Men and Women Substance Abusers & Program Retention

by Darlene Albury, LCSW

This paper will address Substance Abuse and Program Retention specifically for substance abusers. Unresolved past or current psychosocial issues stagnates the growth and healing process of any individual. A vital part of recovery is for an individual to look at what has taken place in the past, to have positive emotions about future optimism, hope, faith and trust. What caused them to medicate their feelings, their inability to cope, and their strengths and weakness in relation to life and combating their addictions. The purpose of substance abuse treatment is to help the individual gain insight into living a happier life, to see connections, and reach a higher level of self awareness that will hopefully result in behavioral change.

Most treatment facilities and institutions were established and set up to meet the needs of males. Sitting in a therapeutic setting to talk about issues in relation to using, coping with life situations and crisis that took place in one’s life, is very difficult for males as well as females who enter into these programs. Individuals usually come into treatment because of a crisis that has taken place and/or, they are mandated or required to seek treatment as a component to their problem resolution. Usually the mandated or required treatment comes about because they are at risk for losing their spouse or children, facing employment or incarceration. These very issues bring about a lot of shame, guilt, discomfort, anxiety, depression, and fear. Additionally, most men and women with substance abuse problems have encountered prior to, or during their drug use some negative or unpleasant involvement with men and men with women. Therefore, being placed in a therapeutic setting with men/women to discuss specific issues has made these individuals feel quite vulnerable.

Substance abuse was always a problem but virtually went unrecognized, probably because of the low percentage of known substance abusers. Individuals who have addictions - whether it be alcohol, cocaine, pills, crack etc, would not even consider letting their addiction be known if they possibly could because of the punitive aspects on disclosure. Substance abusers and situations regarding their abuse seem to be magnified with the disclosure, as well as stigmatizing, especially when children are involved. There is also the shame, guilt, embarrassment, and fear of losing their children as well as fear of being ostracized by their families and friends. However, it manifests itself in other ways. Men and women who use crack cocaine as a drug of choice put themselves at greater risk.

Crack Cocaine is a highly addictive form of cocaine made by mixing small amounts of it with baking soda and water. When dry, the substance is broken or cracked into small pebbles and usually smoked in a special pipe. Crack is relatively inexpensive, highly potent, and can be lethal (The Social Work Dictionary FEF HV 12 .B37 1987).

Crack cocaine is a drug that strips you of your pride, dignity, self-respect, and spirituality. In the course of the writer’s experience in the field, she developed a group as part of program development within the agency. Men and women in the group would talk about issues that came about as a result of their drug use, such as exchanging sexual favors as a means of getting drugs. They would go on roof tops, in hallways, in basements, vacant apartments, parks, and cars. They did not care where, with whom or what they had to do to get these drugs. To many of the abusers buying a condom would take away from their drug money, and if their partner did not have a condom they did not care. One member of the group stated, “If my partner doesn’t ask for a condom, I don’t either. Who cared I just wanted to get high."

As the crack epidemic grew, addiction progressed even faster. Children were being neglected, harmed and even killed. The abusers would resort to other means of supporting their addictions by way of prostitution, shoplifting, and the sale of drugs. Crack has quickly become a major problem in this country because it is inexpensive, readily available, and highly addictive.

Crack addiction among the abusers became even more problematic and alarming because of the HIV/AIDS epidemic and unsafe sexual practices that caused this virus to grow in leaps and bounds in heterosexual relationships. Crack addiction has affected our society in epidemic proportions, and generates other problems such as out of wedlock crack babies, who are also being born HIV/AIDS positive.

Program Retention

Historically, drug abuse research has focused primarily on the characteristics and treatment of men who misused illicit drugs and alcohol. Those few studies that included female subjects found that gender was associated with retention, that women were more apt to drop out of treatment than men. The findings indicated that women dropped out of treatment faster than men regardless of age, type of treatment setting, or race. This greater tendency to leave treatment prematurely might be attributed to the inability of treatment programs to meet the medical, social, and emotional needs of both men and women (Roberts, Nishimoto, 1996).

In contrast to individuals who seek treatment, there are those that come into substance abuse treatment as a means or condition of avoiding consequences in association with their drug use (incarceration, loss of parental rights).

In order to ensure a demographically diverse sample in treatment programs, interviewers repeatedly visited specific residential programs, often interviewing every new client in hard to fill subsample categories. The treatment programs represent Dade County’s two largest residential treatment programs—The Village and Spectrum Programs. The Village is a 150-bed (nontherapeutic community) residential facility that has been in operation since 1969. Of its approximately 450 annual admissions, 90% are cocaine dependent and 50% are court ordered. Spectrum Program has 240 beds and 500 admissions each, 40%-50% which are court ordered. Since Spectrum and the Village represent a collection of long term and short-term TC and non-TC residential programs, bias toward any one particular type of treatment approach was reduced (McCoy & Associates, 1995).

There are various issues that one might hypothesize to be associated with their addiction, as well as the behaviors they exhibit, such as sexual promiscuity, child abuse and neglect. Individuals who have been victims of crime likewise appear to have increased vulnerability to substance abuse. Research conducted among a population of abusers in residential or outpatient drug treatment programs found that 80 percent had been crime victims. Additionally, crime victims were more likely to have major drug and alcohol problems than nonvictims. Abusing crime victims who suffered from Post-Traumatic Stress Disorder (PTSD) were almost 10 times more likely to have major alcohol problems and 17 times more likely to have major drug abuse problems than nonvictims. Numerous studies have shown PTSD to be a strong predictor of substance abuse (National Institute on Drug Abuse, 1996).

Many individuals who use drugs have had troubled lives. Studies have found that at least 70% of drug users have been sexually abused by the age of 16. Most of these victims had at least one parent who abused alcohol or drugs (National Institute on Drug Abuse).

The writer facilitated a group of individuals between 21-50 years of age. This was an open forum group that allowed them to talk about whatever their feelings were concerning any topic. Approximately 75% of these individuals reported that they had been sexually molested at an early age, and never received any type of treatment for the abuse or the trauma in association with the abuse. The perpetrators of the abuse were fathers, brothers, their mother’s boyfriends, uncles and stepfathers. Some of these victims were threatened not to tell, too afraid to tell, or they disclosed but were not believed. In addition, some of their parents were alcohol/substance abusers who prostituted them for a drink or drugs.

Many of these individuals also reported being physically, mentally, and emotionally abused and neglected. Knowing no other way to cope with the pain and suffering they endured, they admitted to finding ways not to feel. They never knew what a healthy, meaningful relationship was like and only knew to respond to others with the behavior that was learned (e.g. Being sexually provocative, promiscuous sexual behaviors, and the use of drugs. These individuals lacked trust in themselves and anyone else. They had very low self esteem, and lacked self-confidence). Using and abusing drugs helped them to cope with these feelings of inadequacy. One member of the group stated, "It takes you away from the pain, hurt, misuse, abuse, loss, and the fact that no one really cares."

The defense mechanism is to fight or flight and unfortunately, abusers tend to feel overwhelmed by the feelings of what they have endured throughout their lives, and turned to drugs as a means of coping. Most people in the group admitted to choosing not to go through the hurt and pain of dealing with their feelings or disclosing themselves to others. Abusers in early recovery have put themselves through so much to survive, that it has become the way of life for them; feeling that all else has failed, they are already stigmatized and labeled, so they continue to survive the best way they know how.

These are the issues that these individuals come with. The feelings of unresolved hurt and pain that they constantly try to avoid but can never seem to get away from. Having the feeling that no one could ever understand the suffering they have endured, being held prisoner or enslaved to the torment of their past, having their innocence robbed from them at such an early age and living with fear.

Group Experience

Treatment facilities have been ineffective in retaining individuals in treatment for several reasons. First, treatment is geared toward meeting the needs of men, and does not meet gender specific issues. Secondly, this mode of treatment intervention is very confrontational in group settings and often addresses very sensitive issues that men and women are made to feel very uncomfortable with. Treatment facilities talk about the need to share one’s feelings, to rid themselves of the baggage that you never really owned. Realistically, individuals are made to feel vulnerable being in a setting with both genders and having to talk about uncomfortable and painful issues. This proves to be counter-productive because if one is not able to talk about their issues, they can not begin to recover, and this is a vital part of the recovery process (ex. abusers in early recovery who prostituted as a means of meeting their needs, and who disclosed this in the group setting were often approached and propositioned by someone in the group). This behavior increases feelings of shame and guilt, subjecting them to ridicule if they do not respond favorably to the advances. This can cause the individual's self-esteem to be even more affected, and often the result is dropping out of treatment. Additionally, the issues of abandonment, incest, rape, and physical and emotional abuse generates a lot of transference of feelings in a therapeutic setting for the women as well as the men. Also, at times members can be very insensitive toward the feelings of others in the group.

This has been, in the writer’s experience, one of the major reasons why there is low retention in treatment.

Groups, as dynamic entities, have direct and indirect influences on their members (Bion, 1959; Yalom, 1985). The presence of others may improve or impair the performance and development of persons depending on their background preparation (Zajonc, 1965, in Gladding, 1995).

Groups go through different stages. Transition of group members into the group process begins with storming. Storming is a time of conflict and anxiety when the group moves from primary tension (awkwardness about being in a strange situation) to secondary tension (intra group conflict) (Bormann, 1975). Each group experiences the storming process differently. Some may encounter all the problems associated with this period, whereas others may have few difficulties (Gladding 1995, pg. 104). Most conventional research focuses on a relatively small group of those whose drug use has become visible, therefore problematic (e.g. crack addicted abusers and their unsafe sex practices that results in the spread of the HIV/AIDS virus).

Drugs and AIDS

Between 1990 and 1991, AIDS cases among abusers rose 17 percent. Today, almost 70 percent of AIDS cases are related to either injecting drugs or having sex with a man or woman who injects drugs. AIDS is now the fourth leading cause of death among abusers. The study of individuals and drugs was altered radically in the 1980’s. As a result of the AIDS epidemic and its relation to drug use, the introduction of “crack” to the drug scene; unprecedented escalation in the war on drugs - all changed the drug experience for men and women. Drugs and prostitution added up to a tangled package creating increased HIV risk for men and women through both needle-sharing and sexual contact. Drug dependent individuals in withdrawal and in desperate need of money were vulnerable to the demands of a “trick” that did not want to use a condom (Rosenbaum, Washburn, Knight, Kelly, 1995) and this also resulted in unwanted pregnancies and increased risk of disease.

Crack addicted/HIV babies: In addition to the spread of HIV/AIDS the crack epidemic brought about an epidemic of babies who were born crack addicted. The crack high dulled the physical symptoms of early pregnancy, and some women were distracted from obvious signs of pregnancy by the hectic lifestyle of buying, selling, and smoking drugs. Smoking crack cocaine was engrossing and compelling, and it offered relief from guilt and fear, but as the fetus began to move and the pregnancy became visible, conflict and stigma increased for women who continued to use drugs and the men they were with (Kearny, 1995).

The effects of drug exposure on infants are fairly well documented. General effects of drug exposure include intrauterine growth retardation, prematurity, neurophysiological dysfunction, birth defects, infections, and other effects. Cocaine related effects include neurobehavioral dysfunction, cardiovascular problems in mother and fetus, spontaneous abortion, fetal compromise, vascular disruptions, increased risk for infectious diseases, including human immunodeficiency virus (HIV), (Bandsta and Burkett, 1991) (Institute on Women and Substance Abuse).

Transmittance of the HIV/AIDS: HIV/AIDS has also grown among the heterosexual population because of the lack of education around the transmittance of the HIV/AIDS virus, as well as the driven obsession of crack and other drugs that leads to irresponsible and dangerous behaviors.

A recent study assessing sexual behavior, sexually transmitted diseases, and cocaine use in inner-city people reported that each of the HIV-positive men and women acknowledged crack cocaine use and/or other substances.

Substance abuse also put individuals at risk with their partner. Studies suggest that many men and women at high risk do not take adequate protective measures when engaging in sexual activities with someone who is known to them (Muller & Boyle, 1996). More than 28,000 (70%) of the AIDS cases among men and women are drug-related (National Institute on Drug Abuse).

Substance Abuse & Crime

It is important to include both men and women in studies of drug use and crime because of their increasing involvement in the criminal justice system, often for drug related offenses. Blumstein et al. (1986) found that women arrestees as well as male arrestees to be drug users. Similarly, of women in prison, 36% of women versus 31% of men were under the influence of drugs at the time of their offense (DOJ/BJS 1994).

There is increased criminal activity among men and women that is filling up the prisons. Studies of individuals and crack have generally examined prostitution and sex for crack exchanges (Chaisson et al., Inciardi, Lockwood, and Pottieger, 1993; Ratner, 1993). Yet there are indications that drug dealing, rather than prostitution, may be the most common crime among drug using individuals (McCoy, Inciardi, Metsch, Pottieger & Saum, 1995).

Why It is Important to Have Gender Specific Treatment In Substance Abuse Programs for men and women: It is important to have gender specific substance abuse treatment programs because it allows men and women to address the very sensitive issues that they are faced with when entering into treatment. The healing process begins when the individual can reflect on the past, reliving the discomforts that have contributed to their feelings, thoughts and behaviors. Understanding why one has deviated from the norm increases self-awareness, motivates change, and promotes one to move towards self-actualization and increased happiness.

Men and women who have been traumatized are very fearful and often put themselves at risk for being re-victimized. Putting them in a setting with the opposite sex who come with their own array of issues besides the substance abuse, often leads to some form of negative encounter. Men and women who enter into treatment must be made to feel that they will not be subjected to the same manipulation while they are seeking and expecting to receive help. Either sex who seeks help should not be made to feel re-victimized oppressed, judged, misused or abused.

Effective Treatment & Outreach for Substance Abuse

It is so very important to have effective treatment and outreach for men and women for several reasons. First, getting the person into treatment and retaining them there, which is what this paper is based on, must be approached with this in mind. Meeting these individuals immediate needs of food, clothing, shelter, medical and possible psychiatric care, is first and foremost for retention. Also, using appropriately trained professionals who are empathetic, caring and non-judgmental to assess the problems that must be addressed immediately such as entitlements, legal matters, and family situations is essential. These are the things that must get immediate attention to relieve some of the stress and worry that contributes to keeping these individuals on the street. Secondly, once they are in treatment, improving their interactions and social skills among their peers will allow them to begin developing a support network. Third, educating the men and women on relapse, relapse prevention, safe sex practices and harm reduction, in a gender specific setting, promotes a healthier way of functioning and lessens the risk for health related concerns. Also, providing educational supportive services and groups that are gender specific helps to decrease the high drop out rate of men and women who seek treatment.

Implications for Social Work Practice

Social workers, who are interested in working with the population of men and women in substance abuse treatment, must keep in mind the feelings and displacement that may be involved. Men and women must feel that they are in a setting that provides them with a safe haven, a sense of security and protection, and also understand that it must not violate the law or go against ethical practices.

The only way we will be able to combat the problem of crack addiction causing the increased spread of the HIV/AIDS virus, crack addicted babies, and heightened crime among individuals, is to advocate for change in program development. Gender specific programs within an agency must (a) address the concerns of the population in which it services, (b) develop customized programs with specialized groups for women and men, (c) develop outreach programs for men and women that are made to feel safe, empathetic, and caring to their needs, and that leads to helping them make a better more happier life for themselves and their families.

What the writer has observed and learned is agencies that offer treatment to this special subset of crack users (i.e., men and women on the street) requires special attention in prevention, treatment, and intervention programs in order to reduce their drug use and their involvement in criminal activities. This means incorporating more aggressive outreach strategies, providing appropriate ancillary services, and studying the causes of drug abuse and physical differences in addiction (McCoy, Inciardi, Metsch, Pottieger, Saum, 1995).

Furthermore, developing relapse prevention plans, aftercare programs, and altering the therapeutic approach (ex: Modifying individual and group counseling styles) to be effective as a program in meeting the needs of men and women in substance abuse issues, and retaining them in treatment, must be designed to meet gender specific needs.

National Institute of Drug Addiction research shows that men and women drug abusers get better when treatment takes care of all their basic needs. There are more than 4 million men and women in this country that need drug abuse treatment. Unfortunately, many men and women cannot enter drug treatment unless they receive help and support from family, friends, and their community. Some men and women do not know where to go to find drug abuse treatment. Studies have found that treatment programs for men and women must also include access to medical care, reading, and job training (National Institute of Drug Abuse 1994).

Social workers have to be empathetic to the concerns and needs of these individuals, and not be judgmental about what has taken place in their past. They must consider the immediate needs of the individual in order to retain them in the treatment process, and to achieve a successful outcome. Also, the one main aspect to working and dealing with an individual who has an addiction is understanding their inability to deal with life on life terms, because they have not been taught to do so.

Darlene Albury, LCSW