Substance Use Disorders: Assessment and Treatment, 2nd Edition _ ___________________________________
been more stigmatizing for women than for men. Although many women who use substances are in relationships with men who also use substances, the reality is that women are more likely to risk losing their relationships if they enter treatment (Stringer & Baker, 2018). Motherhood adds an additional dimension to stigma, and women may fear losing custody of children if they enter treatment, or they may fear being seen as unfit mothers. Being in a group setting with other women who share these same experiences can be both comforting and liberating (Stringer & Baker, 2018). • Practical obstacles to treatment entry may be a greater issue for women than for men. Reasons include logistical barriers such as childcare challenges, transportation issues, or lack of insurance or having insufficient funds to pay out of pocket (Bright et al., 2011). Barriers may be more of an issue for rural women, especially those who are pregnant, than for women living in more urban areas. Acceptability and accessibility seem to be the greatest barriers. Acceptability relates to fear of being judged negatively, being stigmatized, and possible loss of custody of children. Accessibility relates to lack of child-care and transportation (Stringer & Baker, 2018). One unique aspect of women’s substance use compared to that of men is substance use while pregnant. Although the majority of pregnant women choose to abstain during pregnancy, 4.4% of pregnant women engage in illicit drug use (American Col- lege of Obstetricians and Gynecologists [ACOG], 2012). This behavior can have detrimental effects as the substances used by the mother are transmitted to the fetus during gestation. The severity of these effects is based on many factors, including the substance used, the age of the fetus, the length of exposure, and the frequency of use (ACOG, 2012; Straussner, 2011). Drug use during pregnancy can result in permanent damage, including brain damage, or can result in a baby being born addicted to a substance (National Center on Addiction and Substance Abuse at Columbia University, 2012; Straussner, 2011). Alcohol use during pregnancy is linked to several negative outcomes, including fetal alcohol spectrum disorders, miscarriage, and stillbirth (Murawski et al., 2015). Marijuana usage during pregnancy is linked to intrauterine growth retardation, low birth weight, and cognitive impair- ments (Chabarria et al., 2016; Roth et al., 2015). Adverse birth outcomes associated with amphetamines include intrauterine growth retardation, cleft lip and palate, and fetal distress (Chabarria et al., 2016). Opiate use during pregnancy has been associated with a range of maternal complications involving both physical and mental health (Shaw, 2015). A significantly problematic prenatal effect associated with opiate use results from repeated periods of intoxication and withdrawal, which
can lead to serious complications for the fetus (ACOG, 2012). The most common complication associated with maternal opiate use is neonatal abstinence syndrome. This leads to withdrawal symptoms for the newborn that include fever, sneez- ing, irritability, trembling, diarrhea, vomiting, sweating, and possibly seizures (ACOG, 2012). Long-term effects of prenatal drug exposure can be very difficult to assess accurately. It is dif- ficult to control the large variety of intervening variables that affect child development. Even in terms of prenatal factors, identifying the influence of drug use as opposed to maternal nutrition, stress, self-care, and medical care is challenging. It is even harder to tease out long-term effects of maternal prenatal substance use from the effects of the developmental home environment, the impact of maternal nurturing behavior, the presence of adverse childhood experiences, and continued parental substance abuse on the developing child (Behnke & Smith, 2013). The effects of paternal drug and alcohol use on a fetus and infant have not been widely researched; however, maternal drug use can have significant effects on a baby, and many states require that, if it is determined that the baby is addicted or tests positive for drug exposure, child welfare agencies must be contacted (Benoit et al., 2014). This process can result in foster care placement for the child and potential imprison- ment, mandatory treatment, or loss of custody for the mother. The following vignette illuminates how issues unique to women’s substance use might present in a therapy session: Therapist: Mrs. Austin, the couple’s therapist that you and your husband have been seeing referred you to me because of some concerns about your use of cocaine. Am I correct? Client : It’s really all a lot of nonsense. My husband and I have been having some problems for a while—arguments and disagreements about any number of little things. He insisted that we see a marriage coun- selor, and we have been for about 2 months. I’m not so sure it’s doing any good; we still argue a lot. Anyway, my husband, George, found out that I used cocaine occasionally. I mean, he just lost it—yelling and threatening to take the kids and leave. So, I agreed to see you to prove it wasn’t a problem. Therapist : So, your husband is very concerned and angry about your use of cocaine, but you don’t agree that it’s a problem. Client : That’s right. I mean, I work every day—I’m an investment broker—and I earn a lot more than my husband—he’s an engineer. I never use at home—well, almost never. I certainly never use when the kids are there. My health is good. The bills all are paid, and a year ago, I made full partner in the firm where I work. So how much of a problem can it be? Therapist : Can you tell me a bit more about your use of cocaine? Client : Like what? Therapist : When did you start using cocaine?
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