Historically, addiction treatment services were devel- oped with male clients in mind because the vast ma- jority of admissions to substance abuse treatment programs have men. More recently, specialized addic- tion treatment programs and interventions have been developed for both women and men, recognizing that programs with gender-specific groups have better outcomes.116 Mixed gender groups for addiction treatment for the most part have generally not been as successful as gender specific groups. Gender- specific treatment services are now the accepted norm within the addiction treatment field, and have been implemented across the country
Regardless of age or race, men use alcohol and drugs more frequently and in greater quantities than wom- en (SAMHSA’s 2008 National Survey of Drug Use and Health (NSDUH)). Reflecting these differences in use, American men are two to five times more likely to develop a substance use disorder than women alt- hough women take a shorter amount of time from their first use of alcohol and other drugs to demon- strate “dependency” (substance use disorder) symp- toms.
Men’s and women’s responses to substance use and addiction treatment also differ. These insights have improved treatment for women and they can also improve treatment for men. “Men die at a younger age on average than women; men are also more likely than women to have a substance use disorder, to be incarcerated, to be homeless as adults, to die of sui-
115 Ibid (2006a). 116
Substance Abuse and Mental Health Services Administration. (2013). Addressing the Specific Behavioral Health Needs of Men. Treatment Improvement Protocol (TIP) Services 56. HHS Publication No. (SMA) 13-4736. Rockville, Maryland. Substance Abuse and Mental Health Services Administration, 2013, p. 1. (Substance Abuse and Mental Health Administration [SAMHSA]. Office of Ap- plied Studies [OAS] 2007d).
ment among participants from special racial and eth- nic population groups.
Based on results of a cultural competence self- assessment, the drug court program can proceed to identify staff training and development needs, ex- plore staff attitudes, beliefs, and values related to serving cultural minorities; locate culturally valid screening and assessment instruments, and to adapt treatment interventions such as culturally-sensitive substance abuse treatment curricula. Drug courts can also identify barriers to treatment for cultural minori- ties, and work to remove these barriers (e.g., translat- ing program handbooks and treatment manuals for participants who speak English as a second language). As developing cultural competency and proficiency is an ongoing process, drug courts should continue to monitor the composition of their population, their training needs, related program services, and out- comes among special population groups.
There is no single, universally accepted approach to providing culturally competent addiction treatment that is applicable for all drug courts, as the composi- tion of drug courts varies widely, as does the level of resources and community services. Treatment adap- tations for drug courts may include providing individ- ual counseling that addresses issues related to special cultural populations, or groups for persons with lim- ited fluency in English, or persons who have difficul- ties with self-esteem, identity, and alienation related to their racial/ethnic background.114
RACIAL AND ETHNIC POPULATIONS
APPLICATION TO DRUG COURT PRACTICE
x Important culturally relevant substance abuse treat- ment topics to consider in individual or group interven- tions include the following (CSAT, 2006a; Osborne, 2008):
9 Spiritual beliefs, customs, and rituals 9 Relationships with the extended family
9 Beliefs about accepting help from professional
caregivers for personal problems
9 Respect and personal dignity
9 Trust and disclosure with authority figures 9 Gender roles
9 Child-rearing roles and expectations
x Drug court treatment staff should consider the partici- pant’s cultural background in conducting the addiction
114 Ibid (2006a).
treatment assessment and developing a treatment plan. In general, the more acculturated the person is, the less likely that drug court treatment services need to be modified. However, having been born in the U.S. is no guarantee that a drug court participant is fully ac- culturated115;
x Data should be maintained and regularly reviewed to permit the program to determine whether special ra- cial or ethnic populations have a higher/lower frequen- cy of (a) entering the program; (b) remaining in the program; and/or (c) completing the program . Any anomalies identified should be promptly investigated.
E. GENDER-SPECIFIC SERVICES
Historically, addiction treatment services were devel- oped with male clients in mind because the vast ma- jority of admissions to substance abuse treatment programs have men. More recently, specialized addic- tion treatment programs and interventions have been developed for both women and men, recognizing that programs with gender-specific groups have better outcomes.116 Mixed gender groups for addiction treatment for the most part have generally not been as successful as gender specific groups. Gender- specific treatment services are now the accepted norm within the addiction treatment field, and have been implemented across the country
Regardless of age or race, men use alcohol and drugs more frequently and in greater quantities than wom- en (SAMHSA’s 2008 National Survey of Drug Use and Health (NSDUH)). Reflecting these differences in use, American men are two to five times more likely to develop a substance use disorder than women alt- hough women take a shorter amount of time from their first use of alcohol and other drugs to demon- strate “dependency” (substance use disorder) symp- toms.
Men’s and women’s responses to substance use and addiction treatment also differ. These insights have improved treatment for women and they can also improve treatment for men. “Men die at a younger age on average than women; men are also more likely than women to have a substance use disorder, to be incarcerated, to be homeless as adults, to die of sui-
115 Ibid (2006a). 116
Substance Abuse and Mental Health Services Administration. (2013). Addressing the Specific Behavioral Health Needs of Men. Treatment Improvement Protocol (TIP) Services 56. HHS Publication No. (SMA) 13-4736. Rockville, Maryland. Substance Abuse and Mental Health Services Administration, 2013, p. 1. (Substance Abuse and Mental Health Administration [SAMHSA]. Office of Ap- plied Studies [OAS] 2007d).
cide, and to be victims of violent crime. Conversely, men are less likely than women to seek medical help or behavioral health counseling for any of the prob- lems they face.”117 Additionally when men do seek help, “additional negative consequences may arise, such as stress, anxiety, shame, rejection, low self- esteem, depression, and other mental problems that have been sedated or disguised by the substance use.”118
1. Special Services For Women
Given their higher rates of arrest and incarceration in recent years, women with substance use disorders are increasingly being referred to treatment under court supervision. Women involved with the criminal justice system have serious problems across multiple domains (e.g., educational, employment, family, legal, mental and physical health, substance use). 119 Wom- en offenders also typically report more severe prob- lems as compared with men, e.g., higher rates of sub- stance use disorders, injection drug use, drug-related problems, mental health problems, and physical health problems.120 Few studies have specifically evaluated the outcomes of women participating in drug court121 although one study showed lower rates of recidivism among women methamphetamine users than men in drug court.122
A growing body of research supports the provision of “gender specific” or “gender responsive” treatment for women offenders that is tailored to their treat- ment needs. Several comprehensive reviews have shown that women have higher rates of treatment completion and better outcomes when they are treated in: (1) women-only programs, including wom- en counselors, (2) residential programs that have live- in accommodations for children, and (3) outpatient programs that provide child care, parenting services,
117
Tip 56, Substance Abuse and Mental Health Services Administra- tion, page xiii.
118 Tip 56, Substance Abuse and Mental Health Services Administra- tion, page xiv.
119
Grella, C. E., & Greenwell, L. (2007). Treatment needs and com- pletion of community-based aftercare among substance-abusing women offenders. Women’s Health Issues, 17(4), 244-255. 120
Belenko, S., & Houser, K. (2012). Gender differences in engage- ment in prison-based drug treatment. International Journal of Of- fender Therapy And Comparative Criminology, 56(5), 790-810. 121 Shaffer, D. K., Hartman, J. L., & Listman, S. J. (2009). Drug abus- ing women in the community: The impact of drug court involvement on recidivism. JOURNAL OF DRUG ISSUES, 39(4), 803-827. 122 Hartman, J. L., Listwan, S. J., & Schaffer, D. K. (2007). Metham- phetamine users in a community-based drug court: Does gender matter? Journal of Offender Rehabilitation, 45(3-4), 109-130.
transportation, and other comprehensive services.123 Provision of women-specific groups enables women to discuss issues that are unique to them (e.g., trauma and abuse, loss of children, involvement in sex work, relationships) without shame or stigma that may oc- cur in mixed-gender groups.124
Women offenders with substance use disorders typi- cally also have mental health problems, most com- monly anxiety and depression. About half of women on probation or parole have a past-year mental disor- der, which is approximately twice the rate of women in the general population.125 Given their high rates of trauma exposure, women offenders also have high rates of post-traumatic stress disorder (PTSD). Rates of lifetime PTSD among women offenders typically range from one quarter to one third.126 Incarcerated women are especially at risk for trauma re-exposure and PTSD if they engage in prostitution.127
Women offenders also typically have limited em- ployment skills and work128, and may require voca- tional services, including basic education and GED preparation. Because many women have repeated prior arrests and incarcerations, they often have been separated from their children for significant periods and issues concerning family reunification need to be addressed. Such women often lack basic parenting skills and appropriate parental attitudes.129
123
Grella, C. E. (2008). From generic to gender-responsive treat- ment: Changes in social policies, treatment services, and outcomes of women in substance abuse treatment. Journal of Psychoactive Drugs, SARC Supplement 5, 327-343.
124
Beckerman, A., & Fontana, L. (2002). Issues of race and gender in court-ordered substance abuse treatment. Journal of Offender Rehabilitation, 33(4), 45-61.
125
National Survey on Drug Use and Health (NSDUH). (2012). Half of women on probation or parole experience mental illness. Rock- ville, MD: Center for Behavioral Health Statistics and Quality: Data Spotlight, Substance Abuse & Mental Health Services Administra- tion.
126 Hutton, H. E., Treisman, G. J., Hunt, W. R., Fishman, M., Kendig, N., Swetz, A., & Lyketsos, C. G. (2001). HIV risk behaviors and their relationship to posttraumatic stress disorder among women prison- ers. Psychiatric Services, 52(4), 508-513.
127
Millay, T. A., Satyanarayana, V. A., O’Leary, C. C., Crecelius, R., & Cottler, L. B. (2009). Risky business: Focus-group analysis of sexual behaviors, drug use and victimization among incarcerated women in St. Louis. Journal of Urban Health, 86(5), 810-817.
128
Langan, N. P., & Pelissier, B. (2001). Gender differences among prisoners in drug treatment. Journal of Substance Abuse, 13(3), 291-301; See also Pelissier, B., & Jones, N. (2005). A review of gen- der differences among substance abusers. Crime & Delinquency, 51(3), 343-372.
129 Grella, C. E., & Greenwell, L. (2006). Correlates of parental sta- tus and attitudes toward parenting among substance-abusing women offenders. The Prison Journal, 86(1), 89-113.
cide, and to be victims of violent crime. Conversely, men are less likely than women to seek medical help or behavioral health counseling for any of the prob- lems they face.”117 Additionally when men do seek help, “additional negative consequences may arise, such as stress, anxiety, shame, rejection, low self- esteem, depression, and other mental problems that have been sedated or disguised by the substance use.”118
1. Special Services For Women
Given their higher rates of arrest and incarceration in recent years, women with substance use disorders are increasingly being referred to treatment under court supervision. Women involved with the criminal justice system have serious problems across multiple domains (e.g., educational, employment, family, legal, mental and physical health, substance use). 119 Wom- en offenders also typically report more severe prob- lems as compared with men, e.g., higher rates of sub- stance use disorders, injection drug use, drug-related problems, mental health problems, and physical health problems.120 Few studies have specifically evaluated the outcomes of women participating in drug court121 although one study showed lower rates of recidivism among women methamphetamine users than men in drug court.122
A growing body of research supports the provision of “gender specific” or “gender responsive” treatment for women offenders that is tailored to their treat- ment needs. Several comprehensive reviews have shown that women have higher rates of treatment completion and better outcomes when they are treated in: (1) women-only programs, including wom- en counselors, (2) residential programs that have live- in accommodations for children, and (3) outpatient programs that provide child care, parenting services,
117
Tip 56, Substance Abuse and Mental Health Services Administra- tion, page xiii.
118 Tip 56, Substance Abuse and Mental Health Services Administra- tion, page xiv.
119
Grella, C. E., & Greenwell, L. (2007). Treatment needs and com- pletion of community-based aftercare among substance-abusing women offenders. Women’s Health Issues, 17(4), 244-255. 120
Belenko, S., & Houser, K. (2012). Gender differences in engage- ment in prison-based drug treatment. International Journal of Of- fender Therapy And Comparative Criminology, 56(5), 790-810. 121 Shaffer, D. K., Hartman, J. L., & Listman, S. J. (2009). Drug abus- ing women in the community: The impact of drug court involvement on recidivism. JOURNAL OF DRUG ISSUES, 39(4), 803-827. 122 Hartman, J. L., Listwan, S. J., & Schaffer, D. K. (2007). Metham- phetamine users in a community-based drug court: Does gender matter? Journal of Offender Rehabilitation, 45(3-4), 109-130.
transportation, and other comprehensive services.123 Provision of women-specific groups enables women to discuss issues that are unique to them (e.g., trauma and abuse, loss of children, involvement in sex work, relationships) without shame or stigma that may oc- cur in mixed-gender groups.124
Women offenders with substance use disorders typi- cally also have mental health problems, most com- monly anxiety and depression. About half of women on probation or parole have a past-year mental disor- der, which is approximately twice the rate of women in the general population.125 Given their high rates of trauma exposure, women offenders also have high rates of post-traumatic stress disorder (PTSD). Rates of lifetime PTSD among women offenders typically range from one quarter to one third.126 Incarcerated women are especially at risk for trauma re-exposure and PTSD if they engage in prostitution.127
Women offenders also typically have limited em- ployment skills and work128, and may require voca- tional services, including basic education and GED preparation. Because many women have repeated prior arrests and incarcerations, they often have been separated from their children for significant periods and issues concerning family reunification need to be addressed. Such women often lack basic parenting skills and appropriate parental attitudes.129
123
Grella, C. E. (2008). From generic to gender-responsive treat- ment: Changes in social policies, treatment services, and outcomes of women in substance abuse treatment. Journal of Psychoactive Drugs, SARC Supplement 5, 327-343.
124
Beckerman, A., & Fontana, L. (2002). Issues of race and gender in court-ordered substance abuse treatment. Journal of Offender Rehabilitation, 33(4), 45-61.
125
National Survey on Drug Use and Health (NSDUH). (2012). Half of women on probation or parole experience mental illness. Rock- ville, MD: Center for Behavioral Health Statistics and Quality: Data Spotlight, Substance Abuse & Mental Health Services Administra- tion.
126 Hutton, H. E., Treisman, G. J., Hunt, W. R., Fishman, M., Kendig, N., Swetz, A., & Lyketsos, C. G. (2001). HIV risk behaviors and their relationship to posttraumatic stress disorder among women prison- ers. Psychiatric Services, 52(4), 508-513.
127
Millay, T. A., Satyanarayana, V. A., O’Leary, C. C., Crecelius, R., & Cottler, L. B. (2009). Risky business: Focus-group analysis of sexual behaviors, drug use and victimization among incarcerated women in St. Louis. Journal of Urban Health, 86(5), 810-817.
128
Langan, N. P., & Pelissier, B. (2001). Gender differences among prisoners in drug treatment. Journal of Substance Abuse, 13(3), 291-301; See also Pelissier, B., & Jones, N. (2005). A review of gen- der differences among substance abusers. Crime & Delinquency, 51(3), 343-372.
129 Grella, C. E., & Greenwell, L. (2006). Correlates of parental sta- tus and attitudes toward parenting among substance-abusing women offenders. The Prison Journal, 86(1), 89-113.
Women offenders also often have physical health problems that stem from the effects of their sub- stance addiction and associated unhealthy behaviors, which are exacerbated by their lack of access to or utilization of health care services.130 Women offend- ers have high rates of sexual risk behaviors, which make them vulnerable to HIV and other STDs131 sexu- al risk behaviors are particularly high among women with greater alcohol use and psychiatric severity.132
SPECIAL SERVICES FOR WOMEN
APPLICATION TO DRUG COURT PRACTICE
x Drug courts should provide substance abuse treatment services that include components tailored to address women’s needs, including:
9 Pregnancy-related services, including prenatal and
post-natal, comprehensive case management, and supportive services; [studies have shown that the higher costs associated with these services are offset by improvements in pregnancy and birth- related outcome]133;
9 Parenting-related service needs, parenting skills
training, family-focused services, and, if appropri- ate, coordination between treatment and child welfare services;
9 Services to address issues relating to intimate
partner relationships and problems related to do- mestic violence or partner substance use/criminal behavior involvement;
9 Training in relationship skills, including assertive-
ness and skills for negotiating safer sex;
9 Mental health screening and assessment and,
when indicated, integration of mental health treatment within addiction treatment;
130
Staton, M., Leukefeld, C., & Logan, T. K. (2001). Health service
utilization and victimization among incarcerated female substance users. Substance Use & Misuse, 36(6-7), 701-716.
131
Guydish, J., Chan, M., Bostrom, A., Jessup, M. A., Davis, T. B., & Marsh, C. (2011). A randomized trial of probation case manage-
ment for drug-involved women offenders. Crime & Delinquency, 57(2) 167-198; See also
Scott, C. K., & Dennis, M. L. (2012). The first 90 days following
release from jail: Findings from the Recovery Management Check- ups for Women Offenders (RMCWO) experiment. Drug and Alcohol
Dependence, 125(1-2), 110-118.
132 Brooks, A., Meade, C. S., Potter, J. S., Lokhnygina, Y., Calsyn, D.
A., & Greenfield, S. F. (2010). Gender differences in the rates and
correlates of HIV risk behaviors among drug abusers. Substance Use
& Misuse, 45(14), 2444-2469.
133
Svikis, D.S., Golden, A.S., Huggins, G.R., Pickens, R.W., McCaul, M.E., Velez, M.L., Rosendale, C.T., Brooner, R.K., Gazaway, P.M., Stitzer, M.L., & Ball, C.E. (1997). Cost-effectiveness of treatment for
drug-abusing pregnant women. Drug and Alcohol Dependence, 45,
105-113
9 Screening for history of trauma and the ongoing
effects of exposure to trauma, violence, and vic- timization, including post-traumatic stress disor- der (PTSD) and trauma/PTSD groups or services;
9 Referrals for educational services (e.g., literacy
training, GED equivalence) and employment ser- vices (e.g., pre-vocational and vocational assess- ments, interviewing, job search);
9 Health screening, including for infectious diseases,
chronic health problems, dental issues, and re- productive-health problems or needs, and referral for needed health services
9 Other services consistent with evidence-based ap-
proaches specifically adapted for use with women.
2. Special Services For Males
It is reported that 68.2 percent of admissions to sub- stance abuse treatment programs receiving State agency funds were men134; however, data from 2005 show that only 25 percent of programs offered any type of specialized services for adult men.135
Stereotypes of masculine behavior have a lot to do with shaping men’s behavior. These stereotypes push men to restrict their emotional responsiveness, and to be more competitive, aggressive, and self-reliant. These roles may hinder men from seeking needed treatment as well as fully participating in that treat- ment. Men also are likely to be ambivalent about seeking alcohol and other drug addiction treatment, and may perceive treatment involvement as a sign of ‘weakness’ or vulnerability, and these issues should be discussed with them. Men are also typically em- barrassed or reluctant to talk about feelings and often require a more concrete objective, goal specific plan. Men may have problems expressing emotion and some may feel excessive shame, both problems for men in substance use disorder treatment.
Treatment professionals and drug court team mem- bers should recognize the reasons that men enter