Two of the most significant milestones in the modern evolution of addiction treatment and recovery have been the growth of addiction research on women and the emergence of gender-specific approaches to addiction treatment and recovery support. No one has exerted a greater influence on these advancements than Stephanie Covington, PhD, MSW. The books and curricula she has developed for use in addiction treatment programs include the following:
- Helping Women Recover: A Program for Treating Addiction
- Beyond Trauma: A Healing Journey for Women
- Voices: A Program of Self‐Discovery and Empowerment for Girls
- A Woman’s Way through The Twelve Steps
- Beyond Violence: A Prevention Program for Criminal Justice‐Involved Women
- Beyond Anger & Violence: A Program for Women, and
- Becoming Trauma Informed: A Training Program for Correctional Professionals
I have long respected the contributions Dr. Covington has made to our field, and recently had the opportunity to interview her about her life’s work. Please join us in this engaging conversation.
Bill White: Dr. Covington, you currently codirect the Institute for Relational Development and also codirect the Center for Gender and Justice. Could you briefly describe the work of these two organizations?
Dr. Covington: The main distinction is that my clinical work and related organizational consulting is done through the Institute for Relational Development, while my work with women and girls in the criminal justice system has been done through the Center for Gender and Justice which I codirect with criminologist Dr. Barbara Bloom.
Bill White: You have focused on the needs of women and particularly alcoholic women throughout your career. How did you come to develop this focus for your professional life?
Dr. Covington: Actually, it came out of my personal life. I had a graduate degree in social work and was working as a social worker when I had to acknowledge that alcohol was impacting my life. Through my recovery experience I realized that what I really wanted to do was help other women experience what I was experiencing: recovery. I did not know what that meant precisely, but eventually it led me back to school to get a PhD and to focus on women and addiction. Everything else, I guess, is history.
Bill White: Yes, and what a history that’s been. How would you describe the state of addiction treatment services for women at the time you began your work?
Dr. Covington: When I began my work, services for women were not a focus within the addiction field. There had been a little interest at the end of the 1970s, when the federal government funded ten demonstration projects around the country. Those were very unique at the time. When I was in my PhD program, I worked in a treatment program here in the San Diego area that had just opened. I wanted to run groups for women and since I was volunteering my time, they allowed me to do that. However, when I finished my internship and talked about developing more of a women’s program, the director said, “Well, there’s just no need for that. There are no differences.” That really was the general consensus of many people in the addiction field. They could not conceive how treatment could or should be different for women.
Now the irony is that last year I was at a conference where this same director was receiving a lifetime achievement award. In his acceptance speech, he talked about how he had been wrong and that he had finally learned what I was trying to convey to him all those years earlier. At that time, few could see the need for specialized treatment for women. There was just the belief that an alcoholic was an alcoholic, end of discussion. Since then, thinking differently about women and men and what needs to happen to support their recovery processes has come into the foreground and then faded into the background. Sometimes it’s a hot topic and then interest fades. I’m just one of those few people who have sustained my advocacy for women’s services for a very long time.
Bill White: That must have been difficult at a time when the majority of addiction treatment staff members were male, the research community was predominately male, administrators were predominantly male, and the clients were predominantly male. What an upstream battle you had.
Dr. Covington: Yes, there was very little support and I was sometimes ridiculed, but there were a few of us across the country, a core group of ten or twelve women who supported each other in this advocacy related to the importance of gender differences. I had somewhat the same experience a few years later when I started talking about trauma and addiction. People said, “Well, that’s just an excuse.” People didn’t want to hear about the intersection of trauma, addiction, and recovery either, but sometimes you know in your heart when you’re on to something that resonates and you feel it is right. I’m glad I didn’t get intimidated—I’m not one to back down.
Milestones in Gender Awareness and Treatment
Bill White: What do you think have been some of the important milestones in the development of gender-specific addiction treatment?
Dr. Covington: There were the early federal demonstration projects I noted, but I think the biggest milestone may have been Mrs. Ford coming out and talking about her recovery. That was a huge milestone. The states beginning to set aside money for women’s services within the block grants was also a major milestone that enhanced women services in many areas. More recently, I think the acknowledgement that girls are beginning to drink and use more like boys and seeing addiction in women as more than the stereotype of the housewife drinking in the in the closet has provided a much broader perspective on addicted women. Recognizing the role addiction plays in the lives of women in the criminal justice system and acknowledging trauma and its relationship to addiction and to relapse have been important milestones. All of these helped create more sophisticated interventions.
Bill White: As the field began to engage more women and work with women differently, we inevitably had to confront the issue of trauma which, as you note, had been historically neglected within the field. What are some of the important lessons you learned about trauma and its relationship to addiction and addiction recovery?
Dr. Covington: Many of us thought that trauma was important, but we weren’t exactly sure what to do about it. We thought a lot about doing things more sequentially and now we realize that the work with trauma can be initiated in early recovery and in early treatment. There are some things you can do for people who are trauma survivors as part of primary treatment. Initially—twenty-five years ago—I don’t think that that was the general consensus. There was a mantra in the field that women and men could not work on trauma until they were clean and sober for a year. While I didn’t agree with that, I wasn’t sure until I actually had more clinical experience how much trauma work you could do with someone in early recovery or with someone who is still using. So, I think that’s been a shift. If you’re getting federal funds to provide substance abuse treatment today, there is the expectation that such treatment will be trauma informed.
I think the other thing we’ve had to acknowledge is that most of the people working in addiction treatment are trauma survivors and many of them have never received any services. One of the biggest barriers that I have found to getting trauma services in addiction treatment is counselors who are very afraid to bring up this issue or work on this issue because of their own histories. That’s something early on that we did not anticipate being a barrier, and that has increased as the representation of women working in the field has increased—not that we don’t also have men working in addiction treatment who are also survivors of trauma.
Treatment Services for Women
Bill White: As you reflect on the evolution of addiction treatment for women, what have we learned from the standpoint of science about the types of treatment or recovery support services that work best for women?
Dr. Covington: Well, the terms “holistic” and “comprehensive” suggest a common thread. With women, you can just focus on the addiction; it has to be much more broad brush. When we talk about continuing care, what’s really important is continuity of relationship. If a woman can start working with someone and have this person as a support person over a long period of time, that really enhances her recovery options. We are recognizing the importance of treating women across multiple issues and challenges faces in their lives. It’s interesting that in the private sector, if you have resources, you can see a therapist for twenty years. If you’re in the public sector, a client can’t have prolonged contact with the same person, particularly after they terminate treatment, because it’s viewed as dependency on the part of the client or poor boundary management on the part of the counselor. It’s really interesting—these attitudes we have in the field about ongoing support.
Here’s another thing we’ve learned. I can’t do a presentation anywhere without being challenged about the value of separating men and women and having some groups that are gender-specific. The push back is the proposition that women and men are on this planet together and they have to learn to get along. While I certainly don’t disagree with that, achieving this goal is not the focus of primary treatment. The focus of primary treatment is on self and the reality is that women defocus when they’re in coed settings, as do men. We’ve learned that there is great value in women-only groups, but adolescent treatment, for example, continues to be predominantly coed. When people try gender-specific groups, they’re always amazed at how much better both the men and women respond.
Bill White: How would you characterize the current state of gender-specific treatment in the US?
Dr. Covington: I think it’s uneven. I think there are places that are really doing great work, and I think there are other places that are doing really mediocre work and a lot of places where the struggle is not just in program content but in program environment.
Program content to me is what you’re focusing on in the group and how women are spending their time in treatment; program environment is more the climate or the culture of the program. There’s still a punitive atmosphere in many addiction treatment programs that is not therapeutic. When we think about trauma, it is critical that survivors have an environment in which they feel safe. For example, Roger Fallot and I do a lot of work in Connecticut with mental health and addiction services helping them become more gender-responsive and trauma-informed in their services to both women and men. One of the things we suggest is to look at the signs they put up and the difference between someone walking into an agency that has a big sign that says, “Denial stops here,” and having a sign that reads “Change happens here” or “Hope begins here.” Such changes are subtle but really important.
Bill White: You’ve consulted with addiction treatment programs across the country on elevating quality of services for women. What are some of the major obstacles programs encounter in elevating the quality of treatment?
Dr. Covington: Right now, people are stressed out due to resources being cut and being expected to do more with less. Everybody talks about having more challenging clients. I think all of those things are barriers, but what I realize is there’s really no staff care. We talk a lot about what’s needed for the clients in the treatment environment, but the work environment itself is often very unsupportive. Too many settings do not provide adequate clinical supervision. I don’t see a lot of young people clamoring to go into this field. I think we’re going to have a shortage of workers, and I think we’re burning out the workers we do have.
Bill White: If you think back over some of the programs that have done the best work with women, what steps did they take to reach that level of quality?
Dr. Covington: A women’s program that has had any longevity has basically been led by a woman who’s made this her life’s work. There’s been consistent leadership with a lot of heart and soul. That kind of leadership permeates the whole environment and has a trickle-down effect to staff and to clients. They’ve also been able to operate as a team with a less obvious hierarchy.
There is another thing that I have started recommending to people. Instead of just buying the curriculum and implementing it with clients, I recommend that program staff go through these groups themselves. When programs have done this, the directors have told me, one, it’s the best thing they’ve ever done. The director participates and different staff members facilitate the exercises. Staff self-select out when they realize they have the same issues the women do and they haven’t dealt with them and they’re never going to be able to run the material. It’s just a useful tool. So, I’ve always said we should never have our clients do things we’ve never done ourselves.
Women in the Criminal Justice System
Bill White: Let’s talk about some of your specialty work with women in the criminal justice system. How did you come to develop this special interest?
Dr. Covington: That was another one of those flukes of life. I was in North Carolina in 1987 or 1988 speaking at a women’s conference. At the break, I was standing with some of the participants and everybody had on name tags and one woman’s name tag said, “Warden.” I said to her, “I don’t know any wardens.” She said, “I’m the warden in the women’s minimum security prison here.” I was just kind of staggered by it. I had been doing all this work around women and I had never thought about women in prison. So I told her that and she said, “Tonight, when you give your talk in the community, I’m bringing six or seven women out of the prison who are part of the Honoree group to hear you.” So that night I was standing with the warden and six or seven women who’ve come out for the evening. I remember thinking, “Why are you in there and I’m out here?” The next thing that popped into my mind was the answer: privilege.
When I came back to California, I was literally haunted by this experience. I couldn’t get it out of my mind so I called the warden and I said, “I’ll be back at North Carolina again next year at the women’s conference and I‘d like to do something in the prison.” We agreed that I would run some groups while I was there.
I later called her back and said, “I’d like to stay in the prison when I come there to run groups.” She said that was impossible, but I insisted. Finally, she said to me, “I cannot get approval for this, but I’m planning to change jobs anyway so I will arrange for you to come and live in the prison.” So, I went and lived in the prison for a couple of days and it changed my life. I knew the day I walked out of there that this was my work.
Bill White: That is an amazing story.
Dr. Covington: I had no idea how it would evolve. I did not know anyone, other than this warden. I didn’t know anything about corrections and I had just signed the contract to redo women’s treatment at the Betty Ford Center. Here I was, committed to a couple of years of consulting work with the Betty Ford Center. I still had my clinical practice. I was still speaking and writing and all of that, but I knew that I had to take on the issue of the needs of women in prison. That’s how it started.
It was around that time that I had this idea for A Woman’s Way through the Twelve Steps book. I went to Hazelden to discuss it with them and in that process they said to me, “We’re looking for a woman to rewrite the AA Big Book for women.” I said, “Absolutely not.” Can you imagine, taking that on? The backlash? But in the discussion with the Senior Editor about doing A Woman’s Way through the Twelve Steps, he started to tell me about how they were going to start developing criminal justice materials. I told him about my experience in the prison and how this was of interest to me and he said, “Well, you know, we’re putting together a national advisory board. Would you like to be on it?” I said, “Sure, but I don’t know anything.” He said, “No, but you’re enthusiastic.” So through the process of being on Hazelden’s National Advisory Board, I met a lot of very prominent people in the criminal justice system, which began my broader commitment to this work.
Bill White: Your recent work with women in the criminal justice system has expanded to encompass women who’ve been perpetrators of violence, which I find very fascinating and breakthrough work. Could you describe this work?
Dr. Covington: Sure. The Department of Correction in Michigan had me come and do some work with the addiction program in their women’s prison. In the process of that, they asked if I would write a curriculum for women who’ve committed violent, aggressive crimes. I said, “No, it’s not my expertise.” I was back again a few months later, they asked me again. Again I said, “Nope, not going to do it.” Two things happened. While I was on the unit one day, one of the women came up to me and said, “I hear you’re going to write something for us, for those of us who’ve committed a violent crime.” I said, “No. They’ve asked me but I’ve said, ‘no’” and she started to cry. She said, “I killed my best friend of nineteen years and I thought you’d be able to help me.” Well, in that same couple of days, I heard that there was program material for men who had committed violent crimes and when they completed it, they could then go before the Parole Board and the Parole Board took that into consideration, in terms of early release. The women had no such material, and that really ticked me off.
So, I’m on the plane flying home and I thought, “You keep saying ‘no’ because you don’t know what you’re doing, but you could learn.” About two weeks later, I called them and said, “Okay. I’ll write it, but here’s what I have to have. I have to have access to women who’ve committed violent crimes. I need to see them in group and individually. They need to be able to volunteer. I don’t want them assigned to come to see me. I need to talk to these women and I need to learn from them.” I said, “Look, I’ll read all the research, but that won’t be sufficient. I have to have access.” So I got access. I met with women and said, “Here’s the deal. They’ve asked me to write this. This is not my expertise, so I’m learning. You can help me find out if I’m learning the right stuff.” They did.
Bill White: What a great partnership model!
Dr. Covington: Exactly. A researcher from Michigan State and I ran various pilot groups in the prison’s addiction treatment program before this intervention went to press. I then requested that the women who were lifers or long-termers be admitted in to this residential treatment unit and go through my materials because I wanted them to be able to cofacilitate it later in the facility. So we ran groups with them to get their feedback and input on it, and then we did groups in the general population. We did a group with women who had co-occurring disorders to see how it worked with women with more complex mental health issues. We did a variety of things so I could refine the materials before their release. Research was also conducted on Beyond Violence and published in several journals.
That’s how it happened. Bill, it’s probably the best thing I’ve ever done.
The Future of Treatment
Bill White: What are your thoughts about the most important next steps in the development of gender-specific, trauma-informed addiction treatment in the US?
Dr. Covington: Well, in this process of doing all this work for women, I worked with two male coauthors to create a Helping Men Recover resource. This is the first gender-responsive trauma informed intervention for men. We’re looking at the issues of men who have addictive disorders, many of whom have experienced trauma, but we also talk about the violence that they may have perpetrated on others. I think both of the curricula that are focused on women and on men really deepen the treatment experience and make it less superficial. They deal with issues in people’s lives that they are struggling with, and that they have had no place to address. There’s a lot of shame for both men and women, and we’re having an incredible response to these materials. I’ve always said, “If you improve services for women and girls, it will improve services for men. If you only focus on improving services for men, it never improves the service for women and girls.” It just doesn’t work in reverse.
So I think some of the next steps are allowing men and women to be in separate groups to deal with the issues and to be able to speak frankly about them. When I do trainings now, people often want me to do things with Helping Men Recover and Helping Women Recover in the same training. We get to a point, probably halfway through day one, and we have all women’s tables and all men’s tables and they’re processing and doing exercises that are similar but different. At the end of a couple of days, I asked the men at the men’s table, “What was this like?” and they all said they dreaded the idea of it. They all say that the conversation was different because there were no women there. That it was deeper, that they spoke more frankly. I knew the women would say that, but having the men say it from their own experience inspired programs to begin to think about doing it differently. So, I think that’s the next step.
I think another next step is staff development, staff support, and thinking about what it means and how we set things up. If we’re punitive towards our clients, we’re probably also being punitive towards staff. I think everyone’s on the bandwagon for trauma-informed services, but most people think that means picking up a curriculum and running a group versus really looking at the culture of your program.
Bill White: As you look back over your career to date, what have been some of the biggest challenges you have faced?
Dr. Covington: At times, it has been sticking to what I believe when there was a wave going in another direction. It’s hard to be that lone voice. That’s been a challenge. For example, I think the criminalization of addiction in this country is an issue all of us who work in addiction treatment and we should be speaking out about. It’s hard sometimes to find the courage to step out and do that.
The challenges I have faced are nothing compared to the gratitude I feel. I can talk about being the voice out there, but the truth is I have always had supportive colleagues around me. There have been core groups of women, one in the addiction field and one in criminal justice work. We all started as colleagues with the same sort of passion and commitment towards women and have now become good friends. I feel a lot of gratitude for having that support. I’ve always had people I could call and say, “You know, here’s a situation. How am I going to handle this? What do you think would be best?” We all feel that we can call each other and we’ve done it for years. My life has just been really full.
Bill White: Is there a specific thing you feel best about related to the written work you have produced?
Dr. Covington: Ironically, when I look at the list of things I’ve written, I’m horrified. I’m not a writer. I’m really a speaker. I became a writer only out of my belief that what I was saying needed to be on paper. I’m amazed at the amount of material I’ve written.
Bill White: How have you found a way to fit writing into this larger clinical consulting, teaching world that you’re a part of.
Dr. Covington: One, I have a lot of energy. Two, I’m well-organized. Three, I probably work too much. I closed my clinical practice a few years ago, so I don’t do that and I really am winding down, although no one can see any signs of it. Actually, I don’t know how I’ve done it. I just feel really lucky.
Bill White: Stephanie, thank you for taking this time and thank for all you’ve done for individuals and families affected by addiction and related problems.
Dr. Covington: Well, thank you, Bill. I was so pleased that you asked me to do it.
Acknowledgements: Support for this interview series is provided by the Great Lakes Addiction Technology Transfer Center (ATTC) through a cooperative agreement from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT). The opinions expressed herein are the view of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA or CSAT.