Developing a Sociological Framework for Dually Diagnosed Women

Journal of Substance Abuse Treatment, Vol. 17, Nos. 1–2, pp. 91–102, 1999 Copyright © 1999 Elsevier Science Inc. Printed in the USA. All rights reserved 0740-5472/99 $–see front matter

PII S0740-5472(98)00054-3

ARTICLE

Developing a Sociological Framework for Dually Diagnosed Women Wilson R. Palacios, phd,* Catherine F. Urmann, ma,† Richard Newel, ma,‡ and Nancy Hamilton, ba, ccjap† *Department of Criminology, University of South Florida, Tampa, FL; †Operation PAR, Inc., St. Petersburg, FL ‡The Criminological Research Group, St. Petersburg, FL

Abstract – This exploratory study was conducted with the purpose of enumerating both particular social stressors (e.g., the presence of trauma) and the incidence of a comorbid diagnosis (i.e., personality disorder[s] and substance abuse) on a sample of women in a residential therapeutic community. The women in the study were assessed within the first 3 weeks following admission into drug treatment, and then again 6 months after leaving the program. The initial assessment generally took 2 hours and consisted of the Structured Clinical Inventory for DSM-III-R-Patient edition (SCID-II), Addiction Severity Index (ASI), and the Millon Clinical Multiaxial Inventory-II (MCMI-II). Clinically significant scores on the MCMI-II antisocial and borderline personality scales were noted in this study. This study found women with histories of delinquent and/or criminal behavior before drug use were more likely to have used more types of drugs and have used multiple drugs together. These women also tended to have had a history of being abused, either emotionally, physically, or sexually. This group was also less successful on all outcome measures during 6-month follow-up. Moreover, the lifetime incidence of emotional, physical, and sexual abuse reported for this group at the baseline assessment was high—57.1% emotional abuse, 48.9% physical abuse, and 39.7% sexual abuse. These results are consistent with the research literature that indicates abuse plays a central role in the development and chronic effect of personality disorders and, in particular, posttraumatic stress disorder. © 1999 Elsevier Science Inc. All rights reserved. Keywords – dually diagnosed women; personal histories; posttraumatic stress disorder; residential therapeutic community; substance abuse.

INTRODUCTION

cal factors that seem to magnify (Pohl & Boyd, 1992) the severity of the consequences concerning chronic use of drugs and/or alcohol. Also, differences in psychological development and personality structure have been noted (Chodorow, 1978; Gilligan, 1982; Miller, 1976; Pohl & Boyd, 1992). However, the socialization process, or the effects of, are usually given secondary consideration when there is dialogue concerning women’s drug-using behavior. While the abovementioned differences are noted, many of the same factors are also embedded in the socialization of women as it occurs in society. As many changes have occurred in American culture, the impact on women’s roles and identities, responsibili-

Since the early 1980s, the phenomenon of female addiction, in comparison to their male counterpart, has revealed some stark differences for both drug-using/dependent behavior and treatment experiences (Andersen, 1981; Boyd, Blow, & Orgain, 1993; Boyd & Mieczkowski, 1990; Chatham, 1987; Mendelson et al., 1989). While it may be easier to talk about the biological differences between the two, there are many noted physiologiRequests for reprints should be addressed to Wilson R. Palacios, PhD, 4202 East Fowler Avenue, SOC 107, Tampa, FL 33620. E-mail: [email protected]

Received December 5, 1997; Accepted June 10, 1998.

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ties, and expectations has also changed (Harley, 1995). In attempting to understand the process of addiction and its subsequent treatment, it is vital to acknowledge the impact of these changes concerning the construction of women’s gender role and identity. Harley (1995) argued that self-concept and esteem, locus of control, and childhood experiences, were vital dimensions in understanding gender role and identity formation in women with addiction problems. Each dimension has significant consequences for women with such problems. Some of which may include lack of self-esteem, a distorted self-concept, increased feelings of self-hatred, insecurity, hopelessness, problems associated with mothering, sexuality, and the use or reliance of external, rather than internal, locus of control when confronting certain social situations (see Harley, 1995). Miller (1976) suggested the manner in which a women’s self is constructed and maintained differs dramatically from that of a man. For men and women, these differences are grounded in how they experience their social environment. Often, these experiences are related to specific contextual factors, that is, a history of physical/emotional/sexual abuse, a history of familial substance abuse, criminal behavior, and possibly a history of psychiatric disorder(s). Pohl and Boyd (1992) suggested considering women’s psychosocial development as essential, since such factors are considered to be the most salient antecedents to female addiction and recovery. A part of a woman’s psychosocial development that must be considered is the type and level of social stressor(s) present in her life. HIGHLIGHTING THE SOCIAL CONTEXT OF ADDICTION Schliebner (1994) contends that if there is to be any true understanding of the drug addiction process and recovery of women, one must address the economic, gender, and social barriers that affect this group. There must be real encouragement that many of these problems have social as well as personal causes (Cammaert & Larsen 1988; Howard, LaVeist, & McCaughrin, 1996). While this does not release women from responsibility, it does provide a venue for the delivery of practical social services (e.g., affordable child care availability, medical services, assertiveness training, social skills training, coping skills, cognitive restructuring self-esteem building, family and individual therapy). The successful use of these services is based on the presumption of mitigating factors, such as positive social networks, social competencies, and resources; all of which are used to strengthen one’s resiliency to drug use and other high-risk behaviors (Lindenberg, Reiskin, & Gendrop, 1994). In addition to effective command of these social stress modifiers, recovery from drug addiction must address the presence and effects of multiple-role strain, lack of self-nurturance, violence, relationships, loneliness, unex-

pressed anger, racial/ethnic differences, and the presence of psychiatric symptomatology (Pavkov, McGovern, & Geffner, 1993; Schliebner, 1994). Recovery from drug addiction is also predicated on the manner in which drug treatment programs and the current culture respond to these differences. Given current deinstitutionalization practices and changing patterns of drug use in the culture, the drug treatment community has seen an increase in dual diagnoses. According to Drake, McLaughlin, Pepper, and Minkoff (1991) awareness of these issues has been largely responsible for an increase in the number of people identified with a comorbid disorder. Of particular interest is how women are affected under such practices. OBSTACLES FOR DUALLY DIAGNOSED WOMEN Women who are “dually diagnosed”—a chemical abuse or dependency problem and a coexisting psychiatric disorder (Evans & Sullivan 1990)—are a difficult group to work with. Some of the problems common in this group include misdiagnosis, secondary complications stemming from chemical dependency and/or a psychiatric disorder, and recurrent relapse (Salzman, 1981). What is often challenging to mental-health professionals working with this population is achieving a valid diagnostic assessment and developing an appropriate treatment response. In addition, there has been a long-standing debate over the etiological relationship between substance abuse and co-occurring psychiatric disorders. For instance, some contend that in the dually diagnosed person the psychiatric disorder elicits, produces, or exacerbates a substance abuse problem, typically as the individual tries to selfmedicate with alcohol and/or other drugs. This is also referred to as the emotional disease model (Stephens, 1991). While the focus of this model may vary according to the orientation of the theoretician (e.g., drug use as a narcissistic response to an unresolved Oedipal complex, drug use as a response to unresolved problems in living, or drug abusers as defective personality types), drugusing/dependent behavior is seen to be primarily intrapsychic (Stephens, 1991). As a result, the person is considered to be emotionally diseased and, by definition, is afforded treatment. However, this usually leads to the classical “chicken-egg” inquiry. In other words, did the personality disorder create the drug-dependent behavior or did the drug-dependent behavior create the personality disorder? Another alternative for consideration is the genetic disease model. Under such a model, the concept of addiction is viewed as deriving from a physiological foundation in much the same fashion as diabetes or cancer (Stephens, 1991). The individual is seen as a biological organism with a definitive genetic “marker.” However, Stephens (1991) argues that such an approach ignores the social and epidemiological aspects of drug use. In addition, he adds. “Why is it that drug abuse of all types appears to be more preva-

A Sociological Framework

lent in the most economically and socially distressed segments of our population”? (Stephens, 1991, p. 16). Rosenberg (1995) suggests that much of the debate over the etiological relationship between mental illness and drug-dependent behavior is merely academic posturing. In other words, the real test is being able to deliver quality social service programs which demonstrate an awareness and a sensitivity to many of the differences discussed herein. However, the reality is that a great deal of social service delivery for dually diagnosed individuals resembles nothing more than a “band-aid” approach—covered up but did not heal the original disorder (Rosenberg, 1995). Despite which is emphasized, the psychiatric disorder or the chemical dependency, there are those in the field that believe both occur independently of each other (Minkoff 1989). Rosenberg (1995) adds, “whatever the causal sequence, the dually diagnosed need to have the totality of their needs met” (p. 43). If these needs are left unaddressed there may be serious consequences, such as lower retention rates in drug treatment programs (e.g., therapeutic communities), the client is more likely to leave or be referred out prior to program completion, and their relapse odds are higher. MOVING BEYOND THE OBSTACLES Given the complexity of both behaviors and current deinstitutionalization practices, drug treatment modalities, such as therapeutic communities, might better serve their clients by adopting a socioenvironmental approach. Such an approach would view the dually diagnosed person as a socioculturally motivated individual. This would force many to move beyond such questions as: what is it about that person’s heredity and personality that has led him or her to abuse drugs (Henderson & Boyd 1992). A socioenviromental approach would consider one’s life experiences, subculture, development of the self, gender and identity construction as it relates to accompanying drug addiction and psychiatric disorders. Since these behaviors do not occur in a vacuum, neither should its treatment. They are inextricably bound to specific social milieus that warrant careful consideration. Mental-health professionals and researchers in the field must adopt a holistic approach to meet the new challenges dually diagnosed clients present. Of particular interest are women who are given such a label and receive drug treatment in residential therapeutic communities. The current exploratory study focuses on exactly such women residing in a therapeutic community—Operation PAR’s (Prenatal Awareness and Responsibility) Village program serving West Central Florida (Clearwater/St. Petersburg/Tampa) (for a detailed account of this therapeutic community’s philosophy and program elements consult Coletti et al., 1995). The primary purpose of this exploratory study is to enumerate particular social stressors (e.g., the presence of trauma) and the incidence of a comorbid diagnosis (i.e., personality disorders[s] and

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substance abuse) within a residential therapeutic community population. A secondary aim of this article is to theoretically ground these issues in a residential therapeutic community’s Program Enhancement model (e.g., Operations PAR’s Village Program). In addition, suggestions for aftercare treatment will be discussed. LITERATURE REVIEW A particular concern for health professionals and researchers in the field should be the consideration of psychosocial stressors (e.g., child abuse, personal violent histories) as a sequelae to psychopathology. According to Hien and Levin (1994), 43 to 74% of adult female drug abusers have experienced some form of childhood and/or adolescent abuse. However, such a finding has been tempered by the lack of systematic assessments and inquiry. Herman and van der Kolk (1987) found exposure to such abuse to be overlooked by even the most ardent researchers in the field. The failure to consider this type of stressor in one’s life creates, at best, the very real possibility for misdiagnosis or, at worst, imprisons the individual in the continual loop of relapse and recovery from drug use. In addition, van der Kolk (1987) suggested the effects of such trauma should be given careful consideration to accompanying psychiatric problems. In addition, Salzman (1981) found individuals abusing or dependent on drugs can develop symptoms similar to those seen in many psychiatric disorders (i.e., anxiety, depression, schizophrenia, antisocial and borderline personality types). Moreover, according to van der Kolk (1987), many symptoms exhibited may very well be an outcome of posttraumatic stress disorder (PTSD). For instance, symptoms associated with PTSD include severe dissociation and personality disorder (Ouimette, Wolfe, & Chrestman, 1996; Southwick, Yehuda, & Giller, 1993). Evans and Sullivan (1990) warn, “Keep in mind that persons abusing or dependent on chemicals can evidence symptoms that mimic a host of psychiatric disorders” (p. 55). While it is often easy to forget, many of the people seeking drug treatment also have accompanying turbulent personal histories. Assessing the Totality of a Woman’s History These particular life histories are often violent, exploitive, and oppressive (Goldberg, 1995). Carmen, Rieker, and Mills (1987) found that 43% of a sample of adult psychiatric inpatients had a history of physical or sexual abuse. A significant body of research suggests that the presence of these types of personal histories has been closely associated with a variety of psychopathological disorders, including PTSD and personality disturbances, such as, schizotypal, compulsive, antisocial, borderline, and passive aggressive (Lesswing & Dougherty, 1993; Lindberg & Distad, 1985; Ouimette et al., 1996; Rosenheck & Fontana, 1996). Evans and Sullivan (1990) found

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clinical descriptions of borderline personality disorder remarkably similar to descriptions of chronic PTSD. As a result, they argued for a comprehensive assessment of those histories. Such assessments would take into consideration two relevant domains: the intrapersonal and the interpersonal levels of social functioning. While the former is composed of three interdependent systems; the feeling, thinking, and behaving response systems, the latter includes both the quality and quantity of relationships with significant others (Evans & Sullivan, 1990). Maxine Harris (1996) found the effects of untreated trauma history interfering with social and personal functioning (e.g., disruptions in relationships with family members, coworkers, and friends). Clinicians and researchers alike need to be sensitive to the existence and nature of certain stressors an individual may present with at the time of admission into a drug treatment program. In addition to the possibility of a violent history, current and past research studies offer empirical evidence that suggests that for many drug-abusing women there are only weak or nonexisting supportive social networks. Often these same networks promote violent behavior and continued victimization. For instance, aggregate data suggest that between 32 and 40% of women currently in prison had been abused either physically and/or sexually before the age of 18, often by a family member, relative, or intimate acquaintance (Senna & Siegel, 1996). Additionally, 58% grew up in homes without both parents present, and of these adults, 32% abused alcohol and drugs. By adulthood, 43% of these women had been the victims of sexual or physical violence at the hands of spouses, boyfriends, and other intimates (Senna & Siegel, 1996). Chesney-Lind (1997) contends that research on the childhoods of adult women reveals how the powerful and serious problem of childhood and adolescent victimization dramatically circumscribe their choices. Also, for many of these women, victimization continues well into adulthood. If these problems are left unaddressed, what occurs is a specific pathway for many of these women, whereby there is a funneling (Rosenbaum & Murphy, 1990) or a reduction of life options. Trauma and the Drug-Using Woman The effects of traumatic experiences as a factor in the addiction puzzle has received considerable attention since the early 1940s (see Lindemann, 1944). Many of these earlier research efforts were concerned with the effects of exposure to natural events (i.e., earthquakes, and floods). However, since the early 1980s, there has been a concerted effort by both the research and clinical community to delineate the effects of traumatic events, which compromise both the integrity of the self and of the family (Brown, 1994). Unfortunately, such events make for a unique American tragedy concentrated in increased patterns of drug use, exposure to abuse, and community iso-

W.R. Palacios et al.

lation. A tragedy that is often showcased in many jails, prisons, state hospitals, and drug treatment centers. As a result, trauma research has widened to include the effects of violent crime, such as homicide, rape, incest, neighborhood violence, and witnessing or victim of domestic violence (Brown, 1994; Eth & Pynoos, 1985; Terr, 1990). As a consequence, there is a definitive set of quantitative evidence that suggest that many of the observed social and psychopathological adaptations in individuals represent expected outcomes, given certain familial and/or environmental disruptions (Eth & Pynoos, 1985; Pavkov et al., 1993). Moreover, of greater interest has been when these maladaptations have been accented with the use of alcohol and/or drugs.

Taking the Pain Away Briere (1992) found substance abuse to be a significant behavioral response to childhood traumatization. Zweben, Clark, and Smith (1994) found addressing traumatic experiences to be one of the most important clinical challenges today in the area of drug addiction. Additionally, there has been a host of systematic studies that have revealed a high frequency of trauma history in addicted populations (Boyd et al., 1993; Brown & Anderson, 1991; Janikowski & Glover, 1994; Zweben et al., 1994). As a result, a greater understanding of the effects of specific traumatic experiences would inevitably improve drug treatment outcomes. Many researchers have suggested that childhood/ adolescent abuse (i.e., sexual, emotional, or physical trauma) is the most apparent antecedent to the etiology of women’s drug use (see Boyd, Guthrie, Pohl, Whitmarsh, & Hendersen, 1994 and Brown & Anderson, 1991). Carol Boyd (1993) found approximately two of three female substance abusers have had a prior sexual abuse experience, usually before the age of 16 years. Moreover, for some drug-using women, sexual abuse also becomes part of their sexuality and identity. Also, abusive experiences set the stage for later vulnerability to a wide range of disorders, and enhance the likelihood of dysfunctional responses to traumatic experiences in adulthood (Ouimette et al., 1996; Zweben et al., 1994). Clinical reports also suggest that unresolved traumarelated symptoms can contribute to relapse, as individuals may eventually return to alcohol and/or drugs to cope with unresolved long-term effects of trauma (Briere, 1992; Courtois, 1988; Hagan, Finnegan, & Nelson-Zlupko, 1994; Harris, 1996). Hagan and colleagues (1994) contend that a common feature of most substance abusers, men or women, is anxiety. This anxiety stems from family turmoil, employment difficulties, and drug craving. Therefore, using drugs becomes a viable although destructive coping mechanism. Natural reactions and emotions are rarely effective in the chaotic familial and social systems experienced by drug-using/dependent women.

A Sociological Framework

Not All Abuse Is Democratic in Its Effect There is a substantial body of research that suggests that the effects of child and adolescent victimization are aggravated or mitigated, depending on: (a) the relationship of the perpetrator to the child, (b) duration of abuse, (c) the nature of abuse (intra- vs. extrafamilial abuse), (d) age of first abuse, (e) the nature of familial circumstances, and (f) the nature of social support systems (Boyd, 1993; Teets, 1995; Boyd et al., 1994; Ouimette et al., 1996; Dunn, Ryan, & Dunn, 1994). According to Teets’s (1995) exploratory study, a chemically dependent woman who has been abused probably comes from a family where some members are addicted; alcohol or other drugs use started at an early age; the number of years using drugs is considerable; and she is also more likely to have been the victim of rape. Dually diagnosed women with a history of abuse may also evidence more family dysfunction and turmoil because of: (a) family members’ substance abuse history, (b) criminal behavior by both or either parent(s), (c) sibling criminal behavior, (d) their own involvement with the criminal justice system, (e) involvement of local child protection agencies, (f) child custody issues, and (g) extensive drug use history. The significance of these factors may be further amplified, depending upon the nature of abuse experienced by the women (Teets, 1995). A Place for Exactly Such Women Female drug abusers with an accompanying psychiatric disorder are a special population. While a great deal of time and effort is devoted to sorting out the etiological relationship between the two, a much more practical effort is needed in the field. The reality is that many of these women present with a life filled with violence, oppression, and humiliation. Unfortunately, this cannot be disputed, given the amount of empirical support presented in this summary of the literature. In addition, many of these chaotic histories manifest themselves in a variety of psychopathological disorders, including PTSD. Research in the area of trauma has experienced a paradigm shift since the days of Lindemann. Contemporary research efforts are focused more on the effects of family and community violence, and criminal victimization. Therefore, drug treatment programs, especially therapeutic communities, need to acknowledge and thoroughly assess the presence and impact of such events on the lives of their residents. Dually diagnosed women may come from families that are qualitatively more dysfunctional, violent, noninvolved or nonsupportive of drug treatment efforts, and have their own history of drug-using behavior. While the recognition for gender-sensitive therapy is not new (see Schliebner, 1994), adopting such a philosophical framework for a therapeutic community would indeed be a model worth exploring. The PAR’s Village program philosophy is holistic in its approach to providing treatment for its women and

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children. The program focuses on identifying women in need and “finding” reasons to accept individuals in treatment, rather than rejecting them for such factors as poor motivation and the presence of severe psychological dysfunction (Coletti et al., 1995). Also, the program attempts to identify women who have an obvious need for treatment. Many of the services and program elements are individualized and tailored toward specific needs. Overall, according to Coletti and colleagues (1995), treatment elements that focus on the role of the client as a parent comprise an important ingredient in the treatment for substance-abusing women with children at the Village. However, the role of the client as a parent is only one dimension. There are many aspects and dimensions of womanhood that must be addressed. A part of that identity is the possibility that many of these women have experienced some type of trauma in their lives. Again, at issue is not to lessen their responsibility for their behavior, but rather increase awareness and possibly improve their chances at a drug-free lifestyle. METHODOLOGY Site Description In general, residential therapeutic community programs, such as Synanon, historically have been designed to serve the needs of male clients (DeLeon, 1995). While there is diversity within the therapeutic community modality, there are also differences in the types of clients it serves. Operation PAR’s therapeutic community model has been serving women and their children since April 1990 (Coletti et al., 1995). DeLeon (1995) adds, “The profile of the addicted mother in residence is generally not different from other abusers, although this population does reflect a more socially disadvantaged and poorly socialized group” (p. 8). This particular group experiences many barriers to treatment. A significant barrier has been the lack of child-care services for women in treatment facilities. Given this major obstacle, in 1989 Operation PAR expanded its services for cocaine-dependent women with the aid of a National “Institute on Drug Abuse (NIDA) grant—“Perinatal 20”— (Coletti et al., 1995). A major focus of this research initiative was to study the longterm effects of a specialized treatment program for women. Women taking part in the study were permitted to bring one or two of their children into residential treatment with them. In addition to the drug treatment component, the program addressed a myriad of special needs, such as child-care and parenting skills. A unique component of the Village Program was an on-site developmental center, where the children could receive developmental assessments and services while their mother attended treatment group meetings. Women who resided in the Village with their children (n 5 31) were compared to those residing in standard therapeutic community living arrangements without their

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W.R. Palacios et al. TABLE 1 Barriers of Substance-Abusing Women (n 5 143)

Less than a high school education Minority status Single parent More than one child (M 5 2.6) Minimum-wage job skills Arrested at least once

projects required the women be at least 18 years of age, meet Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R; American Psychiatric Association, 1987) criteria for a substance abuse or dependence syndrome, and be able to bring one or two children to live with her while in treatment. During the NIDA (1990–1992) and CSAT (1992–1997) funding periods, clinical staff referred 188 women for participation in one of the two projects. Baseline assessments were completed on 143 women. A review of demographic characteristics highlights the barriers that they need to overcome in addition to their recovery from substance abuse. As indicated in Table 1, the women are predominantly single parents (60.1%), over half of them (65%) with one or more children. Most of the women did not complete high school (53.1%), and almost three quarters (74.8%) of the sample had only minimum-wage job skills. Also, 53.8% of the women were African American and Hispanic/Latina, and 87.4% had a criminal history involving at least one arrest. The chance of successfully overcoming their addiction and becoming self-sufficient is minimal without the benefit of a program addressing a wide range of special needs.

53.1 53.8 60.1 65.0 74.8 87.4

children (n 5 22). Survival analysis methods were used to compare the retention rates of the two study groups. Results indicated that women in treatment with their child(ren) stayed significantly longer than did those in standard treatment, L(n 5 53) 5 9.94; p , .005). Both groups (n 5 46) tended to have somewhat successful outcomes at their 6-month posttreatment assessment. Almost two thirds (65.9%) of the women were successful at remaining drug-free since leaving treatment and 81.8% had no new arrests; 36.4% were engaged in a prosocial activity, including employment or an educational program; and 27.3% had legal custody of their child. The percent of women who were employed was lower than hoped for, primarily due to the fact that the majority of the women had limited job skills and were unable to support both themselves and their child(ren) with minimum-wage jobs. Based on these findings and aftercare issues raised by the women at their posttreatment assessments, additional enhancements were made to the program. These included detailed aftercare plans, a vocational component designed to help the women improve their job skills and an increased number of groups addressing special issues, such as abuse and emotional isolation. Developmental services were also enhanced to include the following, pediatric exams, psychological and developmental assessments, and measures of adaptive and social behavior. There were also intensive parenting classes. In 1992, Operation PAR received funding from the Center for Substance Abuse Treatment (CSAT) to evaluate the effectiveness of these program enhancements. Recruitment into the project began in October 1992.

Procedures Participants were assessed within the first 3 weeks following admission into treatment, and then again 6 months after leaving the program. The initial assessment generally took 2 hours. The Structured Clinical Inventory for DSM-III-R-Patient edition (SCID-II; Spitzer, R.L., Williams, J., Gibbon, M., and First, M.B., 1990) and the Millon Clinical Multiaxial Inventory-II (MCMIII; Millon, 1987) were used as indicators of the presence of psychopathology disorders. The Addiction Severity Index (ASI) provided a self-assessment of problem areas in their life and demographic information (McLellan, Luborsky, O’brian, and Woody, 1980). A modified version of the Treatment Outcomes Prospectives Study (TOPS; Hubbard, 1991) self-report drug use form was used to determine the extent of drug use. A nonstandardized form, The Profile of Substance Abusing Women, was developed by the evaluation team in response to the scarcity of gender specific assessment tools. This form included questions concerning family dynamics, relationships with sexual partners, child-related issues including legal custody, criminal and delinquent behavior, and drug use information.

Sample Composition This article will provide a longitudinal analysis of a subsample of women with their children from both the NIDA and CSAT groups. Participation in either of the

TABLE 2 Distribution of MCMI-II Scores by Group (N 5 116)

Neither (n 5 30)

Antisocial Borderline

One (n 5 50)

Both (n 5 36)

M

Range

M

Range

M

Range

66.97 58.67

(58–75) (31–74)

85.30 69.98

(62–121) (55–101)

98.17 103.36

(77–116) (79–120)

MCMI-II 5 Millon Clinical Mulitaxial Inventory-II.

A Sociological Framework

Information from these instruments provides outcome measures on drug-free status, arrest-free status (new arrests posttreatment), employment or prosocial activity, and reunification with the youngest child the woman brought into treatment. Prosocial activity was included to address the fact that during the first several months after leaving treatment, while not employed, they may be engaged in a positive activity such as attending school or training. Such efforts would eventually provide them with opportunities for work and sufficient income to support themselves and their children.

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Additional measures of prosocial activity considered were receiving additional substance abuse treatment, and/or full-time care of a dependent(s) with another adult in the household providing income. Data on each outcome measure were collected via self-report. In addition, urine and hair samples were randomly tested from 50% of the women to verify self-reported drug use. Measures of self-reported criminal behavior were collected and later verified against criminal justice records. Verification of employment status and custody of children were obtained.

TABLE 3 Demographic Characteristics by Presence/Absence of Borderline and Antisocial Disorders

Age at admission (years) M Range Race/ethnicity African American White Hispanic Education completed (years) M Range Marital status Married Separated Divorced Never married Number of children M Range Legal custody of child Pregnant with first child Self Immediate family Foster care Usual occupation Professional Skilled labor Semiskilled labor Never worked Referral Self Substance abuse treatment program Child protection services Criminal justice system Community referral Length of stay (days) M Range Type of discharge Completed program Transfer within agency Referral Noncompliance Left before completing treatment a 5 .05.

Neither Disorder (n 5 15)

Both Disorders (n 5 19)

29.0 18–37

27.8 18–33

60.0 33.3 6.7

78.9 21.1 0.0

11.1 6–16

11.0 7–15

6.7 6.7 26.7 60.0

15.8 0.0 15.8 68.4

2.67 1–6

2.53 0–7

0.0 33.3 33.4 33.3

5.3 26.3 21.0 47.4

6.7 20.0 73.3 0.0

5.3 15.8 63.2 15.8

13.3

15.8

20.0 40.0 20.0 6.7

21.1 36.8 26.3 0.0

261.73 30–672

235.79 51–900

26.7 6.7 13.3 20.0 33.3

21.1 0.0 15.8 26.3 36.8

p Value

.577 .662

.752 .759

.683 .571

.295

.236

.323 .579

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W.R. Palacios et al.

RESULTS

15) to the group with both disorders (n 5 19) revealed no significant differences between the groups (Table 3).

Baseline Characteristics Of the 143 women with baseline assessments, 116 had valid MCMI-II test results. According to Table 2, 31% of the women had scores on both the Antisocial and Borderline personality scales that were above the threshold suggesting the presence of the disorder. In addition, 26% of the women had neither disorder and 43% had only one of the two disorders. For the women who had only one disorder, it was primarily the antisocial personality type. Background characteristics of the group with both disorders were compared to the group with neither disorder. The Mann-Whitney analysis was chosen to compare these two groups because it does not make assumptions about the normality of the underlying distribution and can estimate statistical significance with small (n . 8) sample sizes. These findings suggest the presence of antecedent variables that may significantly contribute to or affect drug use patterns. The background characteristics were used in analyzing the outcome data. Of the 116 women, 68 completed their 6-month posttreatment assessment. Approximately 76.5% (n 5 52) of the women had a valid MCMI-II report, of which 36% (n 5 19) had baseline scores suggesting the presence of both antisocial and borderline personality disorders. Also, 29% (n 5 15) of the women exhibited neither disorder, and 35% (n 5 18) had only one of the two disorders. Analysis of demographic characteristics comparing the group with neither disorder (n 5

Influence of Abuse The MCMI-II uses a theoretical framework that characterizes people with antisocial personality disorders as being rebellious and deviant, and people with borderline disorders as being volatile, with reduced impulse control, and dysregulation of affect (Millon, 1987). However, the literature shows that both borderline and antisocial personality disorders may be related to a history of abuse, particularly sexual abuse (Ouimette et al., 1996). Background characteristics related to antisocial and borderline personality disorders, including delinquent and criminal behaviors before drug use and lifetime abuse histories, were analyzed comparing the two groups. The MannWhitney analysis revealed significant relationships between the two groups for history of emotional ( p 5 .007) and sexual abuse ( p 5 .028). The women exhibiting both disorders were more likely to have used more types of drugs over their lifetime ( p 5 .001) and have a longer arrest history ( p 5 .004). They were also more likely to engage in delinquent behavior before beginning drug use ( p 5 .040) (Tables 4 and 5).

Influence of Delinquency Eighty-two percent (n 5 56) of the women responded to baseline questions about engaging in delinquent and/or

TABLE 4 Background Characteristics by Presence/Absence of Borderline and Antisocial Disorders

Neither Disorder (n 5 15)

Number of drugs used—lifetime M Range Psychopathology (MCMI-II) Mean number of disorders . 75 Range Abuse history Any abuse (%) Emotional (%) Sexual (%) Physical (%) Number of types of abuse None (%) One (%) Two (%) Three (%) Arrest history—lifetime M Range MCMI-II 5 Millon Clinical Multiaxial Inventory-II. a 5 .05.

Both Disorders (n 5 19)

p Value

.001 3.13 1–7

5.42 2–9

1.73 0–5

7.16 5–11

40.0 26.7 20.0 33.3

89.5 73.7 57.9 57.9

60.0 13.3 13.3 13.3

10.5 26.3 26.3 36.8

2.20 0–7

9.90 1–44

.000

.003 .007 .028 .160 .007

.004

A Sociological Framework

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TABLE 5 History of Delinquent/Criminal Behavior by Presence/Absence of Borderline and Antisocial Disorders

Delinquent behavior before use (%) Criminal behavior before use (%)

Neither (n 5 13)

Both (n 5 15)

p Value

15.4 15.4

53.3 46.2

.040 .096

a 5 .05.

criminal activities before using drugs. Women engaging in delinquent behavior prior to drug use were more likely to have elevated baseline MCMI-II scores suggesting the presence of antisocial (p 5 .002), borderline (p 5 .005), passive-aggressive (p 5 .020), and self-defeating (p 5 .063) disorders. Women with histories of delinquent and/ or criminal behavior before drug use were more likely to have used more types of drugs (p 5 .025) and have used multiple drugs together (p 5 .012). Also, women engaging in delinquent behavior prior to drug use were also more likely to have a history of being abused, either emotionally, physically, or sexually (p 5 .006). The more types of abuse occurring, the more pronounced the relationship (p 5 .002). Thus, engaging in delinquent behaviors prior to drug use appears to have a direct relationship with the presence of multiple psychopathology disorders, a history of abuse and extensive drug use (Tables 6 and 7). Six-Month Follow-Up Findings Changes in MCMI-II antisocial and borderline scores from baseline to the 6-month posttreatment assessment were not statistically significant, suggesting the relative permanence of personality disorders when they are not addressed within a drug-treatment setting. However, analy-

sis of the major outcome variables revealed that women with a history of delinquent and/or criminal behavior before drug use were less successful on all outcome measures (arrest-free, p 5 .034; drug-free, p 5 .000; and reunification, p 5 .031) (Figure 1). Those who engaged in delinquent behavior before drug use had a significantly shorter length of stay in treatment (M 5 152.53 days) than did those with no delinquent background (M 5 292.80 days; p 5 .017). Six months after leaving treatment, they were less likely to have remained drug-free (p 5 .0001), generally having resumed using their primary drug of choice. They were also more likely to have been arrested (p 5 .034), less likely to be involved in a prosocial activity (p 5 .011), and less likely to be reunified with their child (p 5 .031). Women who engaged in criminal activity before drug use were also less likely to remain drug-free (p 5 .004), arrest-free (p 5 .014), to be engaged in a prosocial activity (p 5 .003), and be reunified with their child (p 5 ns). Women who also had a history of being abused, regardless of the type of abuse, were less likely to remain drugfree (p 5 .038). Longer length of stay was found to be positively associated with drug-free status (p 5 .029). Which in turn is associated with remaining arrest-free ( p 5 .005), and being involved in a prosocial activity (p 5 .0001).

TABLE 6 Psychopathology Characteristics by History of Delinquent Behavior Before Drug Use

Variable

Antisocial disorder Mean score Range Borderline disorder Mean score Range Passive-aggressive disorder Mean score Range Self-defeating disorder Mean score Range a 5 .05.

No History (n 5 31)

History (n 5 12)

77.87 52–111

98.25 67–115

76.36 58–118

93.25 68–117

75.10 24–112

93.17 68–117

78.23 37–109

89.5 72–106

p Value

.002 .005 .020 .063

100

W.R. Palacios et al. TABLE 7 Background Characteristics by History of Delinquent Behavior Before Drug Use

Variable

No History (n 5 39)

Number of drugs—lifetime M Range Multiple drug use—lifetime Percent M (years) Abuse history Any abuse (%) Physical (%) Sexual (%) Emotional (%) Mean number types of abuse

History (n 5 17)

p Value

.025 3.56 1–7

4.94 1–9

48.7 3.82

82.4 7.65

56.4 30.8 28.2 46.2

94.1 70.6 64.7 76.5

.012

1.05

2.13

.006 .006 .011 .038 .002

a 5 .05.

DISCUSSION/CONCLUSION

Summary of Results The data analyses thus far have focused on MCMI-II scores that indicated the suggested presence of a personality disorder. Significant relationships were also found to exist between background characteristics, particularly delinquent and criminal behavior patterns, and each of the outcome variables. These data were then reanalyzed for MCMI-II scores that indicated there was “strong” support for the presence of both disorders. Under this new criteria, 52% (n 5 27) of the women had neither disorder and 25% (n 5 13) had scores above the threshold for both disorders. The remaining 23% (n 5 13) had scores above the threshold for both disorders. The remaining 23% (n 5 12) had scores supporting one of the two disorders, predominantly the antisocial disorder. The results were consistent with the earlier findings, where the women with both disorders were less successful on all outcomes, while the women with neither or one disorder generally remained more stable.

In this study, over 50% of the women evaluated upon entering treatment had MCMI-II scores suggesting the presence of three or more personality disorders. Only 15.4% of the women had scores indicating no disorders were present. Over one third of the women had scores suggesting the presence of both antisocial and borderline personality disorders. It was not unexpected that there were insignificant changes in the level of the disorders between the baseline and 6 month posttreatment assessments based on the enduring nature of personality disorders. The presence of both disorders was found to be associated with delinquent behavior before drug use and with a history of emotional, physical, and/or sexual abuse. Women engaging in delinquent behavior before drug use were significantly more likely to have a history of abuse. Women with a history of abuse were more likely to have used more types of drug and to have MCMI-II scores suggesting the presence of more disorders than

FIGURE 1. Posttreatment outcomes by history of delinquent behavior. a 5 .05.

A Sociological Framework

were those with no abuse history. The lifetime incidence of emotional, physical, and sexual abuse reported at the baseline assessment is high—57.1% emotional abuse, 48.9% physical abuse, and 39.7% sexual abuse. These results are consistent with the research literature that indicates that abuse plays a central role in the development and chronic effect of personality disorders, in particular, PTSD.

101

their personal histories. Such responsive behavior is rather common for individuals exposed to violent social events. However, diagnoses are often complicated because many of the symptoms are similar to some of the personality disorders mentioned herein. Future studies of women in residential therapeutic communities need to actively assess for the presence of PTSD and related disorders. Furthermore, such efforts may redirect the manner in which aftercare plans are created.

Limitations of the Study Despite these findings, there were several limitations to this study. The sample was relatively small and limited to one treatment site. Future studies would need to consider multiple sites. In addition, information on ages of first drug use, first delinquent act prior to drug use, and age when abuse occurred were not available. However, future studies will focus on a much more inclusive measure for such factors as abuse history. The presence of abuse is only one part of the total picture. There are both quantitative and qualitative differences, based on the nature of abuse experienced. If this is indeed a part of a woman’s history, as demonstrated in this study, then every effort must be made to thoroughly evaluate its presence. Also, another area of research that is severely understudied in the residential therapeutic community literature is the nature of the interaction between the therapist and the client. Such an interaction may very well influence how social services are delivered to the client. Therefore, a study is already planned that will focus on the such interactions. Despite these limitations, the results presented in this article suggest that some progress has been made in addressing the special needs of substance-abusing women. However, additional steps are warranted. First, while there is an emphasis of women as primary caregivers, the reality is that many of these women are in need of care themselves. Female substance abusers often arrive to treatment settings with a longer history of drug use, history of drug treatment experience, poly and/or multiple drug use patterns, heighten levels of family discord, physiological problems associated with chronic drug use, and a history of victimization. Such events are markers of an extremely unique and turbulent sociocultural environment that many of these women share with one another. While this group differs along many variables (i.e., class and race), they do share a history of violence, victimization, and revictimization much more pronounced than their male counterpart. Although in this study we report elevated scores for the presence of antisocial and borderline personality disorders, we also recognize the possibility that this may indeed be an artifact. In other words, these elevated scores may also be indicators of other types of psychopathological adaptations, such as PTSD, which may very well reflect the type of social adaptation many of these women needed to make given

REFERENCES American Psychiatric Association. (1987). Diagnostic and statistical manual of mental disorders (3rd ed., Rev.). Washington, DC: Author. Andersen, M.S. (1981). Personalized nursing: An intervention model for drug dependent women in an emergency room. Focus on Women: Journal of Addictions and Health, 1, 216–227. Boyd, C. (1993). The antecedents of women’s crack cocaine abuse: Family substance abuse, sexual abuse, depression and illicit drug use. Journal of Substance Abuse Treatment, 10, 433–438. Boyd, C., Blow, F., & Orgain, L. (1993). Gender differences among African-American substance abusers. Journal of Psychoactive Drugs, 25, 301–305. Boyd, C., Guthrie, B., Pohl, J., Whitmarsh, J., & Hendersen, D. (1994). African-American women who smoke crack cocaine: Sexual trauma and the mother–daughter relationship. Journal of Psychoactive Drugs, 26, 243–247. Boyd, C., & Mieczkowski, T. (1990). Drug use, health, family and social support in crack cocaine users. Addictive Behaviors, 15, 481– 485. Briere, J.N. (1992). Child abuse trauma: Theory and treatment of the lasting effects. Newbury Park, CA: Sage. Brown, S. (1994). Alcoholism and trauma: a theoretical overview and comparison. Journal of Psychoactive Drugs, 26, 345–355. Brown, G.R., & Anderson, B. (1991). Psychiatric morbidity in adult patients with childhood histories of sexual and physical abuse. American Journal of Psychiatry, 148, 55–62. Cammaert, L.P., & Larsen, C.C. (1988). Feminist frameworks of psychotherapy. In M.A. Dutton-Douglas & L.E. Walker (Eds.), Feminist psychotherapies: Integration of therapeutic and feminist systems. (pp. 12–37). Norwood, NJ: Ablex. Carmen, E.H., Rieker, P.P., & Mills, T. (1987). Victimes of violence and psychiatric illness. American Journal of Psychiatry, 141, 378– 384. Chatham, L. (1987). Issues related to alcoholism, drug use and abuse, and mental health of women. Public Health Reports Supplement, (July–August), 16–19. Chesney-Lind, M. (1997). The female offender: girls, women, and crime. Thousands Oaks, CA: Sage Publications. Chodorow, N. (1978). The reproduction of mothering: Psychoanalysis and the sociology of gender. Los Angeles: The University of California Press. Coletti, S., Schinka, J., Hughes, P., Hamilton, N., Renard, C., Sicilan, D., Urmann, C., & Neri, R. (1995). PAR Village for chemically dependent women: Philosophy and program elements. Journal of Substance Abuse Treatment, 12, 289–296. Courtois, C. (1988). Healing the incest wound: Adult survivors in therapy. New York: Norton & Company. DeLeon, G. (1995). Residential therapeutic communities in the mainstream: Diversity and issues. Journal of Psychoactive Drugs, 27, 3–15. Drake, R., McLaughlin, P., Pepper, B., & Minkoff, K. (1991). Dual diagnosis of major mental illness and substance disorder: An overview. In K. Minkoff & R. Drake (Eds.), Dual diagnosis of major mental illness and substance disorder (pp. 3–12). San Francisco, CA: Jossey-Bass Inc.

102 Dunn, G., Ryan, J., & Dunn, C. (1994). Trauma symptoms in substance abusers with and without histories of childhood abuse. Journal of Psychoactive Drugs, 26, 357–360. Eth, S., & Pynoos, R. (1985). Post-traumatic stress disorder in children. Washington, DC: American Psychiatric Press. Evans, K., & Sullivan, M.J. (1990). Dual diagnosis: Counseling the mentally ill substance abuser. New York: Guilford Press. Gilligan, C. (1982). In a different voice. Cambridge, MA: Harvard University Press. Goldberg, M. (1995). Substance-abusing women: False stereotypes and real needs. Social Work, 40, 789–796. Hagan, T., Finnegan, L., & Nelson-Zlupko, L. (1994). Impediments to comprehensive treatment models for substance-dependent women: treatment and research questions. Journal of Psychoactive Drugs, 26, 163–171. Harley, D. (1995). Alcohol and other drug use among women: Implications for rehabilitation counselors. Journal of Applied Rehabilitation Counseling, 26(4), 38–42. Harris, M. (1996). Treatment sexual abuse trauma with dually diagnosed women. Community Mental Health Journal, 32, 371–385. Henderson, D., & Boyd, C. (1992). Masculinity, femininity, and addiction. In T. Mieczkowski (Ed.), Drugs, crime, and social policy (pp. 153–166). Needham Heights, MA: Allyn & Bacon. Herman, C., & van der Kolk, B. (1987). Traumatic antecedents of borderline personality disorder. In B. van der Kolk (Ed.), Psychological trauma (pp. 111–126). Washington, DC: American Psychiatric Press, Inc. Hien, D., & Levin, F. (1994). Trauma and trauma-related disorders for women on methadone: Prevalence and treatment considerations. Journal of Psychoactive Drugs, 26, 421–429. Howard, D., LaVeist, T., & McCaughrin, W. (1996). The effects of social environment on treatment outcomes in outpatient substance misuse treatment organizations: Does race really matter? Substance Use and Misuse, 31, 617–639. Hubbard, R. (1991). Drug abuse treatment: A national study of effectiveness. Raleigh, NC: University of North Carolina Press. Janikowski, T.P., & Glover, N.M. (1994). Incest and substance abuse: Implications for treatment professionals. Journal of Substance Abuse Treatment, 11, 177–183. Lesswing, N., & Dougherty, R. (1993). Psychopathology in alcohol-and cocaine-dependent patients: A comparison of findings from psychological testing. Journal of Substance Abuse Treatment, 10, 53–57. Lindberg, F., & Distad, L. (1985). Post-traumatic stress disorders in women who experienced childhood incest. Child Abuse and Neglect, 9, 329–335. Lindemann, E. (1944). Symptomatology and management of acute grief. American Journal of Psychiatry, 101, 141–149. Lindenberg, C.S., Reiskin, H., & Gendrop, S. (1994). The social stress model of substance abuse among childbearing-age women: A review of the literature. Journal of Drug Education, 24, 253–269. McLellan, A.T., Luborsky, L., O’brian, C.D., and Woody, G.E. (1980). An improved diagnostic instrument for substance abuse patients: The Addiction Severity Index. Journal of Nervous and Mental Disorders, 168, 26–33. Mendelson, J., Weiss, R., Griffin, M., Mirin, S., Teoh, M., & Lex, B. (1989). Some special considerations for treatment of drug abuse and dependence in women. In E. Randert (Ed.), Treatment for

W.R. Palacios et al. drug-exposed women and their children: Advances in research methodology. NIDA Research Monograph 166 (pp. 313–324). Rockville, MD: National Institute on Drug Abuse. Miller, J.B. (1976). Toward a new psychology of women (2nd ed.). Boston: Beacon Press. Millon, T. (1987). Millon Clinical Multitaxial Inventory-II. Minneapolis: MN. National Computer Systems., Inc. Minkoff, K. (1989). An integrated treatment model for dual diagnosis of psychosis and addiction. Hospital and Community Psychiatry, 40, 1031–1037. Ouimette, P., Wolfe, J., & Chrestman, K. (1996). Characteristics of posttraumatic stress disorder-alcohol abuse comorbidity in women. Journal of Substance Abuse, 8, 335–347. Pavkov, T.W., McGovern, M., & Geffner, E. (1993). Problem severity and symptomatology among substance misusers: Differences between African-Americans and Caucasians. The International Journal of the Addictions, 28, 909–923. Pohl, J., & Boyd, C. (1992). Female addiction: A concept analysis. In T. Mieczkowski (Ed.), Drugs, Crime, and Social Policy, (pp. 138– 152). Needham Heights, MA: Allyn & Bacon. Rosenbaum, M., & Murphy, S. (1990). Women and addiction: process, treatment, and outcome. In E. Lambert (Ed.), The collection and interpretation of data from hidden populations. NIDA Research Monograph 98 (pp. 120–127). Rockville, MD: National Institute on Drug Abuse. Rosenberg, E. (1995). Crazy addicts: A social structural examination of who falls through the cracks, and why? Sociological Viewpoints, 11, 41–52. Rosenheck, R., & Fontana, A. (1996). PTSD and community-based treatment: A commentary on “PTSD diagnosis and treatment for mental health clinicians.” Community Mental Health Journal, 32, 191–194. Salzman, B. (1981). Substance abuse with psychiatric problems. In J.H. Lowinson & P. Ruiz (Eds.), Substance abuse: Clinical problems and perspectives (pp. 56–72). Baltimore: Williams & Wilkins. Schliebner, C. (1994). Gender-sensitive therapy: An alternative for women in substance abuse treatment. Journal of Substance Abuse Treatment, 11, 511–515. Senna, J., & Siegel, L. (1996). Introduction to criminal justice. St. Paul, MN: West Publishing Company. Southwick, S.M., Yehuda, R., & Giller, E.L. (1993). Personality disorders in treatment-seeking combat veterans with posttraumatic stress disorder. American Journal of Psychiatry, 150, 1020–1025. Spitzer, R.L., Williams, J., Gibbon, M., and First, M.B. (1990). Structured Clinical Interview for DSM-III-R. Patient edition. (SCID-II). Washington, DC: American Psychiatric Press. Stephens, R.C. (1991). The street addict role: A theory of heroin addiction. New York: State University of New York Press. Teets, J. (1995). Childhood sexual trauma of chemically dependent women. Journal of Psychoactive Drugs, 27, 231–238. Terr, L. (1990). Too scared to cry. New York: Harper & Row. Van der Kolk, B. (1987). The psychological consequences of overwhelming life experiences. In B. Van der Kolk (Ed.), Psychological trauma (pp. 1–30). Washington, DC: American Psychiatric Press, Inc. Zweben, J., Clark, H.W., & Smith D. (1994). Traumatic experiences and substance abuse: mapping the territory. Journal of Psychoactive Drugs, 26, 327–344.