For centuries it was believed that since women did not become alcoholics or addicts there was no need for a women’s perspective on addiction, treatment or recovery. In the last century this point of view changed radically. There were a few women in early Alcoholics Anonymous (AA) (AA, 1955) and more acknowledged female alcoholics as years passed. The first treatment center for women was established by Hazelden in 1954. Since then, there has been a growing acceptance and understanding of women and addiction in theory and practice.

History
The history of women’s use and abuse of alcohol and other substances (Straussner and Attia, 2002) is a history of denial — social, cultural, political. Women were not recognized as equal citizens in any setting. They were viewed as secondary — role-bound as caretakers of others. Women were not equal in part because they did not possess agency — an entitlement to exist in their own right, separate from all others, and a corollary requirement to be responsible for themselves. Drinking was a social and cultural ritual for men, a symbol of aggression, autonomy and dominance. It was a symbol of agency. Men were supposed to be able to “hold their liquor” and to “control” their drinking, both signs of masculine power. It was a moral weakness for women to drink and a moral failure for them to have problems with alcohol.

Yet there have always been women alcoholics and addicts. They just couldn’t be recognized, named, or offered treatment for their addictions. Women could have illnesses and problems with their “nerves” however, and they could take all kinds of medications and potions to treat these ills. Lydia Pinkham’s Vegetable Compound was the magical answer for many women in the late 1800s. With its 30 percent alcohol content, it easily fulfilled its advertising promise to “put a blush in milady’s cheek.” She could smile happily as she remained a non-drinker.

Women could have ills and they could treat them openly. Carrying a flask and nipping from it all day long was not a problem. Yet addiction to these medicines remained hidden (Sandmaier, 1980), and is still hidden, despite advances in social, political and cultural equality. As women became entitled to agency, to the reality of selfhood and responsibility, the reality of their addictions became legitimate. But ironically, to this day, secrecy, denial and shame remain hallmarks of women’s addiction and their treatment because the moral stigma has not changed. It is still a shock to many women and men that a woman can lose control.

What is addiction?
Addiction is the loss of control. The definition and the experience of loss of control are exactly the same for men and women. Addiction is the inability to predictably and consistently stop drinking, using other drugs, eating, gambling or other behaviors once started. Addiction is more than behavior. It starts with an emotional attachment that is also the same for both sexes. The individual forms an emotional bond to alcohol, a prescription medicine, food, or even another person which becomes a compulsive attachment. She or he can’t do without it. It’s an unhealthy dependence. The object of her addiction becomes her best friend, her lover and the demon that will destroy her. Addiction becomes a deep loss of self.

Most people believe that any dependence is a bad thing. People should be self-sufficient and not rely on others. They should also be “in control.” Of course, there is no such thing as “no dependence.” Human beings cannot be self-sufficient and they cannot have the kind of control many believe is desirable. Women tend to be particularly vulnerable to these beliefs. They tend to believe that, indeed, they shouldn’t be dependent, they shouldn’t have needs, because they’re supposed to be the caretakers of others who have needs. Many women make a “turn toward alcohol” (Brown, 1985; 2002) as a way of meeting their needs, as a way of not needing anybody or anything. Just like the woman who happily nipped from her flask more than a century ago, the woman today develops her unhealthy dependence on alcohol, other drugs, food, shopping or gambling as a way to cope, to take care of herself. She may also turn to alcohol as a way to feel powerful, just like the men. This solution to her problem of need or desire for power eventually turns on her.

A developmental process
Becoming addicted is a developmental process (Brown, 1985; 2002; 2004) that moves the individual backwards towards increasing loss of control. It’s like an undertow that pulls a woman down until she’s not moving forward at all. A woman becomes dependent on her addiction to take care of her and eventually her addiction harms her instead. She can’t stop and she doesn’t know what is wrong.

As a woman becomes addicted, she buries her real self underneath a toughening layer of false self. Being addicted becomes an ongoing process of backward development, of shutting off what is real and building a protective shell of defense to deny to her self and to others that there is any problem at all. She crafts explanations as to why she needs to drink this much, take all these pills, nibble all day long, spend too much or gamble away her savings in a way that lets her keep on using. She needs to drink to calm down, deal with her job stress, help her cope with kids or a partner or spouse who need her too much. Whatever it is, her addiction gives her power. It gives her fuel, it keeps her going. She says: “I am not an alcoholic; I can control my drinking.” These two beliefs become the anchor of her new false self.

Addiction is trauma
Trauma means helplessness. It’s a state of overwhelming loss of control to the power of something or someone else. Many women have experienced trauma at the hands of others. They may have suffered emotional, physical or sexual abuse as children or adults and later, turned to alcohol to cope with the feelings and memories of abuse and the loss of control they experienced as the victim of another.

A woman also loses control to the power of her own addiction. Being addicted is a trauma (Brown, 1994). Active addiction is the state of helplessness that comes with the loss of control. It’s the reality that the woman works so hard to deny as she sinks deeper into her isolation and despair. The addicted woman lives in a state of chronic self-inflicted trauma. She is her own victim. Recognizing the reality of her own agency, her own responsibility for her loss of control, is the core of movement into recovery.

Yet a woman will fight to deny this reality. If she accepts her agency, she accepts that she exists, that she has a self, a truth she has been denying. If a woman comes to see “I am an alcoholic; I have lost control,” she will likely believe that she has failed. She has failed as a wife, partner, mother or worker. She has failed to be a woman who has no needs, a woman who exists only to take care of others. When a woman recognizes “I have lost control,” she has an opportunity to find her self.

Recovery: a developmental process
Many people think that recovery is not drinking, not using, not eating too much or too little, or not spending all the time. Many people think that recovery means a woman is no longer out of control, that recovery is the same thing as being dry. It’s not. Becoming abstinent is an event. Recovery is a long-term developmental process that follows the event. It’s not a quick fix; nor is recovery a reversal, a restoration of her lost self. Recovery is not going from bad to good or from unhealthy dependence to self-sufficiency; it is a process of radical growth and change, a process of developing a new self. Recovery involves transformation — from a false self to a real self and from unhealthy dependence — addiction — to healthy dependence as part of a healthy self (Brown, 2004).

Recovery development occurs in stages that parallel, metaphorically, human development, from infant to toddler, to adolescent to adult. As the woman comes to the end of her backward development, she separates from her drug of choice and from her active addiction. This separation sets in motion a forward-moving process of healthy self-development.

Transition: recovery shock
The transition stage includes the end of drinking and the beginning of abstinence. Cracks in the woman’s false self — her rigid system of logic, rationalization and behavior — signal its onset. The disadvantages and problems of drinking begin to outweigh the advantages and she begins to doubt her certainty. Perhaps she IS having trouble with control. She will reach a point called “hitting bottom” or “surrender” when she comes face-to-face with the deep reality: I am powerless over alcohol; I have lost control. She will be supported in accepting this truth and in ending her efforts to get control by reaching out for help.

The separation from her drug of choice does not occur in a vacuum. She does not relinquish her attachment to her best friend and live with nothing. That is not healthy development. The woman will accept her dependence on alcohol, stop drinking, and transfer that dependence to new substitutes. For many women, the object of her new attachment is AA, NA, OA, or another 12-step program that invites people to rely on elements of “the program” to achieve and maintain abstinence. People are encouraged to substitute a dependence on meetings, literature, contacts by phone, and “working the steps” for the behaviors, thinking and emotional “rewards” of active addiction.

Both men and women have an unhealthy dependence from which they need to separate, and both will require a healthy dependence to enable their growth in recovery. The AA concepts of surrender and detachment — that is, accepting the loss of control and detaching from an investment in regaining it — are based on separation. The individual “lets go” of the active attachment to addiction, moving to abstinence.

Also, both men and women require a “holding other,” a source of help and safety outside themselves as they shift from the pathological dependence of active addiction to a healthy dependence in recovery. AA and Al-Anon are relational holding objects, used by men and women in the service of containing and building on the deep emotional experience of loss of control.

The newborn infant moves from a merged state of oneness with its mother to a sudden experience of separateness. From that point on, development is an interaction between closeness with the mother and other caretakers, and further separation all the way to old age and death. Although the infant separates, it cannot survive alone. It grows a healthy self through its healthy dependence on others. This is paradoxical. The infant will grow into a healthy self which is “alone-together.” This is also recovery: the addicted woman separates from her drug of choice, and as a “newborn,” reaches out for help. She begins her developmental process of growing a healthy self via her healthy dependence on others.

The tasks
A woman first reaches out. As she grabs an emotional safety line to AA, she begins immediately to focus on behavior. She hears the concrete, clear guidelines: “don’t pick up the first drink,” “go to meetings,” and “listen.” She also is likely instructed to get a sponsor, or at least a temporary big sister to help her in the early days. As she settles in, she begins to hear the new language of recovery. Her new vocabulary is centered in her deep acknowledgment of loss of control. The woman who is stabilizing in recovery hears the action words — go to meetings, get a sponsor, listen. She changes her behavior and strengthens her recovery foundation.

Early recovery: the growthof a new self
Early recovery brings a greater feeling of safety and stability. The intense cravings to drink or use are quiet, or at least softened. The woman anchored in recovery is not driven by impulse. Her sober behaviors are stable and strong and she knows how to act immediately when she feels any danger. Now more like a toddler, she feels comfortable on her feet and is open to deepening language development. She uses her recovery words and concepts to quiet her anxiety and she works to develop her “story” of her active addiction. She is focused on her self — her new recovering self and the real self that she denied and hid under her addiction.
Loss of control is the permanent organizing principle of self-development in recovery (Brown, 1985; 2004). A woman stabilizes her behaviors of abstinence so she will not return to drinking — the active loss of control — and she begins an in-depth process of self exploration through working the 12 steps of her program.

Early recovery is a long period of learning — like grade school — that involves an expansion in a woman’s awareness and feelings of the past and present as she strengthens her recovery behavior and builds her identity as an alcoholic. She is becoming fluent in her language of recovery and she uses these words and concepts to quiet the intensity of her feelings. She has a self now so she also begins to tell her “story.”

The woman in early recovery will continue to focus on her self, which is still a radical difference from her denial of self when she was drinking. She can also begin to think about others, past and present, and to bring her new self into her current relationships. But this new focus on her self and others is not easy. A woman may long for intimacy, but fear it, even more than she did when she was drinking. She may struggle in her closest relationships and wonder if it’s worth it. She wants to feel strong, and she does occasionally, but it scares her. Could she get too strong and not need anybody? She may feel intense shame for the past and a terror of facing it. And she may feel drawn to drink again. The lure of a drink could look like a cure-all for the growing pains of recovery. Early recovery is learning to balance the complexities of self and of self-with-other. It is learning to feel good and to accept and tolerate the pain that is also present.

The tasks
The woman in early recovery is actively building a strong internal foundation of her new self. Her new behaviors and her new identity are centered on her new core beliefs: I am an alcoholic; I have lost control. She pays attention to the incremental, building-block process of recovery development, just like a child builds her vocabulary and understanding of language and math, month by month and year by year.

Memories and feelings of the traumas of childhood and their own drinking now surface for many women. They must attend to the realities of what happened to them and what they did, a difficult challenge. They tighten up their recovery programs to insure that they will stay sober through the hard work. They may also seek professional help.

Relapse is less likely in early recovery, but still a serious possibility. The woman uses her tools and she watches for holes in her recovery development. She questions herself, constantly assessing whether the pain she is feeling is a sign of healthy growth or a warning of relapse. Often, she can’t tell. She stays close to her recovery program until she feels safer. She knows that memories, thoughts, and emotions from the past will surface when she is ready to remember. This is healthy growth.

Ongoing recovery: grown up and living sober
Ongoing recovery is not the end of recovery growth. There is no end. Ongoing recovery is defined by the stabilization of all the dramatic changes in behavior, thinking, and emotion that characterized the hard work of the early stages. Women in ongoing recovery maintain their strong, healthy programs and their strong, healthy identities and they deepen their self-exploration. Many women open up to the traumas of their past for the first time and many seek professional help to do so.

Most women in healthy recovery focus on spiritual development. They have found and grown a healthy self through their dependence on others in recovery and through their deepening dependence on a higher power. They accept responsibility for themselves and they understand healthy dependence. They know the deep meaning of “alone-together.”

The tasks
The woman who is grown up and living sober maintains and deepens her healthy recovery. She learns that letting go of old defenses gives her plenty of work to do and never ends. She can see elements of her old, false self-importance and she chuckles. She catches herself feeling sure that you are angry and then she knows that SHE is angry. This is projection, a way of denying her agency that she no longer needs. Nor does she need rationalization, except now and then when extra permission seems necessary.

The woman in stable long-term recovery will grow bigger, wider and deeper inside. Without the need for unhealthy defense, and without the need for a strong cocoon, she will naturally be more open, more flexible and able to tolerate more complexity within her self and in her relationships. In addition to her long focus on developing her self, she now can look outward to expand and deepen her relationships with others. This often is the central difficult work of living sober — learning how to be in a healthy close relationship.

A woman now has empathy that is not based on her old role-based identity as ONLY a mother, wife, or partner. Now, she is first her self. She can tolerate fluidity in relationship and she can deal with complexity. She can now feel vulnerable and recognize that this is healthy.
Some women also will experience a “second recovery.” Strong and solid in sobriety, they suddenly feel danger. They may suddenly start crying, or perhaps, they experience a slow edginess that creeps in over time. Maybe they now can feel a lifetime of grief for what was lost and cannot be reclaimed. These women learn that there is more work to do. They open up to see what is there and to use their programs to maintain and deepen their recovery.
Do grown-up recovering women ever relapse? Yes, but not too often. They may have old traumas they continue to bury; they may have a depth of painful emotion that feels too threatening. A drink looks like the perfect painkiller, even for a woman who has stable, secure sobriety. She must never forget that drinking used to be a solution and now she chooses to live sober instead. By now, her deeply internalized program works for her as she continues to grow.

Working with women: therapist guidelines
The developmental model guides therapists in helping women who are actively addicted and women who are in recovery — at any stage. But working within the developmental model requires adjustments in thinking and practice for virtually every therapist whether coming from a mental health background or an addiction framework. Working with women can also raise conflicts for therapists who bring their old beliefs and values — particularly, moral judgments or their own unresolved or unrecognized biases about women — to the treatment setting.

The developmental model focuses on normal growth rather than pathology. This alone requires radical adjustments in thinking and intervention. It’s a different role for the therapist to assess the building process of recovery based on a new understanding of what is normal and desirable, rather than what is wrong. The therapist knows that recovery is hard and that growth, just like child development, occurs in fits and starts. The woman will move two steps forward and one or two back. This is normal. It’s important that she is on the recovery path and that she stays there. The therapist who jumps in to diagnose pathology or to quickly determine that a relapse is near, may miss the underlying process of growth that includes ups and downs and ins and outs. Yes, a woman may relapse and it’s important to be on the watch for holes in her recovery program. But having problems in recovery is by no means an automatic sign of pathology or of imminent relapse. Having problems in recovery is perfectly normal. A woman needs support to weather a difficult time and to learn.

The developmental model is also long term, a time frame that conflicts with current a health and treatment focus on short-term cures. Recovery is a radical, starting-from-scratch process of building a new self. It cannot be produced in 10 sessions. A woman’s healthy self can’t be given or stolen. She cannot be fixed up and sent off in 10 sessions. The woman must be the agent in her own self development. A therapist who wants to see quick change can interfere with a woman’s personal pace of growth. A therapist who wants to see quick change can also thwart the natural, normal process of deepening exploration that becomes possible with long-term recovery. The woman comes to understand that she may feel worse before she feels better. Unfortunately, many therapists never understand the pains of healthy growth and immediately want to offer something to take it away. The unwitting therapist can send the woman back into denial, back into defense, and even back into drinking by pushing for quick change. This emphasis on symptom reduction can arrest her healthy development.

The therapist uses the developmental model to assess the stage and task of active addiction or recovery for each woman. There will be similarities among women according to stage and task and there will also be individual differences. It is very important for the therapist to assess both the global and the particular. Thanks to the women’s political and social movement of the late 20th century, women found strength and support by emphasizing their similarities. The woman in recovery needs to identify with other women alcoholics and she needs to also focus on her self. The deep exploration process of early and ongoing recovery allows her to look inward and to see herself alone — just herself. She will need to accept her differences from other women as much as her similarities. This acceptance of differences among women may also be a source of difficulty for therapists who may see and hear a woman’s unique experiences as a defense against recognizing her own alcoholism or attaching to recovery. Indeed, a woman’s need to see herself clearly, to focus on her self alone, may be a defense. But it is also an essential part of a healthy recovery process. The therapist and her female client must constantly attend to the line in the serenity prayer: “... the wisdom to know the difference.”

Recovery growth is paradoxical. A woman comes to accept that she has lost control. This “failure” opens the door for her to find and develop a healthy self. This process is the long-term work of recovery.

Stephanie Brown, PhD, is a clinician, author, teacher, researcher, and consultant in the field of addictions. She is the Director of The Addictions Institute in Menlo Park, Calif., and a Research Associate at the Mental Research Institute (MRI) in Palo Alto, where she co-directs The Family Recovery Research Project.

References
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Straussner, L. and Attia, P. (2002). Women’s Addiction and Treatment Through a Historical Lens. In: L. Straussner and S. Brown, (Eds.). The Handbook of Addiction Treatment for Women: Theory and Practice. San Francisco.

This article is published in Counselor,The Magazine for Addiction Professionals, June 2006, v.7, n.3, pp.12-18.

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