Special

 Popula,ons:  Women,  Older  

Adults,  LGBT,  Individuals  with  HIV  
Psychological  Treatment  for  Substance  
Use  Disorders  
Week  10  
Nancy  A.  Haug,  Ph.D.  
 Women  with  SUD  
•  Gender  gap  is  closing  
•  Risk  factors:  
–  Gene,cs  
–  Exposure  to  trauma  (sexual  abuse)  
–  Change  throughout  the  lifespan  
•  Adolescence:  boyfriend,  best  friend,  older  female  rela,ve;  
stressful  family  dynamics,  ED,  early  onset  puberty,  
transi,ons  
•  Midlife:  children  leaving  home,  partner  infidelity,  divorce  
•  Older:  death  of  partner,  social  isola,on  
 Women  and  Alcohol  
•  Women  more  likely  to  drink  alcohol  for  self-­‐medica,on  
than  men:  
–  Depression  
–  Anxiety  
–  Lower  self-­‐esteem  
•  Telescoping  effect  of  alcohol  
–  Dependence  progresses  more  quickly  
–  Longer  to  metabolize;  more  deleterious  effects  on  organs  
–  Higher  BAC  
–  Female  reproduc,ve  health  
•  Estrogen  levels  
•  Response  to  drugs  changes  with  menstrual  cycle  
 Women  and  Smoking  
•  Cri,cal  women’s  health  issue  
•  Women  who  smoke  have  higher  rates  of  
physical  problems  than  men.  
–  Cancer,  infer,lity,  stroke,  heart  disease  
•  Smoking  during  pregnancy  
–  18%  girls  between  15-­‐17  (SAMSHA,  2011)  
–  22.7%  women  ages  18-­‐25  (SAMSHA,  2011)  
–  11.8%  women  ages  26-­‐44  (SAMSHA,  2011)  
 Women  and  prescrip,on  drug  misuse  
•  Higher  among  girls  and  women  than  boys  and  
men  à  women  not  reducing  rx  use  as  they  
age  
•  Physicians  more  likely  to  prescribe  to  women  
than  men  
•  Pharmaceu,cal  companies  target  women  
•  Accepted  in  culture  
 Women  and  Illicit  Drug  Use  
•  Women  less  likely  than  men  to  use  illicit  drugs  
but  use  has  increased  in  women,  especially  in  
younger  popula,ons  
•  4.7%  women  use  marijuana  (9.1%  men)  
•  0.4%  cocaine  (0.8%  men)  
•  0.1%  heroin    
–  Women  oeen  introduced  to  heroin  by  men  
–  More  likely  to  have  hx  of  childhood  abuse,  partner  
violence,  psychological  problems  
–  More  likely  to  begin  with  painkillers  
 
 Women  and  SUD  
•  White  women  >  Black,  La,no,  Asian  women  
•  Acculturated  women  >  less  acculturated  
•  Lesbian,  bisexual  women  >  heterosexual  
women  
•  Women  with  compe,ng  family  and  work  
responsibili,es  are  at  greater  risk  for  SUD    
 Barriers  to  Treatment  for  Women  
•  Women  are  not  iden,fied  with  SUD  or  entering  
treatment  at  the  same  rate  as  men.  
•  More  likely  to  present  in  segngs  such  as:  
–  Obstetric  and  primary  care  
–  Hospital  ER  
–  Social  service  agencies  
–  Community  mental  health  
–  Correc,onal  facili,es  
•  Only  38%  of  treatment  programs  designed  to  
meet  needs  of  women  
 Barriers  (con’t)  
•  External:  
–  Male-­‐oriented  iden,fica,on  process  and  treatment  models  
–  Involvement  with  substance-­‐using  partners  
–  Greater  pressure  from  family/friends  NOT  to  enter  treatment  
–  Lack  of  diagnosis/misdiagnosis  
–  Inadequate  training  and  sensi,vity  to  women’s  unique  needs  
–  Lack  of  comprehensive  services  in  one  loca,on  
•  Internal:  
–  Shame  and  guilt  
–  Fear  of  losing  children  
–  Fear  of  abuse  from  partner  or  loss  of  partner  
–  Lack  of  self-­‐esteem    
–  Lack  of  informa,on  about  services  
 Treatment  Needs  of  Women  
•  Medical  care  (obstetrical,  HIV/AIDS)  
•  Housing  
•  Educa,on  and  job  skills  training  
•  Psychological  needs  
–  Trauma,  ea,ng  disorders,  depression,  anger,  
shame,  anxiety,  suicidality,  paren,ng  skills  
–  Learned  helplessness,  powerlessness  
–  Sexuality  and  body  image  concerns  
 Treatment  for  Women  with  SUD  
•  Importance  of  context  in  women’s  addic,on  
–  Social,  economic,  culture  
•  Must  address  physical,  emo,onal,  spiritual  aspects  
–  Case  management  à  housing  and  child  care  
–  Co-­‐occurring  disorders  (i.e.,  CBT,  IPT,  Seeking  Safety)  
•  Single-­‐gender  groups  may  be  bejer  
•  Mutual  self-­‐help  groups  
•  Strengths-­‐based  approaches  
•  Mo,va,onal  Interviewing                                                                                                                                    
•  Bejer  outcomes  than  men  when  they  stay  in  
treatment.  
 Older  Adults  with  SUD  
•  Rise  in  propor,on  of  older  adults  who  seek  
treatment  
•  Three  groups:  
–  Young  old  (60-­‐74)  
–  Old-­‐old  (75-­‐84)  
–  Oldest-­‐old  (85  and  older)  
•  SUD  less  common  in  older  adults  compared  to  
younger  groups  
–  May  cut  down  or  decrease  due  to  health  problems  
 Older  Adults  with  SUD  
•  Misuse  of  alcohol  and  prescrip,on  drugs  may  be  
uninten,onal  
–  Lack  knowledge  regarding  interac,ons  
•  Risk  Factors:  
–  Age-­‐related  physical  changes  (e.g.,  higher  BAC)  
–  Re,rement,  loss  of  work  roles,  loss  of  spouse;  grief,  
loneliness,  isola,on  
–  Exacerba,on  of  health  problems    (i.e.,  hypertension,  
cardiac  arrhythmia,  myocardial  infarc,on)  
–  Sleep  disturbances  
–  Chronic  pain  
 Older  Adults  with  SUD  
•  DSM-­‐5  criteria  may  be  less  relevant  for  older  
adults  (e.g.,  social  and  occupa,onal  func,oning)  
•  Physical  symptoms  and  health  cues:  
–  Poor  sleeping  and  ea,ng  habits  
–  Medical  problems  
–  Cogni,ve  func,oning  and  recall  
–  Depression  
–  Demen,a  
•  Assessment  should  include  family  and  friends  
 Older  Adults  with  SUD  
•  Pajerns  of  onset  
–  Early-­‐onset:  lived  with  problems  en,re  life  
–  Later-­‐onset:  onset  aeer  midlife  
–  Intermijent:  early  onset  à  recovery  à  
recurrence  later  life    
 Older  Adults  with  SUD  
•  Core  issues:  
–  Grief  and  loss  
–  Loneliness  
–  Isola,on  
–  Chronic  pain  
 Treatment  of  Older  Adults  with  SUD  
•  Psychosocial  treatments  
•  Twelve-­‐step  &  mutual  help  groups  
•  “Persuasion”  groups  to  discuss  health  issues  
•  Social  and  Family  interven,ons:    
–  Increase  family  members’  awareness  and  
understanding  
•  Empathy,  support,  encouragement  
•  Case  examples,  p.  435-­‐436  (Farkas  chapter)  
 LGB  Clients  with  SUD  
•  LGB  >  heterosexual  
•  LGB  substance  use  does  not  decrease  as  much  
with  advancing  age  as  heterosexual    
•  Higher  rates  of  marijuana  (lesbian  women,  gay  
men)  and  methamphetamine  (gay  and  
bisexual  men)  
•  Inhalants  or  poppers  à  high  among  gay  men  
•  Bisexual  à  may  have  highest  risk  of  SUD  
compared  to  lesbian  and  gay  
 
 LGB  Clients  with  SUD  
•  Homophobia  vs.  heterosexism  
–  S,gma,za,on  of  nonheterosexual  behavior  
•  Societal  or  external  homophobia/
heterosexualism  
–  Fears  and  prejudices  of  society  
•  Internalized  homophobia/heterosexualism  
–  Shame  and  self-­‐loathing  
•  Double  s,gma  of  racism  and  homophobia  
•  LGB  adolescents  at  high  risk  for  SUD  
 LGB  Clients  with  SUD  
•  Important  to  assess  coming  out  process  
–  Is  it  related  to  use  of  substances?  
–  Self-­‐medica,on  of  internal  conflict  
–  Coping  with  fear  of  rejec,on  
–  LGB  network  promotes  substance  use  
•  Use  of  norma,ve  ques,oning  
–  What  gender  do  you  iden1fy  as?    
•  Gender-­‐neutral  language    
•  No  rela,onship  between  self-­‐disclosure  of  one’s  
orienta,on  and  outcome  
 LGB  Clients  with  SUD  
•  Socializa,on  pajerns  
–  Gay  bars  
–  Dance  clubs  à  club  drugs  
–  Frequent  sexual  ac,vity  with  different  partnersà  
substances  used  for  disinhibi,on  and  sexual  
enhancement  
–  Different  sexual  mores  not  necessarily  pathological  
–  Safe  sexual  prac,ces  
•  Males  who  engage  in  pros,tu,on  are  more  likely  
to  have  substance  abuse  problems.  
 LGB  Clients  with  SUD  
•  Family  Dynamics  
–  Inclusion  of  family  members  of  LGB  clients  in  
treatment  
–  LGB  adolescents  with  less  family  acceptance  are  
more  likely  to  abuse  substances  
–  Nontradi,onal  family  units  may  support  or  
impede  recovery  
   
 Treatment  for  LGB  Clients  
•  LGB  Affirma,ve  Model  
–  Homosexuality  or  bisexuality  is  fully  accepted  
–  Rejects  oppression  of  LGB  behaviors,  desires,  
iden,,es  
–  Two  major  aspects:  
•  External  and  internal  homophobia  must  be  addressed  
•  Therapist  must  understand  LGB  issues  
–  Gay  12-­‐step  mee,ngs  
–  Community  resources  
–  Specialized  treatment  groups  
 Treatment  for  LGB  Issues  
•  Coming  out  as  a  treatment  issue  
•  Socializa,on  pajerns  and  relapse  
•  HIV  issues  and  high-­‐risk  behavior  
•  Feminist  perspec,ve  in  trea,ng  lesbian  and  
bisexual  women  
•  Broadening  self-­‐concept  and  self-­‐esteem  for  
gay  and  bisexual  men  beyond  physical  
ajrac,veness  
 Transgender  Clients  
•  High  rates  of  minority  stressors  
–  Physical  and  sexual  violence  
–  Discrimina,on  
–  Gender-­‐related  vic,miza,on  
–  S,gma  
•  Adverse  experiences  have  serious  effects  on  
mental  health:  
–  Suicidal  idea,on  
–  Suicide  ajempts  
–  Substance  use  
 Transgender  Clients  
•  Higher  rates  of  alcohol  and  substance  use  
compared  to  cisgender  counterparts  
•  TG  female  youth  (16-­‐24)  at  high  risk:  
–  Polysubstance  use  
–  HIV  infec,on  
–  PTSD  
•  Trans  women:  
–  Methamphetamine  
–  HIV  
–  Medical  complica,ons  
 Transgender  Clients  
•  Other  considera,ons:  
–  Medical  complica,ons:  HIV,  Hep  B  and  C  
–  Hormone  therapy  combined  with  substance  use  
–  Reluctance  to  disclose  substance  use  due  to  
concerns  about  jeopardizing  hormone  therapy  or  
surgery  
–  Gender  concerns  do  not  need  to  be  resolved  to  
address  substance  use  problems!  
 Transgender  Competence  
•  Assessment  of  gender  iden,ty  at  intake  
•  Respect  for  how  pa,ents  would  like  to  be  
addressed  (e.g.,  pronouns  and  names)  
•  Evalua,on  of  gender  iden,ty  experiences  
(e.g.,  conflict  ,  abuse)  and  impact  on  mental  
health  and  substance  use  
•  Gender  sensi,vity  training  
 Client  with  HIV/AIDS  
•  Direct  services:  home  care,  nursing,  medical  
complica,ons,  case  management  
•  Therapy/counseling    
–  Impact  of  illness  
–  Helplessness  and  hopelessness  
–  Grief  
–  Guilt  
•  Maximizing  quality  of  life  
•  Pain  management  
•  Medica,on  adherence  
•  Clinician  self-­‐care