is a supportive home environment available to foster the substance abuser's attendance in treatment. If not, alternate caregivers must be found for the children, either with members of the client's family or with a foster family until treatment is completed.

With both mother and unborn child at increased risk of injury or death,and the developmental injuries associated with fetal drug and alcohol addiction, the findings of this study regarding the reduced likelihood of completing treatment for pregnant substance abusers are a cause for serious concern. Pregnant women in the DARTS database were significantly less likely to enter and complete substance abuse treatment, just as has been found in past research. Although Medicaid places no limits on the number of treatment sessions a pregnant woman can receive, access may not be available due to the limited number of programs that address pregnant women's treatment needs. These researchers argue that the limited number of programs for pregnant women coupled with stringent eligibility requirements for these special programs causes them to fail to receive the types and amounts of treatment that they need. Furthermore, pregnant women make up less than 10% of the women in treatment. Their small numbers make it difficult to justify the significantly greater expense associated with treatment programs designed specifically for them. Pregnancy is a complicating factor in women's drug treatment, but treatment centers must work at providing the specific care that pregnant women need. More in depth research is necessary to find what drug treatment works best for pregnant women.

Women in the DARTS database who were responsible for the care of minor children also were found to be significantly less likely to complete treatment, just as has been found in other research. Having child care responsibilities continues to be a barrier to treatment completion for women. Women's child care responsibilities must be addressed in the treatment community by providing child care services as part of substance abuse treatment. To date, women, particularly those with infants and small children, continue to be at risk of failure to complete treatment because child care services are not consistently linked to treatment. Until such time as programs are funded to provide safe, reliable, and educational child care programs in conjunction with treatment, the gap between treatment outcomes for men and women is likely to remain.

Foster Care
One out of six of the women in this sample from the DARTS 1996-97 database had children in foster care, but this family status did not directly affect treatment completion. Statistics indicate that a large percentage of children in foster care (24%) have parents who have problems with drug or alcohol abuse. Presently, the literature on foster care and its impact on treatment outcomes is extremely limited. One study found that women who maintained custody of their children completed treatment at higher rates than the women who lost custody, but this research has not been confirmed in other studies. More research addressing the issue of child placement and how it affects women's completion of drug treatment is urgently needed.

The DARTS data have few other ethnic groups well represented besides Caucasians and African Americans, but the differences observed between low-income women from each of these groups are striking. When we examined interactions between ethnicity and family status, a more complex relationship emerged. African American women who had children placed outside the home in protective custody had a significantly better prognosis for treatment completion than did African American women in general or women of other races.

Messer, Clark, and Martin found that African American women were more likely to enter treatment than were women of other races but also were more likely to not show up for treatment after intake and to not complete once they initiated treatment. This suggests that, once they enter treatment, African American women's needs may not be adequately addressed. Because African American women are more likely to have their families at a younger age, they may be entering the treatment system with more dependent children. Studies have found that as the number of children increases so does the likelihood that a woman will not complete treatment. Other studies suggest that it is the type of treatment setting that may be determining treatment retention. African American women report a preference for residential treatment, whereas White and Hispanic women prefer outpatient care.

A further confound to our understanding of the relationship between ethnicity and treatment outcomes is differences in drug of choice. African American women are more likely to report cocaine as their drug of choice than are women of other ethnic groups. Numerous studies have found that cocaine addicts, a predominantly African American subgroup of the treatment population, are less likely to complete treatment than are alcohol abusers, who are usually Caucasian.

Marital Status
In confirmation of past research suggesting that marriage provides less consistently positive environmental influences for wives than for husbands, there were no main effects for being married in the DARTS data. It is important to remember that only 11% of the women who did not complete treatment were married at intake, however. The reason for this finding is not obvious. Perhaps husbands provide limited support for parenting and little encouragement to their wives' recovery process. It may also be that family demands of married women are too numerous to be abandoned while they seek and complete treatment.

It was surprising that homelessness did not significantly affect treatment outcomes or interact with any of the family status variables. In a review of the literature, Robertson suggests that homeless women with dependent children are less likely to complete treatment. However, homeless women accounted for less than 2% of the total women in this study.

There are multiple benefits of residential treatment or detoxification for homeless substance-abusing women including safety, warmth, food, shelter, as well as a supportive environment for recovery from addiction. Sadly, even outpatient treatment settings provide a safer and a more positive, supportive place to be during the day than homeless shelters or being on the street.

Younger women in the DARTS data were less likely to complete outpatient treatment. As with previous research, youth appears to reduce the likelihood of completing treatment. Younger women may be less motivated to get into treatment and stay off drugs for several reasons. A young woman may get less support from her peers to complete treatment, may be more likely to be involved with a male partner who is abusing drugs, may not think her substance abuse problem is serious enough to warrant treatment, or may be less emotionally and psychologically ready for treatment. Young women also are more likely to have younger children who require constant care, which can undermine a young mother's ability to pursue treatment.
- Scott-Lennox, J., Rose, R., Bohlig, A., & Lennox, R. (Nov 2000). The Impact of Women’s Family Status on Completion of Substance Abuse Treatment. Journal of Behavioral Health Services & Research, 27(4).

Why are men 10 times more likely to enter treatment than women, have longer lengths of stay, and have greater rates of treatment completion? To select and enter your answer go to Test

Section 22
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