Women and alcoholism: A biopsychosocial perspective and treatment approaches
Journal of Counseling and Development : JCD
|Authors:||Heidi van der Walde|
|Authors:||Francine T Urgenson|
|Authors:||Sharon H Weltz|
|Authors:||Fred J Hanna|
Substance abuse treatment
Viewing alcoholism in women from a biopsychosocial perspective reveals a unique set of circumstances and challenges that women alcoholics face when compared with men. Biologically, women react differently to alcohol ingestion than do men. Psychosocially, women alcoholics face societal rebuke and chastisement of a greater magnitude than do men. Barriers to treatment faced by women must be overcome to create successful treatment approaches for the female alcoholic.Copyright American School Counselor Association Spring 2002
Viewing alcoholism in women from a biopsychosocial perspective reveals a unique set of circumstances and challenges that women alcoholics face when compared with men. Biologically, women react differently to alcohol ingestion than do men. Women reach higher blood alcohol levels and sustain more somatic and cognitive damage than men when consuming equivalent amounts of alcohol. Psychosocially, women alcoholics face societal rebuke and chastisement of a greater magnitude than do men. Finally, barriers to treatment faced by women, such as the need for child care, cost of treatment, familial opposition, denial of alcoholism, and inadequate diagnostic training of physicians, must be overcome to create successful treatment approaches for the female alcoholic. Obstacles to and implications for treatment are also discussed.
Due to a complex blend of biological and psychosocial factors related to female alcohol abuse that we detail in this article, women present for treatment with a unique set of issues and challenges that must be addressed in order to foster the most supportive atmosphere for their recovery. As of 1994, Grant, Bergman, Glenn, Errico, and King identified 4 million American women aged 18 years or older as alcoholics or problem drinkers. Women for Sobriety, devoted since 1976 to education, outreach, and treatment for the female alcoholic, estimated the number of female alcoholics to be between 5 and 7 million (Kirkpatrick, 1990).
A number of biological realities combine to lead to severe organic damage at a more rapid rate in alcohol consumption for women as compared with men. According to Wilsnack, Wilsnack, and Miller-Strumhofel (1994), a woman's susceptibility to the physiological consequences of alcohol abuse is higher than that of a man's. Among the reasons for the difference is the way men's and women's bodies respond to alcohol (Deal & Galaver, 1994). These circumstances can be partly explained by the fact that alcohol is more soluble in water than in fat (Deal & Galaver, 1994).
The fact that women's bodies contain more fatty tissue proportionately than do men's bodies means that the same quantity of alcohol consumed by both a man and a woman of equal size will result in a higher blood alcohol level for the woman. In addition, women have been shown to produce less alcohol dehydrogenase, which is the stomach enzyme that breaks down alcohol. The consequence of this enzymatic differential is that women break down less alcohol in the digestive process and, thus, again will show a higher blood alcohol concentration than men (Deal & Galaver, 1994). In fact, according to Deal and Galaver, "the hypothesis of increased absolute bioavailability of alcohol in women is supported by scientists who believe women are more susceptible to liver disease, as well as those who believe men and women are at equal risk for developing the disease" (p. 190).
Various studies reported since 1977 (e.g., Krasner, Davis, Portmann, &Williams, 1977; Peres, Gavallero, Brugera, Torres, & Robes, 1986) have shown that the risk for developing cirrhosis is higher in women than in men who consume equal amounts of alcohol. Although the risk for cirrhosis increases with increasing alcohol consumption for both genders, both sets of data support the hypothesis that women are more susceptible to alcohol-induced cirrhosis than are men at each consumption level (Deal & Galaver, 1994, p. 191). In addition, Deal and Galaver have hypothesized that women's increased susceptibility to alcohol-induced liver disease is not the only factor in women's development of cirrhosis. Gender-specific mechanisms may also be at work, according to Deal and Galaver. In populations of those who continued to drink alcohol after being diagnosed with alcoholic hepatitis, more women than men progressed to the more severe form of liver disease, cirrhosis. Among! those in the group who stopped drinking after being diagnosed with alcoholic hepatitis, more women than men died or progressed to cirrhosis more rapidly. Clearly the female alcoholic seems to be at increased risk of death or permanent disability compared with her male counterpart (Deal & Galaver, 1994).
Another area of increased vulnerability for the alcoholic woman concerns the damage done to cognitive functioning as a result of long-term alcohol abuse. According to Nixon (1994), when four domains of neurocognitive functioning-verbal skills, visual-spatial performance, verbal memory, and set-shifting flexibility-were measured, alcoholics of both genders performed more poorly than did nondrinking controls. What was both significant and relevant to the current discussion was that women alcoholics reported shorter durations of consumption and smaller quantities of alcohol consumed when compared with men.
These findings suggest the possibility that women may be more vulnerable to cognitive impairment than are men. In a recent study by Ginsburg et al. (1996), the hormonal patterns of women were studied with particular attention to the effects of alcohol on estrogen levels in postmenopausal women taking estrogen replacement therapy. Ginsburg et al. set out to determine if moderate alcohol use, defined as one to two drinks daily, increased the circulating estrogens in the study population. The findings of this investigation were remarkably revealing. Moderate alcohol consumption increased the circulating estrogen levels of postmenopausal women by 300%. This finding is particularly alarming given that increased levels of circulating estrogens have been linked to a marked increase in the development of breast cancer (Colditz, Stampfer, & Willet, 1990). In one large study conducted by Thun et al. (1997), the death rate from breast cancer was 30% higher among middle-aged and ! elderly women reporting only one drink daily than among nondrinkers.
Breast cancer in women is not the only health risk associated with alcohol consumption that seems to be hormone related. As previously noted, women progress to cirrhosis of the liver at more rapid rates than do men when consuming smaller quantities of alcohol. Tivis and Galaver (1994) hypothesized that alcohol-hormone interaction may influence the development of alcohol-induced liver disease in postmenopausal women who are moderate to heavy drinkers. Not only does moderate consumption of alcohol lead to hormonal imbalances in women, but a link has been established between infertility, miscarriage, spontaneous abortion, and fetal alcohol syndrome and effects when alcohol is consumed by women of childbearing age. The larger the quantity of alcohol consumed, the more severe and frequent these negative occurrences can be (McCaul & Furst, 1994).
Fetal alcohol syndrome and effects (FAS/E) is one potential result of alcohol consumption. Although abstinence provides 100% protection for the fetus, the effects of "moderate" drinking, defined as four drinks a day, are not clear (Jacobson & Jacobson, 1999). According to a report cited by Jacobson and Jacobson, 4 times as many pregnant women drank frequently (seven or more drinks per week or five or more drinks on at least one occasion) in 1995 (3.5%) as in 1992 (0.8%). This statistic translates into thousands of newborns at risk for being born with incurable birth defects caused by the alcohol consumption of their mothers. Research by Royce and Scratchley (1996) suggested that there is a link, in some cases, between dyslexia, learning disabilities, and minimal brain damage and alcohol consumption by pregnant women.
Debate continues as to whether alcoholism is primarily genetically determined or whether it is more the result of personality and coping style, environmental influences, cultural influences, or a combination of these factors. According to Schuckit and Jefferson (1999), genetic factors account for approximately "half the risk for alcoholism."This is confirmed by studies of adoptive children showing that children of alcoholics who are raised by nonalcoholics still have an increased risk of alcoholism. Until the beginning of this decade, the study of genetic factors in the causation of alcoholism was concentrated largely on male populations. Lately, forwardthinking researchers have undertaken the study of these influences in female populations as well. Hill (1995) has identified two forms of alcoholism that seem to be genetically influenced. The first is a severe form of early-onset alcoholism, which often presents before age 21 and is characterized by a high density among f! irst-degree relatives. The second type is a later onset form, which often does not appear until middle age and seems to be triggered by negative life events such as loss of a significant other or other environmental influences. Early-onset alcoholism is a serious progressive disorder that can recur from generation to generation. It is interesting that a possible marker for this type of genetically mediated form of alcoholism seems to be the P300 brain wave. This can be measured by an electroencephalogram. The P300 is an event-related potential in the brain that is measurable as a response to an unusual stimulus, such as hearing a loud tone mixed with soft tones or viewing a red dot in the middle of green squares. In the testing situation, when the research participant sees or hears the dissonant stimulus they are asked to press a button. The amplitude or height of the P300 wave is then correlated with the observation of the stimulus. Women with the earlyonset type of alcohol! ism show a marked decrease in the amplitude of the P300, which is correlated with significant deficits in the information processing functions in the brain (Hill, 1995). Curiously, the children of early-onset alcoholics have also been shown to have decreases in the P300 amplitude when compared with the children of nonalcoholic mothers (Hill, 1995). These children have not yet been followed prospectively to see how often they develop alcoholism. This is an important avenue deserving further exploration.
Keeping in mind that psychosocial factors can only be fully understood from a systemic perspective, the psychosocial realities of women who are alcoholics differ significantly from those of alcoholic men. Women have consistently suffered special social and emotional consequences for drinking. Alcoholic women experience discrimination of an increased magnitude compared with alcoholic men, due to "sex-biased attitudes" (Carter, 1997, p. 473) social stigma, double standards, differing expectations for men and women, and the fact that women are an oppressed group in numerous cultures.
The etiology of alcoholism in women and societal perceptions of women who drink can be more fully understood in the context of Finkelstein's (1993a) relational model. Significant research indicates that a woman's development and experiences throughout her lifetime are in the context of relationship to others (J. B. Miller, 1986). It is within this context of relationship to others that societal attitudes toward alcoholic women and women's views of themselves exist (Finkelstein, 1993a).
Societal expectations of women seem to be intricately linked to prescribed roles such as wives, mothers, caretakers, nurturers, and sexual partners. When women deviate from prescribed roles, they are often stigmatized. In a study of the historical perspective of female alcoholics, "alcoholism in women has been linked to the absence of femininity, sexual misconduct, and parental neglect" (Carter, 1997, p. 472). Although lack of control is negatively attributed to men, it is far more stigmatizing for women, who are supposed to be docile, submissive, responsible, and "avoid unrestrained behavior" (Lex, 1994, p. 216). Alcoholism in women is often viewed as deviant behavior, and as late as the early 1900s, chronic drinkers could be committed to "insane asylums" and receive involuntary hysterectomies (Carter, 1997). This attitude toward alcoholic women remains prevalent in current American culture. Women who drink continue to be seen as sexually promiscuous and neglectful of th! eir significant other and of their children (Carter, 1997).
Research regarding the correlation between women's drinking and increased sexuality is inconclusive. Unfortunately, the myths surrounding female alcoholism and promiscuity place women at increased risk for sexual assault and rape (Norris, 1994). In a study conducted with male and female college students based on both actual incidents and hypothetical examples, the use of alcohol implied consent in a rape situation and drastically altered attitudes toward both the assailant and the victim wherein, frequently, the male was not held responsible for his behavior and the blame was placed solely on the female victim (Norris, 1994). The study is alarming and demonstrates the need for education concerning issues of alcohol and sexuality.
There is research suggesting that, in many cases, alcohol-- abusing women experience sexual dysfunction (often as a result of a history of trauma) prior to drinking and, in fact, are quite ambivalent about sex. Women may use alcohol to self-medicate and to alleviate tension in anticipation of potential intimate encounters (Beckman, 1994; Norris, 1994). However, because of the deleterious effects of alcohol on sexual functioning, a woman may continue to drink as a way to cope with increased feelings of inadequacy and begin a downward spiral. Research is unclear as to whether sexual dysfunction is a cause or a consequence of alcoholism in women (Norris, 1994).
Stress and distress seem to be prevalent factors in the development of a woman's alcoholism (Gomberg, 1994). There is significant research linking women's alcoholism to childhood sexual abuse (Beckman, 1994; Dansky, Saladin, Brady, Kilpatrick, & Resnick, 1995; Gomberg, 1994; Langeland & Hangers, 1998; B. A. Miller & Downs, 1993; Wilsnack et al., 1994). It is estimated that somewhere between 30% and 80% of alcoholic women were victims of incest, although researchers disagree as to whether there is a direct correlation between sexual abuse and alcoholism or whether the lack of a nurturing family environment in itself is a precipitant (Gomberg, 1994). Many women who have suffered sexual, emotional, or physical abuse may develop posttraumatic stress syndrome (PTSD) and use alcohol to self-medicate this disorder. It is estimated that women with PTSD are 1.4 times as likely as other women to develop alcoholism and drug dependency (Dansky et al., 1995).
Both men and women seem to have distinct outcomes and coping mechanisms for surviving a turbulent childhood, especially in cases when physical, emotional, or sexual abuse is present. Although this varies across cultures, for many women the experience can lead to self-destructive behavior, anxiety, depression, poor self-esteem, difficulty in trusting others, and internalized anger and hostility (Langeland & Hartgers, 1998). Alcohol-abusing women, similar to women in general, tended to internalize their feelings, whereas men generally channeled their feelings outward in the form of aggressive behavior (Langeland & Hangers, 1998; Lex, 1994). There is a greater incidence of anxiety and depression among alcohol-abusing women than among men, and women are often seen with secondary diagnoses of mania, somatization, major depression, panic disorder, and phobic disorder (Beckman, 1994). Alcoholic men on the other hand tended to demonstrate more antisocial behaviors (Lex, 1! 994). When women alcoholics presented for treatment, they did not view their drinking as a problem but as a coping response to a crisis or problematic situation (Beckman, 1994). Studies indicate that women who feel powerless over their circumstances may drink as a coping mechanism (Beckman, 1994). This sense of powerlessness, passivity, and the experience of oppression found in alcohol-abusing women has important implications for treatment.
Because women frequently assume a greater responsibility for others than do men (Center for Substance Abuse Treatment [CSAT], 1994), they will drink if they are having problems in their significant relationship, with their family of origin, or difficulty with their children (Beckman, 1994). However, because there is such a strong stigma associated with alcoholic women, the guilt and shame for their "inadequacy to fulfill their roles as wife, mother and sexual partner" (Beckman, 1994, p. 208), is compounded, creating a vicious cycle. Many women have a tendency to define themselves in relation to others (Culp & Beach, 1998; Jordan, Kaplan, Miller, Stiver, & Surrey, 1991), and researchers have found that because of this tendency, many women drink in response to the multiple losses they experience throughout their lifetime (Gomberg, 1994). In general, losses include divorce or death of parents; inconsistent, unavailable, or neglectful behavior of parents that is due t! o their own alcoholism; or a sense of disconnection from themselves and others due to family abuse and violence (Cirillo, 1994). In adulthood, women seem to drink mostly in response to divorce, empty-nest syndrome, and widowhood (Gomberg, 1994).
Another important point is that the onset of alcoholism in women seems to occur later than for men, and, once again, seems to be related to a sense of disconnectedness (Finkelstein, 1993a). In general, men seem to do their heaviest drinking during young adulthood, whereas women's heavy drinking occurs during midlife. Research of alcohol-abusing women by age groups indicated that those in the youngest group who drank (ages 21-34) were single, childless, and not employed; women who drank between the ages of 35 and 49 were divorced, separated, not employed, or had children living outside the home (Gomberg, 1994). Women often drink to gain a sense of connection, but due to the social stigma of alcoholism, drinking only serves to increase a woman's sense of isolation, loneliness, and disconnection. "Because of the centrality of relationships in a woman's life, this isolation which is exacerbated by alcohol use can be terrifying and destructive to her sense of self' (Finkelstei! n, 1993 a, p. 50).
Although there is some variation across cultures, research indicates that a woman's drinking is highly influenced by her peer group or significant other (Hughes & Wilsnack, 1994; Lex, 1994). Studies of adolescents revealed that more girls than boys drank to fit in with their peers. Drinking in boys was related more to individual characteristics (Gomberg, 1994; Wilsnack et al., 1994). In general, women cited more social reasons for drinking than did men (Lex, 1994). Women reported use by their significant others as a primary reason for their own alcohol or substance use (Gomberg, 1994; Wilsnack et al., 1994).
Family history of alcoholism places women at increased risk for becoming alcoholic (Gomberg, 1994). Issues that are prevalent for all women in society are compounded for female children of alcoholics. In addition to abuse and neglect, these women learn to deny their own needs and feelings, are hyper-responsible, blame themselves for the problems of others, and lack an outlet for expressing their pain (Finkelstein, 1993b). The stress experienced by female children or adult female children of alcoholics, can lead women to self-medicate through drinking (Gomberg, 1994). Research indicates that a significant number of women from alcoholic families tend to partner with men who are also alcoholic or drug-addicted (B. A. Miller & Downs, 1993). The male partners are often verbally, emotionally, physically, or sexually abusive and isolate the women from friends, family, and outside connections. The abusive relationship reinforces the woman's lack of self-worth, hopelessness, a! nd powerlessness, all combined with poor coping skills, and places these women at an extremely high risk for becoming an alcoholic.
TREATMENT ISSUES AND IMPLICATIONS: A BROAD SPECTRUM OF SERVICES
A review of the past literature and research in the field of addictions that deal with alcohol abuse and dependence reveals the lack of research and attention given to women by researchers in this field (Copeland & Hall, 1992; Hodgins, El-Guebaly, & Addington, 1997). Historically, alcoholism has been seen as a male disorder, and all criteria for diagnosis and treatment were based on male characteristics (Vannicelli, 1986). As we have attempted to document, it is apparent that whether physical, social, or psychological in nature, the etiology of alcoholism in women differs from that of men. They differ in both causes and consequences. Although the research in the field is scarce, and often unknowingly incorporates myths about women, the majority of recent studies point to the necessity of gender-specific treatment. Most of the literature confirms that genderspecific treatment is most effective (Hodgins et al., 1997; Walitzer & Connors, 1997).
In a study by Dahlgren and Willander (1989), womenonly and mixed-gender treatment were compared. With all aspects of the treatment the same, except for a special focus on women's problems, the women in this special focus group remained in treatment longer, had higher completion rates, and improved biopsychosocial rates compared with women who were in mixed-gender programs. In mixed-gender treatment groups, men and men's issues tend to dominate discussions (Hodgins et al., 1997). Therefore, this indicates a need for groups that are exclusively female to help women confront and confide those issues that might never be touched in a mixed-gender group. This does not necessarily mean that the treatment applied for men cannot be used for women, or that all women require the same treatment modalities, of course. However, there are certain characteristics that are uniquely female that must be included in any treatment or intervention program for women (C. A. Hanna, Hanna, Giordan! o, & Tollerud, 1998). Many of the factors that contribute to female alcohol dependence and abuse also deter those women from seeking treatment for their problem in facilities specializing in the treatment of alcoholism. Thus, many of the barriers to treatment and the features of intervention and treatment for women are discussed in the following paragraphs.
Several studies have concluded that women have underutilized treatment programs for alcohol-related problems compared with men (Walitzer & Connors, 1997). The obstacles for diagnosis and treatment originate from the same myths, stereotypical thinking, and stigmatization of women who abuse alcohol. One of the major myths is that women are more difficult to treat (Copeland & Hall, 1992; Vannicelli, 1986). This may come from the fact that until recent times, virtually all alcoholic treatment was male oriented (Walitzer & Connors, 1997). Thus, women were less likely to have their needs met in treatment facilities and, therefore, did in fact experience more failure. Treatment outcome statistics were skewed because women presented in such small numbers and with more serious pathology. In critiquing the research in the field over a 9-year period, Vannicelli (1986) noted that "of the 23 studies surveyed, 18 showed no significant difference in treatment outcome between! male and female alcoholics. Four studies showed superior outcomes for women and one showed a superior outcome for men" (p. 381). However, there is much evidence to show that negative expectations can produce poor outcomes in therapy and slow the process of therapeutic change (Bandura, 1977; F. J. Hanna, 1996; W. R. Miller, 1985). In a study designed to assess the outcome of treatment for women, the most crucial variable for success was the professional staff's positive prediction for that client (Corrigan, Butler, & Camasso, 1995). W. R. Miller (1985) also noted the importance of positive expectations for clients by counselors.
Other barriers to treatment for women with alcoholism have to do with the stigma attached to women who are problem drinkers. The shame and guilt experienced by women prevent them from seeking treatment. Many more women than men deny that they have a drinking problem and, unlike men, tend not to see drinking as their main problem. They see it as a mechanism for dealing with a specific crisis or difficult social situation or they focus on the physical symptoms (Beckman, 1994). Therefore, women tend to delay seeking help for their problem or pursue help from physicians or mental health services other than alcohol treatment services. Diagnosis and treatment of alcoholism are further impeded by the fact that many doctors and many counselors are less effective in diagnosing women than they are diagnosing men (Beckman, 1994) and tend to misdiagnose women. The many myths about women and alcohol not only lead physicians to misdiagnose the symptoms but also to offer prescription dr! ugs to treat the psychological symptoms rather than the alcohol abuse itself Ironically, the less the alcoholic woman resembles the myth of the "sexually immoral woman," the less likely it is for her to be correctly diagnosed (Blume, 1997).
Other obstacles to women seeking treatment for alcoholism involve the socioeconomic position of women in society. Often, a woman's role as nurturer of and primary caregiver for children can interfere with treatment. Many women will not present to treatment because they have no alternative care for their children, and they often drop out of treatment when there is a problem with their children (Blume, 1997; Cirillo, 1994). There is also the real fear that they will be considered to be unfit and have the children taken away. Some laws include the abuse of alcohol by a parent as child abuse or neglect (Blume, 1997). Pregnancy itself can be a barrier for treatment for women. Laws in some states provide criminal consequences for women who are abusing drugs or alcohol during pregnancy. Estimates collected by attorneys representing pregnant and parenting women document that at least 200 women in more than 30 states have been arrested and criminally charged for drug use during pr! egnancy (Paltrow, 1998). In addition, many treatment programs will not accept pregnant women for fear of liability (Finkelstein, 1993b). Such prominent health organizations as the American Medical Association, American Academy of Pediatrics, and the National Counsel on Alcoholism and Drug Dependence recognize that punitive approaches often frighten women away from treatment. Instead of seeking help, some women opt to deliver their children at home instead of facing reprisals from authorities (Paltrow, 1998). Even groups who place the rights, protection, and treatment of children in the forefront, such as the March of Dimes and the Center for the Future of Children, recognize the detrimental effect of punitive approaches (Paltrow, 1998). Clearly, drug- and alcohol-abusing pregnant women are better off in treatment. A further barrier to treatment is that women are less likely to get support from family and friends, both in entering treatment and while they are in treatment, th! an are their male counterparts (Beckman, 1994).
Economic concerns are a significant barrier to treatment of alcoholism for some women. Often, men divorce their alcoholic spouses. Women are left with fewer financial resources and lack of adequate insurance coverage. Although both men and women are affected by the lack of insurance coverage for alcohol treatment, women are more likely than men to be underemployed and therefore underinsured (Blame, 1997). Finally, the absence of gender-specific treatment further impedes treatment for women. As stated earlier, many women who abuse alcohol have had a history of sexual and physical abuse. These issues can prevent women from seeking treatment unless the program provides for opportunities for women to work through these issues in a safe, gender-- sensitive environment (Copeland & Hall, 1992).
Because women who abuse alcohol represent a wide range of socioeconomic, chronological, race, lifestyle, and ethnic diversity, there is probably no single intervention strategy that would be effective for this heterogeneous group. As of this writing, research has not disclosed those interventions that are most effective for women. However, some qualitative researchers (Dahlgren &Willander, 1989; Davis, 1997) have specified certain guidelines that should be included in a comprehensive treatment approach for women. These include remedies for the physiological, psychological, and social problems that brought about the alcohol dependency. Thus, effective alcohol abuse treatment must meet the social, medical, economic, cultural and emotional needs of women (Brown, 1992). Of course, it must also address the barriers that prevent women from entering and completing treatment.
Critical to female-oriented alcohol treatment is the understanding by the treatment professionals of the status and role that women have in American society and the history of oppression women have experienced. The gender of the counselor is not significant (Braiker, 1989), but research has shown the women do better in counseling with those counselors that are more adept at interpersonal skills, more empathic, and less focused on problem solving, at least initially in the therapeutic process (C. A. Hanna et al., 1998). In addition, understanding, respect, and optimism concerning positive outcomes for women are crucial. Treatment must take into account the manner in which women relate to the world and others and should promote an environment that encourages self-efficacy (Beckman, 1994). Training in social skills and problem-solving skills encourages self-confidence and more supportive relationships with friends, family, and the community, allowing these women to overcome ! the social isolation they experience. In alcoholism treatment for women, an important element is fostering new social roles and the coinciding support network that leads to the development of new relationships. This approach acknowledges that alcoholism is a contextual problem and must be viewed as such for treatment to be effective (Beckman, 1994).
Family services are another important component of alcohol treatment for women. Child care assistance is an essential element for women to enter and maintain treatment. Parenting skills training helps improve a woman's confidence in the childrearing role. This approach also addresses and alleviates some of the shame and guilt that frequently plague women alcohol abusers. In addition, family therapy is helpful in dealing with the impact that a mother's drinking has on family systems. Involvement of the family can enhance women's recovery and seems to help in reducing the client's effort to sabotage treatment in the interest of her addiction. The spouse and children of clients can also be referred to self-help groups specializing in children and youth. These groups include Al-Anon and Alateen.
Vocational counseling and education are other elements in gender sensitive treatment for women. Often, women do not present to treatment until they have reached a low point of desperation (Cirillo, 1994). To build self-esteem and create empowerment, it is important for a woman to develop skills and training to support both herself and dependent children. Educating women on the hazards of alcohol and safe quantities of consumption is a way of limiting the physical and psychological impact of alcohol. Clients can attend classes, read literature, and receive personal explanations from counselors about the dangers of alcohol ingestion both to them and their fetus (Braiker, 1989). One study demonstrated that just 5 minutes of intervention was enough to change the quantities of alcohol ingestion (World Health Organization, 1996). Because a large percentage of women dependent on alcohol have histories of sexual and physical abuse, the addition of culturally sensitive assertivene! ss training facilitates feelings of empowerment rather than feelings of victimization. Culturally sensitive assertiveness training can help the client express personal rights and feelings to others to improve communication and interpersonal relations (Fellios, 1989). A treatment approach based on empowerment is also helpful for women who have been sexually and physically abused.
Legal assistance is another element of a comprehensive program for women. As discussed earlier, women are often penalized by laws that punish them for being alcohol dependent. Frequently they are taken advantage of by the U.S. system of justice, which can have a double standard for men and women. In one case cited by Blume (1997), alcohol abusing women who were entitled by law in Massachusetts to receive treatment were jailed as criminals instead.
Treatment-sensitive programs for women must include experts in physiological and reproductive functions and other health services. Detoxification may also include withdrawal from prescription drugs because many women have multiple addictions (Cirillo, 1994). In addition, as documented earlier, women are faced with more severe physical symptoms than those of their male counterparts. It is essential to enlist medical professionals who specialize in the treatment of the physical vulnerability of alcoholic women. In addition, prenatal counseling and care are important elements of treatment because of the possibility of the physical effect of alcohol on the fetus during pregnancy.
APPROACHES TO COUNSELING AND ASSESSMENT
Of course, successful treatment of alcohol abuse in women must include counseling to address the full spectrum of psychological issues addressed earlier in this article. Treatment can be delivered in individual and group counseling modalities and can be based on a wide range of approaches and theoretical backgrounds. However, all three modalities-individual, family, and group-are important because each addresses a vital aspect of a client's life functioning. Because of the multitude of issues that alcohol abusing women often face, such as a history of sexual and physical abuse, individual counseling approaches to adequately assess their needs would be beneficial. As research indicates, there is often a demonstrated multigenerational transmission of alcoholism; thus, family therapy would be indicated to address these issues when they are present (Finkelstein, 1993b). Research indicates that female alcoholics are often isolated and cut off from traditional sources of suppor! t. Thus, participation in a group could restore a vital connection and establish new sources of support (CSAT, 1994). The setting can be an inpatient or outpatient facility. Finally, setting up and reinforcing attendance in support groups and self-help groups made up entirely of women is an important element in maintaining recovery from alcohol dependence (Beckman, 1994).
It is most crucial, however, to match the counseling to the particular client in order to address her individual concerns and therapeutic needs (Beckman, 1994). "The family and/or significant others should be involved only when the counselor or case manager believes that such involvement will help the client's healing process" (CSAT, 1994, p. 162). It is evident that the needs of a woman are clearly different from those of her male counterpart. As previously stated, it is our view that the most effective treatment for the female alcoholic is one in which her unique biological, psychological, and social concerns are addressed and the many barriers to treatment are removed. As a first step, an aggressive program of education and outreach should be adopted.
Because of the accelerated pace at which the female alcoholic falls prey to the physical effects of drinking, the earlier a woman enters treatment, the better. As previously mentioned, every effort should be made to ameliorate the guilt, shame, and stigma that plague the female alcoholic. Thus, individual counseling treatment approaches provide the counselor with time to concentrate and maintain the focus of treatment through the use of individual techniques such as confrontation, empowerment, encouragement, and assertiveness.
The Center for Substance Abuse Treatment (CSAT), a division of the Department of Health and Human Services, prepared a document in 1994 that sets forth recommendations for treating the female alcohol abuser. It was prepared by a diverse group of substance abuse professionals from public, private, and academic sectors. The document provides recommendations for designing treatment strategies based on racial, ethnic, and cultural variables. Most crucial for successful treatment is a thorough intake orientation and assessment process. It is through this interaction that a comprehensive treatment plan that includes specific goals along a defined time frame are developed. Intake can also be a time for the mutual gathering of information and most significantly, laying the foundation for the therapeutic relationship. CSAT's (1994) Task Force went on to state:
In view of the possibility that the client may have experienced sexual abuse, it is preferable, for the first point of contact at intake to be with a female counselor. If not possible, male counselors who carry out the intake interviews with female clients should be trained in gender-related issues. (p. 62)
During this time, the critical educational process begins for the woman as well as her family. This may help the client to "forgive" herself, and if the family or significant others participate, may help to change those judgmental attitudes that hinder recovery (CSAT, 1994).
It is not surprising that many of the standardized instruments used to detect and measure alcohol abuse are not valid for women because most measurement instruments were constructed for use with men (CSAT, 1994). However, the ASI (Addiction Severity Index) has been adapted for women, and the College of Nursing at the University of North Carolina has developed and initially validated an instrument to measure alcohol abuse in women (CSAT, 1994). A complete psychological and physical assessment and history should be made at this time, with particular attention to the unique physical and psychological aspects of being a woman. In addition, the woman's relational, parenting, economic, educational, sexual, and legal status should be ascertained, and any pressing issues that may have a negative impact on her treatment program should be noted so as to be later addressed during treatment (CSAT, 1994). An essential part of the assessment process, especially for women, is an overvie! w of a client's strengths and skills that they will be able to call on during treatment. This is also an important part of the empowerment process.
Based on the assessment, a formal treatment plan is written that incorporates client initiated goals and a mutually agreed upon timetable (CSAT, 1994). Components of the treatment should include physical and mental health professionals (i.e., consulting physicians, educational and developmental specialists, and a child care specialist; CSAT, 1994). Such an approach should lead to a team recommendation concerning the number of individual and group counseling sessions, and, if necessary, the plan will outline the means to facilitate client attendance in self-help programs such as AA, Women for Sobriety, or Rational Recovery (CSAT, 1994). We recommend that the counselor take on the role of team coordinator, that is, the role of making sure that what is outlined in the treatment plan is being followed.
Spirituality is one aspect of treatment that should be included in all counseling approaches. One researcher remarked that the practical wisdom of people in recovery and of professional addictions counselors concerning the importance of a spiritual awakening to recovery is now backed by empirical research (O'Connell, 1999). Given a broad-based concept of spirituality that focuses on personal empowerment and crosses cultural and religious boundaries, treatment programs can provide an environment that facilitates clients' spiritual journeys (CSAT, 1994, p. 191). Meeting the spiritual needs of the alcohol-abusing woman can assist her, at the most vulnerable time, to reconstruct a meaningful approach to life and renew relationships that have become obscured by her addiction. Traditional professional treatment approaches can also be quite compatible with AA and the 12-step approach (F. J. Hanna, 1992).
In addition to the biopsychosocial approach already presented, it is vital that counselors address additional issues in the treatment program. These include other harmful behaviors such as eating disorders; general health and hygiene; current level of self-esteem; disability-related issues, if applicable; race, ethnicity, and cultural issues; gender discrimination; issues of sexuality and sexual orientation; relationships with family and significant others; unhealthy interpersonal relationships; past and current interpersonal violence including incest, rape, battering, and other abuse; issues related to parenting, child care and child custody; presence of grief related to the loss children or other significant relationships; employment issues; feelings of isolation and loneliness; and life planning (CSAT, 1994). Finally, it is very important to clearly identify and discuss with the client all their biopsychosocial-- related strengths. These should be referred to frequentl! y and should be built upon during the course of treatment. Because women who abuse alcohol present with a unique set of challenges, all of the aforementioned issues must be successfully addressed if women are to achieve and maintain sobriety. Focusing solely on the issue of alcoholism is insufficient to promote a successful outcome (CSAT, 1994; F. J. Hanna, 1996).
In working with women who abuse alcohol, it is essential for treatment providers to consider the following guidelines:
* Bear in mind that women present with a unique set of biological vulnerabilities to alcohol.
* Bear in mind that women are often the primary caretakers of children.
* Women who abuse alcohol often have histories of physical and sexual abuse.
* Women, especially if they are pregnant, may be reluctant to seek treatment.
* Women are especially susceptible to being influenced by their peers, significant others, and family members.
* Continuing care must be comprehensive and focused on individual needs of each woman.
* Designing and implementing successful treatment strategies require racial, ethnic, and cultural knowledge and wisdom, as well as competency to work with diversity issues.
* Women who abuse alcohol must deal with a significant social stigma.
In light of the evidence that alcoholism has a devastating effect on women, it is profoundly disheartening that prevailing societal attitudes continue to stigmatize and punish alcoholic women. Until the perception of alcoholism in women is no longer biased by the distorted views and expectations held about women by both men and women, women will continue to suffer and fail to present themselves for treatment in numbers that would reflect the true magnitude of the problem. However, the guidelines for treatment programs just outlined may be of use for meeting the needs of this highly misunderstood population. We hope that through increased outreach and educational efforts, prevailing societal attitudes will begin to evolve toward a greater understanding of the distinct challenges confronting women who abuse alcohol.
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Heidi van der Walde is a licensed clinical professional counselor and certified addictions specialist currently working at the Montgomery Commission for Women, Family Services Agency Inc., and the Frost Counseling Center in Montgomery County, Maryland. Francine T Urgenson is a counselor and intake coordinator at Family Services Agency Inc. in Gaithersburg, Maryland. Sharon H. Wetz is a staff counselor at The Lighthouse Youth and Family Services in Catonsville, Maryland. Fred J. Hanna is an associate professor in the Department of Counseling and Human Services at Johns Hopkins University in Baltimore, Maryland. Correspondence regarding this article should be sent to Heidi van der Walde, 932 Hungerford Drive, Suite 36-B, Rockville, MD 20850 (e-mail: firstname.lastname@example.org).