Addictive Behaviors, Vol. 12, pp. 137-150, 1987 Printed in the USA. All rights reserved. 0306~4603/87 $3.00 + .OO Copyright 0 1987 Pergamon Journals Ltd RECRUITMENT INTO TREATMENT AND EFFECTS OF TREATMENT FOR FEMALE PROBLEM DRINKERS FANNY DUCKERT National Institute for Alcohol Research, Norway Abstract - Literature on treatment of female problem drinkers is reviewed, focusing on the following topics: Recruitment of female problem drinkers into alcoholism treatment agen- cies, the fate of women in traditional mixed-sex treatment institutions, special treatment approaches for women, methodological problems and needs for future research. Several studies indicate that fewer women than men are recruited into alcoholism treatment agencies and that the referral routes in many ways differ from the referral routes of men. The women also report more negative effects of treatment, and are commonly looked upon as receiving less attention and less adequate care in the mixed-treatment institutions. On the other hand, a substantial number of studies of treatment outcome have shown that women seem to do just as well in treatment in mixed-sex institutions as men do. Several reports of all-female treatment programmes have been presented. Some treatment techniques may seem to have special significance for female problem drinkers, for instance self-assertiveness training and family therapy. But very few controlled studies of such programmes have been carried out up to now. INTRODUCTION In recent years there has been increasing concern over the use and abuse of alcohol by women, which has focussed interest in the treatment of female problem drinkers in many countries. The traditional treatment institutions have been gradually opened up to women, and treatment projects specifically for women have been initiated. A number of statements about the special situation and needs of female problem drink- ers have been advanced, and several recommendations for design and execution of treatment have been given. However, the basis for these recommendations has not always been quite clear; we have often witnessed a rather questionable blending of ideological, theoretical and empirical elements. These views have provoked state- ments about the nature and treatment needs of female problem drinkers which often are vague and conflicting. Attempts to evaluate the effectiveness of the various suggested treatment regimes lead to even more formidable problems. Surprisingly, few controlled studies of treatment techniques have been carried out. The same problem is found in evaluation of treatment of male problem drinkers, but seems to be more acute in the case of women. Vanicelli (1984) have shown that, in the 530 studies of treatment evaluation made during the period from 1952 to 1980, only about seven percent of the subjects studied were women. Even if it is reasonable to estimate the number of female problem drinkers as lower than for men, the proportion of women studies in research samples has historically lagged behind even the most conservative ratios of male/female drinkers. Vanicelli and Nash further demonstrated that women more often are neglected by male than female researchers. They conclude that subtle sex biases may be an important factor in the emphasis of the research literature. This Requests for reprints should be sent to Fanny Duckert, National Institute for Alcohol Research, Dan- nevigsveien 10, 0463 OSLO 4, Norway. 137
Transcript
Addictive Behaviors, Vol. 12, pp. 137-150, 1987 Printed in the USA. All rights reserved.
RECRUITMENT INTO TREATMENT AND EFFECTS OF TREATMENT
FOR FEMALE PROBLEM DRINKERS
FANNY DUCKERT National Institute for Alcohol Research, Norway
Abstract - Literature on treatment of female problem drinkers is reviewed, focusing on the following topics: Recruitment of female problem drinkers into alcoholism treatment agen- cies, the fate of women in traditional mixed-sex treatment institutions, special treatment approaches for women, methodological problems and needs for future research. Several studies indicate that fewer women than men are recruited into alcoholism treatment agencies and that the referral routes in many ways differ from the referral routes of men. The women also report more negative effects of treatment, and are commonly looked upon as receiving less attention and less adequate care in the mixed-treatment institutions. On the other hand, a substantial number of studies of treatment outcome have shown that women seem to do just as well in treatment in mixed-sex institutions as men do. Several reports of all-female treatment programmes have been presented. Some treatment techniques may seem to have special significance for female problem drinkers, for instance self-assertiveness training and family therapy. But very few controlled studies of such programmes have been carried out up to now.
INTRODUCTION
In recent years there has been increasing concern over the use and abuse of alcohol by women, which has focussed interest in the treatment of female problem drinkers in many countries. The traditional treatment institutions have been gradually opened up to women, and treatment projects specifically for women have been initiated. A number of statements about the special situation and needs of female problem drink- ers have been advanced, and several recommendations for design and execution of treatment have been given. However, the basis for these recommendations has not always been quite clear; we have often witnessed a rather questionable blending of ideological, theoretical and empirical elements. These views have provoked state- ments about the nature and treatment needs of female problem drinkers which often are vague and conflicting.
Attempts to evaluate the effectiveness of the various suggested treatment regimes lead to even more formidable problems. Surprisingly, few controlled studies of treatment techniques have been carried out. The same problem is found in evaluation of treatment of male problem drinkers, but seems to be more acute in the case of women. Vanicelli (1984) have shown that, in the 530 studies of treatment evaluation made during the period from 1952 to 1980, only about seven percent of the subjects studied were women. Even if it is reasonable to estimate the number of female problem drinkers as lower than for men, the proportion of women studies in research samples has historically lagged behind even the most conservative ratios of male/female drinkers. Vanicelli and Nash further demonstrated that women more often are neglected by male than female researchers. They conclude that subtle sex biases may be an important factor in the emphasis of the research literature. This
Requests for reprints should be sent to Fanny Duckert, National Institute for Alcohol Research, Dan- nevigsveien 10, 0463 OSLO 4, Norway.
137
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means that we still lack much important and sound scientific research about treat- ment needs and effects for female problem drinkers.
In this paper I will concentrate on the following aspects: l Recruitment of female problem drinkers into treatment. l The fate of women in traditional alcoholism treatment institutions. l Special treatment approaches which have been tried out on women, and the docu-
mented effects of these approaches. l Methodological problems and suggestions for future research strategies.
RECRUITMENT TO TREATMENT
There are several factors that might increase the willingness of a woman to ac- knowledge and seek treatment for her alcohol problems.
As an example women tend to seek help earlier for any kind of health problem, and show more favorable attitudes toward medical treatment than men (Beckman & Amaro, 1982). Several workers have observed a tendency for women to become self-critical almost immediately after they become aware that others are censuring their drinking, while men generally become self-critical much later (Mulford, 1977). Women also tend to seek help much sooner after becoming self-critical then men.
Other studies have shown that female alcoholics are more likely than males to seek treatment because of familial and interpersonal problems (Gomberg, 1974), and that they tend to be more sensitive over criticism of their drinking (Horn & Wanberg, 1973). The most common source of criticism for women tends to be their own children, while for men the major source of censure tends to be their spouses.
Thus it would appear that self awareness of a woman’s drinking problems, if accompanied by familial criticism of excessive drinking, should facilitate the desire to seek help. However, in most countries only a small proportion of the estimated female problem drinkers are treated in the special alcoholism treatment programmes. In the mixed-sex institutions they are significantly outnumbered by men. The lower alcohol consumption by women will of course give a lower number of problem drinkers. However, even when the figures are corrected for this, men are signifi- cantly more likely to use alcoholism services than women, (Beckman, 1984). On the other hand, this does not necessarily imply that female problem drinkers do not seek treatment at all. There is an observed tendency for female problem drinkers to contact psychiatric services or their own physicians (Curlee, 1970; Dahlgren & Myrhed, 1977; Beckman & Kocel, 1982; Duckert, 1984). Women may be more reluctant to seek alcoholism treatment than men. It seems that alcoholic women are more likely to seek help for marital instability, family problems, physical ailments or emotional problems, without informing about their alcohol problems (Johnson, 1965). This is probably because alcohol abuse has fewer social consequences, but more social stigma, for women than for men. Also the drinking regimen of women less often seems to be as dramatic and visible for the outside world as that of men.
Physicians in Nebraska reported that only 11% of their female alcoholic patients appeared with a specified alcohol-identified problem. The remaining 8% presented a variety of related medical and emotional problems (Johnson, 1965). The higher occurrence of use and abuse of legalized drugs by female problem drinkers (Al- doony, 1978; Corrigan, 1980; Dahlgren & Myrhed, 1977; Santo, 1978) is also an indication of rather frequent treatment contacts. However, the problem with these treatment contacts is that the alcohol problem usually remains undetected and un-
Female problem drinkers 139
treated. As a result, the drug addition problem in women is often accelerated by additional addiction.
The traditional explanation for this situation is that female problem drinkers may be adept at hiding and disguising their alcohol problems. An alternative explanation could be a resistance among ordinary health professionals against detecting and handling alcohol problems in their patients. What is interesting in connection is Beckman and Kocel’s (1982) finding that less women than men were referred into alcoholism services by conventional referral routes, the legal system, or their em- ployer’s pressures. More often they were referred by family, friends, advertisements and word-of-mouth. Beyer and Trite (1981) also found that in a job-based alcohol programme, fewer women than men had been referred by job supervisors. This may imply that supervisors more often overlook alcohol problems among female than among male employees.
Beckman (1984) studied male and female alcoholics motivation and barriers to seeking treatment. She showed that among women, families and friends were more likely to oppose their entry into treatment than the families and friends of male alcoholics. If the women were encouraged by family members to enter treatment, this was more often done by parents and children, while spouses were more likely to promote treatment for men. Women also reported more negative consequences associated with treatment entry than did men. These costs included disruptions in family relations, feeling of loneliness and discomfort, lack of money, job loss, avoidance by friends and co-workers, loss of friends and anger of spouse. These findings imply that there are more social and practical barriers for women than men to overcome, if they are to seek treatment for their alcohol problems.
Another common and somewhat conflicting finding is that the women that do seek alcoholism services usually report a shorter history of problem drinking prior to treatment (Dahlgren & Myrhed, 1977; Duckert, 1984; Lisansky, 1957). This finding has often been interpreted to indicate that the course of alcoholism is more tele- scoped in women. But an alternative explanation is, as mentioned, that women are willing to seek help for their alcohol problems at an earlier stage than men. It does not necessarily imply that women fall into decay sooner than men, but might even indicate a better treatment prognosis. The fact so few female problem drinkers seek alcoholism services may be just as much a consequence of the mode of treatment service provided and the effects of entering into treatment, as it is related to the motivation of the woman herself.
If the assumption of a greater potential willingness in women to seek alcoholism treatment than hitherto demonstrated is correct, it should be possible to increase the number of women entering treatment agencies. This would involve providing more appealing services, and to reach out to the individual sufferer more effectively than hitherto.
Few controlled studies have been done on the effect of different outreach strat- egies for treatment, but the feminist therapist Schultz (1975) has demonstrated that by instituting consideration of women’s right and needs in a mixed-sex drug and alcohol rehabilitation center, the number of women in treatment increased from 13 to 33%, and the percentage of women completing treatment increased from 35 to 59.
In their study of 53 alcoholism facilities, Beckman and Kocel (1982) found that women tended to congregate in agencies that hired more professionals, provided treatment for children and provided after-care services. They also preferred outpa- tient to inpatient services. As already mentioned, the women were to a greater
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degree recruited to treatment through family, friends, advertisements and word-of- mouth, rather than conventional referral routes, the legal system or employer’s pressures.
Cahill, Volicer, Neuburger, & Arntz (1982) showed that a special outreach to women in a job-based alcoholism programme gave an accentuated increase in the number of referrals for women. Beyer & Trite (1979) have underlined the importance of using the workplace as the referral source for treatment also for women, and have recommended that information and out-reach should be done with women- dominated workplaces and labour unions as targets.
While the spontaneous reduction of alcohol consumption during pregnancy has been documented (Little & Ervin, 1984), it is unclear if women with drinking prob- lems are more likely to seek help for these problems while they are pregnant. How- ever, the prenatal care associated with the pregnancy, presents an excellent oppor- tunity for intervention in women’s alcohol abuse problems.
In my own research, the use of mass media to advertise an experimental outpatient treatment project with a female director resulted in an increase in self-referrals of women from about 10 to 30% as compared to ordinary alcohol treatment agencies. These findings may indicate that the traditional way of entering into alcoholism treatment is not necessarily natural for women, and needs to be changed if more women are to be recruited into treatment for their alcohol problems.
Another important question is whether the treatment offered is beneficial for women. Many female problem drinkers might be better placed without treatment, if the treatment is not effective, or if the stigmatizing consequences override the even- tual positive effects of treatment. Thus, treatment evaluation must be a very impor- tant part of the research strategy on female problem drinking.
WOMEN IN MIXED-SEX INSTITUTIONS
Traditionally there has been a widespread belief that, because of their greater degree of pathology, women have been more difficult to treat than men, and there- fore have a poorer treatment prognosis (Henderson & Anderson, 1982). Another widespread belief has been that the traditional treatment approaches which have been designed for men, have been unsuitable and therefore less effective for women (Babcock & Connor, 1981).
The most important investigation of this issue has been that of Annis and Liban in their 1980 review of all available English-language reports of treatment of female problem drinking during the years from 1950 to 1978. They found in total 23 studies presenting male and female outcome information on follow-up periods varying be- tween six months and six years. Of these 15 (65%) showed no significant difference in remission rates for male and female alcoholics following treatment. Three studies (13%) supported the hypothesis of better prognosis for males, and five studies (22%) provided evidence of significantly higher improvement rates for females.
Later Vanicelli (1984) has made an analysis of further 15 studies (See appendix I). Twelve of these showed no significant difference in outcome, two showed superior
outcome for women and one showed superior outcome for men. At present, there seems to be very convincing evidence that the prognosis is just as good and treat- ment is just as effective for female problem drinkers as it is for males. Some workers even suggest that the treatment effect may be better for women since they often are in a worse situation prior to treatment, and because the social stigma associated with
Female problem drinkers 141
female problem drinkers is more severe (Rosenthal, Savoy, Greene, & Spillane, 1979; Smart, 1979).
Traditional treatment has often been criticized for not taking adequate care of female needs, and should therefore be altered or replaced with special all-female treatment programs. According to the above cited evidence, the women in mixed- sex treatment programmes perform just as well (or badly) as the males. This implies that changes in treatment would not only be an adequate demand for women, but should also be requested for the men.
The major remaining problem for treatment evaluation for both sexes is the difIi- culty of documenting treatment effects at all, because of the substantial methodolog- ical problems present in most evaluation studies (Emrick, 1975).
The low recruitment rate of women into mixed-sex alcoholism treatment is also a problem. Perhaps the women treated in traditional mixed-sex institutions are a spe- cial sub-group of female problem drinkers with a greater degree of similarity with men. Thus, the women with a different, and not so dramatic, drinking pattern will not be suitable for the traditional treatment system. In my own research I have found some evidence for this phenomenon (Duckert, 1984). If so, changes and alternative treatment programmes will be necessary for attracting new groups of female problem drinkers into treatment.
ALL-FEMALE TREATMENT PROGRAMMES
The literature contains many reports of all-female treatment programmes. These vary from in-patient institutions, more or less designed in the same way as tradi- tional treatment programmes for men, to more or less radical treatment programmes based on feminist approaches (Babcock & Connor, 1981; Kirkpatric, 1977, 1981). Very often the concern about female problem drinking has been about the role of the woman as mother. Subsequently a growing number of programmes for pregnant women and alcoholic mothers have been established (Larsson, 1983; Rosett, Weiner, McKenlay, & Edelin, 1980; Schulte & Blume, 1979; West & Lapp, 1979).
It is not always clear in what ways the programmes differ from mixed-sex pro- grammes, but some descriptional statements seem to be common. Women are looked upon as having more feelings of guilt over their drinking problems. They are viewed as more depressive, as feeling more helpless, and as displaying lower self- esteem than men. They are also observed as having more sexual and marital prob- lems. Often they have a heavy-drinking spouse, and they are reported as drinking alone. Therefore, the staff should be predominantly female, as only women can fully understand and help other women adequately.
The different programmes are more or less clearcut in their dealings with the above-mentioned recommendations. Few programmes are definite in treatment goals and descriptions of treatment techniques. Often the goals appear to be only indirectly related to drinking behaviour, although alcoholism is reported to be the target of treatment. Instead, treatment appears to focus primarily on such issues as the feminist resolution of sex-role conflicts, the improvement of family or social relationships, self-esteem and other areas of psychosocial functioning. It is implied that the problem drinking will disappear with improvement in these areas, without questioning the assumed causal relationship between drinking and other social as- pects of life. Annis and Liban (1980) assembled data on the treatment factors corre- lated with a favourable outcome for women. They found very few variables. Not
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even the sex of the therapist was documented in correlation with treatment outcome either for men or women. However, it should be noted that these workers only presented one limited study to report their case.
In another study, Henderson and Anderson (1982) conclude that there is no evi- dence that inpatient care is more effective than outpatient care (either for men or women) (Stinson, Smith, Admidjaya, & Kaplan, 1979). In general, inpatient treat- ment tends to be more problematic for women than men, due to the practical, legal and emotional problems associated with a woman’s absence from her family during residental treatment. Concerning specific techniques, Henderson and Anderson (1982) state that there is some evidence that rational-emotive therapy, assertiveness training, antabuse, sexuality groups and family therapy are effective for women. However, all these methods still lack good empirical evidence by way of controlled studies.
There have at least been 15 reports in international literature describing special treatment programmes for female drinkers (see Appendix II). Treatment contents varied considerably from traditional AA-approach and medical care (Idestrom, Dahlgren, Bergman, & Bjerve, 1984; Hatsukami & Owen, 1982; Ravndal, 1982), counselling for pregnant women (Larsson, 1983; Rosett, Weiner, McKenlay, & Ede- lin, 1980), parental training (West & Lapp, 1979), family therapy (Davis & Hagood, 1979; Muchowski-Conley, 1981, 1982), behaviour modification (Bander, Stilwel, Fein, & Bishop, 1983; Cohen, Appelt, Olbrich, & Watzl, 1979; Duckert, 1985; West & Lapp, 1979; Zwart, 1985) and more feminist approaches (Kirkpatric, 1981; Schultz, 1975). The length of the programme was often unspecified, but varied from four weeks (Davies & Hagood, 1979) up to one year (Muchowski-Conley, 1981, 1982; West & Lapp, 1979). Follow-up periods varied from none (Kirkpatric, 1981; Larsson, 1983; Mayer & Green, 1967; Schultz, 1975; West & Lapp, 1979) to a maximum of five years (Ravndal, 1982). Only two studies used random assignment to different treatment facilities (Duckert, 1983; Muchowski-Conley, 1981, 1982).
Success rate differed somewhat according to the different programme goals and different parameters examined. In terms of drinking outcome, improvement rates varied from 20% improvement (Bander & al., 1983) to almost 60% improvement (Duckert, 1985).
Three studies report use of additional parameters, namely the use of detoxification units (Schulte & Blume, 1979), employment rate (Bander & al., 1983) and of im- provement in household reported by family members (Davis & Hagood, 1979).
Only two studies reported unfavourable outcome (Mayer & Green, 1967; Muchowski-Conley, 1981/82). But both of these provided valuable information about some of the problems connected with starting group therapy with a group of female exconvicts with alcohol problems, or attempts to involve significant family members in group-therapy.
METHODLOGICAL PROBLEMS AND REQUIREMENTS
Most of the treatment evaluation studies have been carried out in the form of ordinary follow-up studies. Very few use control groups or other elements of the scientific method. The studies often lack adequate sample descriptions; the goals of treatment are vague and non-operationally defined. Also there is often an absence of measurements or descriptions of pre-treatment status. Few papers provide detailed descriptions of the theoretical foundation of the treatment, the techniques applied, or the sex or education of the therapists and staff.
Female problem drinkers 143
If future research is to provide adequate information about treatment effects for female problem drinkers, we have to make some basic requirements in terms of experimental design. These requirements would include: A description of the treatment-setting, staff and theoretical base. l A description of the client sample, both of socio-economic variables and of
baseline of alcohol and drug-using habits. l The use of randomized assignment to treatment and control group, or to two
different kinds of treatment. l A description of the treatment techniques used and time in treatment. l The number of dropouts from treatment and follow-up. l The use of follow-up periods of more than six months. l The use of operationally descriptions of results. l Analyses of both successes and failures.
Since the female alcoholic population is not homogeneous, it is most unlikely that a single form for treatment will be equally efftcacious for all. Nevertheless, conven- tional programming has almost invariably offered the same basic treatment package to all male and female admissions. Not only has the sex of the patient failed to play a major role in the nature of the services rendered, but little attempt has been made to develop treatment techniques to meet the specific problems and needs of the individ- ual patient, whether male or female.
Compared with men the different reasons given by women for seeking treatment and the different degree of acceptability of certain forms of treatment for women suggest that certain treatment modalities may have wider applicability in meeting the needs of female compared with male alcoholics. The examples of these regimes are environmental intervention strategies and family therapy.
Also important is the patient-treatment match. How do the differing charac- teristics among female alcoholics interact with specific treatment intervention strat- egies in determining long-term outcome? To learn more about this, we need to apply more reliable patient assessment procedures, and to develop better-specified treat- ment interventions than are usually provided by conventional alcoholism services.
Only by improving both the quantity and quality of treatment research will we be able to get the necessary information in order to improve treatment for female problem drinkers.
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West, M., & Lapp, L. (1979). Selfconcept and recovery of alcoholic and drug dependent women. Paper presented at the National Counsil on Alcoholism, Washington, DC.
Zwart, W.D. (1985, June). Alcoholism in women: A study in a clinic for women alcoholics. Paper pre- sented at the 31st Institute on the Prevention and Treatment of Alcoholism, Rome.
146 FANNY DUCKERT
APPENDIX I Table A-l. Sex differences in treatment outcome
Chacon, Runclell, Jones, Gregory, Williams & Paredes
Kammeier & Conley
Studies showing men more improved (N= 1)
Seelye
1975 England 1976 England 1976 Canada 1979 USA 1977 Canada 1977 USA 1978 USA 1979 USA 1979 USA 1979 USA 1979 USA 1980 USA
1978
1979
1979
USA
USA
USA
No&. From “Treatment Outcome of Alcoholic Women: The State of Art in Relation to Sex Bias and Expectancy Effects” by M. Vanicelli, 1984, In S. C. Wilsnack and L. J. Beckman (Ed%), Alcohol Problems in Women, New York, Guilford Press. Adapted by permission.
