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Abstract

This qualitative study explores the experience of treatment in a mixed-gender therapeutic community (TC) by Israeli women coping with drug addiction. The vast majority of studies reveal that the techniques used in TCs are designed based on men’s needs. This study focuses on the meanings assigned by women to their experiences within the TC in light of the intersectionality theory and the social construction of gender. The study is based on an interpretative phenomenological approach. Seventeen middle-aged women answered open-ended questionnaires or participated in in-depth interviews. Textual analysis yielded three themes: (1) there’s no place like home—searching for family in the TC; (2) fulfillment and difficulty in intimate relationships in the TC; (3) overall evaluation: mixed-gender TCs are a mixed bag. The discussion focuses on the sociocultural context of women’s treatment in the TC, the male power paradigm, and the individualistic focus that serves as the foundation of the TC approach. The question of how TCs can create safe space for rehabilitating relationships for women is addressed. Finally, implications for policy practice are presented based on the gender-responsive approach.

Keywords

women and therapeutic communities women and drug addiction gender-responsive treatment for drug abuse intersectionality

Substance abuse treatment before the 1970s followed a generic approach in which there was little recognition of the specific treatment needs of women, and until recently, most studies of psychoactive drug use were conducted among males (Agrawal, Neale, Prescott, & Kendler, 2004). Spurred by the feminist movement, which illuminated pervasive gender inequalities in social life, significant differences between men and women with regard to substance abuse have been recognized. These include initiation of substance use, progression to dependence, and factors that facilitate or impede treatment participation. The recognition of gender differences in substance abuse led to the development of treatment services exclusively for women and treatment “tracks” for women within mixed-gender programs (Greenfield & Grella, 2009; Lindsey, 2016).

The therapeutic community (TC) is one of the drug treatment programs for men and women that were developed in Western countries. The TC is a drug-free residential treatment setting that uses a hierarchical model of peer influence and treatment stages reflecting increased levels of personal and social responsibility (National Institute on Drug Abuse [NIDA], 2016). While there are exclusively female TCs or gender-specific tracks within TCs, many countries (including Israel) still offer primarily mixed-gender programs (Greenfield & Grella, 2009).

It has been suggested that mixed-gender programs for the treatment of substance abuse may reinforce women’s invisibility and marginalization especially if the therapeutic techniques employed in these programs are designed for the needs of men (Bauer, 2014). The dual marginality of women in these programs stems from their social status as drug abusers as well as from gender (Gillborn, 2015). According to the intersectionality theory (Crenshaw, 1991), the overlapping social identity characteristics of status and gender operate as underlying factors of oppression and inequality (Bauer, 2014). In a recent political commentary on substance abuse, Tiger (2017) focuses on two additional social characteristics that impact the experience of substance abuse: race and class. Poor drug users are caught in what can be viewed as another type of intersectionality—the intersection of the criminal justice, drug treatment, and child protection systems. At this juncture, Tiger argues that those coping with substance abuse are subjected to both punitive and medical control.

The aim of the current pilot study is to explore the contribution of social status identity characteristics, with the central focus on gender, to the experience of drug treatment within mixed-gender TCs through interpretative phenomenological analysis (Smith, Flowers, & Larkin, 2009) of open-ended questionnaires and interviews with 17 Israeli women during and following their active participation in the TC.

Background

Substance Abuse Treatment for Women

Studies demonstrate that compared to men, women generally have greater obstacles to accessing treatment, more severe problems at treatment entry, and lower rates of treatment completion (e.g., Back et al., 2011). The intersectionality theory which was adopted from the feminist perspective (Viruell-Fuentes, Miranda, & Abdulrahim, 2012) conceptualizes the individual’s characteristics (such as gender, age, economic class, and “disability”) as factors that may create social barriers women face in substance abuse treatment (Gopaldas, 2013). Gender-specific treatment barriers women face include lack of decision-making power; factors that determine physical and mental health status, such as, higher rates of unemployment, lower income, responsibility for childcare, social stigma; and lack of support from family (Back et al., 2011). Taking gender-specific barriers into account, researchers and treatment providers began to identify the specific needs of women coping with substance abuse and the characteristics and components of successful treatment programs for women. Gender-responsive programming for women considers multifaceted aspects of women’s lives including prenatal care, childcare, history of abuse, family and intimate partner relationships, and poverty. Psychosocial treatment for women needs to address coping skills, relapse prevention, relational work, trauma, and other concurrent mental health problems. Attention to practical issues such as medical care, employment, and food is also necessary (De Leon, 2000; NIDA, 2016).

The current study was conducted in Israel, where treatment approaches for substance abuse combine the traditional U.S. disease model, the European harm-reduction model, 12-step programs, and some unique Israeli components that emphasize family and community intervention (e.g., adoption of persons recovering from addiction by families in kibbutzim; Ashenberg-Straussner, 2001). Settings for drug treatment programs in Israel include detoxification units, community-based day programs, NA groups, and TCs for long-term intervention (up to 1½ years). Of a total of 12 TCs, one is exclusively for women. There is a dearth of gender-specific components in Israeli TCs. The mixed-gender programs do offer women-only groups, and there is one TC which accepts mothers with children and works with the women separately around parenting issues (Amram, 2013). Addressing issues of men and women living and poverty and class discrimination are not integrated into drug treatment programs, despite the fact that TCs in Israel are government sponsored and subsidized and mainly deal with those addicted to opiates who are in the lowest socioeconomic class.

The TC Model

TC is a total environment treatment facility in which the community itself, through self-help and mutual support, is the principal means for promoting personal change. Residents and staff participate in the management and operation of the community to create a psychologically and physically safe learning environment (De Leon, 2000). The TC adopts a holistic and multidimensional approach by focusing on social, psychological, and behavioral dimensions of substance use (NIDA, 2016). Residents advance to different levels in the TC, with members “earning” increased responsibilities, privileges, and status as they move through the stages (De Leon, 2000; Manuel et al., 2017).

TCs in Israel offer various treatment modalities: individual psychosocial therapy provided by social workers; family intervention in which the social worker may invite members of the family to the community to deal with a specific issue that arise in the individual sessions; psychodynamic group therapy-facilitated by social workers; confrontation and 12 step groups led by counselors who themselves have overcome addiction, self-governing groups for establishing and maintaining boundaries, and house rules led by senior residents (Michael, 2007).

There is some evidence for the effectiveness of TC compared to other interventions regarding indicators related to recovery: substance use, criminal involvement, employment, psychological well-being, and family and social relations (De Leon, 2010; Malivert, Fatséas, Denis, Langlois, & Auriacombe, 2012). Those who complete treatment shows the best outcomes, and among noncompleters, there is a positive relationship between length of stay and positive posttreatment outcomes (Vanderplasschen, Vandevelde, & Broekaert, 2014). The TC seems to show particularly strong effects among severely addicted individuals including incarcerated and mentally ill drug addicts (Welsh, 2007). Other studies (e.g., Gossop, Marsden, Stewart, & Kidd, 2003) yielded different findings, indicating similar effects of various types of residential treatment when compared with outpatient methadone treatment.

Women and the TC

Despite the holistic and multidimensional approach adopted by the TC, the vast majority of studies reveal that the techniques used in TCs, including exclusively women’s programs, are designed for the needs of men (Gur, 2008; Vanderplasschen et al., 2014). The TC relies heavily on peer pressure and feedback through the group process, a strictly structured set of rules and sanctions (consequences), and a rigidly ordered daily routine. The TC seeks to transform a range of behaviors and attitudes associated with drug addiction, such as denial, lying, engaging in criminal behavior to support drug use, and prostitution (Wiechelt & Shdaimah, 2011). These techniques may be problematic for women, since women in addiction therapy exhibit strong feelings of denial, shame and guilt, over-responsibility, and lack of control (Sacks & Sacks, 2010; Sanders, 2012). Despite these possible drawbacks, Hedrich (2000) found positive TC treatment outcomes among women with lack of sufficient support and resources to manage in an outpatient setting, including women who were homeless or living in a substance-abusing environment, suffering from psychological disorders and domestic violence and those who were severely socially deviant.

Very few studies have explored women clients’ perceptions of drug treatment services such as TCs (e.g., Newton, 2008). Exploring these perceptions is important in order to give voice to these women’s lived experiences as well as to evaluate the efficacy of the service. Hearing and understanding women’s experiences in TCs, especially their perceptions of how their lived experiences were impacted by different characteristics of their social status, will help social workers address women’s unique needs on both direct practice and policy levels.

Research Method

The study was designed according to interpretative phenomenological analysis (Smith et al., 2009), a method that focuses on exploring a person’s experience in a particular process. The researcher accesses rich, detailed, personal accounts and then describes, interprets, and situates the way in which research participants make sense of their experiences. In addition, we adopted a feminist approach that aims to discover what has been termed “subjugated knowledge” by challenging the notion that what is known about dominant groups must also be true for women and other oppressed groups, such as substance abusers. In feminist inquiry, new meanings of the social systems and processes are generated by focusing on the lived experiences of women and members of other marginalized groups (Hesse-Biber, 2012).

Data Collection

Data were collected from 17 middle-aged women in a mixed-gender TC for persons coping with substance abuse and in a half-way house for “graduates” of the TC, in Israel. The research protocol was approved by an academic institutional review board. In the first phase of the research, 10 women in the TC filled out an anonymous questionnaire with open-ended questions. In the second phase, seven additional women participated in in-depth semistructured interviews. The research interviewer was a social worker who worked in the TC. She recruited participants who had not been her clients, and they in turn referred her to other potential participants. Informed consent was obtained from all participants.

The questions in the written questionnaire and the oral interview guide were about how the women came to the TC, positive and negative features of the TC regarding coping with drug addiction, the relationships with others in the TC, and experiences as women in a setting where the majority of the population (about 80%) were male. Those who filled out the questionnaires gave one line to one paragraph answers to each question. The oral interviews began with a general invitation for the women to talk about their experiences as members of the TC followed by a free-flowing dialogue between the researcher and participants. The interviews varied in length from 1 to 2½ hours. They were audio-recorded and transcribed verbatim. The questionnaire distribution and oral interviews took place on the grounds of the TC or half-way house. During the course of the data collection (6 months), the researcher kept a log about her observations regarding women’s behavior in the drug rehabilitation settings.

Data Analysis

The textual analysis of the questionnaires, interviews, and research log followed the four stages outlined in the interpretive phenomenological analytic method: (1) uncensored associations, comments, and reactions to what the researchers found interesting, meaningful, or unusual were noted; (2) succinct phrases that expressed the essential characteristics of textual units were recorded; and (3) the phrases were categorized, and the categories were conceptualized to create themes; and (4) a theoretical model was constructed to explain how the themes are connected (Smith et al., 2009).

Trustworthiness Strategies

A number of strategies were used to enhance credibility and transferability, the two main criteria for trustworthiness in qualitative inquiry (Guba & Lincoln, 1985). The interview and questionnaire texts and theoretical memos in the research journal were repeatedly reviewed during the analysis to enable reexamination, reevaluation, and reformulation. In-depth interviews of long duration allowed us to check consistencies in meanings expressed by informants. The researchers engaged in reflexivity throughout the process in order to identify and bracket their own feelings and attitudes (e.g., regarding women’s aggressive behavior, prostitution, and child neglect). The varying professional experience and involvement of the researchers with women coping with drug abuse provided multiple perspectives, insights, and interpretations. Finally, direct quotes are presented, so the reader can critically evaluate our interpretation of participants’ voices.

Findings

Although the aim of the TC is to work with different levels of the person (biopsychosocial aspects), most women in the study focus on the social aspect of connections with others. The following is a presentation of the main themes that emerged from the data analysis: (1) There’s no place like home—searching for family in the TC; (2) fulfillment and difficulty in intimate relationships in the TC; and (3) overall evaluation: mixed-gender TCs are a mixed bag.

Before delving in to the women’s experience in the mixed-gender TC, it is important to note that the participants were aware that socially constructed feminine roles impeded seeking treatment in a TC. As they put it, they use their looks and sexuality to manage on the outside, thus delaying their entrance into drug treatment programs. Nancy explains:

Women can more quickly get money. It’s less difficult for them like for men, that’s why they don’t come to be rehabilitated. It’s less difficult for them, they work in prostitution, they make money. A male has to steal, to be involved in crime and women don’t.

Nancy speaks in the generalized third person, demonstrating her recognition that this a social issue.

There’s No Place Like Home: Searching for Family in the TC

The women express disappointment in their families of origin and a craving for a sense of “home” in the TC. This often leads to further disappointment since they feel that the atmosphere in the TC is much different than in their internalized real or imaginary home.

This place is good, but it’s hard for me. I am surviving, but I’m not relaxed. It’s hard for me here, it’s not a normative life, it’s not like you live at home, it’s not like the food that’s at home. I can’t do what I want here, it’s not like home. (Shimrit)

Loren describes the regimentation in the TC as “suffering,” the opposite of the caring environment she needs so badly.

It was very hard for me there…the daily routine…and also all of the strange rules…It’s forbidden to take hot water during certain hours, for example…And if you are dying for a cup of coffee, there is none…It’s really not for me, this form of community. I suffered a lot in life, and I don’t need even more suffering. On the contrary, I need that they take care of me nicely, to rest, to eat well.

While the women express disappointment in the nonhome-like atmosphere in the TC, many talk about close family-like relationships that were experienced, sometimes for the first time, in the TC. It is a feeling that someone actually sees them as human beings, as a family member should. Most of these women feel like invisible outsiders in their own families, since their needs were not met or considered. In the TC, they feel a sense of belonging, acceptance, and unconditional love, as evidenced in the following passages:

There is a lot of attention on the part of the therapists, good relations, and most important, they see me, what was always missing for me. (Sharon)

A supportive setting, not judgmental, an empowering setting, what women addicts don’t see in themselves, a lot of love, containment, and conversations. (Elaine)

Some of the women make specific reference to the TC as a surrogate family that fulfills both instrumental and emotional parental functions: Natasha explains:

In this place there is concern that take care of women. They teach us to shower and take care of ourselves, and most important they do a lot of conversations, a lot of love…and that someone will listen to me and related to me as a family should be.

It is interesting to note that in the above passages, Elaine and Natasha both refer to the specific needs of women coping with addiction. They are intuitively aware of the intersectionality of rejection based on gender and substance abuse.

Counselors, who themselves are recovering from drug addiction (drug-free), are cast as significant parental figures for women in the TC. Liron makes the explicit connection between her counselor, the “good mother,” and her own deceased mother:

Margalit, my counselor…she talks with me, she is very much for me [on my side]. She’s like this mother of everyone, this good mother…She is this motherly, it’s hard for me to explain, also in the little things she reminds me of my mother sometimes.

In a moving role reversal, Loren expresses appreciation for the opportunity given to her in the TC to fulfill a maternal role:

I got work in the kitchen. I love it in the kitchen, In the kitchen I am a mom, it’s fun. I make food at the tables like my children sit there. Let’s give them food, yeah!!! I love it.

Even though the counselors are the enforcers of the clear boundaries of the TC, many women are able to experience the counselors as authority figures who have their best interests at heart.

I took from the counselors, Allen, he was the one who pushed me, said to me “get up.” Good for him, Allen. He saw what I needed and encouraged me to rehabilitate my life.

…And Dave, it’s good that he was tough, that’s what I needed then, because that forced me to straighten out. Today [after completing the TC program and moving to a hostel] after I saw and learned what’s relationships, this rigidness isn’t appropriate for me and I need a more pleasant and gentle relationship. (Merav)

The element that interferes with the women’s relationship with the counselors is the formal set of rules that governs the counselor–TC resident relationship: “In the community, I wouldn’t meet with the counselor because it was forbidden to approach him directly.” This nonfamily-like rule is resented. Also, while the women understand and accept the counselors as caring and benevolent authority figures, when it comes to persons higher up and more removed from them in the administration, they express their objection to being told what to do. It is interesting that Loren refers to the presumption of family-like obligation as a basis for her angry objection:

Why this? Why that?…It’s clean there. Why should you [the staff coordinator] come to me. I’m not your mother that you can come and tell me. I’m not your brother, I’m not his, your sister. You leave me alone…A coordinator can’t do this, get out. The queen can do it. Why can’t you? Because you are a coordinaaaator. F--K!

Fulfillment and Difficulty in Intimate Relationships in the TC

Relationships with therapists: preference for individual therapy

The women find it easier to share their thoughts and feelings in individual therapy than within groups.

I connected more to the conversations with the social worker…They listened to me, wanted to help me…In the groups I would talk as little as possible…because I didn’t have anything to tell, and if I did have something to tell, then I didn’t want to tell it. (Loren)

Victoria also states that in her individual therapeutic sessions, she manages to deal with difficult issues, with the help of her social worker, as opposed to her experience in the groups, where she feels ashamed “to tell.”

I had now individual conversations and it wasn’t simple, but it’s for me. We worked on issues…It was a very serious conversation about the children and about everything. She got out of me all of the things…In the group I can tell, but I’m a little ashamed.

Gendered peer relationships

The women’s words indicate that they find it difficult to establish close social relationships with other women in the TC. The social dynamics are often characterized by superficial connections revolving around the daily routine.

In the community, I wasn’t close with anyone…because there was no one to talk to…In the room, it was very hard with the girls. Every time they changed the girls on us in the room. They stole…Once they put Linda in the room and she would bother me terribly.

Some of the women express particular difficulty in being in contact with women and prefer the company of men. Noga expresses alienation from her own gender.

I don’t like women. Women, [I] don’t get along with that nation…Like the grinding [physical flirting] games. I don’t like that nation…With men there’s more to talk about…The women talk about one another. The men talk to the point. The women talk about other [people] or about makeup or about all of that nonsense that doesn’t speak to me.

Victoria also notes that the closer relationship she has in the TC are with the men she met “on the outside.” She has difficulty communicating with the women in the TC because she sees herself as different from them. She is “clean” while they take pills or methadone.

Unlike Noga and Victoria, Lauren dislikes men because of sexual assaults she experienced in her youth:

I don’t like men, I don’t like them…With Eric [husband] I had something, But I don’t love him, I take care of him in my way. But I don’t want another man, don’t want…I hate them…Towards women, I have more respect. I don’t know why, but I thought that I hated them also, but I don’t…It’s because they [men] raped me, you see I don’t like them, yick”

Lauren is not only distressed but also confused about her feelings for men. She continues with a tirade against women:

I hate them [women], I hate all of them…If you talk to them, they don’t listen. I have a young woman in the room, a girl, a two year old girl! If you tell them, they stop turning on the lights. Why do you need light during the day? Open the window. Bitch! Aggravated with that one, and no one cares, that’s the worst.

While it is hard to sort out Lauren’s complaint, it is clear that she is living in a dark world of cruelty and isolation outside and inside the TC. Eric, her husband, appears as the only one toward whom she can express her concern. Overall, the difficulties the women have in developing friendships with both male and female peers in the TC occupy a prominent place in the interviews.

Secret relationships with men: longing for intimacy

Some women highlight their need for physical intimacy with men as a way of gaining attention, and love. The forbidden relationships usually remain secret, since exposure can lead to the woman’s removal from the TC and to her return to the cycle of poverty and drug addiction.

There was someone…We were like friends, he was nice, we got too close…We didn’t say “I love you”, because everyone understands. So he said to me “lipa” in my language, and I understood what he said, but no one else understood. The only one I had feelings for was Morris. But we didn’t do anything bad. We kissed, yes, but nothing else, that’s the truth. (Lauren)

Interestingly, the world of addiction also involves violation of laws, codes, and unique language, but here we see a utilization of the same pattern for the sake of healing and connecting. The irony is that this behavior goes against the concept of rehabilitation in the TC.

Noga is currently been treated in a half-way house, a facility which allows active romantic relationships. Noga’s relationship with her boyfriend began as a forbidden romance in the TC and she now keeps it a secret from her family since her boyfriend is Arab and she is Jewish.

My boyfriend fills everything that is missing for me…We have a very great love between us that my family doesn’t know about because he is Arab…If they knew, oh no for my life…they won’t speak to me…And a love like this I won’t give up on…When he was in the community [TC] it was very difficult for me…I got punishments for receiving the letters from him…They put him back in the TC and me in the day hospital because we used together a half a year ago…How many punishments we had because we would meet like this in hide and seek…Afterwards they allowed us to meet once a week for an hour and a half…and now again [we are] together.

During her stay in the TC, the relationship with her intimate partner was the most significant experience for Noga, even when she put her continued stay in the TC and the connection with her family at risk. There is no evidence that the relationship was abusive, however the secrets and the forbidden love contribute to the excitement in the relationship. Is this a healthy relationship that is contributing to Noga’s rehabilitation and well-being, or is it another form of an artificial high that disrupts her family relationships and provides her with a partner for her continued drug addiction? Noga’s experience also reveals another intersectionality status issue in Israel—ethnic background. All of the participants in this study were Jewish, but clearly social discrimination against Arabs in Israel contributes to the addiction and recovery experience of both men and women.

Another type of forbidden connection between men and women in the TC is one based on sexual relations without emotional involvement. Merav spoke about a woman who prostituted herself in the TC in order to obtain pills.

There was one named Ludmilla. I convinced her to come from the hospital. When she was in the community she would curse me, “you brought me here” I said, “you were in the hospital, you had it good, but the fact that you do shady business with pills and suck every dick of all of the Russians here, that you are guilty of, not me. For that you are in the community. It’s difficult, but you’ll see that you are beautiful.”

On the one hand, Merav is very critical of Ludmilla’s promiscuous behavior in the TC; she also adds an ethnic slur against Russian prostitutes and their Russian clients in the TC. On the other hand, she does not reject her. Merav encourages Ludmilla that despite the difficulties, she will ultimately come to recognize her own beauty.

Overall evaluation: mixed-gender TCs are a mixed bag

In Israel, almost all of the TCs are mixed-gender settings. The difference between men’s and women’s addiction trajectory and behavior patterns, as well as the fact that many women coping with drug addiction were exploited by men, raise doubts about appropriateness and efficacy of mixed-gender TCs. However, somewhat surprisingly, most of the participants expressed a preference for treatment in a mixed-gender TC.

Marina notes the advantage of mixed-gender programs: “I don’t know how to explain it, that like to be in an environment, like normal, complete.” Merav states unequivocally that she prefers a mixed-gender TC despite her traumatic experiences of sexual abuse.

No, no, I wouldn’t want only women. I like that it is integrated, fun to see the two sexes. I don’t like men, maybe because of what I experienced, so I can’t have a relationship with a man because I went through traumas. But actually, with men, the thing of talking, laughing, I manage great compared with women. With women it’s OK, but not with relationships or something. Normal, day to day life, work, normal. I have nothing specific and special that I want women. Mixed is warmer and better, in terms of friends.

Shiraz argues that the possibility of emotional entanglements with men that can prevent individual progress, “My personal example, men and women in the same setting can interfere, when there is emotional involvement.” In Shiraz’s case, the staff convinced her to end her relationship with a man in the TC, as a condition for her continued stay. She apparently agreed with this requirement and willingly complied. Alona cannot decide whether she prefers an integrated framework or a facility which is for women only.

I don’t have a definite opinion about good mixed or not. On the one hand, only a woman can understand what I went through. On the other hand, men in therapy [groups] raises the confidence a little, the self-worth of a woman even though it sounds not feminist.

In addition to comments about the mixed-gender TC setting, the women were asked to reflect on the mixed-gender group sessions. The women in the study reported that almost all groups are mixed-gender and only one was for women only. The groups are activity oriented or discussion/therapy groups that deal with various day-to-day and addiction issues. Noga, now in a half-way house, has positive memories of the mixed-gender group in TC: “In the community, in the group, you can open up you heart and tell…It was a small group, and you can talk, you can tell about your difficulty.…” On the other hand, there are women who clearly state that they would prefer to participate in a women-only group. For example:

It would be better if we were split into groups of women alone and men alone…In my opinion women, with separation from men, is better because this way everything is opened in the group. What I said that here I can’t tell to the men in the group.

Marina elaborates about the uniqueness of women’s only groups:

First of all, what happens with us in the room, what is between us, to not let it out in front of the men who start making fun of us. We are four women. The men do the same things we do, but when we do it, it’s a scene, so we don’t want to be in that picture. So for that there are women’s groups, not to let out things that’s like [dirty] underwear not in front of the men. About my daughter, I don’t talk so much there [in the mixed gender group]. There are things that I do talk about there and there are things that are more comfortable for me to talk about like I told you that I knew that she [a woman member of the group] went through sexual harassment.

Marina is acutely aware of the double standard toward men and women coping with substance abuse and therefore advocates for all-women groups. Interestingly, Merav later explains that the expectation of fuller disclosure in women-only groups can “intensify the difficulty, since [there] we are required to deal with the most feminine and intimate issues.”

Some women explain that the nature of certain groups is just not appropriate for them.

Marina:

There is a group on anger management that is still hard for me, you are supposed to remember some violent incident, that the person was violent and was angry. I’m not violent, so it’s hard for me. Up until now I can’t understand what they want from me!

In TCs, there are also weekly mixed-gender group sessions in which the participants expect to explore cases of violation of the community rules by other members. Victoria feels uncomfortable both for herself and for others in this group, and therefore sometimes avoids attending.

I like that there are art groups and groups in Russian and learning Hebrew. Groups that I don’t like to go to are “attitude groups”…Sometimes it’s not pleasant when they start in, and I see how a person gets excited from what they say to him. I right away think “what will be if they tell me.”

Loren, a resident in a half-way house, experienced both the daily-living and mixed-gender confrontation groups in the TC as unhelpful, a “collective attack,” since in her perception, they focused on the personal faults of the members:

In the setting I am in today, the groups are more relaxed, that is, there aren’t the groups that there were in the community [TC] that I really didn’t tolerate. In those groups [mixed-gender], there was a collective attack on one person, every time a different person. Every time everyone starts to yell at him, and I really didn’t like those groups. They didn’t help me…Everyone telling you all of your faults together. This caused me to feel only alienation and lack of belonging.

Other women express ambivalence regarding the mixed-gender TC groups. Marina summarizes the advantages and disadvantages:

In therapy with men, on the one hand it disturbs, on the other hand, I wouldn’t want to be just in women’s therapy…It disturbs that sometimes it is difficult to talk about the things…There is a problem that someone in the conversation touches me unintentionally, and there are people that hold themselves above in the conversation, and that is hard for me to accept from men. As if I think that men are trying to take control and use the role…Maybe that all my life, men tried to get control over me, even including my brother, even my father. I am worried about this. But on the other hand, men, it’s good, because I hear from them the good things, a little attention, that’s not so easy with women. I’m a little tired of the gossip. We had almost two weeks, that they [the counselors] said to the women to be only together and not to talk to men. Really, it was hard from morning to night to be concentrated one on the other.

To conclude, most women express their fear and reluctance to express themselves in mixed-gender groups, especially regarding women’s issues such as sex and motherhood. Mixed-gender groups largely revolve around the issues of and anger management and compliance to rules. The women found these groups inappropriate for them, both because this was not their major concern and because they find it particularly difficult to be exposed to men’s anger and control and to express their own anger toward males.

Discussion

The aim of the current qualitative study is to explore the experience of women dealing with drug addiction in mixed-gender TCs in Israel, in order to help professionals develop appropriate interventions for women’s drug addiction in general, and in TCs in particular. This study focuses on the meanings assigned by these women to their TC experience in light of the intersectionality theory (Crenshaw, 1991), which posits that lived experiences of marginalized groups are informed by the interaction of multiple discriminatory social biases (Viruell-Fuentes et al., 2012). At the outset, it is important to note that our focus is on two discriminatory social statuses: gender and drug addiction. Other oppressive institutions, that is, ethnicity and poverty were touched on in the findings but were not dealt with in depth. This is partly due to the sample, all of the women in the study were Jewish, and the setting of the study. The women were interviewed while residents of a TC or halfway house, settings that were a temporary respite from life in abject poverty.

The Sociocultural Context of Women’s Treatment in the TC

According to the feminist perspective in general, male social dominance is expressed in the society at large as well as in smaller social contexts (such as the TC; Harrison, 2015). Women’s “disorderly behavior,” such as drug use, is met with greater condemnation than that of men. Female drug abuse is often associated with nonfemininity, weakness, licentiousness, and irresponsibility (Storbjörk, 2011; Stringer & Baker, 2015). In the interviews, the women reported that they suffer from greater discrimination, social stigma, and shame than men dealing with addiction.

The social stigma attached to women dealing with drug addiction is also related to the socially constructed gender code that obligates women to focus on men’s feelings and needs in return for being protected by them (Lindsey, 2016). This role can be a source of happiness, pleasure, power, and satisfaction, when women are appreciated. Or, it can be a source of pain, vulnerability, disappointment, and humiliation when they are exploited (Sznitman, 2007; Wiechelt & Shdaimah, 2011). Most women interviewed in the current study experienced traumatic relationships with men prior to the period of drug abuse and all reported abusive relationships with the men who were their drug suppliers and pimps. Sadly, engaging in sex with the male supplier and/or through prostitution in exchange for drugs and protection can be viewed as kind of “success” in the social role of caring for and submitting to the control of men. These relationships became one of the reasons for delaying entrance into the therapeutic programs, such as the TC. Our sample was comprised middle-aged women living in poverty who could no longer “rely” on male pimps as drug suppliers and as buffers to the extreme conditions of abject poverty—hunger and homelessness.

Despite the strong impact of the overall sociocultural context in women’s addiction and treatment, in the current study, the women focused primarily on their relationships with others in the TC. They spoke less about the stigma and discrimination based on their gender and status as women living in poverty coping with substance abuse. This may be because women tend to adopt the deviant label attached to them as poor women drug addicts and the associated shame (Fletcher, 2013).

The Male Power Paradigm as the Foundation of TCs

Men’s dominance in society is also apparent in that most treatment facilities for drug addiction are based on male norms (Amram, 2013). For example, TC’s focus on the intersectionality of crime and men’s substance abuse, since one of the addiction pathways for men begins with drug dealing and men tend to finance their addiction through theft and other criminal activities. The use of social pressure, power, and strict rules enforced by authority figures and peers in the TC are used as a means of helping the men internalize socially acceptable limits to infringing on others’ rights. The power paradigm is not appropriate for women coping with addiction since their addiction trajectory does not usually involve aggression and criminal acts against others (Wiechelt & Shdaimah, 2011). In addition, the power paradigm puts women in a bind. If they express power directly they risk being perceived as domineering, castrating, and unfeminine. However, if they deny and suppress their power, they have to contend with poor self-esteem and a sense of powerlessness, which limits their development and growth in treatment (Bachrach-Cohen, 2012). In the current study, the women in the mixed-gendered TC often experience powerlessness, shyness, invasion of privacy, and being under “a collective attack.” The groups that are based on direct and often aggressive confrontation are especially difficult for them and are perceived as masculine techniques of bullying, which lead to feelings “alienation and lack of belonging.”

Is It Possible to Create a Safe Space for Women in Mixed-Gendered TC Groups?

The women’s difficulties in mixed-gendered facility and groups also stem from the difference between women and men in their reactions to drug addiction (Kaufman, 2004). Men deny their drug problems more than women, whereas women express more guilt and shame about drug use (Gur, 2008; Sanders, 2012). Shame is associated with negative feelings about the self as being disabled and as a desire to hide; guilt is connected to the desire for revenge for the hurtful actions of others (Sznitman, 2007). It seems that mixed-gender groups require an unrealistic degree of self-exposure connected to being vulnerable and abused by men, in the presence of male peers, in a way that disables women by not allowing them “to talk about things.” Therefore, while most of the women spoke about the benefit of creating a normal environment, by integrating men and women in the community, they cited the women’s only group as the only safe space to deal with feminine identity and issues related to women with peers, as well as a kind of island of control in which women are in charge of the therapeutic space, using behavior and language appropriate for women. On the other hand, some women spoke positively about participation in mixed-gender groups as a way of avoiding discussing feminine issues, including sexuality and drug abuse, and of getting a “little attention” from men. It is possible that these women find it hard to give up the existing benefits of the stereotyped gender system. “Being feminine” can provide the reward of dependency including not taking responsibility for oneself (Crocker & Wolfe, 2001) and the permission to be superficial and shallow, speaking only about “makeup, grinds, and gossip.”

Individualistic Versus Social/Relational Focus

Male norms in the TC include the emphasis on individualistic factors over the more social aspects of female drug misuse (Amram, 2013). The women in the current study indicate that the absence of warm, supportive, and loving family members and the abusive relationships in the family of origin and with intimate partners were significant factors in their drug addiction. Women coping with drug addiction seek emotional connection with others, and their self-recognition is based largely on the ability to maintain relationships that provide them with a sense of security and satisfaction (Covington, 2008). The women in this study expected that the TC served as a family, with the social workers cast as accepting and supportive parents. Some women expressed their disappointment in the TC as home and family because of the rigid and “cold” atmosphere (identified with the male model). The official role of the counselors in the TC is to act as authority figures who enforce the rules of the framework; yet, the women seek the softness and humanity that hide behind their, sometimes tough, exteriors.

Another dimension of the social aspect in women’s drug addiction is the search for relationships with men as a means to define their identity (Gur, 2008). The research participants spoke about their own and other women’s exclusive relationships, provocative behavior, and sexual relations with men in the TC. For some of the women, sex is perceived as the only thing that matters to men and thus a means to achieve material benefits as well as much-needed attention (Bachrach-Cohen, 2012). These relationships which are forbidden in the TC often remain secret, since exposure may lead expulsion from the program. Thus, in the existing TC system, women cannot raise issues regarding sexual and personal relationships with men in the TC in group or individual therapy.

As for female peer relationships, it is evident in the current study that women find it difficult to establish close social relationships with other women in the TC because they don’t want to belong to the “women’s nation” which is cast as immature, petty, and selfish. Studies have suggested that women do not trust other women because they see them as a threat to their own search for male approval or because they prefer to belong to the dominant group and not to the marginalized group (O’Mahony, 2009).

To conclude, most of the women in the study advocate mixed-gendered TCs, expressing their desire to recover in a heterogeneous setting that includes both men and women. However, they find it difficult to experience the treatment in the mixed-gendered TC as a whole as sensitive to their needs as persons dealing with the intersectionality of gender and drug addiction.

Implications for Service Delivery

The intersectionality theory stresses that in order to provide effective treatment for women coping with drug addiction, it is essential to create an environment that reflects an understanding of the overall sociocultural context and the interdependent social identity characteristics of gender, race, ethnicity, age, disability, and economic status that are underlying factors of oppression and inequality for women coping with drug addiction (Bauer, 2014). The current study focuses on the intersectionality of gender and drug addiction. Although not explicitly referred to by the women, the overall social context is a constant undercurrent in their experience of drug addiction and rehabilitation. Thus, treatment of women coping with drug addiction in the TC must address social issues that influence women’s access and response to drug treatment such as poverty, rigid gender socialization, gender roles, and gender inequality. Planning for life after the TC must include ensuring access to education and well-paying jobs. Anything less borders on unethical practice. In addition, as O’Neil and Lucas (2015) point out, efforts to counter stigma and to change public perceptions are important, since women recover and live in the context of their communities and families, not in treatment centers, institutions, or hospitals. On a local level, this could include TC open houses for community leaders and family members and senior TC residents in community volunteer programs.

It is essential that the treatment environment be safe and nurturing for women in order to enable them to gain a sense of power and to reduce the sense of inequality and marginality. This can be promoted by greater representation of women in higher management who can both express sensitivity to women’s needs and effect policy changes within the program. In addition, more women who have overcome drug addiction should be recruited as counselors. TCs should promote therapeutic relationships which take into consideration the basic distrust of the women of themselves and others, the barriers of shame, secrecy and denial, guilt, helplessness, trauma, and psychiatric disorders. All TCs should provide women-only groups as a safe place to experience supportive and nonexploitative human relationships within appropriate boundaries, so that the women will not perceive themselves as sexual objects (Covington & Bloom, 2006). Because of the importance of connections with significant others is a crucial element in women’s lives, it is important that the TC develop a forum for family conversations with parents, siblings, and partners. Finally, this study supports O’Neil and Lucas’ (2015) proposal that the focus of drug treatment for women should be on enhancing their nurturing and relational capacities rather than challenging their deficits. Confrontation seems to be inappropriate for women since it increases anxiety and challenges the safety principle.

Limitations of the Study and Directions for Further Research

This qualitative research study is based on a relatively homogeneous sample of women who participated in one specific TC. In addition, the interviews took place at one point in time, and thus, we cannot fully assess changes that occurred over time. Also, one cannot rule out that the use of an endogenous interviewer may have biased the types of responses to interview questions that were obtained, although she had no professional relationship with the participants and they seemed very genuine in the interviews including the disclosure of negative perceptions. Further research should focus on other oppressive institutions identified in intersectionality theory such as age, poverty, and ethnicity.

This pilot study addresses important issues in women’s drug treatment that has not been explored in much depth previously. It gives voice to a population dealing with intersecting oppressive social institutions. It demonstrates that the treatment of drug addiction relies on understanding the diversity, complexity, and interrelatedness of gender and social status.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Chaya Possick

References

Agrawal

Neale

M. C.

Prescott

C. A.

Kendler

K. S.

(2004). Cannabis and other illicit drugs: Comorbid use and abuse/dependence in males and females. Behavior Genetics, 34, 217–228.

Amram

(2013). Group work method in therapeutic communities for drug addicts. Journal of Addiction: Research & Therapy, 4, 2–15.

Ashenberg-Straussner

S. L.

(Ed.). (2001). Ethno-cultural factors in substance abuse treatment. New York, NY: Guilford Press.

Bachrach-Cohen

(2012). The meaning of romantic relationships in the lives of drug addicted women. Master’s thesis, University of Haifa, Haifa, Israel (Hebrew).

Back

S. E.

Payne

R. L.

Wahlquist

A. H.

Carter

R. E.

Stroud

Haynes

… Ling

(2011). Comparative profiles of men and women with opioid dependence: Results from a national multisite effectiveness trial. American Journal of Drug & Alcohol Abuse, 37, 313–323.

Bauer

G. R.

(2014). Incorporating intersectionality theory into population health research methodology: Challenges and the potential to advance health equity. Social Science & Medicine, 110, 10–17.

Covington

S. S.

(2008). Women and addiction: A trauma-informed approach. Journal of Psychoactive Drugs, 5, 377–385.

Covington

S. S.

Bloom

B. E.

(2006). Gender-responsive treatment and services in correctional settings. In Leeder

(Ed.), Inside and out: Women, prison, and therapy (pp. 9–24). New York, NY: Haworth Press.

Crenshaw

(1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 1241–1299. Retrieved from http://www.jstor.org/stable/1229039

10.

Crocker

Wolfe

C. T.

(2001). Contingencies of self-worth. Psychological Review, 108, 593–623.

11.

De Leon

(2000). The therapeutic community: Theory, model, and method. New York, NY: Springer Publishing Company.

12.

De Leon

(2010). Is the therapeutic community an evidence-based treatment? What the evidence says. International Journal of Therapeutic Communities, 31, 104–128.

13.

Fletcher

A. M.

(2013). Inside rehab: The surprising truth about addiction treatment, and how to get help that works (pp. 5–10). New York, NY: Anne M. Fletcher Communications.

14.

Gillborn

(2015). Intersectionality, critical race theory, and the primacy of racism: Race, class, gender, and disability in education. Qualitative Inquiry, 21, 277–287.

15.

Gopaldas

(2013). Intersectionality 101. Journal of Public Policy & Marketing, 32, 90–94.

16.

Gossop

Marsden

Stewart

Kidd

(2003). The national treatment outcome research study (NTORS): 4–5 year follow-up results. Addiction, 98, 291–303.

17.

Greenfield

S. F.

Grella

C. E.

(2009). What is “women-focused” treatment for substance use disorders? Psychiatric Services, 60, 880–882.

18.

Guba

E. G.

Lincoln

(1985). Naturalistic inquiry. Thousand Oaks, CA: Sage.

19.

Gur

(2008). Drug addicted women: Characteristics and interventions. In Mahal

Hovav

Golan

(Eds.), Addictions, violence and sex offences (pp. 93–117). Jerusalem: Carmel (Hebrew).

20.

Harrison

(2015). Redefining intersectionality theory through the lens of African American young adolescent girls’ racialized experiences. Youth & Society, 49, 1023–1039.

21.

Hedrich

2000). Problem drug use by women: Focus on community-based interventions. Strasbourg: Pompidou Group. Retrieved from http://www.coe.int/T/E/Social_Cohesion/pompidou_group/5.Publications/

22.

Hesse-Biber

(2012). Feminist research: Exploring, interrogating, and transforming the interconnections of epistemology, methodology, and method. In Hesse-Biber

(Ed.), Handbook of feminist research: Theory and praxis (2nd ed., pp. 2–26). Los Angeles, CA: Sage.

23.

Kaufman

. (2004). Psychotherapy of addicts. Kiryat Bialik, Israel: Ach (Hebrew).

24.

Lindsey

L. L.

(2016). Gender roles: A sociological perspective. New York, NY: Routledge.

25.

Malivert

Fatséas

Denis

Langlois

Auriacombe

(2012). Effectiveness of therapeutic communities: A systematic review. European Addiction Research, 18, 1–11.

26.

Manuel

J. I.

Yuan

Herman

D. B.

Svikis

D. S.

Nichols

Palmer

Deren

(2017). Barriers and facilitators to successful transition from long-term residential substance abuse treatment. Journal of Substance Abuse Treatment, 74, 16–22.

27.

Michael

(2007). Addiction and recovery: Selected issues in addiction treatment. Kiryat Bialik, Israel: Ach (Hebrew).

28.

National Institute on Drug Abuse. (2016). Drugfacts: Treatment approaches for drug addiction. Retrieved from http://www.drugabuse.gov

29.

Newton

(2008). African American women’s perceptions of and experiences with mandated substance abuse treatment: Implications for counselors Dissertation, Georgia State University Retrieved from http://scholarworks.gsu.edu/cgi/viewcontent.cgi?article=1022&context=cps_diss

30.

O’Mahony

S. C.

(2009). An exploratory study of the treatment needs of female drug and alcohol misusers. Critical Social Thinking: Policy and Practice, 13, 1–26.

31.

O’Neil

A. L.

Lucas

(2015). Promoting a gender responsive approach to addiction. UNICRI Publication No. 104, Turin. Retrieved from http://www.unicri.it/topics/social_justice_development/dawn/UNICRI_DAWN_new.pdf

32.

Sacks

J. Y.

(2010). Research on the effectiveness of the modified therapeutic community for persons with co-occurring substance use and mental disorders. International Journal of Therapeutic Communities, 31, 176–211.

33.

Sanders

J. M.

(2012). Use of mutual support to counteract the effects of socially constructed stigma: Gender and drug addiction. Journal of Groups in Addiction & Recovery, 7, 237–252.

34.

Smith

J. A.

Flowers

Larkin

(2009). Interpretative phenomenological analysis: Theory, method and research. London, England: Sage.

35.

Storbjörk

(2011). Gender differences in substance use, problems, social situation and treatment experiences among clients entering addiction treatment in Stockholm. Nordic Studies on Alcohol and Drugs, 28, 3–25.

36.

Stringer

K. L.

Baker

E. H.

(2015). Stigma as a barrier to substance abuse treatment among those with unmet need: An analysis of parenthood and marital status. Journal of Family Issues, 39, 1–25.

37.

Sznitman

S. R.

(2007). Drugs and gender. Nordic Studies on Alcohol and Drugs, 24, 2–16.

38.

Tiger

(2017). Race, class and the framing of drug epidemics. Contexts, 16, 46–51.

39.

Vanderplasschen

Vandevelde

Broekaert

(2014). Therapeutic communities for treating addictions in Europe: Evidence, current practices and future challenges. European Monitoring Centre for Drugs and Drug Addiction. Retrieved from http://www.emcdda.europa.eu/system/files/publications/779/TDXD14015ENN_final_467020.pdf_en

40.

Viruell-Fuentes

E. A.

Miranda

P. Y.

Abdulrahim

(2012). More than culture: Structural racism, intersectionality theory, and immigrant health. Social Science & Medicine, 75, 2099–2106.

41.

Welsh

W. N.

(2007). A multisite evaluation of prison-based therapeutic community drug treatment. Criminal Justice and Behavior, 34, 1481–1498.

42.

Wiechelt

S. A.

Shdaimah

C. S.

(2011). Trauma and substance abuse among women in prostitution: Implications for a specialized diversion program. Journal of Forensic Social Work, 1, 159–184.