I N T E R NAT I O NA L J O U R NA L O F SOCIAL WELFARE 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. Introduction 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 1 School of Social Sciences and Psychology, University of Western Sydney, NSW, Australia 2 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.firstname.lastname@example.org 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 165 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. 166 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 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 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. Methodology 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 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 167 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 168 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 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 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 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 169 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 170 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 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 Women, trauma and substance abuse 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. Conclusion 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 171 Salter & Breckenridge foreclosure of agency through ‘surrender’ associated with more traditional treatment modalities. Acknowledgement 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. References Allen, S., Flaherty, C., & Ely, G. (2010). Throwaway moms: Maternal incarceration and the criminalization of female poverty. Affilia, 25(2), 160–172. Austin, R. 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