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A comparison of male and female clients in substance abuse treatment
Journal
of Subslance Abuse
Printed in
Treatment, Vol. the USA. All rights reserved.
0740-5472192$5.00 + .OO Copyright 0 1992Pergamon Press Ltd.
9, pp. 2433248,1992
ARTICLE
A Comparison of Male and Female Clients in Substance Abuse Treatment JACQUELINEWALLEN, PhD, MSW Department of Family and Community Development, College of Human Ecology, University of Maryland, College Park, Maryland
Abstract- To assess the extent to which women appear to have special treatment needs, this paper compares male and female patients receiving inpatient substance abuse treatment. The author analyzed completed intake interview forms from the files of all clients entering two private, nonprofit inpatient substance abuse treatment facilities during an b-month period in 1989 (a total of 181 men and 48 women). The women were similar to the men with respect to sociodemographic characteristics, family history, alcohol/drug history, and treatment completion. However, they were more likely to report a sexual abuse history and indicated more emotional distress than the men. Implications for treatment are discussed.
Keywords-sexual abuse; substance
abuse
treatment;
gender
differences;
women; treatment
completion. chemical dependency treatment have found that women differed from men with respect to socioeconomic factors related to treatment completion, particularly health insurance coverage (Amaro, Beckman, & Mays, 1987; Beckman & Bardsley, 1986). Women have also been found to have more psychiatric symptoms than men (Davis & Morse, 1987) and to report more depression and anxiety (Blume, 1986; Thorn, 1987), lower self-esteem (Beckman, 1978), and higher rates of childhood sexual abuse (Rohsenow, Corbett, dz Devine, 1988). It has been argued that the differences between men and women in treatment imply a need for special treatment modalities for women (Wildwind, 1984), but this may not necessarily be the case. Beckman found, for example, that although women begin treatment with lower self-esteem than men, their selfesteem is comparable to that of males within a year after beginning treatment, even without special interventions in treatment. Researchers have generally found that treatment outcomes for women do not differ from those of men, especially when factors such as age and social class are controlled (Roman, 1988; Vannicelli, 1984).
BACKGROUND THE MAJORITY OF CLIENTS (approximately 75%) in substance abuse treatment programs are men (National Institute on Drug Abuse [NIDA], 1989). This fact has given rise to concern that treatment programs, as they are currently structured, may be more suited to the needs of male clients than to those of female clients. Yet relatively little research has examined the specific characteristics or needs of women in treatment for alcohol or drug dependence. In fact, most research on substance abuse treatment does not include women at all. Harrison and Belille (1987) estimated that only 8% of the subjects in studies of alcoholism treatment published between 1970 and 1984 were women. Even in the studies where women were included, findings for women often were not presented in such a way that they could be distinguished from findings for men (Annis & Liban, 1980). The present trend is toward more treatment research that includes women, but knowledge is still lacking in this area. Studies that have compared men and women in
Requests for reprints should be addressed to Jacqueline Wallen, POD., Room 1204 Marie Mount Hall, Department of Family and Community Development, College of Human Ecology, University of Maryland, College Park, MD 20742.
THE
PRESENT
STUDY
The purpose of the present study is to compare women and men in substance abuse treatment in order to as243
J. Wallen
244
sess the extent to which women appear to have special treatment needs. The study population includes all clients entering two private nonprofit inpatient substance abuse treatment facilities in Maryland between January 1989 and August 1989, a period of approximately 8 months. A total of 229 clients were admitted during this period: 181 men and 48 women. The majority of the subjects in this study were employed at the time they entered treatment (78.9%), and almost all were covered by health insurance that paid for at least a part of their inpatient stay. Their average age was 33.5, and more than half (58%) were white. The nonwhite clients were almost all AfricanAmerican. More than 80% of the subjects had graduated from high school, and 41 Vohad attended at least some college. This study made use of existing data. Counselors in the two treatment facilities routinely interview clients on intake using a standardized protocol that they have been trained to administer. Completed interview forms from client files provided the data for this study. The following data were obtained by this researcher from the interview forms in the client files: 1. Sociodemographic characteristics: The interview forms contained data on each client’s age, race, sex, educational attainment, marital status, number of children, employment status, and arrest history. 2. Alcohol and drug use history: Counselors collected detailed data on the frequency, duration, and quantity of drug and alcohol use. For this study, the age at which the client first began using alcohol or drugs was recorded. 3. Relationship to parents: Clients were questioned concerning their parents’ use of alcohol or drugs (“Does your mother/father have a problem with alcohol or drugs?“) and concerning their relationship to each parent (“How would you describe your relationship to your father/mother?“) For this study, the presence of parental alcohol or drug problems was recorded. Also, the client’s reported relationship to each parent was categorized as “positive” (if the client made any kind of a positive statement, such as “good, ” “very close,” etc.) or “other” (if the client made neutral or negative statements such as “ok” or “terrible”). 4. Sexual abuse history: The intake interview contained several questions related to sexual abuse. Cl& ents were asked: “Were you sexually abused as a child?” “Have you been sexually abused as an adult?” “Have you ever been raped?” and “Are there any sexual matters that you are reluctant to share or discuss?” 5. Physical abuse history: The client was asked “Have you ever been physically harmed by anyone?” While the interview did not include a question that specifically asked about childhood physical abuse, so many clients spontaneously mentioned childhood
physical abuse in response to other questions (for example, the question on physical harm or the questions on parental relationships) that these reports were also recorded for this study. 6. Anger/violence: The intake interview contained a number of questions concerning anger or violence toward others. These questions were: “Have you ever physically injured someone?” “Has anyone else ever been afraid of you?” “ Do you feel you need help with violent thoughts or feelings?” 7. Emotional distress: Clients were presented with a checklist of feelings and asked to indicate which feelings they had been experiencing in the past week. These included: depression, hopelessness, tenseness, loss of appetite, difficulty sleeping, suicidal thoughts or feelings, and suicide attempts. They were also asked whether or not they had difficulties socializing with others and whether or not there were things about their childhood that still troubled them. FINDINGS Analysis of the sociodemographic data indicated that the women studied were quite similar to the men with respect to most characteristics. They did not differ significantly in terms of either race, age, marital status, number of children, or educational attainment. Men and women did differ in two important respects, however. Women were significantly less likely to be employed than men, and they were also less likely to have been arrested. Men and women had begun their alcohol or drug use at similar ages - approximately 15 years old for both sexes-and had similar lengths of stay in treatment (an average of approximately 20 days’). Slightly more women than men completed treatment successfully (9Ocr/o,compared to 84%) but this small difference was not statistically significant. Table 1 shows that men and women did not differ significantly in the proportion who reported that their parents had a drug or alcohol problem or in how positively they perceived their relationship to their parents. It is important to note, however, that clients of both sexes often came from homes in which alcohol or drugs had been a problem. More than half of the clients came from homes in which the father had an alcohol or drug problem and roughly one-quarter came from homes in which the mother had such a problem. It is also interesting that while women were equally likely to report a positive relationship to their mother and their father (51% in both cases), men were far more likely to report a positive relationship to their ‘One of the two treatment facilities typically keeps clients for 28 days while the other offered the option of either a 14-day or a 28-day stay. This accounts for the average stay of 20 days. Actually, very few clients stayed for 20 days-most stayed either 14 or 28.
Male and Female Clients
245
TABLE 1 Relationship to Parents and Feelings About Childhood Among Clients in Inpatient Substance Abuse Treatment
Percent of Males (n = 181)
Percent of Females (n = 48)
t
55.3 22.4 37.3 65.9
56.8 28.9 51.1 51 .l
.03 .81 2.80 3.48
39.2
67.4
11.36
Relationship to parents Father had an alcohol or drug problem Mother had an alcohol or drug problem Positive relationship to father Positive relationship to mother Feelings about childhood Percent troubled by childhood experiences
aNot significant. Because multiple t tests were employed, only differences significant.
mother (66%) than with their father (37%). Significantly more women than men reported that they were still troubled by events that had occurred in childhood (67% of the women, compared to 39% of the men). Table 2 shows that women were far more likely than men to report a sexual abuse history. This is consistent with previous research on both clinical and nonclinical populations (Rohsenow, Corbett, & Devine, 1988; Russell, 1986). Approximately 33% of the women reported being sexually abused as children, compared to slightly less than 10% of the men. Close to 27% of the women reported sexual abuse as an adult, compared to roughly 2% of the men. Sexual abuse in adulthood involved, in most cases, rape, although several of the women reported sexually abusive relationships with a spouse or other partner. Approximately 28% of the women and 10% of the men reported that they had sexual issues or questions that they were reluctant to bring up. All of these differences between the sexes were statistically significant. Table 2 also shows that women did not differ significantly from men with respect to physical abuse history. The two sexes were equally likely to report that
P
NSa NS NS NS .OOl
with a probability of .Ol or less were considered statistically
they had experienced physical abuse in childhood. It should be pointed out, however,that the overall rate of reported childhood physical abuse was quite high, approximately 30% for both men and women, even though all reports of childhood physical abuse were spontaneous, since there were no questions that specifically dealt with childhood physical abuse. Women were slightly more likely to report that they had been harmed by another since childhood, but this difference was not statistically significant. Men were somewhat, though not significantly, more likely than women to report that they had physically injured someone else (Table 3). In spite of this, women were significantly more likely to say that they needed help with anger or violence (approximately 44% of the women, compared to roughly 23% of the men). This is consistent with clinical reports on women in treatment that describe women as more willing than men to discuss and seek help for problems of all kinds (Tamerin, 1978). The various measures of emotional distress reported in Table 3 show a consistent pattern. Women scored higher than men on all of these measures, with one ex-
TABLE 2 Reported Sexual and Physical Abuse Among Clients in Inpatient Substance Abuse Treatment
Percent of Males (n = 181) Sexual abuse history Sexually abused as a child Sexually abused as an adult Raped Reluctant to share or discuss sexual matters Physical abuse history Physically abused as child Ever harmed physically by someone else
Percent of Females (n = 48)
t
P
9.4 1.9 2.3 9.5
32.6 26.8 26.7 28.3
17.12 37.06 34.77 9.97
.OOl ,001 .OOl .Ol
30.1 42.1
29.8 55.3
.Ol 3.36
aNot significant. Because multiple t tests were employed, only differences
of 0.1 or less were considered statistically significant
NSa NS
246
J. Wallen
Anger/Violence
3 Clients in
Emotional Distress
Anger/violence Has injured another other people Needs help with angry/violent feelings Emotional distress Trouble socializing Depression Hopelessness Tension/nervousness Loss of appetite Difficulty sleeping Suicidal thoughts/feelings Suicide attempt(s)
Substance Abuse
Percent of Males (n = 181)
Percent of Females (n = 48)
t
43.1 22.2 23.4
28.3 19.1 43.9
3.36 .20 7.00
NSa NS .Ol
39.4 73.5 52.9 71.3 39.3 52.6 37.2 14.0
60.9 84.1 73.8 75.0 53.5 69.8 35.7 26.1
6.97 2.13 6.03 .24 .24 4.05 .03 3.80
.Ol NS .Ol NS NS NS NS NS
aNot significant. Because multiple t tests were employed, only differences significant.
ception: men had slightly more suicidal thoughts and feelings. Women were more likely to have actually attempted suicide. Female-male differences were significant only for items relating to difficulty socializing and hopelessness, however. These findings are consistent with those of previous studies, in which women have typically manifested more emotional distress than men. The only treatment outcome variable for this study was treatment completion. While the majority of clients of both sexes completed treatment successfully, approximately 15% left before completing their stay. To assess how client characteristics related to treatment completion, several summary scores were created to characterize the various groups of client characteristics. The emotional distress items (see Table 3 for a list of these items) were all significantly correlated with one another and each was significantly correlated with the summed scores for all of the other emotional distress items. The same was true for the sexual abuse items (see Table 2 for list), the physical abuse scores (Table 2), and the anger/violence scores (Table 3). Summing the scores for each of these sets of items resulted in four summary scores. The scores that differentiated between men and women were the emotional distress scores and the sexual abuse scores. Women had significantly higher scores on both of these indices. To determine whether scores on these indices affected treatment completion, the correlations were examined. The analysis revealed that scores on the emotional distress scale were not associated with treatment completion (Pearson product-moment correlation = -.003). Surprisingly, reported sexual abuse was positively related to treatment completion (Pearson product-moment correlation = .231, p = .Ol).
P
with a probability of 0.1 or less were considered statistically
Scores on the anger/violence index were also positively correlated with treatment completion (Pearson product-moment correlation = 2.80, p = .OOl). Reported physical abuse scores were positively related to treatment completion (Pearson product-moment correlation = .135), but the relationship was not statistically significant. DISCUSSION This study confirms the findings of earlier studies that women in substance abuse treatment are more likely than men to report symptoms of emotional distress and to indicate a willingness to seek help for emotional problems. The study also confirms previous findings that women are more likely than men to report a history of sexual abuse. To the extent that any of these characteristics were significantly related to treatment completion, however, the relationship was positive rather than negative. The high rates of childhood physical abuse in the population studied were striking, as were the high rates of parental alcoholism. Even though the men expressed less emotional distress and desire for help than the women, 40% of the men reported that they were still troubled by childhood experiences, almost a felt that they needed help with anger or violence, and more than f had suicidal thoughts or feelings. The question of whether substance abuse treatment should also address the client’s emotional problems is a controversial one. Traditionally, substance abuse treatment has focused on the substance abuse itself, encouraging recovering individuals to postpone working on childhood issues until later in recovery, whenever possible. This study suggests that experiencing
Male and Female Clients negative feelings concerning childhood experiences does not detract from treatment and may actually be a positive sign, indicating an involvement in the treatment process and an intention to complete treatment. Unresolved issues connected to childhood sexual abuse or other childhood trauma may pose a risk factor in recovery after individuals leave treatment, however, contributing to relapse in vulnerable individuals (Rohsenow et al., 1988). Individual psychotherapy is often recommended as an adjunct to traditional alcohol or drug treatment for individuals with sexual abuse related posttraumatic stress disorders (ibid), but therapists and chemical dependency treatment personnel have a history of mutual distrust (Brown, 1985), and both groups lack a clearcut model for integrating individual psychotherapy with substance abuse treatment. The development of such a model could be of value both to substance abuse treatment professionals and to psychotherapists treating chemically dependent or recovering clients. As well as providing guidelines for the referral of substance abuse clients to individual therapy, such a model could also guide therapists in screening clients for alcohol and drug dependence and in referring them to substance abuse treatment when appropriate. Sexual abuse issues, in particular, may be difficult to discuss in the group settings that characterize substance abuse treatment programs. This may be especially true for women, who often find themselves in predominantly male groups. Short-term women’s groups or single-sex groups for individuals with histories of childhood sexual abuse might be used in substance abuse treatment to assist individuals in identifying or coming to terms with childhood sexual abuse issues. Such groups have been used successfully in substance abuse treatment (Bollerud, 1990) and in other mental health settings (Donaldson & Gardner, 1985; Lindberg & Distad, 1985; Skorina & Kovach, 1986) and might increase the appeal of substance abuse treatment to women. There is some evidence that women are more likely to be attracted to substance abuse treatment services when they also address emotional and family problems (Beckman & Bardsley, 1986; Roman, 1988). The provision of women-only programming or of interventions aimed at alleviating emotional distress might result in increased numbers of women seeking treatment. It is generally believed that childhood sexual abuse is under-reported by men even more than by women (O’Hare &Taylor, 1983). Even so, almost 10% of the men in this study reported that they had been sexually abused as children. If one in 10 men in substance abuse treatment, at a minimum, has a sexual abuse history, then it may also be important to consider whether short-term groups dealing with sexual abuse might be of value to sexually abused men in treatment as well. In addition, or at the very least, educational
247 materials on childhood sexual abuse and its possible long-term effects, as well as on therapy and self-help resources for adults with histories of sexual abuse, might be made available to male and female clients in substance abuse treatment. Individual or group therapy would be a valuable element in the aftercare plans developed for either men or women with a childhood that includes sexual abuse. In conclusion, the findings of this study do indicate that women in substance abuse treatment would benefit from special programming that addresses childhood trauma, particularly childhood sexual and physical abuse, and feelings related to anger and victimization. On the other hand, they also indicate that men would benefit from such programming, as well. Furthermore, they suggest that women’s greater tendency to express emotional distress and to seek help in dealing with feelings while in substance abuse treatment may be a sign of recovery rather than a complicating factor in treatment.
REFERENCES Amaro, H., Beckman, L.J., & Mays, V.M. (1987). A comparison of black and white women entering alcoholism treatment. Jour-
nal of Studies on Alcohol, 48, 220-227. Annis, H.M., & Liban, C.B. (1980). Alcoholism in women. In O.J. Kalant (Ed.), Alcohol and drug problems in women (pp. 385422). New York: Plenum Press. Beckman, L.J. (1978). Self-esteem of women alcoholics. Journal of
Studies on Alcohol, 39, 491-498. Beckman, L.J., & Bardsley, P.E. (1986). Individual characteristics, gender differences, and drop-out from alcoholism treatment. Al-
cohol and Alcoholism, 21, 213-224. Blume, S.B. (1986). Women and alcohol.
Journal of the American
Medical Society, 256, 1467-1469. Bollerud, K. (1990). A model for the treatment of trauma-related syndromes among chemically dependent inpatient women. Jour-
nal of Substance Abuse Treatment, 7, 83-87. Brown, S. (1985). Treating the alcoholic. New York: Wiley, Davis, L.J., & Morse, R.M. (1987). Age and sex differences in the responses of alcoholics to the self-administered alcoholism screening test. Journal of Clinical Psychology, 43, 423-430. Donaldson, M.A., &Gardner, R. (1985). Diagnosis and treatment of traumatic stress among women after childhood incest. In C. R. Figley, (Ed.), Trauma and its wake (pp. 356-377). New York: Brunner/Mazel. Harrison, P.A., & Belille, C.A. (1987). Women in treatment: Beyond the Stereotype. Journal of Studies on Alcohol, 48, 574-578. Lindberg, F.H., & Distad, L.J. (1985). Post-traumatic stress disorders in women who experienced childhood incest. Child Abuse
and Neglect, 9, 329-334. National
Institute
on Drug Abuse (NIDA).
the National Drug and Alcoholism
(1989). Highhghtsfrom Treatment Unit Survey
(NDATUS). Rockville, MD: NIDA. O’Hare, J., & Taylor, K. (1983). The reality of incest.
Women and
Psychotherapy, 5, 215-229. Rohsenow, D.J., Corbett, R., & Devine, D. (1988). Molested as children: A hidden contribution to substance abuse. Journal of Substance Abuse Treatment, 5, 13-18. Roman, P.M. (1988). Women and alcohol use (DHHS Publication No. ADM 88-1574). Rockville, MD: National Institute on Alcohol Abuse and Alcoholism.
248 Russell, D.E.H. (1986). The secret trauma. New York: Basic Books. Skorina, J.K., & Kovach. J.A. (1986). Treatment techniques for incest-related issues in alcoholic women. Alcoholism Treatment Quarterly, 3, 17-30. Tamerin, J.S. (1978). The psychotherapy of alcoholic women. In S. Zimberg, S. Blume, & S. Wallace, (Eds.), Practical approaches to alcoholism psychotherapy (pp. 183-203). New York: Plenum Press.
J.
Wallen
Thorn, B. (1987). Sex differences in help-seeking for alcohol problems: 2. Entry into treatment. British Journal ofAddiction, 82, 989-997. Vannicelli, M. (1984). Treatment outcomes of alcoholic women. In S.C. Wilsnack & L.J. Beckman, (Eds.), Alcohol problems in women. New York: Guilford Press. Wildwind, L. (1984). When women resist treatment: Approaches for counselors. Journal of Substance Abuse Treatment, 1, 47-54.
of Subslance Abuse
Printed in
Treatment, Vol. the USA. All rights reserved.
0740-5472192$5.00 + .OO Copyright 0 1992Pergamon Press Ltd.
9, pp. 2433248,1992
ARTICLE
A Comparison of Male and Female Clients in Substance Abuse Treatment JACQUELINEWALLEN, PhD, MSW Department of Family and Community Development, College of Human Ecology, University of Maryland, College Park, Maryland
Abstract- To assess the extent to which women appear to have special treatment needs, this paper compares male and female patients receiving inpatient substance abuse treatment. The author analyzed completed intake interview forms from the files of all clients entering two private, nonprofit inpatient substance abuse treatment facilities during an b-month period in 1989 (a total of 181 men and 48 women). The women were similar to the men with respect to sociodemographic characteristics, family history, alcohol/drug history, and treatment completion. However, they were more likely to report a sexual abuse history and indicated more emotional distress than the men. Implications for treatment are discussed.
Keywords-sexual abuse; substance
abuse
treatment;
gender
differences;
women; treatment
completion. chemical dependency treatment have found that women differed from men with respect to socioeconomic factors related to treatment completion, particularly health insurance coverage (Amaro, Beckman, & Mays, 1987; Beckman & Bardsley, 1986). Women have also been found to have more psychiatric symptoms than men (Davis & Morse, 1987) and to report more depression and anxiety (Blume, 1986; Thorn, 1987), lower self-esteem (Beckman, 1978), and higher rates of childhood sexual abuse (Rohsenow, Corbett, dz Devine, 1988). It has been argued that the differences between men and women in treatment imply a need for special treatment modalities for women (Wildwind, 1984), but this may not necessarily be the case. Beckman found, for example, that although women begin treatment with lower self-esteem than men, their selfesteem is comparable to that of males within a year after beginning treatment, even without special interventions in treatment. Researchers have generally found that treatment outcomes for women do not differ from those of men, especially when factors such as age and social class are controlled (Roman, 1988; Vannicelli, 1984).
BACKGROUND THE MAJORITY OF CLIENTS (approximately 75%) in substance abuse treatment programs are men (National Institute on Drug Abuse [NIDA], 1989). This fact has given rise to concern that treatment programs, as they are currently structured, may be more suited to the needs of male clients than to those of female clients. Yet relatively little research has examined the specific characteristics or needs of women in treatment for alcohol or drug dependence. In fact, most research on substance abuse treatment does not include women at all. Harrison and Belille (1987) estimated that only 8% of the subjects in studies of alcoholism treatment published between 1970 and 1984 were women. Even in the studies where women were included, findings for women often were not presented in such a way that they could be distinguished from findings for men (Annis & Liban, 1980). The present trend is toward more treatment research that includes women, but knowledge is still lacking in this area. Studies that have compared men and women in
Requests for reprints should be addressed to Jacqueline Wallen, POD., Room 1204 Marie Mount Hall, Department of Family and Community Development, College of Human Ecology, University of Maryland, College Park, MD 20742.
THE
PRESENT
STUDY
The purpose of the present study is to compare women and men in substance abuse treatment in order to as243
J. Wallen
244
sess the extent to which women appear to have special treatment needs. The study population includes all clients entering two private nonprofit inpatient substance abuse treatment facilities in Maryland between January 1989 and August 1989, a period of approximately 8 months. A total of 229 clients were admitted during this period: 181 men and 48 women. The majority of the subjects in this study were employed at the time they entered treatment (78.9%), and almost all were covered by health insurance that paid for at least a part of their inpatient stay. Their average age was 33.5, and more than half (58%) were white. The nonwhite clients were almost all AfricanAmerican. More than 80% of the subjects had graduated from high school, and 41 Vohad attended at least some college. This study made use of existing data. Counselors in the two treatment facilities routinely interview clients on intake using a standardized protocol that they have been trained to administer. Completed interview forms from client files provided the data for this study. The following data were obtained by this researcher from the interview forms in the client files: 1. Sociodemographic characteristics: The interview forms contained data on each client’s age, race, sex, educational attainment, marital status, number of children, employment status, and arrest history. 2. Alcohol and drug use history: Counselors collected detailed data on the frequency, duration, and quantity of drug and alcohol use. For this study, the age at which the client first began using alcohol or drugs was recorded. 3. Relationship to parents: Clients were questioned concerning their parents’ use of alcohol or drugs (“Does your mother/father have a problem with alcohol or drugs?“) and concerning their relationship to each parent (“How would you describe your relationship to your father/mother?“) For this study, the presence of parental alcohol or drug problems was recorded. Also, the client’s reported relationship to each parent was categorized as “positive” (if the client made any kind of a positive statement, such as “good, ” “very close,” etc.) or “other” (if the client made neutral or negative statements such as “ok” or “terrible”). 4. Sexual abuse history: The intake interview contained several questions related to sexual abuse. Cl& ents were asked: “Were you sexually abused as a child?” “Have you been sexually abused as an adult?” “Have you ever been raped?” and “Are there any sexual matters that you are reluctant to share or discuss?” 5. Physical abuse history: The client was asked “Have you ever been physically harmed by anyone?” While the interview did not include a question that specifically asked about childhood physical abuse, so many clients spontaneously mentioned childhood
physical abuse in response to other questions (for example, the question on physical harm or the questions on parental relationships) that these reports were also recorded for this study. 6. Anger/violence: The intake interview contained a number of questions concerning anger or violence toward others. These questions were: “Have you ever physically injured someone?” “Has anyone else ever been afraid of you?” “ Do you feel you need help with violent thoughts or feelings?” 7. Emotional distress: Clients were presented with a checklist of feelings and asked to indicate which feelings they had been experiencing in the past week. These included: depression, hopelessness, tenseness, loss of appetite, difficulty sleeping, suicidal thoughts or feelings, and suicide attempts. They were also asked whether or not they had difficulties socializing with others and whether or not there were things about their childhood that still troubled them. FINDINGS Analysis of the sociodemographic data indicated that the women studied were quite similar to the men with respect to most characteristics. They did not differ significantly in terms of either race, age, marital status, number of children, or educational attainment. Men and women did differ in two important respects, however. Women were significantly less likely to be employed than men, and they were also less likely to have been arrested. Men and women had begun their alcohol or drug use at similar ages - approximately 15 years old for both sexes-and had similar lengths of stay in treatment (an average of approximately 20 days’). Slightly more women than men completed treatment successfully (9Ocr/o,compared to 84%) but this small difference was not statistically significant. Table 1 shows that men and women did not differ significantly in the proportion who reported that their parents had a drug or alcohol problem or in how positively they perceived their relationship to their parents. It is important to note, however, that clients of both sexes often came from homes in which alcohol or drugs had been a problem. More than half of the clients came from homes in which the father had an alcohol or drug problem and roughly one-quarter came from homes in which the mother had such a problem. It is also interesting that while women were equally likely to report a positive relationship to their mother and their father (51% in both cases), men were far more likely to report a positive relationship to their ‘One of the two treatment facilities typically keeps clients for 28 days while the other offered the option of either a 14-day or a 28-day stay. This accounts for the average stay of 20 days. Actually, very few clients stayed for 20 days-most stayed either 14 or 28.
Male and Female Clients
245
TABLE 1 Relationship to Parents and Feelings About Childhood Among Clients in Inpatient Substance Abuse Treatment
Percent of Males (n = 181)
Percent of Females (n = 48)
t
55.3 22.4 37.3 65.9
56.8 28.9 51.1 51 .l
.03 .81 2.80 3.48
39.2
67.4
11.36
Relationship to parents Father had an alcohol or drug problem Mother had an alcohol or drug problem Positive relationship to father Positive relationship to mother Feelings about childhood Percent troubled by childhood experiences
aNot significant. Because multiple t tests were employed, only differences significant.
mother (66%) than with their father (37%). Significantly more women than men reported that they were still troubled by events that had occurred in childhood (67% of the women, compared to 39% of the men). Table 2 shows that women were far more likely than men to report a sexual abuse history. This is consistent with previous research on both clinical and nonclinical populations (Rohsenow, Corbett, & Devine, 1988; Russell, 1986). Approximately 33% of the women reported being sexually abused as children, compared to slightly less than 10% of the men. Close to 27% of the women reported sexual abuse as an adult, compared to roughly 2% of the men. Sexual abuse in adulthood involved, in most cases, rape, although several of the women reported sexually abusive relationships with a spouse or other partner. Approximately 28% of the women and 10% of the men reported that they had sexual issues or questions that they were reluctant to bring up. All of these differences between the sexes were statistically significant. Table 2 also shows that women did not differ significantly from men with respect to physical abuse history. The two sexes were equally likely to report that
P
NSa NS NS NS .OOl
with a probability of .Ol or less were considered statistically
they had experienced physical abuse in childhood. It should be pointed out, however,that the overall rate of reported childhood physical abuse was quite high, approximately 30% for both men and women, even though all reports of childhood physical abuse were spontaneous, since there were no questions that specifically dealt with childhood physical abuse. Women were slightly more likely to report that they had been harmed by another since childhood, but this difference was not statistically significant. Men were somewhat, though not significantly, more likely than women to report that they had physically injured someone else (Table 3). In spite of this, women were significantly more likely to say that they needed help with anger or violence (approximately 44% of the women, compared to roughly 23% of the men). This is consistent with clinical reports on women in treatment that describe women as more willing than men to discuss and seek help for problems of all kinds (Tamerin, 1978). The various measures of emotional distress reported in Table 3 show a consistent pattern. Women scored higher than men on all of these measures, with one ex-
TABLE 2 Reported Sexual and Physical Abuse Among Clients in Inpatient Substance Abuse Treatment
Percent of Males (n = 181) Sexual abuse history Sexually abused as a child Sexually abused as an adult Raped Reluctant to share or discuss sexual matters Physical abuse history Physically abused as child Ever harmed physically by someone else
Percent of Females (n = 48)
t
P
9.4 1.9 2.3 9.5
32.6 26.8 26.7 28.3
17.12 37.06 34.77 9.97
.OOl ,001 .OOl .Ol
30.1 42.1
29.8 55.3
.Ol 3.36
aNot significant. Because multiple t tests were employed, only differences
of 0.1 or less were considered statistically significant
NSa NS
246
J. Wallen
Anger/Violence
3 Clients in
Emotional Distress
Anger/violence Has injured another other people Needs help with angry/violent feelings Emotional distress Trouble socializing Depression Hopelessness Tension/nervousness Loss of appetite Difficulty sleeping Suicidal thoughts/feelings Suicide attempt(s)
Substance Abuse
Percent of Males (n = 181)
Percent of Females (n = 48)
t
43.1 22.2 23.4
28.3 19.1 43.9
3.36 .20 7.00
NSa NS .Ol
39.4 73.5 52.9 71.3 39.3 52.6 37.2 14.0
60.9 84.1 73.8 75.0 53.5 69.8 35.7 26.1
6.97 2.13 6.03 .24 .24 4.05 .03 3.80
.Ol NS .Ol NS NS NS NS NS
aNot significant. Because multiple t tests were employed, only differences significant.
ception: men had slightly more suicidal thoughts and feelings. Women were more likely to have actually attempted suicide. Female-male differences were significant only for items relating to difficulty socializing and hopelessness, however. These findings are consistent with those of previous studies, in which women have typically manifested more emotional distress than men. The only treatment outcome variable for this study was treatment completion. While the majority of clients of both sexes completed treatment successfully, approximately 15% left before completing their stay. To assess how client characteristics related to treatment completion, several summary scores were created to characterize the various groups of client characteristics. The emotional distress items (see Table 3 for a list of these items) were all significantly correlated with one another and each was significantly correlated with the summed scores for all of the other emotional distress items. The same was true for the sexual abuse items (see Table 2 for list), the physical abuse scores (Table 2), and the anger/violence scores (Table 3). Summing the scores for each of these sets of items resulted in four summary scores. The scores that differentiated between men and women were the emotional distress scores and the sexual abuse scores. Women had significantly higher scores on both of these indices. To determine whether scores on these indices affected treatment completion, the correlations were examined. The analysis revealed that scores on the emotional distress scale were not associated with treatment completion (Pearson product-moment correlation = -.003). Surprisingly, reported sexual abuse was positively related to treatment completion (Pearson product-moment correlation = .231, p = .Ol).
P
with a probability of 0.1 or less were considered statistically
Scores on the anger/violence index were also positively correlated with treatment completion (Pearson product-moment correlation = 2.80, p = .OOl). Reported physical abuse scores were positively related to treatment completion (Pearson product-moment correlation = .135), but the relationship was not statistically significant. DISCUSSION This study confirms the findings of earlier studies that women in substance abuse treatment are more likely than men to report symptoms of emotional distress and to indicate a willingness to seek help for emotional problems. The study also confirms previous findings that women are more likely than men to report a history of sexual abuse. To the extent that any of these characteristics were significantly related to treatment completion, however, the relationship was positive rather than negative. The high rates of childhood physical abuse in the population studied were striking, as were the high rates of parental alcoholism. Even though the men expressed less emotional distress and desire for help than the women, 40% of the men reported that they were still troubled by childhood experiences, almost a felt that they needed help with anger or violence, and more than f had suicidal thoughts or feelings. The question of whether substance abuse treatment should also address the client’s emotional problems is a controversial one. Traditionally, substance abuse treatment has focused on the substance abuse itself, encouraging recovering individuals to postpone working on childhood issues until later in recovery, whenever possible. This study suggests that experiencing
Male and Female Clients negative feelings concerning childhood experiences does not detract from treatment and may actually be a positive sign, indicating an involvement in the treatment process and an intention to complete treatment. Unresolved issues connected to childhood sexual abuse or other childhood trauma may pose a risk factor in recovery after individuals leave treatment, however, contributing to relapse in vulnerable individuals (Rohsenow et al., 1988). Individual psychotherapy is often recommended as an adjunct to traditional alcohol or drug treatment for individuals with sexual abuse related posttraumatic stress disorders (ibid), but therapists and chemical dependency treatment personnel have a history of mutual distrust (Brown, 1985), and both groups lack a clearcut model for integrating individual psychotherapy with substance abuse treatment. The development of such a model could be of value both to substance abuse treatment professionals and to psychotherapists treating chemically dependent or recovering clients. As well as providing guidelines for the referral of substance abuse clients to individual therapy, such a model could also guide therapists in screening clients for alcohol and drug dependence and in referring them to substance abuse treatment when appropriate. Sexual abuse issues, in particular, may be difficult to discuss in the group settings that characterize substance abuse treatment programs. This may be especially true for women, who often find themselves in predominantly male groups. Short-term women’s groups or single-sex groups for individuals with histories of childhood sexual abuse might be used in substance abuse treatment to assist individuals in identifying or coming to terms with childhood sexual abuse issues. Such groups have been used successfully in substance abuse treatment (Bollerud, 1990) and in other mental health settings (Donaldson & Gardner, 1985; Lindberg & Distad, 1985; Skorina & Kovach, 1986) and might increase the appeal of substance abuse treatment to women. There is some evidence that women are more likely to be attracted to substance abuse treatment services when they also address emotional and family problems (Beckman & Bardsley, 1986; Roman, 1988). The provision of women-only programming or of interventions aimed at alleviating emotional distress might result in increased numbers of women seeking treatment. It is generally believed that childhood sexual abuse is under-reported by men even more than by women (O’Hare &Taylor, 1983). Even so, almost 10% of the men in this study reported that they had been sexually abused as children. If one in 10 men in substance abuse treatment, at a minimum, has a sexual abuse history, then it may also be important to consider whether short-term groups dealing with sexual abuse might be of value to sexually abused men in treatment as well. In addition, or at the very least, educational
247 materials on childhood sexual abuse and its possible long-term effects, as well as on therapy and self-help resources for adults with histories of sexual abuse, might be made available to male and female clients in substance abuse treatment. Individual or group therapy would be a valuable element in the aftercare plans developed for either men or women with a childhood that includes sexual abuse. In conclusion, the findings of this study do indicate that women in substance abuse treatment would benefit from special programming that addresses childhood trauma, particularly childhood sexual and physical abuse, and feelings related to anger and victimization. On the other hand, they also indicate that men would benefit from such programming, as well. Furthermore, they suggest that women’s greater tendency to express emotional distress and to seek help in dealing with feelings while in substance abuse treatment may be a sign of recovery rather than a complicating factor in treatment.
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