FASD Learning Series: Gender and Addictions Webinar

Kirsty Prasad’s webinar on Gender and Addictions, part of the Government of Alberta series on Fetal Alcohol Spectrum Disorder: Across the Lifespan, looks at substance use issues particular to women and the barriers women face. Kirsty works for the Alberta Health Services Mental Health and Addictions: Enhanced Services for Women program, and has extensive experience in working with multi-barriered women with substance-use issues.  The program works with women throughout the child-bearing years.

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What is unique about women’s substance use?

Key issues addressed by the program include:

• Health factors
• Guilt, stigma and shame
• Experience of violence
• Co-occurring mental health problems
• Women as mothers
• Misinformation and denial among those in a position to help

Kirsty makes the point that our society tends to have higher expectations of women, especially women with children, and this exacerbates the sense of guilt and shame experienced by women with substance use issues.  She says she always asks the question of service providers, “Does gender matter?”  “Research studies show men often relate their addiction typically as a build up of grandiose sense of self that must be challenged before they can discover their true self (AA describes it as inflated self ego, king baby or grandiosity)”, whereas “women however have a diminished sense of self.  They have learned to negate and neglect their true selves in favour of other people.”

Kirsty advocates a Comprehensive Integrated Approach involving three components:

1. A Theory of Addiction involving both a holistic health model and a women-centred approach
2. A relational model (Stone Center) Theory of Women’s Psychological Development
3. A Theory of Trauma:  there is a high relation between trauma and addiction for women

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Health Factors

Kirsty draws from research findings that to become healthy, functioning adults we need to achieve psychological independence and separation from our parents.  She draws on the Stone Center (USA) model that shows that women tend to be relational and rooted in their relationships and attachments to other people.  So, for women, disconnection is more likely to contribute to low self-esteem, increased feelings of hopelessness, and loss of trust in oneself and in others.  Traditional theories of psychology focus on the self and avoid discussion of relationships.  However, women are more likely to self-identify in relational terms, so Kirsty has found in practice that there is a need to acknowledge and affirm women in their relational roles in order to work effectively with them.

As well, Kirsty describes the difference in physiological process for men and women when ingesting alcohol.  Women have a significantly increased impact on their general health when combining alcohol with other substance use.  Men produce an enzyme in their stomachs which helps to break down about 30-40% of alcohol before it is absorbed into their systems.  For women, only 3-4% of the alcohol is broken down before the alcohol leaves the stomach, so alcohol and other substances go straight to the organs in women and blood alcohol levels are raised for far longer.  This leaves women at far higher risk of cirrhosis of the liver, heart disease, multiple cancers, and Korsikov-Warnicky (“wet-brain”).  It is not uncommon for women with substance-use issues to have strokes or heart attacks whilst still in their twenties.  Menstrual cycles are also likely to be significantly impacted (irregular or sometimes as long as 6 months to two years between periods), which makes it harder to judge onset of pregnancy.  Often women in this situation, therefore, do not have confirmation of their pregnancy until the second or even third trimester.  Men can drink heavily for 10-15 years before they begin to see impact on their body, whereas for women it is 7-10 years.  It is of vital importance, then, that women who are involved in substance use have regular, consistent access to health care.

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Guilt, Stigma and Shame

She goes on to outline the challenges to women accessing the health care they need, including the difficulty of getting a regular GP, as well as significant and complex trauma histories which can create barriers and even make accessing health care a terrifying experience for many women in this situation.  In her own work, Kirsty has had clients who have major issues around being touched, or who have reached their forties without ever having a full physical exam by a doctor.  There is a huge need for women to feel safe with the doctor they are seeing, and to know that the doctor will respect their trauma issues.

Another significant piece for many of the women she deals with is dental hygiene.  Trauma histories can make accessing dental care extremely terrifying, so finding trauma-informed dentists is a particular challenge.

She points out that relational roles within their existing community can create a barrier for change for many women.  For those who were the “lost child” or “scapegoat” in their family of origin, to have evolved into a role of significance in their using community (the “mom” or “doctor” or “counsellor” figure) is deeply meaningful and can form a considerable barrier to change.  Also, if other family members are involved in the using community, change can be challenging.  There is even the sense of community involved in using together, particularly for women who have partners that also use.  Asking a woman to quit using is often asking her to change everything in her life.  Women with partners who use will most likely lose their partner if they quit substance use themselves.

Research shows that women tend to have been introduced to substance use by either a partner or family member, and substance use can have started as early as childhood.  Women with substance use issues frequently also come from families with a history of addiction issues.

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Experience of Violence

“Women who misuse alcohol or other drugs are significantly more likely to report a history of physical or sexual abuse and overall victimization.  Research indicates that up to 85% of women in treatment for a substance use problem have experienced abuse.”  Kirsty says that in her experience, and that of her colleagues in the program, the incidence is close to 100% and most often is multiple times, from multiple sources.  The women that she works with tend to begin using substances to numb out or disconnect from something that is going on in their life.  Often they are self-medicating to cope with either a current abusive relationship or trauma from previous relationship(s).

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Co-Occurring Mental Health Issues

The next topic addressed is mental health issues.  Kirsty points out that it is very common for women with substance use issues to have depression and/or concurrent mental health issues.  Experience has taught their program that intervention requires an integrated approach.  They have found that it is more useful in practice to treat the symptoms holistically rather than to try to figure out which caused which.   Continuity of care becomes very important, particularly if women are taken off medications during pregnancy.  This group of women is also of high risk for post-partum depression, but they often fall through the cracks for screening.  In Kirsty’s experience, support workers need to advocate for their clients to receive screening for post partum.  The screening routinely happens when children are taken for immunization, and as it is very common for women in this group to have their children apprehended, they are often not the ones to take the child to their immunization appointments.  In her program, Kirsty tries to ensure that women have several appointments booked with their psychiatrist around their delivery dates, so that they are likely to receive the screening from the psychiatrist soon after delivery, whenever the baby arrives.  Kirsty and her co-workers find that post-partum in this group of clients can appear up to six months after delivery, and due to previous trauma history, it has a much higher incidence of being at the severe end of the range, with psychosis.

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Poverty and Social Isolation

Kirsty points out that, in this group, women tend to be the primary caregiver of the family, often as a sole parent, and finding appropriate, affordable, safe housing is a huge problem.  She says that if she and her colleagues had a wish list, safe and supported housing for women and children would be at the very top.  So it is highly likely that a woman in this situation will be living, and often raising children, in inadequate housing, extreme poverty, and social isolation.

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Body Image and Self Esteem

There is a high correlation between substance use issues and eating disorders.  A lot of the women Kirsty and her colleagues see have body image issues and eating disorders.  This is a particular problem during addiction recovery.  Crack use suppresses appetite and burns calories at an accelerated rate.  A crack user who goes into recovery at around 90 lbs will usually start to gain weight. This poses significant problems if there is a body image/eating disorder present as well, and often leads to relapse.  Important questions are:  “Did you eat today?”; “What did you eat?”; “Were you able to keep it down?”

In a questionnaire done by Nancy Poole, the number one reason women are hesitant to enter recovery relates to issues around shame and self-esteem.  This is such a huge piece for many women and Kirsty and her colleagues have found that this is central to the support work they do with their clients, using a strength-based approach.  It is important to help clients build a plan that includes pre-residential treatment interventions and follow-up programs to support continued recovery and assist in prevention of relapse.  It is also important to have a health care plan that supports issues around diabetes and other chronic health conditions resulting from long-term substance use.

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Challenges to Quitting Drugs

• Peer pressure
• Lack of support
• Crisis
• Determinants of health
• Past survival skills/coping
• Fear of success
• Fear of withdrawal
• Loneliness
• Lack of knowledge of resources
• Lack of available resources
• Emotional avalanche
• Too much pressure: clients are often working with multiple professionals and have several plans to coordinate – Kirsty often organizes case conferences to bring the professional team together to coordinate the client’s plans
• Multi-issue problems
• Addiction

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Interpersonal Barriers

• Fear of losing their children
• Lack of low cost, reliable child care
• Lack of family or partner support
• Lack of education/job skills
• Outstanding criminal justice issues
• Power imbalance:  in dealing with health-care and social agency professionals

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Structural/Program Barriers

• Lack of flexible services:  it is important to be able to assist client’s with personal referrals to appropriate service models
• Costs associated with treatment
• Lack of community capacity
• Lack of gender-specific treatment:  women often have to wait longer than men for residential treatment spaces, as there are less beds available for women than for men;  also, research has shown that women tend to stay longer, be more engaged, and do deeper work in a gender-specific group

Kirsty’s team recommends the following approach in working with clients:

• Introduce discussion:  “The approach you take is one of the strongest indicators of whether a woman will change.”
• Reflect on why it may be difficult for you as a worker to ask about substance use and addiction:  Useful questions are “Do you drink?” or “Did you drink before you recognized that you were pregnant?”  Kirsty advises asking more than once during a pregnancy, because circumstances can change.
• The one thing...”Regardeless of how much or how little time we have to spend with the woman, our ability to be compassionate and understanding will be the one thing that she remembers.  This is our bridge to an effective helping relationship in the future.”
• Screen for RISK of problems and for READINESS to change:  “Ask ALL WOMEN! As part of overall health questions or life issues, about ALL substance use (before pregnancy and now) and ask more than once in her pregnancy.
• Offering information: “Ask about her knowledge of the risks of substance use during pregnancy.  Ask about any concerns she may have about her use for herself and the baby.  Ask about how she feels about these concerns.”
• Explore options for change:  Harm reduction; treatment; community support.
• Substance Use Interventions:  Teach safer substance use (e.g. proper injection techniques); offer methadone maintenance for heroin and morphine users; teach abscess management and vein care; offer information about substance combinations and interactions; suggest changes in method of use (e.g. moving from injection to smoking); suggest substitution of less harmful substance (overdose prevention); suggest modifying substance use (control of dosage, cutting down); suggest making related behaviour safer (condom use, techniques for avoiding violence); relapse prevention; sexual health
• Basic Tenets:  recognize dignity; maximize social and health assistance; recognize the right for care; emphasize the reduction of drug-related harm; recognize the competency of users; involvement in co-creation strategies; expectation of flexible, accessible, non-judgmental care; supports such as syringe exchange and supply of sterile drug using equipment; challenge misinterpretation and misinformation; accept that drug use is present in all facets of societies and choose to minimize harmful effects; acknowledge that certain ways of doing drugs are safer than others; build on quality of life for persons based on their own perceptions; establish empowering relationships with individuals.

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