GPSolo Magazine - October/November 2006
Out of the Shadows Women and Addiction
Scientists have finally verified what certain people have long suspected—boys and girls learn differently—and many public schools have thus introduced gender-specific classrooms. Professionals in the field of substance abuse treatment have also seen that women are impacted by addiction differently than are men, and that the psychological and physiological effects of drugs and alcohol are often more severe for women.
The percentage of women who have mental health problems such as depression in addition to addiction or who show signs of post-traumatic stress disorder (PTSD) is significantly higher than it is for men; in addition, the mortality rate for women with addiction(s) is 50 percent to 100 percent higher for women than men. Because of their size and hormone fluctuations during the menstrual cycle, women generally become intoxicated more quickly than men—and become clinically “addicted” much more quickly (according to the National Institute on Alcohol Abuse and Alcoholism).
Societal influences that historically have contributed to the disease of alcoholism or drug addiction also are different for men and women, sometimes influencing women to be even more reluctant to admit to substance abuses.
Obstacles to Treatment
Although 40 percent of all alcoholics are women, women account for only 25 percent of all who receive treatment for addictions (according to the Alcohol and Drug Problems Association of North America). Aside from society’s general expectations of women, as well as its association of women and alcohol with loose morals, women face specific barriers to treatment that men do not. Barriers for women are usually very practical: lack of childcare, fear of losing their children, lower wages, and less money.
Throughout American history, society and traditional family structures have contributed to women’s roles being central to the stability and “nurturing” of the immediate family, and often of the extended family of parents and in-laws and close friends. And whereas drinking a couple of beers with his buddies makes a guy “manly,” an alcohol or chemical abuse problem makes a woman shameful and suspect, and her family, the object of pity and scorn. Women are more likely than men to lack social and family support for going into treatment. Because alcoholism is also a family disease, and however dysfunctional the family may be, the roles of mother and wife are seen as essential in meeting the needs of the others, and everyone’s denial remains a powerful barricade to treatment.
In the workforce, women are often able to hide substance abuse because they tend to have less visible positions than men and are less likely to “act out” when intoxicated. Because they’re also more likely to stay home with sick children, they often can use this excuse repeatedly for absences that are actually alcohol related. Women are more sensitive than men to the stigma about substance abuse and generally are afraid of losing their jobs if anyone finds out about their drinking. Unfortunately, this also holds true for many professional women already in recovery, who are still afraid that employers or clients may find out that they had a drinking problem. In addition, many women in treatment do not fully realize they are addicted to medications or alcohol or that physical illnesses or emotional complaints such as depression may be the result of addiction. They often report having visited physicians for stomach pains or psychologists for depression or anxiety, believing that drinking helped them cope with the illness rather than caused it.
Women’s Addiction Process
How do women become addicted? Let’s start with history. For more than 100 years in this country, women and girls have been encouraged to self-medicate for emotional and physical symptoms of the hormonal cycle (which Freud in the nineteenth century famously labeled “hysteria”). Physicians regularly prescribed opiates for moodiness, pain, or fatigue; and Coca-Cola, which in the early part of the twentieth century still contained cocaine, was served at soda fountains and promoted in consumer advertising as an afternoon “pick-me-up” for ladies.
According to the National Institute on Drug Abuse, doctors currently prescribe twice as many psychotropic medications for women as for men—and many are refilled for decades. But a psychotropic medication that was originally prescribed for a temporary anxiety problem yet has been used continuously for years poses a serious risk for physical addiction. Many women in treatment have asked, “How can I be addicted to this? After all, my doctor prescribed it.” This is called accidental addiction in treatment, but it can escalate to a coping mechanism to get through the day and then to conscious self-medication on the part of the addict, who may even go from doctor to doctor and get multiple prescriptions that she fills at numerous pharmacies.
Complex factors are involved in the development of an addiction, including hereditary susceptibility. Research and clinical experience show that women may experience not only dramatic mood shifts but also strong cravings at different points of their hormonal cycles (generally encompassed by the term premenstrual syndrome, or PMS). A majority of girls report being introduced to alcohol and drug use by their boyfriends, with inebriation as a part of their first sexual experiences. Physical, emotional, and sexual abuse play a strong role in the course of addiction development in women. The prevalence of abuse, often sexual, is statistically confirmed, with some estimates going as high as 85 percent of all women admitted to treatment. Related to abuse are the high rates of post-traumatic stress disorder (PTSD) seen in recovering women. (For more on PTSD, see the sidebar “What Is PTSD?” on page 45.)
A recent and disturbing development is the prevalence of competitive drinking bouts that young women undertake against young men. This is dangerous because women physiologically feel the effects of alcohol sooner than men and from lesser amounts of alcohol. Interestingly, treatment centers report that their women clients from midlevel and higher management positions have said they felt the need to hold their own on many fronts, including macho drinking behaviors when out with colleagues. Although this issue is seldom discussed, it seems part of women’s struggle to be seen as equals and admitted to higher strata of power.
Loss of Self
According to Stephanie Covington, author of A Woman’s Way Through the Twelve Steps, the treatment manual Helping Women Recover, and other books, women tend to lose their identities and relationships as addiction spirals downward. Covington says that women are less empowered in society in general because traditional views of women cast them as more feminine, attractive, and lovable if they do not have—or behave as if they do not have—power.
This traditional disempowerment contributed to women’s instinctive development and refinement of their own tools (often called “feminine wiles”), one of which is manipulation. Rather than directly ask for what they need, these women flatter, flirt, please, and play helpless to get what they want. In addiction, a woman not only has no power over her disease, she lacks a sense of her own self. Addiction to alcohol, drugs, food, gambling, or sex always provides a perceived benefit—not because it is pleasurable but because it is a way of coping, of masking a woman’s feelings about herself and her emotional pain. This denial is often unwittingly supported by a dysfunctional family system, the workplace, the physician who doesn’t ask the right questions, or the parents of a teen addict who can’t believe the extent to which she drinks or drugs.
For a woman who adroitly multitasks and manages multiple roles in her profession as well as at home, admitting that her life is actually unmanageable is extremely difficult. In order to maintain her outward sense of order or perfection, a “Type A” woman may start micromanaging even implausible things to have that sense of control and keep her anxiety at bay—but she has little control over anything. Letting go of things beyond one’s control is the essence of recovery, which is captured in the Serenity Prayer used by many 12-Step groups: “God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference.”
In recovery, a woman must learn how to acknowledge the power of the addiction while discovering her own personal power. Accomplishing this entails looking within and honestly asking What do I feel? What do I think? What do I want or need? When a woman has masked her own needs and values for so long in order to take care of others’, or shaped her personality to fit other people’s concept of herself, the answers may be frighteningly elusive.
The relational concept of treatment grew out of the experience of four women psychologists who met informally every week in Boston in 1977 and was introduced by researchers at the Stone Center at Wellesley College, who premised that women’s desire for relationship and their tendency to be emotionally sensitive to the reactions of others was not “pathological.” They found that losing those connections with others was a devastating aspect of addiction.
To put this in broad perspective, a landmark UCLA study has shown how special women’s friendships are, and that women in general may enjoy longer life and better health in part because their strong bonds with friends are emphasized on a regular basis. In their friendships, women tend to share feelings and problems more than men do with friends; and in times of stress or anxiety, women are more likely to turn to their friends and confidantes for emotional relief.
In recovery, women find that they do need other women and often begin to reconnect with a sense of self and others, spirituality, and healthy sexuality.
In holistic programs (such as that offered by the Center for Women’s Recovery at the Hanley Center, where I am employed), the patient receives a physical and psychological assessment before an inter-disciplinary team implements a specific treatment program, and length of stay varies with individual needs. The program includes wellness, nutritional, and spiritual components as well as individual, group, and experiential therapies. At the Hanley Center, establishing a sense of safety and security is also considered essential, especially for the large numbers of traumatized addicted women. The center also features a female professional staff.
Because hormonal shifts play a role in relapse—possibly in the development of addiction as well—a hormonal shift assessment and treatment plan are integrated into treatment. As many women know only too well, hormonal shifts produce emotionality, anxiety, irritability, and depression and can be powerful triggers that may accelerate a woman’s pattern of abuse or even contribute to relapse.
Self-assessments during treatment cover life cycles, physical and emotional effects of menstruation and pregnancy, sexual history, family history, and attitudes about life experiences. One of the most valuable aspects of this approach is patients’ validation of their own experience, especially as they connect the effects of PMS or menopause, for example, with episodes of depression, anxiety, and insomnia. Moving through new stages of life can be debilitating and confusing; may disrupt relationships with family, friends, and work; or may contribute to relapse or late-onset addiction. Learning new coping skills to meet life’s challenges is a major part of any treatment plan.
Experiential therapies—less theorizing, more reexperiencing feelings that have been buried or covered up by dramatic behaviors—may work well for women in treatment. They help guide women to rediscover themselves, examine and evaluate issues and relationships, and create new paths for themselves. The strong emphasis on spirituality, particularly in adjunctive 12-Step programs, helps engender a willingness to become open to new possibilities and participate in life.
Narrative therapy was founded mainly by Michael White and David Epston of Auckland, New Zealand, authors of the 1990 book, Narrative Means to Therapeutic Ends. The therapy addresses the chronic mindset of people with addictions, depression, and feelings of shame: that the person is the problem, not the substance abuse. By creating a new story of her life, a woman learns to see the problem as outside herself, finite, and changeable; externalizing the problem lets her create a new point of view about her life and a healthier way to interpret the past.
Motivational interviewing, developed by William Miller, depends on the therapist’s ability to empathize and connect with the patient and validate her experience without judgment. Learning to trust the counseling process is the goal, which eventually helps the patient let go of the addiction and embrace change.
Expressive therapies such as interpretive dance, journaling, and art therapy provide creative outlets for emotions, memories, dreams, and desires. Engaging in expressive therapy is often meditative and can help defuse cravings or obsessive thinking, focus creative energy in a nonrational way, and foster relaxation. The National Expressive Therapy Association was founded in the mid-1970s. A current fellow of the association, Joseph Zinker, was one of the founders. However, the movement may go back to roots in gestalt therapy and Fritz Perls.
Dialectical behavior therapy (DBT) was developed by Marsha Linehan and draws its inspiration from Zen Buddhism and the power of mindfulness—being present in the moment—to quell brain chatter. DBT instructs women to live effectively in the present and eventually accept reality without impossible expectations, rigid rules, or old debates. Mindfulness is also promoted in wellness treatment through yoga and team-building exercises.
Because the spiritual component is so essential to recovery, treatment may also include access to a spiritual counselor who helps women connect to a higher power, to themselves, and to a new sense of the possible. Counseling, group therapy, and 12-Step programs also examine the influences of grief, religious beliefs, and religious rigidity, among other issues.
An unusual aspect of substance abuse treatment is that it accepts the likelihood of relapse, where a woman returns to alcohol or drugs after having been abstinent and in recovery for a time. An effective treatment program includes an element of relapse prevention. This may mean inviting family members to weekend programs during the patient’s treatment, to educate families about broad and specific factors surrounding addiction and to involve them in supporting the development of a healthy family system.
In some cases, a woman may require further residential treatment, an intensive outpatient program, or a referral to a sober living residence (halfway house) before she returns home. All residents are introduced to an appropriate 12-Step program during treatment and are encouraged to continue attending meetings and following the recommendations for continuing care.
Women in successful recovery learn over time how to create and use tools that will work in their sober personal and professional lives. They discover healthier life choices for their bodies and often report feeling a new sense of “wholeness.” They make connections with themselves and with others and gain a new appreciation of their potential and abilities that were once masked by the disease of addiction.
Cindy McAlpin is marketing director for the Hanley Center, which offers gender- and age-specific treatment for addiction, as well as a family program and a range of prevention programs. She can be reached at firstname.lastname@example.org.