The role of social mechanisms of change in women’s addiction recovery trajectories

Abstract

Recovery from substance use addiction is a socially mediated process, with the formation of pro-social networks and engagement in community resources acting as catalysts for growth and change. Gender is a key mediator in pathways into and out of substance use, however literature that considers gender dimensions within the recovery paradigm is limited. This paper presents a secondary analysis of two qualitative studies undertaken with nine women in recovery—recruited based on their engagement with community support services. Thematic analysis of the women’s narratives elucidates the role of social mechanisms in the recovery processes of women who are accessing community support, in order to inform progressive policy change that better acknowledges, understands and enhances women’s experience of recovery. Based on the emergent themes of trauma; intimate relationships; social networks; and identity, we consider practical implications for community based recovery support.

Keywords:

• Addiction
• recovery
• women

Introduction

Contemporary understandings of recovery are progressively holistic in their nature and research has begun to acknowledge the social mechanisms of recovery initiation, maintenance and growth (Bathish et al., 2017; Best, Beckwith, et al., 2015). Borkman et al. (2016) for example have developed an experiential definition of recovery which acknowledges that although an aspect of recovery-orientated lifestyles may involve living a life free from substance use, recovery can more broadly be understood to be a process of growth and learning which includes evidence of moral values, self-awareness and responsibility. Recovery has been found to provide an opportunity for improvement in a variety of life domains including enhanced wellbeing (Laudet, 2011), higher rates of employment and volunteering (Best, Albertson, et al., 2015), and closer relationships (Veseth et al., 2019). The influence of social networks has been established as strongly associated with recovery onset and maintenance: for example, social networks that are characterised as supportive of recovery as opposed to supportive of substance use, and increased contact with people who are also in recovery, is known to lead to improvements in quality of life and recovery prospects (Best et al., 2012; Longabaugh et al., 2010; Martinelli et al., 2021; Mawson et al., 2015).

However, the social factors which affect and shape experiences of recovery from addiction have yet to be fully understood within the gendered context. This is despite what is already known about important differences between how men and women experience recovery. Women are more likely to enter treatment indirectly, via mental health services and the child welfare system (Grella et al., 2008) and in a vicious cycle, women who have had children removed from their care report disadvantaged social networks and low support (Kenny & Barrington, 2018): further distancing women from the resources identified as being supportive of recovery. This is likely exacerbated by experiences of stigmatisation, which can create barriers to recovery for women (Lee & Boeri, 2017; Neale et al., 2007), and the intersectional nature of gender as impacting upon, and being impacted by, marginalising factors can entrench this problem (Gunn & Canada, 2015).

Despite what is known about differential experiences of recovery by gender, it is argued that there remains a gap between policy and practice. The latest Alcohol Strategy (HM Government, 2012) and Drug Strategy (HM Government, 2017) note the importance of supporting recovery, and whilst both strategies recognise that recovery encompasses much more than abstinence, there has been limited focus on the gendered implications of addiction and recovery to date (Andersson et al., 2020; Wincup, 2016, 2019).

Although there has been a noted growth in women-only services or supports which are responsive to the needs of women, including support with childcare and dealing with past experiences of trauma (Day et al., 2018; Neale et al., 2018; Radcliffe et al., 2019), there likely remains a ‘dark figure’ for women suffering from addiction. Some women are reluctant to access support because of factors such as stigmatisation (Hammarlund et al., 2018), or fear of having their children removed from their care (Becker & Duffy, 2002; Covington, 2002; Wincup, 2016).

The complexity and extent of the impact of experiencing addiction on women’s social networks, families and relationships is likely to be multifaceted and interconnected, in ways that are specific to those identifying as female and associating with related gender norms and roles. Given the evidenced importance of relational support, social networks and identity to recovery as outlined by existing literature (Angulski et al., 2018; Best, Beckwith, et al., 2015; Hall, 2019; Wyse et al., 2014), and the potential intersecting barriers women face with regards to enhancing these variables, this research examines these social factors in association with women’s recovery from addiction. By better understanding these social mechanisms of addiction recovery through a gendered lens, the current paper seeks to address lacunae in the current understanding of the gendered nature of recovery trajectories, and thus make a contribution to the evidence-base for policy and practice.

Understanding the role of relationships in recovery for women

A variety of relationship types can impact, and be impacted by, addiction and recovery. Although not specifying by gender, research has established that the quality of a relationship is positively associated with reduced substance use, for example being in a committed relationship is associated with reduced binge drinking (Angulski et al., 2018). Research has also found that consistent relationship status over time was negatively associated with substance use (Angulski et al., 2018).

Further qualitative research highlights that strong interpersonal relationships for a sample of 15 (nine men and six women) have also been shown to help support and sustain recovery (Stokes et al., 2018), and marital relationships have been found to improve mental health generally for men and women (Simon & Barrett, 2010) and are associated with reduced substance use (Simmons et al., 2009). People or groups perceived by research participants as being important have also been acknowledged as a trigger for recovery (Dingle et al., 2015), demonstrating the capacity for positive relationships to encourage positive recovery-orientated change. For women, although research has demonstrated the importance of healthy and supportive relationships: substance use can cause fragility to networks, and network members can both provide vital support and pose potential relapse triggers simultaneously (Francis et al., 2020). Peer relations can also perpetuate stigma through intragroup tension, developed when comparative judgements are made by women whose sense of self is constrained by societal expectations of their gender role (Gunn & Canada, 2015).

A lack of healthy relationships or experiences of trauma are features often present in the narratives of women who have experienced addiction (Covington, 2002; Meulewaeter et al., 2019). As Covington (2002) explains, experiences of trauma expand beyond the suffering of direct violence to also include the witnessing of violence and the stigmatisation of these experiences, with women at a greater risk of experiencing harm from a partner or loved one. Experiences of trauma are known to co-occur with addiction (Covington, 2008; Devries et al., 2014; Meulewaeter et al., 2019), suggesting there are structural and internal factors affecting access to positive social networks (Best et al., 2021). It has also been acknowledged that women are more at risk of experiencing mental ill-health as a result of an intimate relationship break-up than men, and partner strain in young adults’ relationships is associated with greater substance use for women, supporting the notion that intimate relationships can indeed present risks if characterised by inconsistency and strain (Simon & Barrett, 2010). Intimate relationships for people who are in the early stages of recovery are often therefore discouraged in practice: clinicians have been known to warn people in recovery away from relationships—with an article by one clinician even providing the acronym Real Exciting Love Affair Turns Into Outrageous Nightmare—Sobriety Hangs In Peril (Duffy, 2011).

Although social support can enhance recovery there are therefore a number of caveats, limitations and barriers that can affect its availability. People who use substances disproportionately enter intimate relationships with one another despite such relationships often being detrimental to recovery (Cavacuiti, 2004). The UK Life in Recovery survey (Best, Albertson, et al., 2015) found female respondents more likely to be single, divorced or separated (31.4% compared to 20% of men); to be victims of domestic abuse (8.6% compared to 4.9% of men); have lost custody of a child (6.4% compared to 1.5%); and to be receiving support for emotional and psychological problems (45.6% compared to 29.8% of men). Such research suggests that overall, women face issues including isolation, abuse and disadvantage—each of which can act as a barrier to recovery-enhancing factors such as positive and healthy relationships.

Relationships have been cited as influential in the recovery trajectory, with women attributing drug use, relapses and offending to intimate relationships (Leverentz, 2006; Light et al., 2013). It is salutary to recognise that women who use substances and offend, more consistently associate their offending with drug taking than men, and more women who are incarcerated are drug users (Light et al., 2013). Regarding this relational influence it should be noted that women’s experiences of intimate relationships with men who may be attempting to desist can increase their proximity to and even involvement in violence and crime (Laub & Sampson, 2003, p. 46). If vulnerable and disadvantaged when entering into a relationship with a man who uses substances/commits crime therefore, women are more likely to be negatively impacted by this. If a couple can redefine itself however, (e.g. both in recovery) this can have positive long-term effects (Leverentz, 2006): intimate relationships can therefore act as powerful pivotal points for women in recovery, with either positive or detrimental results dependent on their life experiences and resource access.

Similarly, familial relationships can be both positively and negatively influential when it comes to women’s recovery, although it can be complicated to establish the effect of family for women with addiction histories as they are more likely to have family members who use drugs (Gunn & Canada, 2015), a known risk-factor for lapse and relapse (Dingle et al., 2015). For females, relapse is associated with living apart from one’s children, poor psychological health and problematic relationships (Grella et al., 2008). Parenting may also act as a disincentive for women to access treatment due to perceived risks of loss of parental responsibility (Becker & Duffy, 2002; Covington, 2002; Wincup, 2016). Despite this, if women do enter treatment, parenting can act as a strong incentive to engage positively within the recovery process, motivated by the desire to feel like a good parent (Best, Albertson, et al., 2015; Radcliffe et al., 2019). The experience of being a mother can therefore be motivational for women in recovery but may also exert role-strain for mothers experiencing addiction which could put pressure on recovery progress. This research therefore considers the role of intimate and familial relationships for women in recovery.

Identity, social networks and socio-structural context: navigating the self in recovery

The influence of social relations can also catalyse internal change. Belonging to pro-social support networks to promote recovery is supported by social identity theory, which posits that in a range of social contexts our sense of self is derived from our membership in certain groups, and that the resulting identities can structure and change a person’s perceptions and behaviour (Dingle et al., 2015; Haslam, 2014; Tajfel & Turner, 1979). The Social Identity Model of Recovery (SIMOR) (Best, Beckwith, et al., 2015) has synthesised existing social identity literature from the recovery field, and argues that recovery is a socially negotiated process which emerges through processes of social learning and control, and can therefore be spread through social networks. The importance of recovery-supportive social networks for women is clear from this perspective: the contagion of hope and access to positive resources that recovery-supportive groups can provide are fundamental to women who are stigmatised and disadvantaged.

It is important to consider the potential identity-related barriers gender may create however: layers of disadvantage can also reduce women’s access to positive social networks (Francis et al., 2020; Gunn & Canada, 2015). Patriarchal social constructions around women and their roles can also create barriers—the ‘good mother’ is the term used to describe the socially idealised identity for women (Gunn & Canada, 2015; Peterson, 2018) which may in fact further restrict women in their recovery (Radcliffe, 2011), particularly in early recovery. Focusing on oneself juxtaposes against the socially idealised conception of a mother and their role, leaving the potential for stigma perceptions to be exacerbated: the representation of women as a moral compass and foundation for the family (Nelson-Zlupko et al., 1995) can mean that women feel criticised for their circumstances and held responsible for children's wellbeing (Jackson & Mannix, 2004).

Research concerning women’s perceptions of stigmatisation who attend Narcotics Anonymous’, found that 60% felt that women with addictions are perceived as dishonest and 40% felt they are perceived as bad mothers (Sanders, 2014). The stigmatised figure of substance using mothers can present women with the challenge of managing a spoiled identity (Goffman, 1963). With phrases such as ‘slut, lush or bad mothers’ (Covington, 2002, p. 2) being associated with substance using women, males do not encounter the same level of shame which casts shadow on his competence as a parent: the societal stigma attached to women who use substances produces greater levels of shame and guilt (Wincup, 2019) and can act as a barrier to seeking support (Cloud, 1987). Women who feel they represent stability for their families can therefore encounter greater societal pressures and can cite the use of substances as a way of reducing, or numbing this experience (Nelson-Zlupko et al., 1995). Radcliffe (2009) identifies however that becoming pregnant can be an opportunity for drug-using women to engage with treatment services and to turn their lives around: ‘motherhood can be transformative’ (Radcliffe, 2009, p. 21). In spite of a higher percentage of females being more likely to have lost custody of a child (6.4% compared to 1.5% of men), females are also more likely to regain custody of a child upon gaining recovery status (16.5% compared to 8.1% of men) (Best, Albertson, et al., 2015), suggesting a complex interaction between motherhood and recovery which is susceptible to a number of variables.

Experience of incarceration can also create a further stigmatic barrier for women who have experienced addiction and are trying to recover (Gunn & Canada, 2015; Moore et al., 2020; Van Olphen et al., 2009), as does the association of sex work which also intersects with gender and drug use, further compounding the stigmatised identity of women who are addicted (Gunn & Canada, 2015; Wincup, 2019). Strongly identifying with marginalised groups could also increase perceptions of stigmatisation (Wolff & Draine, 2004), as identifying generally to groups of people who are negatively targeted by the media and society has the potential to strengthen in-group solidarity and consequently reduce access to external resources (bridging capital) (Chapman & Murray, 2015). It is therefore important to better understand social contexts and their influence on identity for women in order to better support their recovery progress in practice.

Methods

The current paper reports on a secondary analysis of two pre-existing data sets. Secondary analysis involves the analysis of data previously collected to develop new scientific or methodological understanding (Cheng & Phillips, 2014; Szabo & Strang, 1997). The existing mixed-methods data sets—collected for two doctorates (Hall, 2019; Collinson, 2021) - involved participants completing interviews and REC-CAPs (a measure of recovery capital) (Best et al., 2016; see also Best et al., 2017; Cano et al., 2017). As the original data was anonymised, the interviews and REC-CAP data could not be matched and therefore could not be analysed collectively for the current paper. Owing to this and to better understand the lived experience social mechanisms of recovery, the qualitative interviews are analysed alone within this paper. Within this section the rationale for merging the two qualitative data sets for the context of the current paper will be further elucidated.

The qualitative data presented consists of face-to-face interviews with women (Collinson, 2021, n = 3; Hall, 2019, n = 6) in addiction recovery. Across the two original doctoral studies, qualitative data was also collected from 24 males. The analysis of female data only in the current project allows the researchers to examine the social experiences of women specifically and to analyse the transcripts through a gendered lens, adding to the growing female specific body of knowledge regarding women and their recovery processes. Similarly to how recovery is defined in the current paper (Borkman et al., 2016), there was no prescribed definition of recovery dictating inclusion in the research: the length in which an individual had been in recovery did not determine involvement in the research.

Women were recruited from four mixed-gender community support services across England with interviews carried out in private, on site. Table 1 below outlines key characteristics of those within the cohort. Whilst the two female researchers conducted the original studies independently, they had both previously spent time at all four of the community support services. This is important for the current paper, as it meant both researchers were familiar with the context in which the interviews were carried out and in which support was provided to women in the sample. Time was spent by the researchers building rapport with the community support services before interviews were conducted. Examples of engagement from both researchers across the research settings included attending mutual aid meetings, having informal conversations over coffee and participating in boxing classes. In line with feminist methodologies, spending time with the women prior to interviews sought to minimise any hierarchical relationship. Both researchers reflected on how these relationships were formed based on informality, rapport and empathy—concepts identified by Gilbert (2001) as being critical to feminist research.

During the semi-structured interviews, chosen for their ability to facilitate ‘fluid encounters’ (Cotterill, 1992, p. 604) and document life narratives (Saldaña, 2011), women disclosed personal topics such as bereavement, intimate relationships, violence and criminal activity of their own accord, reflecting the level of trust built between the researchers and those within the cohort. The researchers depended on one another for professional support throughout the data collection process—often debriefing with one another after interviews were conducted. Such support, described within existing literature as a ‘community of coping’ (Korczynski, 2003, p. 58; Waters et al., 2020, p. 8) was important considering the emotional dimensions associated with social feminist research (Blackman, 2007).

The secondary analysis of qualitative data is less well established than quantitative data (Long-Sutehall et al., 2012). This could be attributed to issues related to confidentiality (Corti et al., 2000; Heaton, 2004) and the importance of the context in which qualitative data is collected in (Owens et al., 2016). Data from both of the original projects utilised for this paper focused on the social mechanisms of recovery, with both interview schedules covering aspects of the women’s life narratives, social networks and relationships and recovery and community based support.

Due to the sensitive nature of the research, strict ethical procedures were implemented and adhered to within the original projects. Ethical approval for both projects were passed by the same ethics committee (Sheffield Hallam University) and adhered to both the universities research ethics policy (Sheffield Hallam University Research Ethics, n.d.) and the British Society of Criminology’s Code of Ethics (n.d.). This minimises any ethically associated criticism of the secondary analysis of qualitative data (Ruggiano & Perry, 2019). Women were informed of the aim of the studies and provided with information sheets prior to consenting to participate. As the audio transcripts were anonymised and any personal identifiers were removed, participants’ identities remained anonymous for the secondary analysis to be conducted, with pseudonym names given (see Table 1). The original information sheets outlined that the data may be used for other research purposes, so consent was upheld for the current paper.

Table 1. Key characteristics of the nine women in the cohort.

Name	Age	Ethnicity	Living with who	In recovery from (alcohol and/ or other substances)	City in which service was located
Roselia	47	White British	Friend	Alcohol and other substances	City 1
Fran	54	White British	Alone	Alcohol	City 1
Christine	48	White British	Son	Alcohol	City 1
Katie	33	White British	Alone	Alcohol and other substances	City 1
Megan	46	White British	Daughter	Other substances	City 2
Lucy	25	White British	Mother	Alcohol	City 2
Alexandre	46	White British	Unknown	Alcohol	City 3
Neave	46	White British	Unknown	Alcohol and other substances	City 3
Laura	48	White British	Alone	Alcohol and other substances	City 3

The secondary analysis undertaken for the current paper was conducted by the same female researchers who undertook the original data collection. Due to these similarities and the explorative nature of qualitative research (Turk & Kalarchian, 2014), this contributed to the rationale for merging the two data sets. The reworking of qualitative data has been acknowledged to hold particular advantage when it captures the views and experiences of marginalised populations (Smith, 2006) and the research topic is of a sensitive nature (Long-Sutehall et al., 2012)—two criteria the current paper meets. The secondary analysis of qualitative data has been criticised previously when it is collected and re-analysed in different time periods (Ruggiano & Perry, 2019), however the original projects were conducted simultaneously between 2016 and 2019, limiting any differences in the socio-cultural and political context in which the research was conducted. Both researchers also defined recovery within their independent projects as being an experiential process and acknowledged the importance of the social mechanisms of change to aid recovery.

There are notable limitations associated with secondary data analysis however, as such the combination of the two data sets—both with different interview schedules—(Hall, 2019; Collinson, 2021) is a drawback of the current study. Furthermore, the small sample size (n = 9) and lack of diversity across the ethnicity of the cohort limits the generalisability of the findings. Although the sample included women who used both alcohol and/or other substances, future research may wish to explore the social mechanisms of recovery for each of these two subgroups (alcohol or other substances) independently to identify whether differences exist. The current sample was too small to draw any conclusions in this regard and whilst women were recruited from four different mixed-gender community support services, findings cannot be generalised across other treatment settings (e.g. residential rehab or female-only services). The women’s processes of service selection may also have implications for the sample characteristics for this research, due to their historical lived experiences and the impact this may have on their service engagement choices. Although steps have therefore been taken to maximise the validity and reliability of the secondary analysis, limitations remain which should be considered.

Analysis

Verbatim interview transcripts were analysed thematically (Braun & Clarke, 2006) using NVivo 11. The original coding framework – influenced by Hall’s (2019) doctoral research—was structured around the social mechanisms of recovery (relationships, identity, social networks and group membership, and social capital) but it was also important to acknowledge the individuality of each woman’s narrative and the context within which these mechanisms functioned. The researchers therefore approached the coding with flexibility, being open to new codes emerging from the data.

The researchers analysed the data independently, meeting frequently throughout to discuss key emerging findings. Once the initial analysis was complete, the researchers met to cross-reference their analysis and explore any disparities. The researchers then discussed the interaction and relationship between codes before agreeing on the final themes: trauma; relationships; social networks; and identity.

Results

Trauma: abuse and violent histories

It is important to acknowledge the contexts which have shaped the women’s substance use and their recovery journeys, due to the capacity these experiences have to present barriers to recovery and socially supportive resources. Three different forms of violence and abuse were mentioned across the interviews: intimate partner violence, child sexual abuse and domestic violence. Four women disclosed experiencing intimate partner violence but none of these women were currently with their perpetrators that they disclosed. This violence was experienced whilst the women were using, and the perpetrators were also users: ‘[Partner] went on coke, and from him being on coke, he battered me every day’ [Katie]. Partners were also sometimes implicated in substance use onset: ‘He was a druggie as well. That's why he introduced me into weed (…) if I didn't roll him one for when he come in from work, eruption’ [Christine].

Three women disclosed witnessing violence within their families growing up, most commonly between their parents, and one woman experienced sexual abuse as a child. Women often reported suffering the consequences of these experiences throughout their life narratives. For some women, using substances was a means to help cope with their trauma and this also influenced their experience within treatment and support, with some reporting not feeling comfortable in mixed gender groups:

‘In therapy (…) there was men as well as women and then we were living like in the same houses as them and some of the men were really arrogant and I started finding it really hard to talk about stuff. About all the abuse that I put up with. It made me feel uncomfortable because some of the men were really arrogant and would sit there laughing in the group.’ [Roselia]

Whilst not all women discussed previous trauma, this had a significant impact for those who did. When considering the social mechanisms of recovery for women, policy and practice must be gender-sensitive—showing awareness of the past experiences of women entering recovery and the gender-specific barriers this can create.

Influential relationships: intimate relationships in recovery

Several women discussed their previous intimate relationship(s), but this was often in light of their substance use as opposed to their recovery. Relationships were frequently described as ‘unhealthy’ and were recognised as a contributing factor to their substance use, with women often using substances in the context or the company of their partner: ‘I met a guy and he was a drinker (…) So like a really bad concoction (…) He were a drinker, I were a drinker and the weeds, well, weeds, coke, everything at a point’. [Katie]

Two women who had experienced the death of a partner discussed their substance use as a means to cope with the grief: ‘Their dad’s got cancer and having to deal with that and my children grieving as well. That’s why I ended up turning to drink more’ [Roselia]; ‘It was after he passed away I got addicted to heroin (…) My first husband died of cancer when he was 38 so, I was 34′ [Laura].

Megan and Fran however attributed intimate relationships as being conducive to their recovery. Megan’s partner was in recovery from mental ill-health and the relationship was perceived to be positive as both individuals were experiencing a period of change and growth:

‘The relationship with my partner is great. He's not a drug user but he is a bit of a drinker but we both have personality disorder and I think that has been really good because he has spent a long time getting to grips with his personality disorder.’ [Megan]

For Fran, starting to date again whilst in recovery helped her to feel empowered. However, Fran later discussed how she had refrained from entering into relationships which she thought may be detrimental to her own recovery, demonstrating her agency in a recovery-supportive manner:

‘I've had a couple of sexual relationships that have been good for me in some ways, because I felt like it was important that I get out there again and I've actually thought I'm not that bothered you know (laughter) but that was good for me confidence-wise.’ [Fran]

The juxtaposition of intimate relationships as having the potential to be both detrimental to recovery due to their promotion and normalization of substance use; and supportive of recovery through the support and sense of agency provided, speaks to the importance of relational quality to recovery for women.

Social networks: network change, peer support and identity formation

Upon entering recovery, women discussed disassociating themselves from their using peers. As described by Laura ‘I stay away from places I know other users hang around’. This was not always easy however. For women entrenched in using and deviant networks, moving away from these peers was challenging, highlighting the need for community support services as a means to form new pro-social networks: ‘The problem I have is all my friends out of recovery they are users or dealers. And they’re all like friends for years and years and years. So I find it hard to like get rid of them’ [Katie].

That said, there was a noted shift between active addiction and recovery, with women exerting increasing agency and demonstrating a sense of awareness of their social network. Women were empowered to overcome structural disadvantage by making conscious decisions regarding who to ‘let in’ their newly forming pro-social network. As summarised by Fran:

I've made a couple of really good friendships through here. I am still very careful about my relationships I think and I've actually pulled back from a friendship that I made here, quite consciously. Which is something I've not really ever done in the past (…) Making friends with some of the people here and keeping away from some of the people here as well has also been quite empowering, if that makes any sense. People that you think “Well I don’t want to be friends with you”. [Fran]

Many discussed the formation of women-focused networks, often supported and nurtured through engagement with recovery services. Whilst there was a sense of shared experiences between women, these networks were more than a form of peer support. Women detailed building lasting friendships and frequently socialised outside of the recovery service:

One of the best friendships I've made here, she goes to AA and so I have been to a couple of meetings with her but it’s been, to be honest, it’s been more of a kind of social thing, come over, we’ll go to a meeting and then have a sleepover (laughter). [Fran];

I've become quite good friends with her. She came on the Llandudno trip and we are actually booking a holiday [together]. [Roselia]

The nature of these friendships demonstrates that whilst recovery becomes an aspect of the women’s lives, it is not the entire focus; with wider engagement with new peers and activities not immediately associated with recovery also holding importance. One woman described how ‘giving up the drugs just takes you to the base of the mountain and then you've got the rest of the mountain to climb to actually get you to where you need to be’ [Megan], with engagement in wider activities helping to maximise opportunities for lifestyle change: ‘[Recovery] helped me getting a job. Employment, changing my life as well, changing my lifestyle’ [Alexandre].

It was however important for women to feel a sense of membership with the groups they attended, and not feeling stigmatised was fundamental to membership growth and personal development: ‘I just talk and it doesn't matter they don’t judge me, no one judges and it makes me feel good’ [Christine]. As women gained stability in their recovery journeys and gained confidence, they aspired to take control of their lives and develop a sense of ownership through wanting to try new things and becoming engaged in the wider community:

Things have been really, really good actually this year. I feel like I've done a lot. I've increased my days at work (…) and then at the end of April I applied for another temporary job, which was like a freelance job, because I just really fancied it. It was a volunteer coordinator job [Fran].

Engaging with recovery-orientated networks and community supports, during which members shared experiences, resulted in the women beginning to form new identities which incorporated their ‘recovering self’. Women reported stigmatic barriers to embracing recovery however, such as feeling judged by others:

I was working in a café (…) and there was just really judgmental people coming in, they were calling them junkies and homeless people (…) just being really judgmental, I always thought like living two lives, because I didn't wanna – I couldn't open up. [Neave]

Women discussed how this experience of stigma impacted upon their self-worth and self-esteem: ‘Until that point I just thought (…) it's your fault, you're a bad person, you're useless, you're not worthy of being on this planet’ [Megan]. This stigma then acted as a barrier to positive recovery identity formation:

All these things keep you in addiction, it's not just the withdrawals (…) it's the stigma and, you know, a lot of stuff that you put on yourself and when you get to a point where you accept that, yes, you have done some bad things in your life but that does not necessarily make you a bad person and the fact that you absolutely cannot change anything that has been done, all you can do is change what you're going to do. [Megan]

Motherhood and recovery: identity, relational impact and trust

The impact of motherhood on substance use and on recovery varied for women, but two clear subthemes emerged with motherhood (a) creating role strain and conflict or (b) being motivational for recovery. Women often reported feelings of shame and guilt which were associated with the role strain of being a mother, with these feelings amplified whilst women were using:

When I did sort of stop drinking and I answered the phone, she [daughter] was furious with me (…) she just said ‘I am going to have to give up uni and come back home and look after you’ and that was a horrifying thought to me that she would do that. It made me really ashamed and I've been ashamed of things in the past but that somehow seemed worse. [Fran]

One woman described how: ‘He [son] used to say “you’re horrible mum” because I was drinking’ [Christine], exemplifying the impact damaged familial relations can have on self-esteem. Role conflict was also evident, with women torn between motherhood, substance use and the two seemingly incompatible identities battling to take precedence. Whilst women were using, they were perceived to be ‘bad’ or ‘incompetent’ mothers and faced external pressures to refrain from substance use from formal figures: ‘The solicitors kept telling me to stop, “You need to stop drinking now or you're not going to have no contact with your children” and so that really frightened me’ [Roselia]; and from informal relations such as family: ‘I was completely pissed as a fart the whole time and I think that my daughters said to my brother “We can’t cope” (…) I was just oblivious to all this because all I really cared about was drinking’ [Fran]; ‘My brother (…) He's got no responsibilities, so in his eyes he's like it's simple, just stop (…) It's like, "Look how you turned out. That is what's gonna happen to your children”’ [Katie].

For some, motherhood acted as a motivation to both initiate recovery—‘When people say, “What made you change?” I think my daughter made me fight through it’ [Neave]—and sustain recovery, due to being aware of the potential consequences if they were to use again—‘I know the consequences because if I picked up again, my daughter, because she’s got special guardianship, she can actually stop me from seeing the boys and I ain’t risking that’ [Roselia].

Trust also emerged as a theme throughout—with women feeling an increased sense of trust, particularly regarding their familial relationships, and this supported their senses of self-worth. The acknowledgement of doing well in recovery was also an important factor: ‘Hearing my boys actually saying that they are proud of me, that I'm doing so well’ [Roselia] and ‘She wasn’t even going to stay [at university] because of me (…) it’s [my proudest achievement] being able to say to my daughter “Stop worrying about that money. I've got it covered”’ [Fran]. These changes attributed to recovery may help women to manage feelings of shame and guilt previously noted and whilst there may still be some conflict between the roles of ‘mother’ and ‘person in recovery’, this conflict is reduced by the women who begin to successfully amalgamate the two identities.

For others, motherhood presented its challenges and there was a perceived expectation that women would prioritise their child over themselves. This pressure takes the focus away from the woman herself and may even be detrimental to recovery, hindering the individual’s ability to prioritise themselves, their recovery and their own wellbeing:

It’s like people tell you to be selfish in recovery, put yourself first, but what they don't realize is when you got two kids though who want their mum, you can't help but put them first, do you know what I mean? [Katie]

It is important to consider therefore that although recovery was an important aspect of the women’s identities, it was framed by women in this research as a component of their identity alongside other important identity-related variables, such as identity agency and space to redefine their sense of self outside of structural patriarchal constraints associated with their role as a mother.

Women also reported feelings of stigmatization associated explicitly with being ‘socially undesirable’ mothers: ‘Being a parent when you're young is a really bad thing’ [Lucy] which resultantly impacted on an individual’s perception of their self and self-worth. Such stigmatisation was reported as a barrier to seeking support: ‘That's why a lot of women can't do it [access support] (…) people say they’re shocking as mothers. They keep that behind closed doors. They don't ask for help.’ [Katie]

Discussion: the role of the social mechanisms of change for women

The emergent themes aligned with existing literature regarding the social aspects of the recovery process, with several nuances influenced by the gendered lens applied during the analysis. The first theme of ‘trauma: abuse and violent histories’ is of vital contextual relevance to understanding the socially mediated recovery trajectory for women. Four women discussed experiencing intimate partner violence, three women witnessed domestic violence and one experienced sexual abuse as a child. This supports research which highlights the co-occurrence of experiences of trauma and addiction, commonly experienced by women (Covington, 2002, 2008; Devries et al., 2014). This resulted in some women discussing their discomfort in mixed gender groups, highlighting the potential for women to experience gender-specific barriers to recovery due to trauma. The growth of gender-specific and gender responsive services can therefore be encouraged in light of this (Agenda, 2017; Andersson et al., 2020; Covington, 2008; Day et al., 2018), however as noted by Neale et al. (2018) and Wincup (2019) women may still benefit from mixed-gender services provided they are gender-sensitive.

Although each woman’s recovery trajectory is unique, the findings have identified commonalities regarding relational influences on recovery, and as supported by existing research (Grella et al., 2008; Leverentz, 2006; Light et al., 2013; Simon & Barrett, 2010) our analysis found that the majority of women in this sample described substance use in association with an intimate partner. The minority of women described experiencing intimate relationships as supportive of sobriety. Those that did, described relationships centred on recovery principles again aligning with literature that posits that recovery is possible for those in intimate relationships in which both partners use substances as long as they commit to change together (Leverentz, 2006).

There was one reference to intimate relationships as enhancing agency promotion in recovery, an important and less discussed experience given the capacity for intimate relationships to have the potential to introduce women to and perpetuate substance use, therefore often reducing a sense of agency. It could be argued given the results presented, and the prevalence of literature which points to the negative influence of relationships on women who use substances (Leverentz, 2006; Light et al., 2013; Wincup, 2019), that women need to be better supported and empowered to gain agency regarding their relational component and its influence on their recovery. Regarding the women’s social networks, disassociation with using peers characterized recovery trajectories: this supports the SIMOR (Best, Beckwith, et al., 2015) and wider research which recognises the value of increased contact with social networks which are supportive of recovery as a means to promote the process and improve quality of life and wellbeing (Best et al., 2012; Longabaugh et al., 2010; Mawson et al., 2015; Meulewaeter et al., 2019).

Challenges were however experienced due to the level of bond between peers, although the knifing off, or relational detachment, process did encourage feelings of empowerment and a sense of control (Maruna & Roy, 2007). This highlights the importance of offering pathways into new community resources to aid the transition from using to non-using social networks. The women’s narratives also revealed the development of supportive friendships with other women in recovery. Interestingly, a key subtheme and a characteristic of these friendships was engagement in activities that were not all explicitly recovery-centric (again supporting the development of a full and well-rounded identity), and supportive of existing literature (Best et al., 2017; Collinson & Best, 2019; Rettie et al., 2020). Friendships based on shared experience were also described as protective against stigma, a key barrier to recovery for women (Gunn & Canada, 2015; Hammarlund et al., 2018; Neale, 2004). Engagement in meaningful activities, including volunteering and employment also increased for the sample upon entry into recovery: supportive of the findings of the Life in Recovery survey (Best, Albertson, et al., 2015).

Arguably the main theme which arose however was concerning identity in recovery, which is intrinsically linked to the discussion of social networks. Framed within social identity theory (Tajfel & Turner, 1979), it is known that our sense of self and resulting identities are formed through our group memberships. Networks which are supportive of recovery are essential to aiding recovery (Best, Albertson, et al., 2015) and help support the shift from a substance using identity to recovery identity (Dingle et al., 2015; Haslam, 2014). Although the women in the current sample discussed the development of a recovering self, stigmatic barriers to feeling proud of this identity were also cited, and it should be considered that this barrier does in fact limit the potential of a recovery identity for women if not overcome. Stigma and structural disadvantage are therefore barriers which must be considered regarding women’s evolving recovery identities, but given the experiences of disadvantage and marginalisation that women with addictions also experience it is perhaps too simplistic to only promote access to recovery-supportive networks as a recovery enhancement mechanism.

Recovery identities were only one aspect in the sample’s experience: recovery helped to catalyse the women’s identity growth and change but following this initiation the women frequently redefined their identity to centre on other aspects of their lives. This is perhaps in contrast to Hall’s (2019) research on male’s recovery/desistance identities in which recovery often becomes the primary social component with which they guide their recovery journeys and structure their lifestyles. The intersections of disadvantage women often experience (Vu et al., 2019) and the social expectations women must juggle with regards to their social identity (Gunn & Canada, 2015) perhaps mean women experience structural limitations which may restrict the development of a primarily recovery-focused identity. It could however be argued that in fact this balance is a healthy approach to the adoption of a recovery identity, due to the multitude of meaningful activities women became engaged in.

In line with the discussion of identity formation, for the mothers within the sample, there was a perceived incompatibility between motherhood, addiction and recovery identities. Whilst motherhood was a motivation for recovery for some, supportive of existing literature (Villegas et al., 2016), this placed role strain on the women whilst in active addiction. If women experienced stigmatisation such as being labelled ‘incompetent’ or ‘bad mothers’ whilst using, this had a lasting impact on the women’s self-esteem.

In the women’s recovery narratives, there was noted evolution of familial relationship quality and trust, highlighting the potential for recovery and family-orientated identities to co-exist with one another. As recovery and motherhood progressed however, the expectation of the ‘good woman’ (Gunn & Canada, 2015; Peterson, 2018) also became more prevalent. If not managed carefully, this exerted additional pressure on women early in recovery. The role of parenting must be acknowledged in both policy and practice to ensure women who are early in recovery can prioritise their own wellbeing to ensure that the emotional energy invested in parenting can be managed in a way which does not hinder recovery progress.

Practical considerations

Whilst the findings presented must be considered in light of the acknowledged limitations, the thematic analysis highlights the importance of the role of social mechanisms of change for women’s recovery trajectories. Awareness of the identified caveats and challenges to promoting the identified social components could therefore be beneficial for services supporting women’s recovery in the community. The results of this paper also support the importance of gender and trauma sensitivity in practice (Agenda, 2017; Andersson et al., 2020; Covington, 2008)—in both community settings and during data collection.

The role of women’s recovery identities are complex, intricately connected to and influenced by multiple social factors, contexts and societal constraints. This research revealed the potentially conflicting impact of patriarchal tropes like the ‘good mother’ in connection to women’s recovery identity formation—the resultant pressure on women to conform and the implications this has for their recovery can be pivotal. Although the influence of motherhood on identity can therefore be transformative it can also cause role conflict. The ultimate development of a well-rounded identity for women in recovery was therefore a key theme in this research, highlighting the positive impact of developing a multi-faceted identity which, whilst being recovery-supportive, does not eclipse other important components of a holistic identity. The support and empowerment of women to act agentically to develop new social networks and become engaged in activities which support the formation of a holistic identity, one which is not solely recovery-orientated, could therefore be of benefit to their recovery trajectory.

In response to these findings, we suggest community based recovery services might consider using the Asset Based Community Engagement (ABCE) framework (Collinson & Best, 2019) as one potential method to support the women who reported an absence of pro-social networks and involvement in such activities, subsequently promoting the development of a balanced identity. ABCE is an evidence-based framework which is intended to support practitioners to identify a service users’ current levels of community engagement and barriers to engagement, whilst also mapping community resources and identifying pathways into these resources. This approach to recovery progression aligns with previous research which recognises the value of engagement in meaningful activities (Best et al., 2017; Cano et al., 2017; Dekkers et al., 2020).

Support provided by practitioners when using the ABCE framework must however be both holistic and person centred (Neale et al., 2015), to enable women to take ownership of their engagement in activities and development of social networks whilst being mindful of their current commitments and social aspects of recovery. As evidenced in recent literature, the provision of alternative activities which are not necessarily recovery-orientated are an important aspect of recovery progress (Rettie et al., 2020).

If used sensitively, the use of the ABCE framework can support women to break down experiences of structural disadvantage and provide opportunities to form and develop pro-social networks. This is supportive of the findings in the current paper which suggest for women the relational social components are more conducive to recovery initiation, maintenance and growth than the formation of identities which are solely recovery-centric. Focusing on women’s relational component and how to enhance it through the application of a recovery-supportive framework such as ABCE would therefore benefit from further research and may ultimately provide appropriate gender-responsive guidance for policy and practice.

Conclusion

The paper elucidates the role of social mechanisms in the recovery processes of women who are accessing community support and does so with the aim of informing progressive policy change that better acknowledges, understands and enhances women’s experience of recovery. Through the secondary analysis of two sets of interviews with women in recovery, key themes emerged pertaining to the social mechanisms of women’s recovery, including the importance of identity formation shaped by engagement in a range of groups/activities outside of recovery-centred support. This was seen as a way to detach from the stigmatisation and marginalisation associated with substance use and recovery, and a means to develop holistic identities. The formation of new friendships (often with other women) were frequently built on foundations of shared experiences—whether that be of addiction, trauma and/or motherhood—but expanded beyond the recovery sphere. Friendships and holistic identities developed also enhanced women’s agency and helped to increase their sense of empowerment. Policy and practice should therefore acknowledge the importance of the relational components of recovery for women, drawing upon practical frameworks such as ABCE (Collinson & Best, 2019) where appropriate to link women in with new meaningful activities, subsequently maximising agency, opportunities for identity development, and relational potential.

Disclosure statement

No potentialconflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Alcohol Change UK (RS 15/03).