CHAPTER 1
What the Facilitator Needs to Know About Providing Gender-Responsive Services

Understanding the need for gender-responsive treatment services for men is critical for anyone who will be using this curriculum. It is important to understand the process of trauma and its effects on addiction and recovery. It is also important to understand the connections between gender, trauma, addiction, and crime. There is much room for improvement in traditional treatment for men, and a discussion of the history of the development of gender-responsive services for both men and women and how these have been expanded beyond the binary model can help to explain this. This chapter provides a brief overview of these issues as well as the theoretical foundation for this curriculum.

New Approaches to Men's Treatment

It would be reasonable to assume that men's issues are adequately addressed in alcohol and other drug (AOD) treatment, because the overwhelming majority of treatment was developed for, by, and about men. However, we believe that “gender-neutral” treatment models are inadequate to meet the service needs of both women and men.

If we did not begin with the assumption that we know what men need, what would we discover? If we look at the effects of male socialization, what issues will arise? Through the creation and implementation of this curriculum, we have discovered that, when they feel safe enough, people are willing to look at many important, although difficult, issues commonly overlooked in traditional treatment. Some of these are relationships, sexuality and sexual behavior, power and control, criminal behaviors, privilege and entitlement, and grief. Working collaboratively with professionals in the field, we have created activities that help participants begin to reflect on their common experiences and that are designed to improve their chances of achieving sustained recovery.

Much of this curriculum would work well for individuals in other behavioral health programs that address issues such as anger management and interpersonal violence.

What We Have Learned

Our understanding of addiction and the best ways to treat it has changed in the past decades. Previously, there was a disconnection between mental health systems and addiction services systems. This left clients stuck between the two as they attempted to deal with their addictions and any accompanying mental health issues. Today, we have clear research that shows the effects of drugs on the brain and the mechanisms of addiction. We have known for some time that addiction is a chronic disease. The service systems, the funding streams, and the research that supports the systems are finally being set up to enable providers to treat clients and evaluate their services in this context. Now, after years of poor outcomes for clients, trainings in co-occurring disorders are becoming the expectation (rather than being regarded as the exception) for addiction professionals.

There also have been changes in what we consider effective treatment for men. Two elements of the old treatment model that have deep roots, especially for men, are no longer considered to be as effective as was once thought. First is the concept of denial and the need to break through an individual's denial in order for him to be receptive to treatment. This approach tends to be shame-based and assumes that the person is willfully ignoring the reality and consequences of the problem. Our understanding of the process of change—through the “stages of change” model—has forced us to rethink the idea of denial (DiClemente, 2006). Rather than simply being about people's lack of ability or willingness to look honestly at their problems, this model puts the burden on the clinician to connect with each client and provide services based on which stage of change the client is in.

Second is the idea that confrontation is an effective strategy for getting people to engage in treatment and be willing to look at their problems. There is no clinical evidence pointing to the therapeutic efficacy of confrontation, and there is ample clinical evidence that this approach results in poor outcomes and can even cause harm (Miller & White, 2007).

Men, Addiction, and Crime

According to the U.S. Department of Justice, in 2019 there were 1,430,805 individuals in custody in state and federal correctional facilities. Of these, 1,322,850 (92 percent) were male (Bureau of Justice Statistics, 2020).

The correlation between substance use disorders and criminal behavior is well-documented. A comprehensive study by the National Center on Addiction and Substance Abuse (CASA) titled Behind Bars II: Substance Abuse and America's Prison Population (2010) found that 65 percent of all incarcerated individuals met criteria for a diagnosis of substance use disorder or dependence. The following statistics from the CASA report illustrate the relationship between substance use and criminal behavior:

• Alcohol is implicated in the incarceration of over half (56.6 percent) of all inmates in America. In addition to the inmates who were convicted of an alcohol law violation, 51.6 percent of illicit drug law violators, 55.9 percent of those who committed a property crime, 57.7 percent of inmates who committed a violent crime, and 52.0 percent of those who committed other crimes were either under the influence of alcohol at the time of the crime, had a history of alcohol treatment, or had an alcohol use disorder.
• Illicit drugs are implicated in the incarceration of 75.9 percent of all inmates in America. In addition to the inmates who were convicted of a drug law violation, 54.3 percent of alcohol law violators, 77.2 percent of those who committed a property crime, 65.4 percent of inmates who committed a violent crime, and 67.6 percent of those who committed other crimes either committed their crimes to get money to buy drugs, were under the influence of drugs at the time of the crimes, had histories of regular drug use, or had a drug use disorder.
• Of the 1.5 million prison and jail inmates who met clinical diagnostic criteria for a substance use disorder in 2006, only 11.2 percent had received any type of professional treatment since admission. Only 16.6 percent of facilities offer treatment in specialized settings (which can produce better outcomes for offenders, as has been measured by drug use and arrests post-release). Few inmates actually receive evidence-based services, including access to pharmacological treatments. The availability of highly trained staff is limited. Simply offering treatment, even in specialized settings, does not mean that the treatment is available to all who need it or of adequate quality.
• Substance-involved offenders are likelier to recidivate than those who are not substance involved. Over half (52.2 percent) of substance-involved inmates have one or more previous incarcerations, compared with 31.2 percent of inmates who are not substance involved.
• Relative to the population at large, people of color and Hispanics are overrepresented in America's prisons and jails. Substance involvement does not explain this overrepresentation, as Black and Hispanic inmates report lower rates of drug use in the months prior to their arrests and have lower rates of substance use disorders than white inmates. Blacks make up 12.3 percent of the U.S. population but comprise 41.0 percent of the inmate population; 60.2 percent have substance use disorders. Hispanics make up 14.8 percent of the U.S. population but comprise 18.8 percent of the inmate population; 58.3 percent have substance use disorders. Whites make up 66.4 percent of the U.S. population and 34.6 percent of the inmate population; 73.1 percent have substance use disorders.

Over the past 50 years, the “war on drugs” has resulted in a massive infusion of addicted men and women into the criminal justice system. (As is noted, the increased enforcement of drug crimes has disproportionally affected men of color.) The criminal justice system has become the primary catchment area for people with addictions. This presents an opportunity for cost-effective intervention. For every dollar spent on community-based treatment for offenders, the community saves as much as $12.00 in related costs (National Center on Addiction and Substance Abuse, 2010). Jail and prison-based treatment is even more cost-effective because housing is already provided.

Historically, the socialization process for individuals who have been raised as men contributes to the problematic attitudes and behaviors that underlie both addiction and criminal behavior. Helping Men Recover is the first curriculum for men (and those who identify as men) involved in the criminal justice system that addresses addiction through the lens of socially conditioned masculinity. In the decade since this curriculum was first published, we have discovered that, when they feel safe enough, participants are willing to engage in the challenging issues that are commonly overlooked in traditional treatment. Some of these issues are: anger, power and control, the tolerance of violence, physical and sexual abuse, trauma, effective expression of emotions, conflict resolution, supportive relationships, healthy sexuality, and spiritual development. Participants learn that the “rules” of manhood that previously reinforced addiction and antisocial behaviors can be recast into a more prosocial and self-enhancing belief system.

Implementing This Program in a...