Gender Differences in Psychosocial

Functioning Across Substance

Abuse Treatment^

Sandhya R. Rao, Ph.D.*; Michael Czuchry, Ph.D.** & Donald F, Dansereau, Ph.D. ***

AbstractThe present study investigated gender differences in psychosocial functioning among

clients mandated to substance abuse treatment. In the current study, 210 probationers' self reports of
depression, anxiety, self esteem, decision-making, life beliefs, role modeling, cooperation, and AIDS
risky behavior were gathered. Ratings were collected at intake as well as midway and toward the end
of the residential phase of treatment. A series of growth curve models were used to examine changes
in psychosocial functioning across these time periods. Improvements were recorded in several areas
of psychosocial functioning over the course of treatment (including anxiety, depression, self esteem,
decision-making, role modeling, and life beliefs). Importantly, significant gender by time interactions
indicated that females showed greater rates of change than their male counterparts in such areas as
self esteem, decision-making, and role modeling. The importance of psychosocial change and the
implications of these gender differences are discussed.

Keywords gender differences, mandated drug treatment, psychosocial functioning, therapeutic

communities

Female substance abusers entering treatment differ from
their male counterparts in several domains of functioning
including psychological and social functioning, drug abuse
histories, family dysfunction, and physical and sexual abuse
histories (e.g., O'Connor et al. 1994). Typically, women entering
tThis work was supported by the National Institute on Drug Abuse
(Grant No. ROl DA08608). The interpretations and conclusions, however,
do not necessarily represent the position of NIDA or the Department of
Health and Human Services. We would like to thank the staff and counselors
at the Tarrant County Correctional Facility in Mansfield, Texas, for their
assistance in conducting this research project.
*Manager, PricewaterhouseCoopers, LLP, Fort Worth, TX.
Assistant Professor of Psychology, Department of Psychology,
Texas Lutheran University, Seguin, TX.
Professor of Psychology, Department of Psychology, Texas
Christian University, Fort Worth, TX.
Please address correspondence and reprint requests to Michael
Czuchry, Ph.D., Texas Lutheran University, Department of Psychology,
Seguin, Texas 78155. Email; mczuchry@tlu.edu.
treatment are younger than men, have less extensive criminal
pasts, are less likely to be employed, have morefinancialand
medical problems, and report greater depression, anxiety,
and other psychological distress (e.g., Chatham et al. 1999).
Gender differences are present in dropout from treatment as
well. Among women, factors such as childcare, motivation,
problem severity, social support, and lack of spousal support
are among key predictors of premature dropout from treat-
ment (e.g., Simpson & Joe 1993), and economic and family
concerns can also serve as barriers to entering treatment
(Green 2006). Moreover, specialized programs that pro-
vide some kind of childcare, gender-specific interventions,
and curricula including information on health, HIV/AIDS
prevention, and communication training have been found
to improve retention and other during- and post-treatment
outcomes in females (e.g., Hughes et al. 1995; Schliebner

Journal of Psychoactive Drugs 267 Volume 41 (3), September 2009

Rao, Czuchry & Dansereau
1994; Dahlgren & Willander 1989), while more traditional
approaches that do not take into account women's special
needs may not be as effective (although see Kaskutas et al.
2005). However, research suggests that, in general, once
economic, family, and other barriers to treatment entry are
addressed, women are as likely as men to engage in and
successfully complete treatment (Green 2006) and may
even have better long-term recovery outcomes compared
to men (Green 2006) particularly with regard to abstinence
from alcohol (Dawson et al. 2005). It nonetheless remains
clear that much remains to be learned about the relationship
between gender and substance abuse treatment.
One treatment modality that has received increased
attention and empirical support is the corrections-based
therapeutic community (TC), which is associated with
lowered rearrest and reconviction rates (e.g., Wexler et al.
1992). However, as indicated by Hiller, Knight, and Simp-
son (2006), much more research is required to illuminate
the treatment process and its relationship to client change.
In other words, researchers are being called to identify key
factors or events that must occur in the course of treatment
that lead to desired outcomes such as decreased drug use or
reconviction rates. Simpson's treatment process model pro-
vides guidance in this endeavor, indicating that psychosocial
changes that occur during treatment are vital for successful
outcomes after treatment has concluded (Simpson 2004,
2001; Simpson & Joe 2004). The treatment process model
also indicates that different characteristics of clients (e.g.,
gender) entering treatment will infiuence how treatment
unfolds.
Given women substance abusers' unique needs, their
reaction to treatment may be different from those of men.
Messina and Prendergast (2001) report that very little is
known about female offenders' responses to treatment
in TCs, although early indications suggest that there are
important differences. For example. Hiller and colleagues
(2006) found that women were more likely than men to
drop out of treatment prematurely. This is especially trou-
bling as sufficient time in treatment is consistently related
to favorable treatment outcomes (Simpson, Joe & Brown
1997). Moreover, other researchers similarly suggest, for
example, that women's response to treatment in TCs needs
to be researched more thoroughly (Messina & Prendergast
2001; McCorkel, Harrison & Inciardi 1998).
Although improvement in psychosocial functioning has
been shown to be an important aspect of the treatment pro-
cess (e.g., improvements in the quality of familial and peer
relationships and psychological dysfunction; e.g.. Knight
& Simpson 1996), few studies have examined differential
effects in psychological and social change among males
and females. Existing research on changes in psychosocial
functioning over the course of treatment use mixed popu-
lations (i.e., both men and women) or treatment settings
that are exclusively for women. In mixed-gender studies,
effects are aggregated and psychosocial change is typically
Journal of Psychoactive Drugs
Gender Differences in Psychosocial Functioning
examined in the whole population without special attention
to gender differences in these changes (e.g., Simpson et al.
1995). More research needs to be conducted to examine
gender differences in change across treatment, as it will
help further understanding of the metaphoric "black box"
of treatment.
The present study compliments previous research on
psychosocial change across treatment, but, more important-
ly, it extends this research by examining gender differences
in this change. Although differences were expected between
males and females with regard to their rates of change in
psychological functioning over the course of treatment, this
study was exploratory in nature and a priori predictions about
the nature of these differences were not made.
METHOD
Description of the Project
Data for the present study was gathered as part of a
federally funded project called CETOP (Cognitive En-
hancements for the Treatment of Probationers). CETOP
was designed to enhance substance abusers' response to
mandated substance abuse treatment with cognitive and
behavioral tools. It was implemented in the Community
Correctional Facility in Mansfield, Texas between 2000
and 2001. Typically, probationers mandated by judges to
this substance abuse treatment facility (SATF) spend four
months in a small community of residents where counseling
is provided daily. The Texas Christian University (TCU)
research staff conducted studies that led to the development
of a comprehensive system of cognitive techniques designed
to enhance probationers' response to treatment. Core ele-
ments of the cognitive enhancement system introduced by
this project included node-link mapping and motivational
tools and activities. These tools were used independently
and interactively to enhance the drug abuse treatment
components at the SATF. Node-link mapping is a visual
representation counseling technique that has been shown
to be effective in substance abuse treatment (see Czuchry
& Dansereau 2003 for a review of findings). Several types
of mapping approaches were implemented, including ^ e e
mapping and guided mapping. Free mapping involves a cli-
ent and counselor working together to produce a map using
paper and a pencil. Typically a problem is identified and then
placed in a central location on the sheet of paper inside a
circle or box (called a node) and then additional ideassuch
as what may have caused the problemare connected to the
original problem with lines (called links) to the next idea,
also placed inside a circle or box (node). The map grows with
additional nodes and links until both the counselor and client
feel the problem has been adequately examined or potential
solutions have emerged. Guided mapping is similar except
guide maps are preformed maps with a series of blank nodes
with guiding questions that can either be completed within
or between counseling sessions by the client. For example.
268 Volume 41 (3), September 2009
 Rao, Czuchry & Dansereau Gender Differences in Psychosocial Functioning

TABLE 1
Background Characteristics of Sample

Total Males Females

(N = 210) (N = 147) (N = 63)
Age* 30 (9.84) 29 (10.23) 31 (8.86)
Race
White 60 58 67
Black 25 23 28
Other 15 19 5
Married or Living as Married 22 22 22
Have Children 48 45 59
Probation/Parole 97 97 97
Need for Medical Counseling'* 1.15(2.03) 0.96(1.84) 1.64(2.40)
Need for Psychological Counseling'* 3.20 (3.01) 3.04 (3.03) 3.58(3.11)
Need Alcohol Counseling'* 4.55 (3.34) 4.99 (3.26) 3.47(3.31)
Need Drug Counseling'* 6.58 (2.63) 6.35 (2.79) 7.16(2.08)
Note: All numbers are percentages unless otherwise indicated.
* (Mean. SD)
' Scale from 0 (not at all) to 9 (extremely)

a client may itidicate a current goal in a blank tiode that has
the heading "My Goal" and then indicate sources of support
in a blatik node with the heading "People who can help tne
Reach my Goal" atid then indicate the steps they need to
achieve their goal in a blank node with the heading "Steps
to take to reach my goal. " The number of nodes and number
of guiding questions that are deemed necessary can be de-
termitied by the coutiselor. Key motivational activities that
were included in this study included Utider Construction,
a strengths based activity that has been shown to calibrate
mood and self-esteem (Sia, Czuchry & Datisereau 1999) and
the Downward Spiral (Czuchry, Sia & Datisereau 1999), a
game in which each client takes on the role of someone who
continues to abuse drugs and then sees the associated impact
that occurs on his or her health, social support networks,
self-esteem, and financial/legal situation. These activities,
when combined, have been shown to facilitate engagement
and success in treatment (Czuchry, Sia & Dansereau 2006;
Czuchry & Dansereau 2005). In addition to these cognitive
enhancements implemented by the research staff, the SATF
also offers a variety of educational and life management
activities like a modified therapeutic community approach,
counseling to provide professional guidance and support in
recovery efforts, special induction and transition sessions
to plan for treatment, and later, for recovery maintenance,
life skills instruction and recovery education activities.
Participants
Two hundred and ten probationersincluding 147 men
and 63 women were admitted to the SATF from 2000 to
2001. Adtnissions data, obtained from individual interviews
with incoming probationers (via a computerized Addiction
Severity Index for Criminal Justice Survey, McLellan et al.
1992), indicate that a majority of this group was White (60%)
and male (71%). Average age was 30 years, and roughly
50% of the probationers had completed at least 12 years
of education (i.e., had graduated high school or completed
the GED). Of the total, 21% were unemployed, 71% had
some kind of employment, with the remainder not in the
workforce. Twenty-two percent were married or living as
married (see Table 1).
Preliminary descriptive analyses were conducted to ex-
amine gender differences among probationers. With regard
to demographic variables, there were no major differences
between the sexes. However, a larger percentage of women
(31 %) than men (23%) reported no previous incarcerations.
More women (42%) than men (32%) reported a family
history of drug abuse problems. Sexual abuse was more
prevalent among women (10%) than men (5%). Lifetime
use of alcohol and cannabis was reported by more men
(84% and 87%) than women (77% and 76%), while greater
numbers of women reported lifetime use of cocaine and
amphetamines (63% and 49% among women vs. 52% and
39% among men).
Procedures
An extensive battery of information including demo-
graphics, reports of psychological, social, emotional and
financial functioning, criminal and drug use history, and
family background was taken at admission to the SATF.

Journal of Psychoactive Drugs 269 Volume 41 (3). September 2009

Rao, Czuchry & Dansereau Gender DiHerences in Psychosocial Functioning

TABLE 2
Factors Description and Coefficient Alphas for Psychosocial Functioning Scales (N = 210)

Scale/Items Coefficient Alpfias

Depression 0.68
1. You feel interested in life.*
2. You feel sad or depressed.
3. You have thoughts of committing suicide.
4. You feel lonely.
5. You feel extra tired or run down.
6. You worry or brood a lot.
Anxiety 0.69
1. You have trouble sitting still for long.
2. You have trouble sleeping.
3. You feel anxious or nervous.
4. You feel tense or keyed-up.
Self Esteem 0.77
1. You have much to be proud of.
2. In general, you are satisfied with yourself
3. You feel like a failure.
4. You feel you are basically no good. *
5. You wish you had more respect for yourself.
6. You feel you are unimportant to others.
Decision-making 0.73
1. You consider how your actions will affect others.
2. You plan ahead.
3. You think of several different ways to solve a problem.
4. You think about what causes your current problems.
5. You make good decisions.
6. You have trouble making decisions.
7. You think about probable results of your actions.
8. You make decisions without thinking about the consequences.
Personal Effectiveness 0.80
1. You feel hopeful about the future.
2. You clearly express your thoughts.
3. You think clearly/objectively.
4. You use good problem-solving strategies.
5. You understand what other people are talking about.
6. You are a leader.
7. You are gaining insight about yourself.
8. You do things as well as most people.
Life Beliefs 0.84
1. In most ways your life is close to your ideal.
2. You are satisfied with your life.
3. So far you have gotten the important things you want in life.
4. If you could life your life over, you would change almost nothing.
5. The conditions of your life are excellent.
Cooperation 0.81
1. You are easy to talk to.
2. You are cooperative.
3. You get along with other people.
4. You work hard to get things done.
HIV/AIDS Risky Behavior 0.70
1. You will do what has to be done to protect yourself from getting AIDS. *
2. You sometimes do risky things that will cause you to get AIDS.
3. You will need to make some changes to reduce your risk of getting AIDS.
* Items reverse scored prior to being combined

Journal of Psychoactive Drugs 270 Volume 41 (3), September 2009

 Rao, Czuchry & Dansereau Gender Differences in Psychosocial Functioning

TABLE 3
Change in Psychosocial Functioning over Treatment

Males (N = 147) Females (N = 63)

Mean (SD) Rate of Change Mean (SD) Rate of Change
Psychological Variables
Anxiety" 4.01(1.46) -0.21 4.41 (1.48) -0.21
Depression"''' 3.10(1.18) -0.28 3.83 (1.48) -0.40
Self Esteem"''^ 4.86(1.35) 0.26 4.60(1.29) 0.47

Social Functioning
Decision Making''''^ 4.92 (0.94) 0.11 4.84(1.01) 0.34
Personal Effectiveness^''^ 5.27 (0.98) 0.08 5.24(1.10) 0.28
Life Beliefs'''''''^ 3.65 (1.43) 0.30 3.05(1.46) 0.58
Cooperation 5.69(1.21) -0.03 5.93(1.07) 0.05
Aids Riskv Behavior^ 2.94 (1.59) 0.09 2.99 (1.75) -0.14
" Main effect for time (p < .05)
'' Main effect for gender (p < .05)
'^ Gender X Time interaction (p < 05)

Further, during-treatment and follow-up assessments were Data Analysis

also conducted to evaluate reactions to treatment, therapeu-
tic relationship, and changes in psychological and social
functioning. During-treatment assessments were conducted
at admission to treatment (i.e., intake), two months into
treatment, and at the end of treatment (i.e., month 4).
The research complied with all Federal and Institutional
Review Board (IRB) requirements to protect the rights and
welfare of human subjects. Informed consent was obtained
and documented, and all intake and during-treatment assess-
ments received IRB review and approval.
Measures
For the purposes of this study, measures of psychoso-
cial functioning were used. These were created from the
modified TCU Self Rating Form (TSRF; Knight, Holcom
& Simpson 1994) and the TCU Client Evaluation of Self
and Treatment (CEST; Simpson et al. 1997). The TSRF as-
sessed psychological and social functioning while the CEST
permitted probationers to assess their own participation and
progress in treatment, as well as to evaluate critical aspects
of the treatment program. Responses to all of these scales
consisted of ratings on a seven-point rating scale, which
ranged from 0 (not at all/never) through 4 (some/sometimes)
to 7 (a lot/almost always). Composites were used to represent
anxiety, depression, self esteem, decision-making, life be-
liefs, role modeling, cooperation, and AIDS risky behavior.
Four of the factors (anxiety, depression, decision-making,
self esteem) were derived from the TSRF. These factors have
good psychometric properties (Knight, Holcom & Simpson
1994). Factor analyses were used to create the remaining
four factors (i.e., life beliefs, role modeling, cooperation,
and AIDS risky behavior). Satisfactory coefficient alphas
were obtained for these factors, ranging from 0.70 to 0.83.
Table 2 includes a description of the factors.
The goal of the present study was to investigate changes
in psychosocial functioning over time and to determine
whether there were gender differences associated with these
changes. Growth curve analyses were used to satisfy this
goal. Growth curve models have advantages over more tradi-
tional techniques (e.g., analysis of variance) as they account
for individual growth trajectories and are better equipped
to deal with missing and unbalanced data at different time
points. This statistical procedure can be understood as a
"slopes and intercept model," in which significant differ-
ences between the slopes indicates a significantly different
rate of change for men and women.
RESULTS
Results from the growth curve analyses are summarized
and presented in Table 3.
Overall improvement in probationers' psychosocial
functioning was observed over time, particularly in the
areas of anxiety, self esteem, decision-making, role mod-
eling, and life beliefs. That is, significant increases were
noted in probationers' self-reports of self esteem (F,^ jog)
= 61.61, p < 0.05), decision-making (F/[ 20g) = 40.75, p <
0.05), role modeling (i'(, 208) = 22.29, p'< 0.05), and life
beliefs {F^^ 208) = 72.69, p < 0.05) from intake to month 4
of treatment. Conversely, significant decreases were noted
in probationers' ratings of depression (F., 208) = 45.62, p <
0.05) and anxiety (i'(i 208) = 29.85,/7 < 0.05; see Table 3 for
the magnitude of the rate of change for males and females,
where a negative rating indicates a decrease for a given
psychological variable and a positive rating indicates an
increase.
More interestingly, as evidenced by interactions be-
tween gender and time, significant gender differences were

Journal of Psychoactive Drugs 271 Volume 41 (3), September 2009

Rao, Czuchry & Dansereau
obtained on changes in psychosocial functioning. Overall,
these gender differences suggested that female probationers
showed greater improvements than males in several areas
of psychosocial functioning. Females showed greater im-
provement in self esteem {F,^ 210) - 5.14,/ < 0.05), decision
making (f/, 210) = 10.76, p < 0.05), role modeling (F,^ JQS)
= 22.29,/7 < 0.05), life beliefs (F^, 210) = 7.30,/7 < 0.05)'and
AIDS risky behavior {F,^ 209) = 4.31,/? < 0.05) compared to
their male counterparts. Interestingly, female probationers
showed a decrease in their perceptions of their AIDS risky
behavior over the course of treatment (rate of change = -
0.14), whereas a slight increase was noted among the male
probationers (rate of change = 0.09).
Additionally, main effects of gender were also obtained
for depression and life beliefs, which suggested that there
were significant differences between males and females at
intake on these ratings. Consequently, it is possible that the
gender differences observed for rates of change on life be-
liefs were obtained because women had significantly lower
ratings on life beliefs than males at intake.
To summarize, there were significant improvements
in some domains of psychosocial functioning across time
among all probationers. However, these changes were more
marked for women, and women showed greater psychosocial
change than men.
DISCUSSION
The main goal of this study was to examine changes in
psychosocial functioning across treatment, and to determine
if these changes differed among males and females. Results
indicated that significant gender differences in psychosocial
functioning did exist, and that female probationers exhib-
ited greater change in treatment when compared to their
male counterparts. This study provides more evidence to
demonstrate that treatment affects psychosocial change and
extends previous findings by indicating that these changes
occur more rapidly in women probationers than in their male
counterparts.
Results from the present study are congruent with
previous studies that have noted improvements in psycho-
social functioning over time (e.g.. Knight & Simpson 1996;
Simpson et al. 1995). In this study, decreases were noted
in depression and anxiety, and increases were noted in self
esteem and other aspects of social functioning. Taken to-
gether, these findings provide more evidence for the notion
that "treatment works."
Another major finding from the present study was that
women show greater psychosocial change over treatment
compared to men. Although further research is required
to support these findings, the possibility that women may
progress more quickly than men with regard to psychosocial
changes in treatment is intriguing. A preliminary examina-
tion of data from earlier phases of the CETOP project suggests
Journal of Psychoactive Drugs
Gender Differences in Psychosocial Functioning
that women may have benefited to a somewhat greater degree
from the cognitive enhancements we developed than did men
(on a variety of assessments). If these data hold under more
rigorous analyses, an important question is why females may
have benefited in this setting, even though no special inter-
ventions were oriented toward them, and they were greatly
outnumbered by men (29% vs. 71%). One possibility may
be related to an openness to getting involved in the treatment
experience. These treatment enhancements were developed,
in part, to increase openness to treatment and willingness
to make important steps toward personal change. Perhaps
women in this setting were more open to change and to
treatment, and this openness facilitated therapeutic progress.
Miller and Rollnick (1991) have shown that even the small-
est steps toward change can have meaningful, measurable
consequences, and these are likely to be most powerful
when they are intrinsically generated. Further investigations
into gender differences and their relationship to treatment
process may thus be very important in understanding and
magnifying positive changes during treatment.
While findings from this study suggest that improve-
ment in psychosocial change is observed among women
even when gender-specific interventions were not provided,
it does not imply that such interventions are not recom-
mended. A variety of findings suggest that women respond
better to treatment that includes childcare and women-
specific interventions such as improving communication
(e.g., Hughes et al. 1995), and therefore inclusion of such
interventions may still be desirable (although see Kaskutas
et al. 2005).
Some shortcomings of the present study should be
noted. In the present study there was a comparatively small
sample size for women (N = 63), and this research sample
consisted of individuals who had been court mandated to
treatment. Consequently, the findings from the present study
can be generalized to similar corrections-based treatment
facilities. Further, changes in psychosocial functioning were
followed over a period of four months and the sustained
effects of treatment and their relationship to other "bottom-
line" behavioral indicators (such as urinalysis and rearrest
rates) require additional study. Still, a wealth of empirical
evidence suggests that these psychosocial changes will
convert into favorable behavioral outcomes after treatment
(e.g., Simpson & Joe 2004).
In conclusion, findings from the present study begin
to illuminate psychosocial changes that take place among
male and female substance abusers in treatment settings.
However, further research is necessary to determine the
best treatment approaches for males and females alike. It is
also not clear the extent to which the current findings will
compare with treatment facilities that involve being admit-
ted voluntarily or how avoiding a correctional facility (as
occurred for the clients in the current study) may impact
intrinsic and extrinsic motivation for change.
272 Volume 41 (3), September 2009
 Rao, Czuchry & Dansereau
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