“From an ecological perspective, the addiction process doesn’t happen accidentally, nor is it preprogrammed by heredity. It is a product of development within a certain context and is maintained by factors in the environment. The ecological view sees addiction as a changeable and evolving dynamic that expresses a lifelong interaction with a person’s social and emotional surroundings and their internal psychological space.
Healing must take into account the internal psychological climate—the beliefs, memories, mind-states, and emotions that feed addictive impulses and behaviors—as well as the external milieu. In an ecological framework, recovery from addiction does not mean a “cure” for a disease, but the creation of new internal and external resources that support different, healthier ways of satisfying one’s genuine needs. It also involves developing new brain circuits that facilitate more adaptive responses and behaviors.” — Gabor Maté, In the Realm of Hungry Ghosts
Throughout the history of substance abuse treatment, counselors have focused primarily on addiction and assumed that other issues would resolve themselves during the recovery process or would be addressed by another mental health professional later. Additionally, many interventions were based on the needs of addicted men. For instance, The Big Book of Alcoholics Anonymous, which serves as a manual for many twelve-step AA meetings, was written by a man and largely reflects a male perspective on chemical dependency.
Research demonstrates that addiction treatment services for women need to be based on an integrated, women-centered approach that acknowledges their psychosocial needs (Covington, 2008). Covington states, “The keys to developing effective services for women are acknowledging and understanding their life experiences and the impact of living as a female in a male-dominated society.” She identifies common themes in the lives of addicted women, which include: shame and stigma; physical and sexual abuse; relationship issues such as fear of losing children or partners and needing a partner’s permission to seek treatment; treatment issues like lack of services for women, misunderstandings about women’s treatment, long waiting lists, and lack of childcare services; and systemic issues including lack of financial resources, clean sober housing, and poorly coordinated services (Covington, 2008).
Finkelstein, VandeMark, Fallot, Brown, & Cadiz define trauma as “experiencing, witnessing, or being threatened with an event or events that involve actual serious injury, a threat to the physical integrity of oneself or others, or possible death. The responses to these events include intense fear, helplessness, or horror.” The rate of sexual and physical abuse among women in substance abuse treatment programs is estimated to range from 30 percent to over 90 percent, depending on the definition of abuse and the specific target population (Finkelstein et al., 2004). Gil-Rivas, Grella, & Prause (2009) found that among individuals with co-occurring disorders sampled from 11 substance abuse treatment programs in Los Angeles County, CA, a staggering 98.5 percent experienced at least one lifetime trauma exposure event.
Longitudinal evidence shows that after an assault, the odds of both alcohol and drug use significantly increase among women with no previous history of substance use or assault. This same study found that drug use increases the risk of future assault, which then leads to an increase in substance use (Walters & Simoni, 1999). Since a large proportion of sexual victimization events involve drug or alcohol use, there has been significant theoretical and research interest in the causal link between alcohol and drug use and subsequent sexual victimization (Testa, VanZile-Tamsen, & Livingston, 2007).
Some women, particularly American Indian women, face multiple cumulative traumas from the last two centuries, including colonization events such as relocation to reservations, local tragedies like high rates of motor vehicle accidents and homicides, and interpersonal victimization reflected in the disproportionately high levels of violence against American Indian women and children (Walters & Simoni, 1999). The Red Lake Reservation massacre on March 21, 2005, which devastated a community by killing seven people and wounding five others, is a poignant example of trauma with far-reaching effects.
Long after the national media leaves the scene of a school community tragedy, a series of cascading events continues to impact survivors. Since the shootings, two teens have completed suicide, several others have attempted suicide, and there has been a general increase in depression among youth in the Red Lake community (Carlson, 2005; Rave, 2005). Such occurrences are part of the rising tide of victimization that often follows tragedy but is seldom reported.
Classes reconvened at Red Lake High School three weeks after the shootings. Approximately one-third of the students returned for half-day sessions until the end of the school year (Robertson, 2005; Zenere, 2005).
Covington states, “Although the addiction treatment field considers addiction a ‘chronic, progressive disease,’ its treatment methods are more closely aligned to those of the acute care medical model than the chronic disease model of care.” She recommends a recovery model more aligned with disease management approaches to other chronic health problems, focusing on quality-of-life outcomes as defined by the individual and family. Covington advocates for offering a broader range of services earlier, including pre-treatment (recovery priming), recovery mentoring during primary treatment, and extending services and support beyond the traditional medical services model into post-treatment recovery support (Covington, 2008).
Covington cites Dr. Judith Herman and defines trauma as a “disease of disconnection.” She presents a three-stage model for trauma recovery: 1.) safety, 2.) remembrance and mourning, and 3.) reconnection. Herman emphasizes that a trauma survivor working on safety issues needs to be in an all-women’s recovery group until they reach stage three, reconnection (Covington, 2008). She notes that a woman stabilized in her addiction treatment may begin stage two, remembrance and mourning.
Addicted women are more likely to experience co-occurring disorders such as depression, dissociation, post-traumatic stress disorder, other anxiety disorders, eating disorders, and personality disorders, with mood and anxiety disorders being the most common. Women are diagnosed with “borderline personality disorder” (BPD) more frequently than men. Many descriptors of BPD can be viewed differently when considering a history of childhood and adult abuse. The American Psychiatric Association is considering adding the diagnosis of “complex PTSD” in the next edition of the DSM (Herman, 1997; Covington, 2008).
Gil-Rivas et al. suggest that assessing individuals’ anxiety sensitivity and their tendency to use avoidance as a means of managing anxiety and depressive symptoms may be beneficial. Additionally, beliefs and expectations regarding the extent to which substance use can alleviate distress symptoms may contribute to the resumption of substance use (Gil-Rivas, Grella, & Prause, 2009).
Finkelstein et al. (2004) caution that for women with active substance use and those in early recovery, the focus should be on stabilization, safety, and understanding the links between trauma and substance use and abuse—not on recounting traumatic stories. This approach strengthens and supports the client, helping them learn and engage in new coping strategies before moving into later stages.
Brené Brown, a shame researcher, discusses shame as a basic universal human experience. She states, “Our culture sends continuous shaming messages. For example, we accuse mothers of not doing what’s best for their children, accuse women of not looking good enough, and accuse men of being weak. We try to use shame to teach people—to reinforce or control behavior. But shame only makes people feel rejected, diminished, and ridiculed. It causes excruciating and scarring damage. Shame only teaches us to feel alone.”
She further explains that “ultimately, shame isolates one person from another. It disconnects people. Shame can be thought of as the fear of disconnection. Because people want to be connected, they feel desperate when they experience shame. They are desperately afraid of being disconnected. Courage, compassion, and connection help us overcome experiences of shame. They help us become resilient to shame. It takes compassion to listen to another’s story of shame. The combination of courage and compassion creates connection, and connection heals shame.”
Men and women don’t experience shame differently, but the societal and cultural expectations that fuel shame are organized by gender. There are no universal shame triggers; what triggers shame in one person may differ significantly from what triggers shame in another. Brown identifies twelve categories of shame triggers: appearance and body image; money and work; motherhood/fatherhood; family; parenting; mental and physical health (including addiction); sex; aging; religion; speaking out; surviving trauma; and being stereotyped and labeled.
Women experience shame as a “web of layered, conflicting, and competing expectations and messages.” Men, conversely, face one overarching expectation: the pressure to be strong and not weak.
There is substantial research supporting the use of EMDR (Eye Movement Desensitization and Reprocessing) in trauma treatment. In this modality, clients must first be stabilized with well-developed coping and grounding strategies, which are built in earlier stages of treatment. In EMDR, clients are initially guided to establish a ‘safe place.’ According to the EMDRIA website (www.emdria.org):
“EMDR therapy is an eight-phase treatment. Eye movements (or other bilateral stimulation) are used during one part of the session. After the clinician has determined which memory to target first, they ask the client to hold different aspects of that event or thought in mind and track the therapist’s hand as it moves back and forth across the client’s field of vision. As this happens, internal associations arise, and the clients begin to process the memory and disturbing feelings. In successful EMDR therapy, the meaning of painful events is transformed on an emotional level. For instance, a rape victim may shift from feelings of horror and self-disgust to the firm belief, ‘I survived it, and I am strong.’ Unlike talk therapy, the insights gained in EMDR arise from the client’s accelerated intellectual and emotional processes rather than clinician interpretation. The net effect is that clients conclude EMDR therapy feeling empowered by the very experiences that once debased them. Their wounds have not just closed; they have transformed. As a natural outcome of the EMDR therapeutic process, clients’ thoughts, feelings, and behaviors are robust indicators of emotional health and resolution—all without detailed verbal exploration or homework typical of other therapies.
There is constantly new research being conducted that clinicians and laypeople alike can learn from and apply to help those in our programs, families, and communities treat substance use disorders effectively.
References:
- Covington, S. (2008). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, 5(Nov), 377-385.
- Finkelstein, N., VandeMark, N., Fallot, R., Brown, V., & Cadiz, S. (2004). Enhancing substance abuse recovery through integrated trauma treatment. CSAT: National Trauma Consortium.
- Gil-Rivas, V., Grella, C., & Prause, J. (2009). Substance use after residential treatment among individuals with co-occurring disorders: The role of anxiety/depressive symptoms and trauma exposure. Psychology of Addictive Behaviors, 23(2), 303-314.
- Testa, M., VanZile-Tamsen, C., & Livingston, J. (2007). Prospective prediction of women’s sexual victimization by intimate and nonintimate male perpetrators. Journal of Consulting and Clinical Psychology, 75(1), 52-60.
- Walters, K., & Simoni, J. (1999). Trauma, substance use, and HIV risk among urban American Indian women. Cultural Diversity and Ethnic Minority Psychology, 5(3), 236-248.
- Zenere, F. (2005). Tragedy at Red Lake: Epilogue. Retrieved from http://www.nasponline.org/publications/cq/cq341redlake.aspx
