For women who use drugs, treatment can be a man’s world
Walking through the door of a drug service can be daunting. Can women-only spaces make a difference?
Dani used drugs for the first time two years ago. Her thirteen year marriage was characterised by violence and abuse but she “did what I was told”, looking after the house and their five children while her husband often worked away. When the marriage eventually ended her husband told social services that she was an unfit mother. The threat of having her children taken away, coupled with the scars of years of abuse, made her “want to block out the world”.
She was referred to a mental health team who prescribed her diazepam (Valium). On the drug she “didn’t have to worry, everything just went away”, so she started buying more from the internet. Within six months she was using prescription opiates, going to up to five different chemists a day as well as local drug dealers. “It was a quick fix, it happened in the blink of an eye”.
Research by Agenda, the alliance for women and girls at risk, found that women who have experienced extensive violence and abuse are eight times more likely to be drug dependent than women who haven’t. Jessica Southgate, Policy Manager at Agenda, says while trauma is a big factor in both male and female substance use, “relationships with a partner play a much larger role in women’s drug use”. Women are more likely to be introduced to drugs by a partner, while men are more likely to be introduced by a friend. Women’s use often begins out of “necessity”, as a coping mechanism, whereas men are more likely to first use drugs recreationally. Women also progress from first use to problematic use more quickly , a process known as ‘telescoping’.
Addaction North Somerset run a weekly women’s group in the coastal town of Weston-super-Mare. The women chat as they file into the room and warmly greet the two members of staff who are facilitating. They discuss their weekends as they make teas and coffees and affectionate laughter fills the air when one regular, who’s famed for her poor timekeeping, comes in 10 minutes after the official start time.
But the discussion moves quickly and easily to their traumatic experiences. Five out of the seven women present have experienced domestic abuse. They talk about drug use as a way to cope with pain, often hiding it behind closed doors and even from friends and family.
Zoe had a “brilliant childhood”. Her father struggled with heroin and crack addiction so wasn’t around much but her mum was her “rock”. When she was 19 she took her newborn daughter to visit her father. While the baby slept upstairs her dad took out his crack pipe, took a hit, then offered it to her. She accepted because “I was trying to get my dad to be a dad to me”. She thought nothing more of it, but, following a string of abusive relationships and the death of her younger brother, she remembered that feeling of “sweet abyss” and turned back to it. Her use escalated quickly.
When her mum started deputising for Zoe at the school gate, social services began enquiring about Zoe’s health. They advised her to go to Addaction to seek support but at first she refused because she was worried about losing her children. When discussing potential barriers to accessing treatment this anxiety looms large for the women in the group. They understand that social workers have a duty of care towards their children and that in some cases the best course of action is to remove them from potentially traumatic situations. Some also say that the threat of losing their children was critical in motivating them to make a change. But there’s also a sense that social workers sometimes don’t understand how hard it is to leave drugs behind — that it’s a messy process, with lots of ups and downs. Both Zoe and Dani have relapsed several times. Southgate says this is to be expected. “A good trauma informed service recognises that a journey is not always a straight line”.
But are women less likely to access services in the first place? The prevailing wisdom in the media is yes. This is supported by official statistics for 2017/18 which state that 140,202 men accessed treatment for drug use compared to 52,401 women, meaning men make up 73% of the treatment population. The general consensus is men are twice as likely to take drugs and are therefore more likely to access treatment (67% would be representative). However, women make up 24% of the overall number of opiate users yet account for 27% of opiate users in treatment, indicating that female opiate users are actually more likely to access treatment. The issue is more nuanced than it first appears.
Regardless, there’s no doubt many services are dominated by men. Collett O’Connor and Kim Morris run Addaction’s women’s group in Weston-super-Mare. O’Connor says she started the group to help engage some of the service’s most “high risk” female clients. She describes how mixed groups are often male dominated which can be “extremely daunting for women, especially if they’ve never had a positive experience with a man”. Drug using communities are also often small, meaning some women were attending groups and seeing “the same people who were exploiting them”.
Zoe describes how she attended a mixed group and a man stood up and said “I don’t want to hear about if you got raped or beaten up, that shouldn’t be shared here”. The facilitator and other members of the group intervened quickly, but it was enough to prevent Zoe from sharing that day. Dani has had similar experiences and says it makes her “feel very small, like what I have to say isn’t important and I don’t really deserve support. I would never go back to the group again”. Both Dani and Zoe talk of being shamed for their drug use on the “outside”. People telling them they are weak and they “chose to use drugs”. Zoe believes there’s a particular label applied to women who use drugs because “we’re made out to be these goddesses and we aren’t allowed to be down”.
Research shows it can take years for a woman to ask for help but if they don’t receive the right support immediately they are significantly less likely to return. Karen Tyrell from Addaction has worked with people using drugs for more than 20 years. She describes how “walking through the door of a drug service can be a very scary prospect for a woman for lots of reasons. You don’t know anyone there, it might feel intimidating, you’re worried who you might see, or who might see you. You’re worried about your kids. I’ve been visiting drug and alcohol services for a long time and even I sometimes feel a bit nervous when I first walk in the door.”
Dani feels the women’s group has “helped me open up more than ever before. I feel listened to, people understand me, they get what’s happened.” According to Southgate from Agenda, the ability to share and be understood is vital because women who’ve been through abusive relationships are used to an environment that’s very oppressive. “Every word you say, everything you do, is moderated, observed and controlled by somebody else. They’re told ‘there’s nothing for you, no one will believe you’ and they start to internalise that. The power of sharing with others with common experience, that collective conscience, can help a woman regain her identity”.
But she also argues that running a properly gender and trauma informed service is about more than “putting women in a room together. It’s as much about how you run a service, the governance arrangements and the overall strategic approach, as it is about the day-to-day and the environment.” If a service were to hold a women’s group in one room, while allowing men with a history of domestic violence to be elsewhere in the building, the group wouldn’t adhere to gender and trauma principles.
O’Connor says the power of the women’s group is that the women own it, “we really want them to feel that it’s theirs and they can do more or less what they want within our co-produced guidelines.” She encourages them to “be honest, truthful and challenge each other. They’re going to take advice and criticism better from each other than from any key worker because it’s real”. Sitting in on the group, this ethos comes through strongly. The women lead the discussion, good news stories are cheered but they also sensitively challenge each other on their behaviour, with their advice steeped in genuine experience. Many have also developed close friendships and talk of calling each other up in the middle of the night when they’re struggling.
Fostering this kind of atmosphere isn’t easy. It’s the skill of the practitioner to create a safe, non-judgemental environment, allowing women to speak freely without fear of recrimination. Dani says this comes down to “trust”. She has shared things in the group which she hasn’t even told her key worker because she knows it’s confidential and she won’t be judged.
But practitioners also need to tread a thin line. O’Connor says many of the women she’s worked with “haven’t had any positive experiences with authority figures”, meaning it can take time and patience to develop trusting relationships. She doesn’t push people to talk if they’re hesitant as this may prompt resistance, damaging the woman’s trust in the group. There’s also a danger that allowing women to challenge each other can spill into real conflict, which can be triggering. O’Connor and Morris take on the traditional mediator role, stepping in if they think things may get heated but in the main taking a back seat. Encouraging the women to be “honest and truthful” with each other is “a really appropriate way to learn boundaries”, O’Connor says.
O’Connor also acknowledges that “one women’s group a week isn’t enough” and that she would like to see more female only services. But at the same time she believes it’s important the women “have the opportunity to mix with men if they would like to”. She worries that completely separating them may “add to their anxiety, reiterating all their fears through promoting difference”. Dani agrees, having been in a violent marriage since the age of 16 she feels she needs to “build that trust with men again. I need to realise that everyone isn’t the same, as hard as that is”.
Agenda’s 2016 study, Mapping the Maze, found over half of local authority areas in England and over three quarters in Wales don’t offer any female only substance use services. The report cites cuts to local authority budgets as a key reason for this lack of provision as specialist services, like female only support, often fall outside the core service a local authority has to offer. At the same time research shows that female substance users experience a worse quality of life than their male counterparts both before and after treatment and female drug deaths are rising at a faster rate than male drug deaths. As Ian Hamilton, substance use researcher at the University of York, said, “the absence of support often ends in tragedy”.
Southgate argues that female drug deaths haven’t touched the public consciousness in the way they deserve. She believes more needs to be done to raise “people’s empathy and awareness” of the issue through giving people with lived experience the opportunity to “share a side of themselves and their human story in a way that makes people’s attitudes shift”.
As Dani says of her friend Zoe, “yes she has issues, but as soon as you meet her you can tell she’s a good person and loves her kids. At the end of the day she’s here out of choice. She’s trying and that’s all you can ask”.
If you or someone you love needs help or support, reach out. You can chat to a trained advisor at addaction.org.uk.