A Qualitative Analysis of Women’s Experiences in Single-Gender versus Mixed-Gender Substance Abuse Group Therapy

Abstract

The present study of women with substance use disorders used grounded theory to examine women’s experiences in both the Women’s Recovery Group (WRG) and a mixed-gender Group Drug Counseling (GDC). Semi-structured interviews were completed in 2005 by twenty-eight women in a U.S. metropolitan area. Compared to GDC, women in WRG more frequently endorsed feeling safe, embracing all aspects of one’s self, having their needs met, feeling intimacy, empathy, and honesty. Additionally, group cohesion and support allowed women to focus on gender-relevant topics supporting their recovery. These advantages of single gender group therapy can increase treatment satisfaction and improve treatment outcomes.

The prevalence of substance use disorders among women has dramatically increased in the past two decades (Compton, Thomas, Stinson, & Grant, 2007; Grucza, Bucholz, Rice, & Bierut, 2008; Hasin, Stinson, Ogburn, & Grant, 2007; Kessler et al., 1994). Specifically, the rate of any lifetime substance use disorders among women has risen from 17.9% (Kessler et al., 1994) to 26.6% (Compton et al., 2007; Hasin et al., 2007). Moreover, the phenomenon of telescoping in the course of substance use disorders in women is well documented demonstrating that compared to their male counterparts, women experience a faster progression from substance use to abuse or dependence and then to first treatment (Ehlers et al., 2010; Haas & Peters, 2000; Hernandez-Avila, Rounsaville, & Kranzler, 2004; Johnson, Richter, Kleber, McLellan, & Carise, 2005; Randall et al., 1999). This accelerated course may be associated with the development of more adverse medical, psychiatric, and social consequences in women than men (Brady & Randall, 1999; Grella & Lovinger, 2012; Hernandez-Avila et al., 2004; Randall et al., 1999) in spite of fewer years and lower levels of use. For example, compared with men, women may experience more problems with employment (Back et al., 2011; Hernandez-Avila et al., 2004), greater psychiatric severity/distress (Back et al., 2011; Grella & Lovinger, 2012; Hernandez-Avila et al., 2004), more chronic health and medical problems (Back et al., 2011; Grella & Lovinger, 2012), and family/social impairments (Back et al., 2011).

Because there are gender differences in the antecedents and consequences of substance abuse, gender-specific treatment may provide additional benefits and enhanced treatment outcomes for women (Ashley, Marsden, & Brady, 2003; Greenfield, Back, Lawson, & Brady, 2011). Substance abuse treatment in the community is most often delivered in group therapy format (Kominars & Dornheim, 2004). Single gender group therapy for women provides the opportunity to discuss gender-specific recovery issues and a treatment environment that feels safe and comfortable compared with a mixed-gender setting (Greenfield et al., 2007a; Greenfield & Grella, 2009; Kauffman, Dore, & Nelson-Zlupko, 1995; Sun, 2007). The interpersonal environment and the opportunity to share similar experiences with other women can be critical factors for women's sense of comfort in treatment (Godlaski, Butler, Heron, Debord, & Cauvin, 2009), and may provide other therapeutic factors that have been hypothesized as mechanisms by which group therapy is effective (Yalom, 1985). For example, in his theory of group therapy and its potential mechanisms of action, Yalom postulated that interpersonal learning and group cohesiveness may be especially important (Yalom, 1985). While several studies have demonstrated that in mixed-gender treatment, women’s treatment needs can be minimized (Nelson-Zlupko, Dore, Kauffman, & Kaltenbach, 1996), addressing these issues can be helpful to treatment outcomes. One study of women with substance use disorders (Nelson-Zlupko et al., 1996) demonstrated that eighty percent of women felt that discussing women’s issues was helpful in maintaining sobriety.

Gender-specific group therapies have been developed for women with substance use disorders to address some of these relevant factors in women's recovery such as co-occurring post-traumatic stress and substance use disorders (Brady, Dansky, Back, Foa, & Carroll, 2001; Hien et al., 2009; Najavits, Weiss, Shaw, & Muenz, 1998), co-occurring borderline and substance use disorders (Linehan et al., 2002), and pregnancy and parenting in opioid dependent women (Luthar & Suchman, 2000). While these single-gender group therapies were developed to address the needs of specific sub-populations of women with substance use disorders (Hien et al., 2009; Linehan et al., 2002; Luthar & Suchman, 2000; Najavits et al., 1998), no manual-based group therapy had been designed and tested for women with substance use disorders who were heterogeneous with respect to type of substance abused, co-occurring disorders, and other demographic and clinical characteristics. The Women’s Recovery Group (WRG) is an empirically supported treatment that was developed and tested in a Stage I trial in order to address these needs (Greenfield, Trucco, McHugh, Lincoln, & Gallop, 2007b).

The WRG is a manual-based 90-minute relapse prevention group therapy that consists of 12 weekly sessions based on women-focused content and a single-gender composition. Examples of the women-focused content include the effect of substances on women’s health, women’s social and family relationships, and co-occurring mood, anxiety, and eating problems with substance use disorders (Greenfield et al., 2007b). The study hypothesized that both a single-gender group composition and women-focused group content would result in better substance abuse treatment outcomes than mixed-gender group therapy. In the Stage I pilot study, women were randomly assigned to the single-gender WRG or the mixed-gender Group Drug Counseling (GDC) control condition. GDC is an empirically supported, manual-based substance abuse group therapy, delivered in a mixed-gender format. Like WRG, it was delivered in 12 weekly, 90 minute sessions and covered many recovery topics but did not have gender-specific content. In the Stage I trial, all therapists for the WRG and GDC groups were women thereby ensuring a therapist gender match for women participants in both groups (Greenfield et al., 2007b).

The WRG has demonstrated positive results for women in the single-gender substance group therapy (Greenfield et al., 2007b). Specifically, in the Stage I trial, women with substance dependence who were randomly assigned to WRG exhibited enhanced treatment outcomes and greater satisfaction compared to women assigned to mixed-gender GDC. In particular, although women in both treatment groups demonstrated similar reductions in substance use during treatment, during the 6-month post-treatment follow-up, WRG members demonstrated a pattern of continued reductions in substance use while women in GDC did not. Furthermore, women in WRG reported greater satisfaction with their treatment relative to women assigned to GDC.

In order to further our understanding of women's experiences in treatment and their potential relationship to treatment outcomes and satisfaction, qualitative research can help elucidate specific patient experiences of treatment to gain both a greater understanding of the target population (Hohmann & Shear, 2002) as well as the study's results (Wagner et al., 2012). Qualitative research is useful in examining “what works for whom, under what circumstances, and why” (Hohmann & Shear, 2002). Few studies examine patients’ perspectives on group interpersonal factors that increased their satisfaction with group treatment. Moreover, there are no previous qualitative studies comparing women's experience in manual-based, empirically supported, single-gender group therapy compared with mixed-gender group therapy.

The aim of the current study was to conduct a qualitative analysis of semi-structured interviews in order to compare women's self-reported experiences and their satisfaction with single-gender WRG versus mixed-gender GDC substance abuse group therapies. Our purpose was to investigate whether the single-gender group composition would provide an enhanced sense of comfort and support and a cohesive group environment, as well as opportunity for women to openly discuss gender-specific triggers and relapse prevention when compared with the mixed-gender group therapy.

Methods

This qualitative interview study was informed by the theoretical perspective of social constructionism (Gergen, 1994, 1999; Holstein & Gubrium, 2008). Social constructionist perspective emphasizes the meaning making and knowledge production processes within different social groups. Epistemologically, meaning and knowledge are constructed in the interplay between individuals. Furthermore, a self is always relational and understood as a “product of historically and culturally situated interchanges among people” (Gergen, 1994).

Study Participants and Data Collection

Thirty-six women were enrolled in the Stage I behavioral treatment development study, WRG (n = 29), GDC (n = 7 females) (Greenfield et al., 2007b). The protocol was approved by the McLean Hospital Institutional Review Board. All participants had a current dependence on at least one substance other than nicotine. The sample was predominantly white (97.2%), well-educated, and the majority of participants reported alcohol as their primary substance (82.6% WRG and 100% GDC women). See Greenfield et al. (2007b) for a complete description of study participant demographics, baseline characteristics, and study completion. To summarize, in the pre-pilot and pilot stages of treatment development, there were four WRG groups with 5–8 participants in each group and two GDC groups with 2–5 women in each. Of the 13 enrolled subjects in the pre-pilot groups, 100% completed the treatment phase and the 6 months post-follow-up assessment. Of the 23 randomized in the pilot phase, 18 completed all group treatments and 20 completed the six month post-follow-up assessments (Greenfield et al, 2007b). This interview study took place at the study completion (i.e., 6 months after the end of treatment). Of the 33 potentially eligible participants for this interview study, twenty-eight women (84.8%; 22 WRG, 6 GDC) completed the 30-minute individual, semi-structured interview with the principal investigator (SFG). Of the five who did not complete the interview, insufficient time, scheduling, or movement out of the geographic area were cited as reasons to decline. The interviews focused on women’s experiences and satisfaction with the 12-week group therapy they had completed as well as past experiences in other single-gender and mixed-gender substance abuse group therapies. Interviews were audiotaped with the consent of participants, and were then transcribed for analysis (see Table 1 for Exit Interview Questions).

Table 1.

Exit Interview Questions

What did you most like about the group? What did you least like about the group? What was the most helpful about the group? What was the least helpful about the group? What did you think about the length of each group session? What did you think about the duration of the group (12 weeks)? Too short? Too long? What did you think about the mix between information presented and discussion? *How important did you feel it was to be in an all-women’s group instead of a mixed-gender group? What was different or significant about it? (FOR WRG) *How important did you feel it was to be in a mixed-gender group versus a single-gender group? What was different or significant about it (FOR GDC) Have you ever been in an all women’s recovery group before? If so, how did this compare? Have you ever been in a mixed-gender recovery group before? If so, how did this compare? What do you think was the KEY INGREDIENT in this group that was most helpful in your recovery?

^*(Question #8 varied with whether the woman had been randomized to GDC or WRG)

Data Analysis

In this study we used grounded theory (Charmaz, 2000, 2005; Glaser, 1978, 1992; Glaser & Strauss, 1967) to analyze our data. Verbatim transcripts were open coded collaboratively by the research team. During our coding process we proceeded from the specific details of the data to the general statements about the data. Open codes were categorized and grouped to form axial codes. Theoretical codes, in turn, were used to create a meaningful description of the data in the form of a conceptual model.

More specifically, we followed Strauss and Corbin (1998) and Charmaz’s (2000, 2004, 2005) processes for grounded theory analysis, namely: creating open coding, axial coding, and theoretical coding. During the open coding process we identified concepts and their properties and dimensions. Our open codes included codes such as “no need to hold back,” “lack of empathy,” “feeling safe,” and “silence.” Open codes were emerged and categorized to create axial codes. In our study we used axial codes to reassemble data that was fractured during open coding, to code more for relationships, and to link categories with subcategories. Some examples of axial codes included: “having needs met in treatment,” “women as caretakers,” “stigma,” and “importance of gender of therapist.” Axial coding was followed by theoretical coding which enabled us to theorize connections between various concepts found in data. During the theoretical coding process we also integrated and refined categories. Our theoretical codes included: socio-cultural influences, perceptions of the atmosphere in the group, discussion topics, characteristics of communication, and self-perceptions in the group. Finally, all codes were constantly compared with each other to develop an inductive and data-based conceptual model that illustrated women participants’ experiences in single- versus mixed- gender group therapy.

Results

Based on the grounded theory analysis of the exit interviews with women participants in this Stage I trial, Figure 1 illustrates the conceptual model of women's experiences in single- versus mixed-gender group therapy. The model illustrates primary and secondary interactions that shaped women’s experiences when participating in recovery groups with different gender composition. The primary interactions, which form the main focus of this paper, describe participants’ understandings and experiences of interactions and communications that took place between women in the WRG group and among women and men in GDC group whereas the secondary interactions describe the relationship that occurred between the women and the therapist. Women’s experiences were shaped by perceptions of the group atmosphere, different characteristics and discussion topics within the recovery groups, and women’s perceptions of themselves as women, group participants, and individuals living through the recovery process. These theoretical codes are presented in the boxes (e.g., perceptions of the atmosphere in the group) and they are categorized according to the type of the recovery group. Two types of theoretical codes are also associated with secondary interactions (“gender of the therapist” and “sociocultural influences”) and these codes are presented in circles. In the following we will discuss more in detail each aspect of the model and how study participants viewed the differences between single-gender and mixed-gender groups.

Figure 1.

Conceptual model of women’s experiences in single- versus mixed- gender group treatment based on grounded theory analysis of exit interviews with participants

Women’s Experiences in Single-gender Group Therapy

Self-perceptions in single-gender group therapy

Women emphasized that being in the all women's groups enabled them to be “all aspects of oneself.” Being “all aspects of oneself” included “freedom to be different things …being a mess one week and strong another week.” Women reported shifting their perceptions of self in relation to the interactions with other group members. For example, one participant described: “there are filters in mixed-gender groups either self-imposed or externally-imposed that are not present in the women’s group” and another women stated in contrast to the women's group.” Another woman stated that in contrast to the women's group, in a mixed gender group, "I think in some ways, what I feel around men is categorizing of you… it feels like when there are men around you're having to be more careful of your image because do you want to project a confident person…I don't feel as much ability to be the whole person that you are.” One of the elements that women said affected their self-presentation within the group was the sense of safety in the all women’s group. Shared experiences among women group members created a safe atmosphere that enabled participants to talk about sensitive issues without feeling pressure, questioning, or sexual tension. For example, women in the single-gender groups felt that they could be fully honest. One woman said that "with alcohol, and being a problem drinker, alcoholic, whatever - it makes you very vulnerable sexually, and it's hard to have men there, because you don't feel you can be as honest." Another woman stated, “I can be more honest, and open up, and relate to people that… [I] have something in common with.” In discussing the way she could present herself as a woman in group, another participant said the following:

“It was a shared experience, and there were things that - experiences that we shared in there, because we were women, and we were caretakers…[that] wouldn't be experienced the same with men. And I think that our experiences with alcohol, and the way our bodies even deal with it, are more similar, and they’re not the same with men. I don't think men and women think the same way, and I don't think men and women deal with problems the same way, and I don't think that men and women are honest in the same way.”

Perception of group atmosphere in single-gender group therapy

Women participating in WRG reported having a variety of positive perceptions about group atmosphere including "having needs met" in the group, "sharing the same language," feeling the women were "supportive of each other," that the group was a "supportive network," and the group engendered "feelings of intimacy." One woman mentioned that in group “there was a positive, supportive atmosphere," and she also acknowledged that there was “chemistry” among the women in the group. In addition, another woman said that “[the] women really cared about me, and…I really cared about them." Perception of the positive group atmosphere in the WRG group was supported by such statements as women showed “their acceptance when you failed and their joy at when you succeeded.” Women also commented that WRG was very personal, small and intimate, and that “things go a little bit deeper” in the women’s group.

Characteristics of communication in single-gender group therapy

Women in WRG characterized communication with other women in the group as "honest," empathic," "comfortable," “intuitive,” and "emotional" and that there was an "ease of communication" that made them have a "willingness to take risks" in the group. Specifically, one woman said, “We didn't have to make any effort about communication. I never felt that was an issue, ever. It was so natural.” This ease in communication may have contributed to women talking more openly to each other and taking risks in communication. For example, one woman stated that “A lot of painful moments [were] shared, but no one took advantage of that.” Another element women identified as characteristic of women's communication style included a more “intuitive style of processing” which in turn, made communication among women easy and more effortless. Women commonly described how “women communicate differently than men” and commented that “women can speak ‘womanese’ to each other.” Alternatively, they reported that they often felt constrained within a mixed-gender group that silenced some women who could not “talk about things important to women that men might minimize.” One woman summed up her perception of the intuitive nature of communication in the single gender group as follows:

“I think that even though there are women who aren't very intuitive and there are men who are very intuitive, I think in general women have a more intuitive style of processing and communicating and relating. And it was nice to just all be in the same place. We didn't have to make any effort in that sphere, so we could focus all our energy on the recovery piece. We didn't have to make any effort about communication. I never felt that was an issue, ever. It was so natural. And again, that's not a women good, men bad statement. I think it's just, sometimes when there's a mix you spend more time interpreting than really connecting. And so, I think that was, for me, what made the group feel so easy for everybody.”

Discussion topics in single-gender group therapy

Discussion topics in WRG included women's relationships as partners and their roles as caretakers. For example, one woman described how she could “talk about the effects spouses have on women’s recovery in all women’s group” and another participant expressed that she could "talk about the men in your life without feeling like you are bashing other group members because there weren’t any men.” In general, women felt that they were able to speak openly about the issues they had with intimate partners as well as their shared their experiences as caretakers and their sense of responsibility for their children. Furthermore, women in this study shared that caretaking and balancing multiple roles can be a major source of stress and a continuous burden. For example, women stated that it is hard to cope with balancing and that “women have many tugs and pulls,” “women have so many different responsibilities in today’s world,” and that it is hard to “balance roles in male-dominated society." In the WRG, participants also felt they were able to discuss their experiences of “what it is to be an addicted woman.” Women explained that it was important to talk about the way their “bodies deal with alcohol differently.” Women noted differences between their drinking patterns and those of men, including their own likelihood to drink in isolation and often at home whereas men “get addicted through bars and drinking after work.” Women in the single-gender group also noted that “alcohol makes women vulnerable sexually."

Women’s Experiences in Mixed-gender Group Therapy

Self presentation in mixed-gender group therapy

Women in mixed-gender group therapy described more negative and constrained self-perceptions than those in the single-gender group. Women felt that their sense of self was "constrained," they had to be "polite," and women expressed "feeling different," "being judged," and "feeling guarded." Women in this study also expressed concern about stigma and shame associated with substance use. One woman stated that she was “cognizant of the fact that [she] was in the minority” in the mixed-gender group. Overall, women in this group focused more on the limitations that the mixed-gender group placed on women’s identity and self-image based on social expectation and traditional gender roles.

Perception of group atmosphere in mixed-gender group therapy

Women in the mixed gender groups reported that a "lack of empathy" and "sexual tension" can be experienced in mixed gender groups. Such an atmosphere may hinder the group process. Some participants noted that they identified best with other women participants who had experienced addiction and its impact on women’s lives. For example, a woman explained that she “identified with the women in the group because of where they were at in their recovery.” However, women experienced some positive aspects of the group atmosphere in the mixed-gender group. For example, one benefit women noted of being in the mixed-gender group was learning about both "men's and women's experiences." Furthermore, one woman commented:

“I was in mixed gender groups and in female groups and there's a quality difference. It's kind of a simple thing of a little bit more support and affinity. And in the female groups, things go a little bit deeper. But then I think in the mixed gender groups, there is more of that quality of a little bit more accountability. The women[’s] groups are almost, they're like so supportive that they might not actually have the confrontation element…”

Another woman noted, “I don't think it was necessarily negative to have a mixed group. I don't think that really contributed to any negative feelings.” Overall, women in the GDC group found it interesting to learn more about how both genders experience addiction and recovery, yet they reported feeling more connected to other female participants.

Characteristics of communication in mixed-gender group therapy

Women in the mixed-gender group observed differences in ways in which men and women communicate, share, and frame their experiences during group therapy sessions. For example, women commented that men and women had "different communication styles" and "different cognitive styles" and that sometimes there was "unproductive communication." Women also found that men did not easily talk and sometimes men did not say anything at all during the group meeting. Instead, some women explained that "women motivated men to talk” and women’s conversations served as prompts for men to respond. Another woman reported that “women tend to raise more discussions than men and kind of get the men going a little bit.” Additionally, women noted that in the absence of men the nature of discussions changed and women were able to relate to each other differently. For example, one participant had observed that “the few times that there were only women present…[communication] seemed to be more open” and that while "men…talk about what they did and what happened with relationships…women are more relational.” This openness to share was seen as one element of meaningful and productive group therapy as expressed by a woman in the mixed-gender group: “I would have gotten more from all women's groups…women have stronger conversation…"

Discussion topics in mixed-gender group therapy

Discussion in the mixed-gender group tended to be "limited to gender-neutral topics.” Women also reported that the experiences for men and women in recovery are different. When men missed GDC groups, making it a women’s only group, one woman stated that “there was a sense that we were talking about women's issues, just having to do with women, no matter what the topic was.” Feelings of being constrained within a mixed-gender group silenced some women who could not “talk about things important to women that men might minimize.” For example, one woman reflected "men have different addiction issues than women do" and "if men were not there, menopausal issues would have come up…a lot of addiction issues are based on hormones" and "a lot of my addiction issues are based on hormonal stuff within my body." She reflected that these issues were not discussed in the mixed-gender format. However, it was clear that some women might have gained some male-specific insight n the mixed-gender group. For example, one woman in WRG said, “I wish that I could have…attended the mixed gender group to hear if there was anything specific to male-- treatment of males that I might-- that might make it easier for me to deal with my husband, or provide insight into what he might be going through…”

Secondary Interactions

Gender of the therapist

In general, more women highlighted the gender composition of their group as having a significant effect on their group experience than the gender of the therapist. However, some participants endorsed the importance that their group therapist was a woman. Specifically, women generally reported that they felt comfortable with the female therapists. One WRG participant stated, “For me, it was a huge deal to have the leader be a female…and I don’t think I would’ve benefited like I did [if I had a male therapist]. Because I know myself. I probably just would've withdrawn, tried to keep a low profile and pay my dues and get out, versus what really happened.” In addition, while talking about having a female therapist, another woman said that, “I think it makes a difference. I really do.” The same woman also stated that, “It would have to be the exceptional kind of guy [therapist] that would be able to win me over on that one, as far as really feeling that they have the right to discuss these issues.”

Socio-cultural influences

Women endorsed stigma and shame associated with being an addicted woman as an important factor in their recovery. Women discussed how they experience shame, guilt, and distress and that women could talk about this with each other, but “the men wouldn't talk about it so much.” Another woman said that, “women experience the stigma of alcoholism in a different way than men do.” Women’s discussion also focused on how drinking is less acceptable for women. For example, one woman explained that “women that are addicted…drink in isolation,” which, for her, was related to her following thought:

“[Drinking] is much less acceptable [for women] than with men, whereas I feel that with men, through my meeting experiences that a lot of times they became addicted by just going to a bar, or a VFW, or something right after work. And that became a problem. They didn't come home, whereas I felt as though women, more so, drank at home, so it was a tougher place to go back to, after you detox or you quit.”

Discussion

Women in single-gender WRG endorsed feeling safe, being able to be all aspects of the self, having their needs met, feeling support and intimacy, and experiencing empathy, honesty, and comfort. Women in the mixed-gender GDC group reported feeling constrained in both discussion topics and self-presentation, the need for women to motivate men to speak in group, and a perception that there are differences between men's and women’s recovery. Women in single gender group therapy found an ease of communication with other women as well as a sense of support and commonality. These reported experiences contributed to our conceptual model of women’s experiences in both groups, and this model may provide a framework for the mechanisms of effective group treatment. Specifically, the mutually supportive group setting provided by the WRG may enhance the effectiveness of the treatment through some of the posited therapeutic mechanisms of group therapy such as universality (e.g., the opportunity to have a frank and candid interchange and recognize a shared problem), group cohesiveness (e.g., sense of acceptance, being supportive, and forming meaningful relationships in the group), imparting of information (e.g., topics specific to women's recovery), and interpersonal learning (e.g., provision of a safe environment, supportive interactions, and open feedback; Vinogradov & Yalom, 1989). Women in the single-gender WRG endorse many of these attributes described by Yalom (1985) as mechanisms of effective group therapy.

Previous qualitative studies found that women endorsed the help they received from single-gender groups while noting their relative inaccessibility. Nelson-Zlupko et al. (1996) found in their survey of twenty-four women in drug treatment that there was a major gap between helpfulness and availability of gender-sensitive substance abuse treatment services. For example, while seventy-eight percent of their sample endorsed single-gender groups as helpful compared with forty-six percent that found mixed gender groups helpful, only fifty-six percent said that single-gender groups were available to them. They also found that most mixed-gender treatment did not provide a "forum for open expression of women's needs and experiences" and that the effectiveness of treatment was diminished if women did not feel that they were perceived "with dignity and respect" by staff and participants (Nelson-Zlupko et al., 1996). Another study documented important themes that thirty-four women who participated in both mixed-gender and single-gender groups found easier to discuss in single-gender groups including interpersonal relationships, a coherent personal identity, the mothering role, and life stress (Kauffman et al., 1995). In contrast to these studies, the present study is the first to investigate women's subjective experiences of single versus mixed-gender treatment in the context of a trial comparing two empirically supported, manual-based group therapies. Specifically, we demonstrate that there are several significant aspects of women's experiences in groups that are affected by group gender composition including the way group gender composition affects self-perception, communication among members, the group atmosphere, and the topics of discussion.

The WRG and GDC are both manual-based relapse prevention group therapies with similar structures (90 minutes with topic presentations and open discussions), and length of treatment (weekly sessions for 12 weeks) and both group treatments were professionally led by women therapists. The major variation between these two groups was in their gender composition and the recovery topics that were gender-sensitive (i.e., WRG) versus gender-neutral (i.e., GDC). Thus the qualitative experiences endorsed by the women randomly assigned to the two treatment conditions are more likely to reflect responses to the group environment engendered through the interpersonal conditions established in a single-gender compared with mixed-gender group environment, as well as the focus on gender-sensitive issues and concerns.

We previously reported that satisfaction scores on the Client Satisfaction Questionnaire (Nguyen, Attkisson, & Stegner, 1983) were high for both WRG and GDC among women who participated in the Stage I trial; however, women in the WRG had significantly greater satisfaction than women in GDC (Greenfield et al., 2007b). The present study's qualitative analysis elucidates women's subjective experiences in the single and mixed gender groups that may have contributed to greater satisfaction with the single-gender WRG compared with the mixed-gender GDC.

One rationale for single-gender treatment for women with substance use disorders is patient preference (Greenfield et al., 2007b). A recent meta-analytic review (Swift & Callahan, 2009) demonstrated that treatment preferences are related to treatment outcomes. The review summarized data from 26 studies that examined treatment preferences and outcomes. Their findings indicated a small significant effect in favor of participants who received their preferred treatment. When examining the studies individually, the authors found that all but one of the studies indicated effect sizes in favor of participants who were given their preferred treatment. Additionally, Swift and Callahan (2009) found that clients matched with their treatment preference had a 58% chance of showing greater improvement over clients that were not matched. This review demonstrates that participants who receive their preferred treatment are at an advantage for a more successful treatment outcome. Substance abusing women's preference for the mutual support and gender-focused content of single-gender group therapy may play a role in treatment outcome. Unfortunately, single-gender group therapy for women with substance abuse is often unavailable in treatment programs (Campbell et al., 2007). This may also play a role in the lowered likelihood of women more than men to ever seek treatment for substance use disorders (Dawson, 1996; Dawson, Goldstein, & Grant, 2012; Wu & Ringwalt, 2004). In addition, elucidating potential preferences for single-gender group treatment among diverse populations of women with addiction such as ethnic/racial minority women and sexual minority women, as well as selected special populations such as women veterans, may provide additional insight on patient preferences, treatment experiences, and outcomes.

This study has a number of limitations. The sample size was small and consisted mostly of white, well-educated participants. This limits the study’s generalizability to other populations with different demographic characteristics. In addition, we had a greater number of interviews with women assigned to WRG than GDC and this may have limited the perspectives we elicited on mixed-gender group therapy. Despite these limitations, this is the only study that we know of that has qualitatively compared women’s experiences in manual-based, empirically supported single-gender and mixed-gender substance abuse group therapy. The findings indicate that single-gender group composition enhances women's perception of comfort, safety, group cohesion, interpersonal communication, and mutual support, and allows women to focus on gender-relevant topics that are important to their recovery. These advantages of single-gender group therapy may heighten women's satisfaction with treatment and enhance outcomes. The role of patient preferences for single-gender group therapy and its relationship to treatment outcomes including retention in treatment, functioning, and quality of life would be important avenues for future research. Finally, to our knowledge, qualitative research examining men's experiences, satisfaction, and preferences regarding single- versus mixed-gender group therapy for substance abuse has not been conducted and might be useful in determining whether a specific focus on gender-sensitive content for men would enhance treatment satisfaction and effectiveness. Research on patient preference, satisfaction, and outcome can help facilitate treatment and program planning to match available resources to patient need.