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Women, Trauma, and Substance Abuse

DOI: 10.1111/ijsw.12045
Int J Soc Welfare 2014: 23: 165–173
ISSN 1369-6866
Women, trauma and substance abuse:
Understanding the experiences of
female survivors of childhood abuse in
alcohol and drug treatment
Salter M., Breckenridge J. Women, trauma and substance
abuse: Understanding the experiences of female survivors of
childhood abuse in alcohol and drug treatment
Despite the available evidence suggesting gender should be
considered in the provision of alcohol and/or drug (AOD)
treatment, programmes are frequently offered in an apparent
‘gender vacuum’. This article argues that the generalist ‘one
size fits all’ approach of many AOD services is not gender
neutral but should be understood as implicitly gendered in that
it neglects the specificity of women’s needs in relation to
abuse, mental illness and parenting. The discussion presented
in this article is based on a qualitative study of the experiences
of adult women with histories of childhood sexual abuse
and/or domestic violence in AOD treatment. By examining
the ways in which AOD treatments effectively ignore or
minimise gender, this article uncovers intervention practices
that efface the complexities underpinning AOD use among
women and suggests ways in which alternative models
of service delivery can create more validating and supportive environments.
Key Practitioner Message: • Some of the common assumptions
underpinning alcohol and drug treatment do not adequately
acknowledge the specific needs of female clients and so
gender-neutral service provision can be disenabling for
women; • Punitive service cultures or behaviour change strategies have a differential impact on female clients, many of
whom have prior and ongoing experiences of abuse and violence; • Service models that acknowledge the complex responsibilities and relational histories of female clients are more
likely to engender a positive response and provide the opportunity to address the multiple and complex needs that can go
unmet in non-specialist services.
While the available evidence suggests that alcohol
and/or drug (AOD) use is highly gendered, service
provision often adopts a generalist ‘one size fits all’
approach to treatment and recovery. This article examines the vocabulary of individuality, responsibility and
choice that dominates gender-neutral treatment discourse and practice. We argue that this discourse takes an
idealised neoliberal subject as its focus and neglects
the specificity of women’s needs in relation to past
childhood sexual and other abuse, mental illness and
Michael Salter1, Jan Breckenridge2
School of Social Sciences and Psychology, University of
Western Sydney, NSW, Australia
Centre for Gender Related Violence Studies, University of
New South Wales, Sydney, NSW, Australia
Key words: child sexual abuse, trauma, substance abuse, AOD
use, treatment, Australia
Michael Salter, School of Social Sciences and Psychology,
University of Western Sydney, Locked Bag 1797, Penrith, NSW
2751, Australia
E-mail: Michael.salter@uws.edu.au
Accepted for publication 12 March 2013
parenting. This article draws on a qualitative study of
adult women with histories of childhood sexual abuse to
explore this particular group of women’s experience of
AOD treatment in New South Wales, Australia. By
examining the ways in which AOD treatment has
ignored the relational histories and realities of women’s
lives, this article uncovers the overlap between the politics and treatment of substance abuse and the subsequent
effacement of the specific needs of women with AOD
problems. The article concludes by suggesting ways in
which alternative models of service delivery can create
more validating and supportive environments.
Int J Soc Welfare 2014: 23: 165–173
© 2013 The Author(s). International Journal of Social Welfare © 2013 John Wiley & Sons Ltd and the International Journal of Social Welfare
Salter & Breckenridge
The politics and treatment of AOD abuse
In the 1970s and 1980s, social concerns about crime
legitimised punitive changes in welfare and penal
strategies that turned away from Keynesian and social
democratic approaches towards the classical liberal
principles of deterrence and punishment (Garland,
2001). The increasingly punitive flavour of crime control has been linked to the influence of neoliberalism,
a re-envisioning of liberal ideology that advocates for
the dismantling of most government welfare provisions
in favour of a globalised capitalism underpinned by
harsh criminal punishments (Bell, 2011; Wacquant,
2009ab). In practice, this has involved not simply a
shrinking of publicly funded health and welfare services but also a reshaping of them in ways ostensibly
designed to produce ‘self-governing, enterprising individuals’ and to punish those who stray from these
values (Hartman, 2005, p. 63).
Integral to this neoliberal moral realignment has
been a ‘war on drugs’ that has demonised AOD users
as irrational and irresponsible deviants who are failing
to take ‘responsibility’ for themselves and their
families (Bunton, 2001; Maskovsky, 2001; O’Malley
& Valverde, 2004). In the neoliberal mode of
subjectivity, individuals are considered responsible
for their own ‘care of the self’ in lieu of a governmental or collective responsibility for health and
well-being (Peterson, 1997). Such ‘individualisation’
ignores the complex circumstances and personal histories that are associated with AOD problems and
legitimises a punitive and policing-driven response to
AOD abuse that has further exacerbated health and
social inequalities in underprivileged communities
(Moore, 2009).
The policy environment that surrounds AOD services is so consumed with neoliberal concepts of
responsibility, autonomy and rational choice that it is
unsurprising to find they have come to shape treatment
in important ways (Bunton, 2001; Moore, 2009;
Moore & Fraser, 2006). In treatment contexts, the
political antecedents to the rhetoric of responsibility
and morality are often veiled by appeals to the biology
of ‘addiction’. Addiction is conceived of as a biological state of dependency in which the most valued
characteristics of neoliberal subjectivity – that is, independence and rationality – are ceded to an often illicit
substance. Various neurological mechanisms are currently being identified as the potential source of this
moral dereliction. However, Moncrieff (2006, p. 302)
suggested that such biological explanations for
mental illness (which includes AOD use) tend to
posit neoliberal standards as the ‘normal or ideal
neurochemical state against which everyone can be
measured’, impeding exploration of the social and
political antecedents to mental illness.
Feminist theorists, such as Pateman (1988), have
argued that the rational, autonomous person imagined
by classical liberal theory has always been a masculine one. Liberalism has focused on ‘public’ rather
than ‘private’ rights and hence ‘private’ violence
against children and women has been poorly
addressed in liberal discourses or those institutions
based upon them. Neoliberalism exacerbates this gendered differential by focusing almost solely on the
individual’s responsibility and efficiency and obscuring the role of ‘private’ life as ‘a fundamental source
of power and inequality in relations between the
sexes’ (O’Connor, Orloff, & Shaver, 1999, p. 45).
However, the accumulation of psychological trauma
and the complex life circumstances that contribute to
AOD abuse among women are overlooked by a neoliberal vocabulary of individual choice, autonomy and
rationality, and hence women with AOD problems are
increasingly finding themselves in the criminal justice
system. The punitive response to AOD abuse among
women has resulted in the mass incarceration of
vulnerable and victimised women around the world
(Mauer, Potler, & Wolf, 1999; Norton-Hawk, 2010;
Parker, Kilroy, & Hirst, 2009).
While other studies have underscored how neoliberalism impacts on the encounters between drug users
and services generally (DeVerteuil & Wilton, 2009;
Moore, 2009; Moore & Fraser, 2006), this article is
interested in the poorness of fit between the neoliberal
model of personhood and the lives and needs of
women with AOD problems. Research suggests that
men’s relational histories and needs are important
factors in their AOD abuse and recovery (McMahon &
Rounsaville, 2002; Stover, Hall, McMahon, & Easton,
2012; Stover, Urdahl, & Easton, 2012), but female
AOD clients are differentiated from males by higher
levels of sexual and physical victimisation, mental
illness, self-harm and suicidality (Fiorentine, Pilati, &
Hillhouse, 1999; Greenfield, Back, Lawson, & Brady,
2010; Jarvis & Copeland, 1997) and childcare and child
protection matters (Wechsberg, Craddock, & Hubbard,
1998). The call for women in AOD treatment to ‘take
responsibility’ for substance abuse often enjoins them
to accept responsibility for the disruptive symptoms of
past abuse but excludes considerations of current abuse
and/or the pressing responsibilities they have to their
children and others.
As we will show, women in AOD treatment can
experience this model of ‘responsibility’ as incoherent
and impractical. However, Garland (2001, p. 22)
warned against the ‘temptation to see discontinuities
everywhere’, and this article shows how the contradictions of ‘responsibility’ in AOD contexts aligns with the
ideological imperatives of contemporary AOD policy.
We identify this as the ‘treatment politics’ of AOD
abuse and suggest that it has particular implications for
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Women, trauma and substance abuse
women, as it utilises an individualised and ‘responsibilised’ model of personhood that ignores the relational
dimensions of the lives and needs of women with
AOD problems.
The primary aim of the present study was to document
the experiences of adults with histories of child sexual
abuse in AOD treatment, and the experiences of
workers within this population, in order to examine the
subjective dimensions of the treatment encounter.
Client and worker participants were recruited from a
wide range of AOD services with the intention of
documenting the diverse service experiences of
sexually abused AOD clients in New South Wales. The
rationale for interviewing workers as well as clients
was to provide an additional vantage point on treatment and to identify good practice as well as obstacles
and challenges from the perspective of both workers
and clients.
In-depth, semi-structured interviews were undertaken with 16 survivors of child abuse (13 female participants and three men) recruited from rehabilitation
services, counselling services or community self-help
organisations. The interviews focused on participants’
history of AOD abuse, the manner in which they came
to access AOD services, their experiences in treatment
and their reflections post-treatment on the efficacy of
service, particularly as it relates to their history of
abuse and trauma. It became clear in the course of the
research and analysis that adult survivors of sexual
abuse constitute the majority of women in AOD settings but not men (for a meta-analysis, see Simpson &
Miller, 2002). Hence, the female participants who were
interviewed were typical of female AOD clients in ways
that male participants were not.
Fifteen workers (14 female and one male worker)
were interviewed, and their professional experience
spanned a wide range of services and treatment modalities. Six workers were employed in rehabilitation services, six workers in counselling services where AOD
clients are seen, four workers were employed in courtmandated AOD services and the remaining two workers
worked in detoxification programmes. Some of the
rehabilitation workers and clients were based in a
women-only service, and the other participants were
based in mixed-gender services. Client and worker participant experience encapsulated the available treatment options for AOD clients in New South Wales.
Clients and workers were engaged in semistructured interviews with the aim of documenting their
perceptions and experiences and thus to generate ‘verstehen’ or an interpretive understanding of treatment
from the perspectives of workers and clients. The
qualitative data were transcribed, and themes were
identified within the accounts of clients and workers.
Data analysis was loosely based on the principles of
grounded theory to create coded categories and to
develop concepts that emerged from the data (Glaser &
Strauss, 1999). During analysis, emerging themes and
concepts were considered in light of existing evidence
on the gendered aetiology of AOD problems, the mental
health literature on trauma and abuse, and questions
about service efficacy and equity. Client and worker
voices were coded separately and then compared with
one another, which had the function of highlighting a
range of common themes although from different
vantage points.
A number of themes relating specifically to AOD
treatment and practice have been explored in previous publications (Breckenridge & Salter, 2012;
Breckenridge, Salter, & Shaw, 2012). However, the
study identified a broader set of issues about the linkages between the prevailing paradigms of drug and
criminal justice policy and the politics of AOD treatment, and the particular location of female clients
within this complex interplay of ideology and practice.
This article addresses these issues in more depth by
focusing specifically on the accounts of female AOD
clients and the accounts of workers with female AOD
clients. As such, it is designed to provide some critical
and potentially provocative reflections on the political
and gendered dimensions of AOD treatment drawing on
the perspectives of female clients and the workers who
treat them. As with most qualitative studies, sample
numbers are small, and the validity of the research
findings are based on a rigorous analysis of detailed
narratives rather than claims to generalisability per se.
All qualitative data are presented in italics to maintain
the authenticity of participants’ voices.
‘Surrender to treatment’: agency, passivity and the
female ‘addict’
There is a widespread expectation in the AOD sector
that clients will approach services with a deferential,
penitent and apologetic demeanour that reflects their
status as the irresponsible and chaotic ‘addicts’ constructed by AOD policy and discourse (see Fraser &
Moore, 2008). In the present study, the stigmatised
figure of the ‘addict’ served to legitimise punitive institutional cultures characterised by significant power
differentials between workers and clients. These power
differentials provoked fear among women whose abuse
histories gave them reason to be distrustful of regimes
of control and discipline. One worker commented that
some services ‘even seem to perpetuate feelings of
abuse’ as there is a ‘hierarchical structure of people
who can sanction and punish you for things that you
do’. In New South Wales, most AOD services are mixed
gender, and the majority of both staff and clients are
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Salter & Breckenridge
male, although the staff/client distinction is somewhat
blurry since the Australian AOD sector is heavily
reliant on the recruitment of ex-clients as staff. This has
led to a troubling dynamic for many female participants
who remarked on the ways in which the controlling and
coercive behaviour of staff resonated with similar
behaviour by clients, creating an intolerable situation
framed by a sense of powerlessness and threat.
[In the service I attended] other patients were either
paroled or had been in jail and didn’t want to be
there. Other addicts had responsibility for running
the service which seemed to be ‘slave labour called
therapy’ – even the food was out of date . . . lots of
bullying and coercion and lots of intrusion from staff
stopping or controlling contact with family and other
professionals. Other clients had behaviour problems
– and there was no segregation of genders. There
were four male clients verbally attacking me in the
group meeting which made me feel like going and
having a drink. I decided to leave when I realised I
was pregnant and the staff would not let me see a
doctor. (Female service user)
Many rehabs employ ex-addicts who are on a power
trip. They act controlling, ‘Do this because I’m in
charge, do as I say not as I do.’ Group dynamics are
influenced by this. Programmes may sound all well
and good, but staff are really influenced by the
service dynamics whether they are good or not.
(Service worker)
In AOD services, treatment positioned the female
‘addict’ in contradictory ways: held responsible for
their AOD use on the one hand, while being considered
incapable of exercising agency and choice on the other
due to ‘addiction’. Treatment frequently included the
goal (and sometimes the requirement) of abstinence,
despite the fact that the cessation of AOD use for abuse
survivors can have catastrophic implications. AOD can
provide sexually abused girls and women with a way of
regulating the psychological and emotional impacts of
abuse and experience feelings of confidence and
belonging in interpersonal relations that might otherwise elude them (Filipas & Ullman, 2006; Johnson &
Kenkel, 1991; Morrow & Smith, 1995). At worst, AOD
treatment may deprive sexual abuse victims of a vital
coping strategy, exposing the victim to intolerable
memories or feelings that may prompt self-harm and/or
suicidality (Griffith, Pearson, & Bear, 2004, p. 17). A
service worker commented:
Depending on the intervention context, the importance of the links between self-medication, symptom
control and past abuse can be missed. This is particularly concerning because treatment insistence on
total abstinence can result in a massive increase in
negative feelings and memories that exacerbate
mental health conditions such as depression and
suicide ideation which in turn can trigger a relapse in
AOD use.
This complexity is effaced by the biomedical
model of addiction, as are women’s own understandings of the linkages between their alcohol and drug
use and their trauma history. One woman made this
linkage succinctly:
The majority of women using drugs would’ve
had some sort of trauma. Most have had a shit
upbringing. You don’t hear very often ‘I don’t know
why I use. I’ve had a great upbringing’. (Female
service user)
It was commonly remarked upon by clients and by
workers that AOD services are poorly equipped to
support women with mental health problems additional
to their alcohol and drug problems, despite the fact that
the majority of women with problematic AOD use are
recognised as having comorbid diagnoses (Tuchman,
2010). This was true of women-only services as much
as of more traditional mixed-gender service models.
One worker from a woman’s service noted:
We reject clients of the basis of their destructive
behaviour, problems with other clients. I guess if
they had the inability to tolerate difficult emotions,
because our programme does bring up a lot of emotions for women who have used substances to push
those emotions aside. If they don’t have stable
accommodation to return to – that’s another exclusionary criterion. I guess, when they have absolutely
no supports in the community, we would exclude
them as well. You wouldn’t want to open up all this
stuff for them, only to have them return to a community where they have no support. I mean, that is a
problem. There is a lack of resources out there for
these women, and the majority doesn’t have the
financial means to seek therapy on an ongoing basis.
(Service worker)
In this study, high-needs women were being rejected
by women-only services on the basis of a duty of care to
them and others, while more traditional mixed-gender
services excluded them on more punitive and discriminatory grounds. While the motivation may have been
different, the effect was the same, which was that
women with the highest level of need were the least
likely to receive any care. In this study, it was clear that
worker attitudes and judgements made about clients
were significant factors in determining whether clients
would receive a service at all. The picture of the ideal
client was complex and contradictory: she must exercise
her agency by committing to treatment while surrendering her agency to treatment; she must exhibit a high
level of need without being chaotic; and throughout this
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Women, trauma and substance abuse
process, she must conform to worker expectations in
relation to appropriate appearance and behaviour.
Workers commented on how their own service and
other AOD services were likely to view women who
linked their abuse histories to their AOD use as denying
‘responsibility for their own addiction’, ‘making themselves out to be a victim’ and ‘using their past to excuse
their drug-taking behaviour’. One worker explained
that relapse is understood to mean that the client is ‘not
surrendering enough’ and instead ‘running on their
own will’. Garland’s (2001) concept of ‘responsibilisation’ has been used to describe the ways in which individuals and communities, rather than state agencies, are
increasingly enjoined to manage social problems. In
this process, the contexts and determinants of social
problems are effaced by a neoliberal focus upon individual ‘choice’ and ‘agency’. The epidemiology of
AOD abuse in women shows consistent gender differentials in exposure to traumatic abuse that is linked to
psychological and emotional disturbances that are
beyond the capacity of victimised women to selfmanage (Danielson et al., 2009; Greenfield et al., 2010;
Greenfield, Manwani, & Nargiso, 2003). However,
these complex needs are incompatible with the ‘responsibilised’ client invoked in AOD treatment contexts. As
a result, both workers and clients in our study reported
instances in which clients were denied service or
required to leave treatment because of ‘borderline’ or
emotionally dysregulated conduct that was beyond the
capacity of the woman to control.
Independence and responsibility: children as a form
of dependency
Within the neoliberal paradigm, AOD use is framed as
a shameful act of dereliction by the ‘addict’ who has
failed in the project of self-care and self-management
and lost his/her rationality and independence (Fraser &
Moore, 2008). However, the ways in which dependency
is understood and independence is idealised in treatment contexts had particular consequences for research
participants and their children. In the present study, the
majority of women entered AOD service contexts as
mothers, and childcare responsibilities are a key issue
that distinguishes female from male AOD clients
(Wechsberg et al., 1998). However, their relationships
with their children were understood as impediments to
treatment that was conceptualised in terms of a progression from AOD dependency to autonomous abstinence.
Suspicion of dependency was not limited to substance
use but extended to familial and social relations that
workers felt might prevent the client from ‘accepting
responsibility’ for herself.
In the present study, some workers acknowledged
the ways in which ‘recovery’, as defined by the prevailing culture of service provision, was understood as a
process of personal transformation in which the individual must liberate herself not only from her dependence upon substances but from her dependents as well.
In our service, the woman is our client and her recovery is our focus. This can mean she forsakes her
children if obligations or worry regarding her children seem to compromise her recovery. Making
decisions regarding care of children – for example
‘putting up with’ a poor relationship, accepting
financial support, even fighting to get children back
– can be framed as ‘selfish’ and not in keeping with
recovery. In one case recently, it was thought that
doing things to care for a grown child was not in her
interests, that is, in the interests of her recovery.
(Service worker)
In effect, motherhood was viewed as a complicating
factor in women’s progression into a new, autonomous
personhood free from dependency. Even at services that
were said to be for parents and children, many clients
did not feel well supported in their parenting.
They say they’re child-friendly but it’s not. Mothers
here are more stressed. There is nothing for them
(the kids), no TV, they’re stuck in the house unless
they go to school. There’s no programme for them.
They go into a playroom when the mothers are in
groups but they’re bored. One mother took off ’cos
her 7-year-old was bored witless. One boy has
hungered for attention. He is better now that another
kid is here. But they are desperate to watch TV.
Staff put pressure on mothers to keep the kids occupied and be a good parent, while the parent is sick
and that’s why she’s here. They have to do chores,
like they’re in the kitchen but the kids are in there
too screaming and the parent will be in trouble if
dinner is not done. It is really unfair for parents and
children. Others are not allowed to give help ’cos it’s
their responsibility. Parents are really stressing and
others are upset by it. I miss my kids. I hear a girl is
coming in. There were boys before and that was ok.
I don’t know if I can handle being in here without my
daughter. I feel like leaving. (Service user)
There were few referral options for families or provisions made for childcare, and in many cases, mothers
were expected to find alternative arrangements for their
children while in residential treatment. As many women
were in fact mandated into treatment by a court order,
this could mean a foster placement and the interruption
of contact with their child for an extended period. This
was associated with significant loss and grief for
women, which was only compounded by the moralising
and punitive nature of child protection interventions.
I’m thinking even with DoCS [child protection services], when they intervened with my son . . . I
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Salter & Breckenridge
didn’t get pointed in any direction. It was all about
dirty urines and court. I was 16 when I had my son
and just didn’t know. Not all mothers that use are bad
mothers. They need guidance unless the child is in
immediate threat of harm. If a service had worked
with me, I’d have been really willing to break the
cycle then. I pretty much gave up hope. It was a
really big opportunity missed. (Female service user)
Women’s descriptions of their treatment by child
protection services and in AOD treatment had a number
of commonalities. In particular, they described a singleminded focus on abstinence that ignored the complexity of the factors that underlay their alcohol and drug
abuse. Abstinence was prioritised above the well-being
of either mother or child as the overriding criterion of
good parenting, and the use of sanctions and threats
was the primary behaviour change strategy implemented by the authorities. This resonates with populist
discourses about AOD-dependent mothers that have
flourished during the ‘war on drugs’ and various ‘law
and order’ initiatives in which punishment has featured
as the central tool of control over deviant women
(Campbell, 2000). This has driven an unprecedented
increase in female imprisonment in developed countries such as Australia and the United States (BushBaskette, 2004; Parker et al., 2009). This punitiveness
is also evident in AOD-using women’s encounters with
child protection services and related agencies (Allen,
Flaherty, & Ely, 2010; Austin, 2002) and in this study.
One service user said:
I have a son, and DoCS intervened saying I needed
clean urines to keep him. They didn’t give me any
help, no counselling or welfare. I couldn’t stop using
and we went to court and he was taken out of my
care. All I was told was ‘stop using’ but I couldn’t. I
had a DoCS worker but no counsellor . . . They
wanted me to go to parenting classes but the parenting wasn’t related to drug use. They said do A, B, C,
then I did that and there was more to do. I just ended
up using. Now he is with his grandparents permanently and I have a relationship with him thank god.
I thought he was better off without me. I suffered at
mum’s hands and I didn’t want that for him. But him
being taken away enabled me to use more.
While punishment is a key crime prevention and
behaviour change strategy advocated by neoliberalism,
it is ineffective in addressing the consequences of disadvantage and chronic violence. In effect, punishment
sanctions those whose problems are so entrenched that
they cannot change without significant investment in
care and support. In the interviews, the women articulated a need for comprehensive services that included
counselling and social work support in order to make
treatment gains, such as a reduction or cessation in their
substance use, or to meet the standards set by the
authorities in order to continue to care for their
children. However, the multiplicity of their needs was
systematically construed by a range of agencies as
evidence of individual failing. Women’s responsibilities to their children, particularly when mandated by
statutory bodies, can make compliance with the
requirements of AOD treatment more difficult (Brady
& Randall, 1999). Responsibilities to children bring
with them a heightened need for comprehensive services such as housing, transportation and income
support in order to achieve and maintain treatment
goals (Marsh, Cao, & D’Aunno, 2004). However, these
issues remain unaddressed in the majority of services
(Greenfield, Brooks, et al., 2007). In this study,
women’s struggles to juggle their responsibilities to
themselves and others in the context of multiple
‘responsibilising’ systems (including AOD services,
child protection and criminal justice agencies) were
often construed as evidence of an individual and moral
(rather than systemic) failure.
Treatment in context: gender and intersubjectivity
The emphasis of treatment on individual factors in
determining readiness and responsiveness to treatment
was at odds with the strong preference of both client
and worker participants for women-only treatment contexts. As women’s traumatic experiences have generally occurred at the hands of men, both clients and
workers have said that it is both provocative and emotionally unsafe for women to be asked to seek treatment
in the presence of men. The present study included
workers and clients from a women-only service who all
spoke of the opportunities available for women to raise
issues in treatment that they would feel constrained
discussing in a mixed-gender context:
I’m glad that this service is all women because it is
the only way I could talk about my past experiences – if services are mixed, women are inhibited
and all sorts of sexual dynamics are set up. (Female
service user)
Women’s trauma is often based on their sexuality,
so not having men around can be less intrusive.
Even a [male] gardener here can be a problem.
(Service worker)
Although this study was based on a small sample,
the distinction between the satisfaction of female
clients of mixed-gender services and female clients of
women-only services was marked, which correlates
with research showing greater service satisfaction
among women in women-only services in comparison
with mixed-gender treatment (Greenfield, Trucco,
McHugh, Lincoln, & Gallop, 2007). This may be
related to the ways in which gender-specific services
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can simultaneously address AOD abuse and underlying trauma-related mental health problems and
other needs common to women in AOD contexts.
Co-occurring problems among women with AOD
problems are often considered as distinct issues in
mainstream services, resulting in a fragmentation of
care that can seriously compromise recovery efforts.
One woman recalled:
I attempted suicide at fifteen. The suicidality became
more pressing and I became more emotionally
tumultuous over the pot. I was hospitalised for a few
days or a week and I disclosed [sexual] abuse there.
They didn’t help much.
The way it was explained to me was that funding
didn’t allow us to look at the abuse and that counselling would be complicated due to the pot use. I
was steered towards drug and alcohol services even
though I wasn’t seeking help for the pot. I wasn’t
allowed help for the abuse until I dealt with the pot.
I went to a private hospital and walked out after a
few days as they refused to talk about the abuse
without me giving up the pot. Where I’m going
with this is that I have continued to seek help and I
can’t find someone who understands the needs of
both issues.
A needs-based rather than diagnosis-based approach
to care appeared to be a particularly valued aspect of
gender-specific services. However, one worker suggested that an all-female environment was supportive
for female staff as well as clients.
There is definitely something to be said about the
emotional energy that exists in a women – only
service. Women are thinking of that same perspective – not that a man couldn’t, but if a man was here
it would trigger a whole bunch of new stuff that we’d
have to cope with. That we don’t want to, because
there is an element of safety being around women.
(Service worker)
In many respects, it would seem that ‘what works’ in
relation to gender-specific service provision involves a
recognition of the relational realities of women’s lives
rather than enforcement of the fiction of the ‘responsibilised’ neoliberal individual. In traditional liberal
theory, individuals are characterised as autonomous,
rational and calculating individuals who pursue their
own interests while undertaking an assessment of the
relative benefits and drawbacks of their conduct. This is
in contrast to a more relational or ‘sociocentric’ model
that suggests that subjectivity emerges from within and
is sustained through a network of constitutive social
relations that inform decision making and social practice (Radden, 1996). Feminist psychoanalysts and philosophers have drawn on the notion of intersubjectivity
to describe the dependency of self-identity upon social
interactions and relations (Benjamin, 1990; McClure,
Chavez, Agars, Peacock, & Matosian, 2008; Stolorow,
Brandchaft, & Atwood, 1987). However, in this study,
the embeddedness of female clients within larger
familial and social networks, and the ways in which this
impacts upon their AOD use, was occluded within AOD
service contexts that insist that women conform to a
‘gender-neutral’ model of autonomous selfhood that
not only denies their status as mothers but their specific
needs as women as well.
The ways in which linkages are made between substance abuse, responsibility and morality in healthcare
settings can be understood as gendered in important
respects. Constructions of ‘autonomy’ and ‘responsibility’ in service contexts can ignore the realities of
women’s lives as mothers but also as survivors of violence in relational contexts. In the accounts of the participants in the present study, the regimes of discipline
and surveillance that predominated in AOD services
aimed to constitute women as a particular mode
of neoliberal personhood in which ‘responsibility’
referred first and foremost to ‘self-responsibility’,
except that this image of ‘self’ did not reflect the realities of these women’s lives. Discomfort with, or resistance to, this process was interpreted as a moral failing
of the woman client. However, treatment failure could
potentially reflect a system refusal to acknowledge the
needs of clients as mothers and women with complex
relational histories. In contrast, those modes of service
delivery that adopted a relational and intersubjective
approach to personhood delivered positive outcomes
for women who expressed satisfaction and relief at the
validating quality of service delivery.
The findings of this research suggest that the
‘medical model’ of addiction is underpinned by a set of
neoliberal presumptions about choice and decision
making with little relevance to women with AOD problems. Furthermore, it points to the ways that ‘informal’
gendered expectations can become implicated in
‘formal’ assessments and practices and enmeshed
within disciplinary regimes of surveillance and control.
The neoliberal model of behaviour change mandates
punishment as a way of rebalancing the ‘pros’ and
‘cons’ of AOD use; however, the female ‘addict’ embodies an array of derelictions from gender norms that
can also become the targets by punitive judgements and
practices. Emerging from the experience of women in
gender-specific services is a set of alternative subject
positions that acknowledge the role of biography and
relationships in women’s AOD use and decision
making. This acknowledgement appears to open up new
opportunities for action and change in contrast to the
Int J Soc Welfare 2014: 23: 165–173
© 2013 The Author(s). International Journal of Social Welfare © 2013 John Wiley & Sons Ltd and the International Journal of Social Welfare
Salter & Breckenridge
foreclosure of agency through ‘surrender’ associated
with more traditional treatment modalities.
This project was funded by the Mental Health
Coordinating Council (MHCC) of New South Wales,
Australia, under the Non-Government Organisation
Mental Health and Drug and Alcohol Research
Grants Program.
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