Pape and Associates

Counseling * Psychotherapy * EAP Services * DUI Evaluation

Chemically Dependent and Adult COA Women in Recovery
by Patricia A. Pape, ACSW and SCAC

Since ancient times, women who have alcoholism or are chemically dependent have been the victims of extreme stigma and stereotyping. An old Romulus law decreed that women who engaged in adultery and drinking could be sentenced to death. Society still associates the two, only instead of death, female alcoholics today are often sentenced to rejection, disgust, labeling, misdiagnosis, prejudice and sometimes apathy or indifference. Society today often verbalizes an intellectual acceptance of alcoholism and the disease concept, while rejecting those who suffer from it. Perhaps this is why many women, when they are having problems with alcohol, turn to the use of more acceptable and respectable “drugs” - legitimately prescribed medications.

For women, the stigma of the disease is a triple stigma, and often a barrier to her being identified and getting the treatment she needs. First, there is the general stigma of the disease of alcoholism. Despite the acceptance in 1956 of alcoholism as a disease by the American Medical Association, many people today figure an alcoholic drinks because of choice and moral weakness. The second stigma comes from the fact that the moral standards for women are often higher than those for men. To “drink like a man” and occasionally get drunk is often viewed as humorous; a woman who is drunk is viewed with disgust. Women are defined as the nurturers and caretakers of society; placed on a "pedestal" that in turn supports isolation; and as mothers, face ultimate disgrace. The third stigma relates to the continued association of drinking and sexual promiscuity. In reality, the research indicates that female alcoholics have decreased sexual desire; that what actually increase is their chance of being sexually victimized because they are considered acceptable targets for male aggression.

Because women are raised and socialized in the same society and with the same values as everyone else, they are acutely aware of the stigma-and in fact they turn it against themselves, creating two of the major issues with which they must deal in their recovery: guilt and shame. A majority of these women who have the disease of alcoholism grew up in families where one or both parents were alcoholics. As children of alcoholics, they incurred two things: first, an increased risk of genetically inheriting the disease (research indicates a 50% chance of becoming alcoholic with one alcoholic parent, a 95% chance with two alcoholic parents) and, secondly, the suffering of a great many emotional problems from being raised in an alcoholic family. Children of alcoholics develop an inability to trust, an extremely high need to control, an inability to identify or express their feelings or their needs and an excessive sense of being responsible for those around them.

Children of alcoholics tend to become and/or marry alcoholics. Nine times out of 10, a daughter of an alcoholic father will marry an alcoholic man. Alcoholic women in general tend to marry alcoholic men. Thus if a woman is both alcoholic and an adult child of an alcoholic parent, her chances of being married to, or in a relationship with, an alcoholic increases dramatically.

TWO-YEAR TREATMENT MODEL

The two-year treatment model presented in this paper attempts to address both the issues of the recovering alcoholic female and the issues of the adult child of an alcoholic.

Many treatment models look at a two-year treatment, aftercare and follow-up plan. This length of time is consistent with the research done on PAWS - the Post Acute Withdrawal Syndrome - which can last from 6 months to two years. It is the time period when the risk of relapse is highest. There are predictable symptoms of PAWS, which recovering alcoholics need to be aware of and learn to cope with and to compensate for. Some of these predictable symptoms are: short-term memory problems, inability to concentrate for long periods of time, and neurological augmentation and mood swings. Research on the treatment of female alcoholism presents evidence of the value of all-female treatment groups that address the specific needs of women during early recovery. This also prevents them from taking on their usual roles and behaviors that they do with men - passivity, non-assertiveness, care-taking - and allows them to talk about issues they might not feel free to talk about in the presence of men - physical and sexual abuse, incest or rape, and other sexual issues in their relationships with men. The issues of sexual preference and being lesbian would appear to need addressing in yet another group specifically for gay alcoholic women, as many of the gay women are uncomfortable talking about these issues in a heterosexual women’s group.

Dr Sheila Blume (1988) stresses the need for a thorough assessment and diagnosis prior to any kind of treatment. Because women tend to exhibit more physiological problems than men, a good physical - including a gynecological examination and a pregnancy test for sexually active women is extremely important.

There needs to be a thorough alcohol and drug history, because so many women have a history of the use of tranquilizers, barbiturates, sedatives and amphetamines in addition to alcohol. The treatment staff needs to be alert to any delayed withdrawal symptoms, from other sedatives - particularly the benzodiazepines - which are longer-acting than alcohol. In diagnosing women, it is important not to focus on the quantity of alcohol consumed (women tend to drink less than men), but rather on the chemical use patterns and also the effects on both personality and personal functioning.

Someone trained in both alcoholism and psychiatry needs to do a thorough differential diagnosis to determine if there is primary alcoholism (most patients have this diagnosis) or secondary alcoholism (the presence of a pre-existing, diagnosable psychopathological state or a state which develops during prolonged abstinence). In females, depression, anxiety disorders (panic disorders or agoraphobia are the most common) and eating disorders often coexist with the alcoholism. In the case of dual diagnosis, the psychological problems are usually secondary to the alcoholism. And always treatment must begin by addressing the alcoholism and the goal of total abstinence from all mood-altering chemicals.

Some of the major issues women bring into treatment are: low self-esteem, dependency, identity confusion, guilt and shame from the stigma, socialization related to their role as nurturers of others, inability to identify and express their own feelings (especially anger), inability to identify their own needs and get them met, and such practical problems as employment, child care, housing and finances. They often have the unrealistic expectation that others should know and meet their needs without their having to ask, because this is what they have done for others. Most women have been isolated for years and would prefer not to be part of a group. In addition, they often don’t like or trust other women and have a particular resistance to a women’s group - professional or AA. They sometimes state that the find it easier to relate to men than to women.

The research indicates that women gain a great deal of value from both structure and from education. Treatment programs need to build in structure and provide a variety of forms of education - audiovisual with discussion, reading materials and continued education in groups.

Involving family and significant others from the beginning of treatment is crucial. It is even more important in the treatment of women than men. Part of the reason for this is the priority women have placed on relationships and also the centrality of their roles of wife and mother to their own identity. The entire family - everyone who lives in the home, including the young children - needs to be involved in treatment. Before looking at the issues, themes, special needs and goals of the women in treatment, I’d like to address three questions: Why two years? Why just women? Why ACOA?

There are three main reasons for the two-year time frame. The first is related to the research on the Post-Acute-Withdrawal Syndrome (PAWS).

According to Terence Gorski (1988), PAWS is the number one cause of relapse during early recovery. The symptoms are predicable and last anywhere from 6 to 24 months, depending on how long and to what degree and combinations a person used alcohol and other drugs. Three, six, nine, 12, 18 and 24 months are periods of highest risk of relapse, and it only makes sense to structure treatment to be inclusive of these time periods. Secondly, surveys done by AA indicate that people who stay active in AA for two years - getting a sponsor and working the steps - have about an 80 - 85% chance of lifelong sobriety. Third, the research on grief and loss - which is central to the treatment of both chemical dependency and ACOA issues - suggests that two years is about minimal to complete the grief work involved in major losses in life.

DISEASE PROGRESSES DIFFERENTLY

Why just women? Again, the research indicates that the disease progresses both differently and more quickly in women and also that women have special needs - particularly in early recovery. Women appear to enter treatment with lower self-esteem than men. They have more guilt ( a woman, wife or mother “should not” be an alcoholic!) and shame because of their “lack of control” over having this disease. They have suffered more loss - both real and psychological - and been the object of more societal stigma and stereotyping. In co-educational therapy groups, women often take on their old roles - as caretakers and nurturers of men, more passive about speaking up and getting their needs met - and there is more sexual acting out and focus on the men, rather than on their own recovery. Finally, there are issues such as physical and sexual abuse, being raped or survivors of incest that women will not initially talk about in co-educational groups. Since 75-80% of chemically dependent women face these circumstances, it appears necessary to offer them the best opportunity in early recovery to work on them.

Why ACOA? Eighty percent of the chemically dependent women with whom I have worked have one or both parents who are alcoholic. Also, relationships are traditionally the number one concern for women, and ACOA treatment is all about relationships. The profile of an ACOA - inability to express feelings or get needs met, fear of taking risks or responsibility for oneself, lack of trust in the world, people-pleasing, existing for others, overextended because of an inability to say “no” and ambivalence about relationships (approach-avoidance behaviors) - is the description of women’s issues! The degree of damage to the ACOA woman is greater than that of a non-ACOA woman but the themes are the same. Because the ACOA groups are co-educational, the opportunity to learn and practice new behaviors toward men is available during the second year of treatment. Hopefully by this time women have been able to enhance their self-esteem and begin to establish their own identity apart from men. They are ready to move on from stances of victimization and learned helplessness to taking responsibility for themselves and making choices.

In summary, this treatment is “the best of both worlds” - a year with only women to lay the foundation for life-long sobriety and a year with both men and women to learn and practice new behaviors toward both.