Clinicians and researchers have become increasingly aware of the pervasiveness and profound impact of physical and sexual abuse in the lives of women receiving mental health and substance abuse services. Violent victimization increases the risk of subsequent mental health problems and substance use disorders (1,2). In turn, people with severe mental disorders report higher rates of current trauma exposure than the general population (3). Similarly, current substance use increases the risk of exposure to violent assault, which carries with it an increased probability of additional substance abuse (4). Individuals with histories of physical and sexual abuse often have poorer substance abuse treatment outcomes, perhaps because of increased psychiatric and interpersonal difficulties (5). These interwoven relationships among trauma, substance abuse, and mental disorders raise important questions for the study of relapse prevention and long-term recovery.
The purpose of the study reported here was to examine key themes in sustaining recovery among women trauma survivors with co-occurring disorders. Because of the multiple vulnerabilities of these women, recovery encompasses not only abstinence from substance use but also relief from the effects of mental illness and trauma.
Qualitative interviews were conducted as part of the Washington, D.C. Trauma Collaboration Study, one of nine sites funded under the federal Substance Abuse and Mental Health Services Administration's Women, Co-occurring Disorders, and Violence Study. The interview participants were 27 women with histories of physical or sexual abuse who also had co-occurring mental health and substance use disorders. The inter-viewees were selected from a group of 86 study participants at one urban mental health agency. Each had received a package of integrated trauma-focused services and had completed baseline, six-, and 12-month interviews that included measures of mental health (the Brief Symptom Inventory) (6), symptoms of posttraumatic stress disorder (the Posttraumatic Symptom Scale) (7), and substance use (composite alcohol and drug use scales of the Addiction Severity Index) (8).
Changes in standardized scores on these measures were calculated, and the 50 participants who reported the greatest combination of reductions in symptoms and substance use at 12 months were identified. From this pool, at 12 to 18 months after the 12-month interview, 27 women were identified by their primary clinicians as being interested in and available for open-ended interviews: 14 women who had maintained abstinence (on the basis of both self-reports and clinician reports) and 13 who had had a significant substance use relapse in the interim period. The mean±SD age of the women was 42±6.7 years. Twenty-two women (81 percent) were African American, and five (19 percent) were white. Eighteen (67 percent) reported childhood physical abuse, and 20 (74 percent) reported childhood sexual abuse; 22 (81 percent) reported physical assault, and 24 (89 percent) reported forced sex in adulthood. Three (11 percent) of the women were married at the time of the interview, and nine (33 percent) were either divorced or widowed. Seven of the women (26 percent) had completed high school, and ten (37 percent) had less and ten (37 percent) had more than a high school education. Six women (22 percent) were employed. On the basis of chart diagnoses, 21 (78 percent) women had a primary affective disorder diagnosis, three (11 percent) had a diagnosis of psychotic spectrum disorders, and three (11 percent) had an anxiety disorder. By self-report, major substances of abuse were cocaine (11 women, or 41 percent), alcohol (five women, or 19 percent), and more than one substance (11 women, or 41 percent).
Semistructured interviews included a focus on participants' perceptions of what was most influential in sustaining and hindering their overall recovery, specifically including substance abuse. After some background questions about their history and their expectations of the recovery program, the participants were asked to describe the influences that had proved most helpful in their recovery. The interview included follow-up questions about sources and types of support as well as particular areas of change—for example, new ideas, behaviors, and skills. The participants were then asked to talk about the obstacles to change that had been most problematic. Additional questions addressed specific choice points women experienced in recovery, images of change, and ideas for sustaining change. All women responded to the same set of questions.
In the winter of 2003 and 2004, the project's clinical director and a senior clinician conducted all interviews, ranging in duration from 75 to 120 minutes. The interviews were taped and transcribed. Institutional review boards approved all study procedures, and the interviewees were paid $50 for their participation.
After each interview, the interviewers identified key statements that reflected the participant's understanding of the supports and obstacles she experienced in attempting to maintain abstinence. As the interviews progressed, the first author identified the most frequently mentioned themes and organized them into generally descriptive experiential themes (9). The second author read the transcribed interviews and followed a similar procedure. Subsequent discussions among the authors led to a consensus on the organizing themes.
The seven themes that emerged included four relating to supporting recovery and three relating to obstacles to recovery. Some of these themes are similar to those outlined in studies of recovery from schizophrenia (the theme of the need for connection) (10), recovery from substance abuse (the spirituality theme) (11), and recovery from trauma (the theme of the impact of destructive relationships) (12). However, the unique combination of these experiences often highlighted the relationships among mental health, substance use, and trauma and gave distinct emphases to the various themes.
Below are illustrative quotes reflecting key experiences of the women under the various themes. Women who had relapsed did not describe significantly different experiences from those who had sustained abstinence. Rather, the former group stated that the obstacles were simply more powerful than the resources available to support recovery.
Themes related to sustaining recovery were connection, self-awareness, a sense of purpose and meaning, and spirituality.
Connection. One woman said, "At last I found someone who had walked in my shoes. It was such a relief not to be alone any more." For many women a sense of connection began with an acquaintance with another woman in the recovery community who had achieved abstinence and who took on the persona of a role model. This other woman not only served as a living and practical example of how recovery might proceed, being available to give a step-by-step approach to abstinence, but also shared many of the same struggles and conflicts as the woman who was beginning her own process. This "special friend" served as a guide and mentor, but, more significantly, became a reminder that "someone like me can make it."
Beyond an individual relationship, connection also entailed involvement in a recovery community, what Belenky and others have called public homeplaces (13). Such communities, which included peers, natural supports, and professional helpers, fostered acceptance, offered women a place where they could be heard and could hear others, and gave them a chance to develop needed skills and strengthen their will to stay sober. Moreover, these communities also posed a powerful alternative to the communities of addiction, which for many had previously been their only source of human contact.
Central to the ethos of these public homeplaces was an acceptance that many women had longed for but failed to find in other relationships. As one woman said, "It was so important that the women here never rejected me. My whole life I was told that I was nothing and I was never going to be nothing. But when I got here, it was like a whole different family." In the context of an accepting community, many women found the courage to put a voice to private struggles and cited this as an important element in sustaining recovery.
Self-awareness. One woman said, "I've spent so much time lying to myself that sometimes I don't know if I could recognize the truth if I ran straight into it." Many women described a shattering of illusions that occurred when they were forced to face themselves. For most women, addiction necessitated believing and perpetuating a series of lies about themselves, about others, and about their own ability to "master the drug" itself. When circumstances forced them to look in the mirror and to experience the subsequent terrifying realization that things were not as they had imagined, many women report making a pledge to seeing themselves more honestly and making a commitment to sustained recovery. As one woman asked, when she looked in the mirror at the image of her 90-pound body, emaciated from crack use, "Oh, my God, is that really me?"
Self-awareness also required the women to be willing to look inside themselves and to gain a greater understanding of themselves and the forces that influenced their behavior. Many women chose therapy as a vehicle for their journey inward, others worked with peers within a recovery community, and still others worked alone, using various self-help guides. As one woman put it, "As long as I am afraid to change the person that is inside my skin, I am going to run from that person and use [substances]."
However, self-awareness on its own was not sufficient for sustaining recovery. All the women shared a belief that constant vigilance was required to remain sober. For many who had ignored their bodies and their feelings for years, such vigilance involved cultivating a sense of mindfulness that was new and effortful. The women had to learn how to pay attention, and for many who had cultivated dissociation and distraction as ways to cope with frightening memories, this was a significant challenge. One woman likened her addiction to a caged monster: "Once you release that monster from the cage, he just keeps getting bigger and bigger until he controls everything."
A sense of purpose and meaning. One participant made the comment, "There's a hole in my heart where my self used to be. For so long, I worried that I would never be able to fill it up again." Years of addiction and painful abuse had left many of the women feeling empty and bereft of any meaning and purpose in life. The experience of bleak emptiness was so pervasive that the process of recovery required an endeavor that we have termed the "repersonalization of the self," a series of activities and commitments that fill the void left by years of devastating addiction and numbing trauma. For many of the women in this study, this repersonalization of the self began with the acquisition of very concrete skills needed to live the life of a sober woman. Despite the fact that many of the women had survived on the streets for years, most lacked even basic healthy living skills. As one woman who had run her own drug business commented, "I had to learn how to manage basic things, paying bills, keeping clothes clean, making sure there was food in the house. I didn't realize that living life on life's terms was so hard."
For others, constructing a strong sense of personal competence demanded that they get a job and compete in the working world. Working was closely tied to having a direction and a focus in life. Women contrasted the organized and purposeful life that they experienced as a sober member of the workforce with the shiftless and chaotic existence of an addict.
Whereas some women focused their skill development on acquiring the skills of everyday living, others believed it was important to master strategies that would specifically assist them in combating the urge to use drugs. Women who sustained their recovery had a "workable method" for dealing with the signs and symptoms of addiction. In some cases that method was simply learning the value of talking to someone rather than using drugs when life circumstances became overwhelming. For others, however, a specific problem-solving approach involving cognitive-behavioral techniques was essential in sustaining recovery.
Finally, a sense of purpose and meaning often entailed a personal mission to share the healing with others. Some women expressed this concern by volunteering to assist other women who were in earlier stages of recovery. However, most saw reaching out to women in their own families as being part of their own progress—most significantly, reaching out to the next generation of daughters, nieces, and granddaughters who were also struggling with addiction and trauma. Many women shared the sentiments of one of the interviewed women, who insisted, "Whatever I get or whatever I learn has to be for the benefit of the children."
Spirituality. One of the women said, "I knew that God didn't make no trash, but sometimes it was hard to believe in myself when everybody kept telling me that I wasn't going to make it." A series of somewhat elusive and transcendent forces that we have grouped under the heading "spirituality" also contributed to the ability to sustain recovery. Spirituality reflected a woman's recognition of her place in the cosmos and her appreciation of all the small and natural things that have the power to make a life rich and full.
Many women described a forgiving, loving attitude that came to replace their past feelings of anger and resentment toward life and the circumstances that had violated their most basic sense of security. This loving attitude began with a feeling of self-love and personal empowerment. Experiences of abuse and addiction had left women believing that they were little better than "society's trash," to be discarded and ignored. Reclaiming a sense of personal worth, through remembering past successes and building a portfolio of current and new triumphs, gave women a realistic sense of worth and accomplishment.
Other women spoke of a sense of inner peace, an experience of calm that seemed to follow from leading a more ordered and predictable life that was free from the drama of addiction. This inner calm also seemed to reflect a woman's realization that healing was a life process and that there was no pressure to accomplish the task of healing according to some arbitrary timetable. One woman shared the sense of calm she felt at knowing she was "not a scared little girl anymore; I don't have to run away. Now I can stand there toe to toe and face things."
Finally, spirituality encompassed a woman's deep recognition that she was no longer alone, that she truly belonged to a community of other women who shared her experiences and her struggles. A sense of being part of something bigger than oneself and one's immediate problems helped women to put their own concerns into a larger perspective and gave them courage to resist the temptations to relapse.
Themes relating to obstacles to recovery were battles with depression and despair, destructive habits and patterns, and lack of personal control.
Battles with depression and despair. One participant said, "I think I've probably been depressed all of my life. But nobody ever called it that. They just kept telling me I was just a bad kid." Many women referred to their addiction as "a feeling disease," and more often than not the feelings that they were trying to escape were profound depression and despair. Some came to believe that they suffered from a diagnosable mood disorder that required medication and ongoing monitoring. However, those who continued to be plagued by depressive symptoms found the quick fix of drugs and alcohol to be a better source of immediate relief from psychic pain than the more long-term approach of finding and reliably taking the correct medication. Proper psychiatric care required that the woman develop a trusting relationship with a psychiatrist who could hear her concerns and take them seriously.
Some women attributed their bouts of depression to the aftermath of early childhood and ongoing sexual and physical abuse. Women complained of flashbacks and nightmares that seemed to go away only when they were high, and although many commented that dealing with their abuse histories might ease their distress, those who continued to use drugs and alcohol feared that the effort of recovery would be too difficult to endure. One woman commented about her abuse history and her unsuccessful attempts to heal: "I feel like my heart is full of holes and I am bleeding and all the life is coming out of me and all I can think to do is to get high."
Finally, some women saw their failure to find a nonabusive relationship as the source of their depression. Women talked of their loneliness and their difficulty living alone. Yet at the same time, they found it difficult to trust relationships and feared that every new encounter would result in more abuse. Using drugs often gave the women a superficial social network that allowed them at least the illusion of companionship.
Destructive habits and patterns. One woman commented, "I stay in recovery for a couple of years and then I go back to the cocaine. I just keep going back. It's a pattern with me that I'm used to." A number of women described feeling defeated by the weight of their past bad choices. Using drugs and alcohol had become a way of life that, although it had its obvious negative consequences, also had a certain predictability that left a woman feeling oddly comfortable.
Some women lamented that using drugs was an accepted and expected way of life within their families. More than half the women reported that relatives not only used drugs but sold them and that the family elders expected that girls in the family would eventually use drugs and enter the sex trade to support their habits. Some women even commented that mothers, cousins, or aunts who were already involved in the drug subculture introduced them to drugs and prostitution. In such families, news that someone had achieved sobriety was met with derision and scorn, making it all the more difficult to sustain abstinence.
Finally, some women talked of being addicted to the drug culture itself. For these women the activities that accompany addiction had an allure of their own. One woman confided that even when she was free of drugs she maintained her lifestyle: "I gave up getting high, but it was so hard to give up the lifestyle."
Lack of personal control. One of the women made the comment, "I used to tell myself that, if I had all these things, that my life would be better. But the truth is that I can't handle more than one thing at a time or I'm drowning." Many women saw their relapse as stemming from having felt overwhelmed and out of control. Paradoxically, women often felt stressed by some of the very things that had motivated their recovery initially. Many women specifically requested a home of their own, a job, and reunification with their children. However, it was often these very issues that contributed to a woman's sense that life was "just too much."
For other women, a single crisis event shook their fragile adjustment. Women explained that their time-consuming recovery efforts, coupled with their all-too-real poverty, left them with no emotional or practical margin with which to manage unexpected events. The loss of a job, the death of a family member, the arrest of a son, and a miscarriage were all events that preceded relapse for individual women interviewed. As one woman, commenting on her vulnerability to crises put it, "It don't take but a hot second and you're back out there using."
Finally, for many women relationships, which they had both longed for and sought, were the source of their sense of powerlessness. Women described how their past experiences with abusive relationships had left them without the skills for managing relationships without losing all sense of personal identity. They complained that no matter how hard they tried, they seemed to "slip away" once they become enmeshed in a romantic relationship.
Women in recovery—from addictions, mental disorders, and trauma—stress the importance of interpersonal connectedness in sustaining an abstinent lifestyle. Relationships with family members (including dependent children), mentors, counselors, and other men and women in recovery help to support a woman in her individual efforts. These relationships not only offer practical supports and counter feelings of loneliness but also provide women with alternative relationships, powerful enough to compete with the network of addiction and abuse.
Paradoxically, however, some of these same relationships also generate interpersonal demands and stresses that lead some women to return to using drugs and alcohol. Relationships, although essential to developing a substance-free lifestyle, also subject women to emotional stresses and conflicts (14). Until women learn to establish healthy boundaries and manage those stresses, the very relationships they seek may trigger the relapses they strive to avoid.
Successful long-term recovery also requires that women find strategies for dealing with their often pervasive feelings of boredom, emptiness, and tedium. Many trauma survivors, in particular, report feeling empty inside, as if the abuse had literally gutted them of any personal identity and any sense of entitlement to normal activities. Recovery activities must not only help these individuals to discover the healthy self that may have been obscured by both trauma and years of substance use but also enable them to "repersonalize" the empty self by acquiring a range of activities and relationships that are meaningful and that help to define a healthy identity.
Finally, successful long-term recovery necessitates that women develop specific recovery skills (including skills that address trauma and mental health recovery as well as addictions) and a supportive interpersonal context in which to practice those new skills. Relapse prevention skills alone seem insufficient. In fact, women who practiced their recovery in isolation often fell victim to relapse. Without a changed and supportive social context, the skills themselves proved insufficient to sustain abstinence.
It is important to note that, because the sample used in this study was not a random sample, the results may not represent the larger population of women abuse survivors with co-occurring disorders. In addition, it should be noted that the methodology used in this study is highly qualitative and in some ways more akin to a journalistic than a scientific approach. As such, the stories told by the women interviewed give us a flavor of their recovery but do not stand as scientific data.
The results of these interviews indicate specific concerns for sustained recovery among women with trauma histories and co-occurring mental health and substance use disorders. They highlight the need for clinicians to attend closely to reports of negative emotions such as boredom and loneliness. Although these affects may not have the intensity of clinically diagnosed mood disorders, they frequently serve as triggers for relapse.
In addition, the themes uncovered in this study suggest that program administrators and clinicians need to attend simultaneously to the development of individualized relapse prevention and recovery skills and a context that is supportive of the woman who is trying to use those skills. Women who are in recovery describe the importance of a community whose culture—values, norms, and characteristic behaviors—is consistent with abstinence and the pursuit of meaningful and enriching activities.
The authors are affiliated with Community Connections in Washington, D.C. Send correspondence to Dr. Fallot at 801 Pennsylvania Avenue, S.E., Suite 201, Washington, D.C. 20003 (e-mail, email@example.com). This article is part of a special section on relapse prevention among patients with co-occurring substance abuse and other mental disorders. Robert E. Drake, M.D., Ph.D., served as guest editor of the section.