Based on two personal interviews, this paper presents the journey of Angelina, a substance-abusing woman, in her pursuit of recovery. Although this paper focuses only on one woman, it provides an indepth and intimate close-up of the world of a substance-abusing woman. Relevant passages of the story are followed with analyses, highlighting key factors and elements to better understand and more effectively help the woman. While quantitative studies often focus on isolated variables, this case study ties relevant variables and creates a holistic and more meaningful picture. The data were part of the data collected for a larger project; the project was approved by the university institutional review board.

Angelina was a 30-year old, two-month pregnant woman attending a residential treatment program. This was her first time receiving substance abuse treatment in her 18 years of drug-use. Prior to this treatment, she had never sought help on her own, nor had any one intervened to help her get treatment. She came to this treatment at her probation officer’s request. He told her to either go to treatment or to prison. She chose treatment although she didn’t really want to be there, but she disliked prison even more. The reason she got involved with the legal system was shoplifting. She stole and sold things to buy cocaine. She said if it weren’t for her probation officer, she would never have gone to treatment.

Analysis:

A substance-abusing woman may never seek treatment if it were not for her involvement with the criminal justice or child welfare systems.

In the past decade, the proportion of women among the total substance abuse treatment admissions nationwide appears to have increased, from 30.1% in 2002, to 31.8% in 2006, and to 33.1% in 2011 (men’s proportions were 69.9%, 68.2%, and 66.9%, respectively; Substance Abuse and Mental Health Services and Administration [1]. Considering that the total number of treatment admissions was around one million and 800 thousand or so, a three percent increase means a more than 50 thousand admissions increase for women from 2002 to 2011. More analysis needs to be conducted to determine whether women have made progress with respect to substance abuse treatment entry and whether women still have reduced access to substance abuse treatment compared to men, as the estimated percentage of men who met the substance use disorder (SUD) criteria seems to have decreased within the past decade (e.g., from 12.8% in 2002 to 12.3% in 2006, and 10.4% in 2011) whereas the trend for women was not as clear (e.g., 6.1% in 2002, 6.3% in 2006, and 5.7% in 2011).

Regardless, researchers have suggested that substance-abusing women are less likely than substance-abusing men to enter treatment [2,3]. Both men and women may encounter barriers to seeking treatment, so it’s important to identify those barriers and facilitate treatment entry [4]. Multiple factors may prevent women from seeking treatment, including stigma, child care responsibilities, a lack of insurance, transportation, perceiving addiction as too powerful, not confident in making changes, not knowing where to get help, and so on [4-7].

The collaboration between the criminal justice system or the child welfare system and substance abuse treatment programs may turn a crisis into an opportunity [7]. Marsh and Smith’s review of empirical studies showed that the integration of the child welfare system and the substance abuse treatment system in the past two decades has made progress with respect to women’s treatment outcomes. However, they suggest continued commitment to the improvement of services for women.

Angelina was a good-looking woman and appeared to be healthy and well groomed. She has been in the program four months. The structured schedules and care of the residential treatment program seemed to have washed off most of the traces of those chaotic years of drug use. However, she appeared to be sullen and was silent most of the time; sometimes, she had a hard time concentrating or memorizing things.

Analysis:

A residential treatment program can help stabilize a woman’s life.

American Society of Addictions Medicine Mee-Lee suggests that clients should be placed and treated at the least restrictive setting [8]. Many lowresource women who live in a high-risk environment (e.g., homelessness, poverty, domestic violence, and drug-infested neighborhood), however, may benefit from residential treatment programs. Studies have found that substance-abusing women who receive residential treatment have better treatment outcomes than their counterparts who receive intensive or regular outpatient treatment [9,10]. It is important to continuously monitor and evaluate the needs and situation of a woman and adjust the level of placement thereafter [8].

Her sadness may be related to her upcoming court hearing where her parental rights could be severed. “Permanently,” she said, with tears in her eyes. She explained: she has used up all the time the Child Protective Services (CPS) can give her for reunification. The law allows parents 12 to 15 months to be reunited with their children and if this is not done, the child will be adopted permanently by someone else. She stated that either the workers did not explain the process (time limitation) clearly to her or she must have not paid enough attention to what they told her, but she was not aware of this consequence. Worse was that her children, a six-year, a four-year, and a two-year old who were currently in foster care, will be permanently adopted by strangers if she loses the parental rights. Both her mother and brother were using drugs, and she lost contact with the children’s father. No one among her relatives or acquaintances could adopt her children. She was upset with the treatment program for not recommending her for release, which will have a negative impact on her upcoming hearing. She had been in the program four months, which had exceeded the minimum three-month requirement. However, she said, with a hesitant, soft, yet resentful tone, “The program does not think I am ready.”

Analysis:

The 1997 Adoption and Safe Families Act (ASFA) is very relevant to substance-abusing mothers because of the high likelihood of their involvement with the child welfare system. In general, the overall communications between a mother and her child welfare worker in the system should be improved; specifically, the ASFA needs to be explained to the mothers and have them well informed.

She started using marijuana at the age of 11, with the permission of her parents who were both heroine and cocaine users. At age 12, she was “introduced” by her parents to their drug dealer. She had sex with him, and he provided drugs to her parents, as well as taught her how to do cocaine. She started skipping school and hanging out with friends, doing drugs or going to bed in a cheap motel with the 50 year old drug dealer her parents introduced her to. Her father later left her mother and their children. She encountered a man, a drug dealer again, but a rich one, while she and her mother were looking for a place to stay. She was 16 and became this married man’s mistress. He helped her mother pay all the rent and bills, bought her jewelry and clothes, and provided her with cocaine. He even brought her on a “honeymoon” trip. They had a baby together. She thought she was in love until one day he found out that she left the baby alone with her younger brother and went out “partying” all night. He was in a violent rage and beat her up, took the baby away, and abandoned her. She said although she sometimes may attribute her problems to her parents, she was really not entitled to because, “I shouldn’t blame them . . . . See what I did to my own children!”

Analysis:

It is easy for “mainstream” society to judge a substance-abusing individual (man or woman, especially a mother) to be immoral and irresponsible when it’s dominated by the “free will” theory. The woman may have intense feelings of guilt and self-blame for the negative outcomes she imposed on other people, including her children. However, the “unequal footing” could be the alternative theory. It is crucial that practitioners have the insight that a client’s substance-abusing behavior may be related to her childhood exposure to neglect, abuse, and other family dysfunction [11,12] and that the practitioner helps reduce the guilty feelings of the mother [7]. The genetic component of addiction, the brain disease theory (Volkow, Wang, Fowler, & Tomasi), and the trauma and self- medication theory could also be relevant to the etiology of a client’s addiction and should be shared with the client [13]. In addition, the rates of violence exposure may be high among substanceabusing women; practitioners should conduct routine screening of violence exposure and be equipped with strategies for helping the women [14-17].

The third man in her life became the father of her four children (including the one she is pregnant with). He was not rich but always provided a roof over her head and food on the table. He did not use drugs, except he drank beer during weekends. He did not like Angelina’s drug-use and had tried numerous times to make her stop, without success. She had continued her cocaine use and abuse, causing several fights between them. One day, after a big fight, she left in the middle of the night and had not returned the next day. He left for work in the morning, thinking she may have gone to the neighborhood store for cigarettes, but found both of the children had been left alone at home all day long . . . without food . . . without changed diapers . . . and crying. . . . He was extremely mad and called the police. One of the neighbors probably also called CPS after seeing her two-year old son wandering around the neighborhood. “This is how my kids got taken away by the CPS,” she said, with her head lowered and eyes looking into the ground.

Analysis:

A mother’s substance abuse can undoubtedly put her children at risk for child neglect and other maltreatment, particularly when there is a lack of resources in her environment. The woman’s (and/or her partner’s) substance abuse will also likely precipitate conflicts in her relationship with her partner (a user or non-user). In addition, it is important for treatment programs to reach out to the community. Both the woman and her partner/ family may lack knowledge and resources about professional substance abuse treatment [18].

The residential program finally discharged Angelina and referred her to transitional housing in the community. Her social worker helped her locate the father of her three children who were, therefore, able to be placed with his relatives. She had not used any drugs while she was in the residential program, nor in the transitional housing. She said she wanted to give the baby in her stomach a chance; despite this, not too many people believed she would ever stop using drugs. The transitional housing was a one-room apartment which she liked very much because of its quietness and privacy. She paid slightly over 100 dollars a month for the rent, out of her 275 dollar government check. The food was free. She also attended individual counseling and groups weekly.

Analysis:

Aftercare and case management are critical for substance abusing women/mothers. Practitioners must help the women acquire necessary community resources, such as housing and continued counseling.

The big day finally came. Angelina gave birth to a healthy boy. Both the mother and baby tested negative for drugs. Still, the new-born was taken from her bedside by CPS because of her “previous record” and because her three other children were currently in foster care. She said, “My heart was totally broken . . . . I felt I was like a mother kitten, witnessing all her baby kittens being taken away by other people, but can do nothing about it. . . .”

Analysis:

A substance-abusing mother whose baby is taken away from her may experience intense feelings of hurt, powerlessness, and pain. A substance-abusing woman may experience repeated traumas in her lifetime. In Angelina’s case, she was sexually abused and exploited during childhood, encountered domestic violence from her male partners during adulthood, and re-traumatized by the CPS system (even if CPS was following the protocol and their action of taking the baby away was legal). A substance-abusing woman may be re-traumatized by other systems, such as sexual harassment or assaults from male prison guards [19].

Although both substance-abusing men and women are more likely to experience traumas than the general population, substance-abusing women are more likely than substance-abusing men to experience sexual and/or physical traumas during lifetime [11,20]. Experts have advocated trauma-informed practice and integrated trauma treatment for helping substance-abusing women (and men) [21,22]. Various models that address trauma and substance use disorders are available, including Helping Women Recover Program, Prolonged Exposure Therapy, Seeking Safety, Trauma Affect Regulation: Guide for Education and Therapy, Trauma Recovery and Empowerment Model [23].

With the advocacy of her assigned attorney and her completely “clean” results of routine drug-testing (both urine and hair), the CPS finally returned the baby boy to her after two weeks. She said she was so happy to have the baby back, at least for now. “One day,” she said, “I held my baby in my arms and slow-danced with him. . . . I hummed this song that I loved so much . . . . and my tears were just uncontrollably dropping out of the corner of my eyes . . . .”

Analysis:

Reunification with children brings great joy to the mother and can serve as an utmost incentive for her to comply with the treatment and get well.

Angelina returned to her transitional housing apartment, where she can stay up to two years. She has to complete six months of outpatient substance abuse treatment to comply with both the CPS and her parole officer’s requirements. She took a bus four days a week from 11:00 a.m. to 3:00 p.m. to attend the women’s groups. She likes the intensive outpatient groups because: (1) she can bring her baby with her to the programs; (2) all the women in the group share similar backgrounds and experiences in that they all fight with their addiction, they all have children in the child welfare system, and they all have to work with their probation officer; and (3) the place offers free breakfast and lunch. She also gave credit to the residential program and her parole officer.

Analysis:

A treatment program that meets the unique needs and background of the substance-abusing woman can successfully engage her into treatment and increase treatment retention. A large number of empirical studies have continuously revealed that women-only and women-responsive treatments result in better retention and treatment outcomes [24]. Even among women who attended mixed-gender treatment programs, those who attended more gender-sensitive treatment programs tended to have better treatment outcomes than those who attended less gender-sensitive treatment programs [25].

Although Angelina has not used drugs for over 20 months, she said she was not completely healed. She was scared of triggers. She said, “What’s really crazy is that in the back of my brain, there is something in there still tells me, ‘you like that, remember how good it feels?! You like it! You still like it!!!’ I do still like it, but I don’t want to do that any more . . . . I remember consuming it, loading it up, and lighting it and smoking it, and . . . . I still like it, but I don’t want to do that! I wish I had never known how to do drugs! I don’t want ever, ever to do drugs. I definitely don’t want to expose my children to that. I want to be a positive role model and provide a warm home for them . . . . ”

Analysis:

In addition to issues related to the various levels of systems (e.g., the criminal justice system, the child welfare system, the substance abuse treatment programs, the relationship with her male partners, her ability to provide a financially adequate and healthy environment for her children, etc.), Angelina has to deal with the struggle of the biological nature of addiction and its interaction with the psychosocial issues in her life. Psychoeducation and addiction counseling can be beneficial.

Research in the past two decades has suggested that addiction is a chronic and relapsing disease of the brain (Volkow, Wang, Fowler, & Tomasi). It may be helpful to share with clients the brain disease theory, in that neuro-adaptation caused by chronic drug use may require time to recover and prolonged abstinence can recover some of the brain’s previous functioning, allowing the person to regain control .

It is critical to teach clients relapse prevention skills, including recognizing triggers, learning and applying coping skills that involve no alcohol and/or drugs, and being attentive to the long-term negative consequences of use. In addition to the traditional cognitive behavioral therapy in that practitioners work with clients, identifying external and internal triggers and developing non-using strategies to counteract those triggers [26,27], more recently developed “mindfulness-based relapse prevention” that emphasizes practicing “acceptance of uncomfortable states or challenging situations without reacting ‘automatically’” has been suggested to have efficacy (Witkiewitz and Bowen, Witkiewitz and Lustyk). Studies have found several risk factors that are especially relevant to women’s relapse, including low self-worth and a lack of selfidentity, the relationship with men, lower level of resources (education, employment, and social support), interpersonal conflicts, negative emotions (such as loss and grief, loneliness and boredom), co-occurring disorders, reduced ability to sever the tie with the using network and establish a non-using social network, a lack of substance abuse-related knowledge and relapse prevention coping skills [28,29]. Practitioners should tailor the individual woman’s situation and needs and help her develop non-using coping skills accordingly.

The court will decide in the near future whether to restore Angelina’s parental rights. She said one of the criteria that would qualify her to take her kids back, according to her social workers, was having a place, a home, for the kids. The transitional housing where she is living right now is only temporary, although she can stay for up to two years. The one-room apartment is also a bit too small for four kids and one adult. The lack of a kitchen is another problem. In addition to the relatively longer-term worry of the housing, she has been experiencing financial difficulties. Her 275 dollar monthly government check has to cover 120 dollars rent, 40 dollars in court fines for her previous criminal behaviors (shoplifting), and a 30 dollars storage fee (for her kids’ toys, and some furniture). Although she gets free formula from the WIC, she has to find baby’s diapers on her own. One community resource program does offer free diapers, but she is allowed to take only 12 pieces at a time every other week. Not only did she have to worry about diapers, she had difficulty affording shampoo, soap, and other daily-use items. She relies on store samples of those items and often worries that those samples would soon run out. On top of all these difficulties, the baby’s father was sentenced to one year in prison for DUI, which makes his financial support to her and the children impossible. Angelina is fully aware that the only way for her to improve her current life situation and financial condition is to get a job.

Angelina has never worked before and has not received any employment training while in treatment. She has a GED. She also has to complete the six-month intensive outpatient counseling requirement, which has occupied half of her weekly time. Other obstacles to becoming employed are that she does not have a car and has to rely on busses; she needs a babysitter or day care for her son; she does not have appropriate clothing for job interviews. She applied for a neighborhood apartment for more permanent housing, but was rejected due to her past criminal record. She said, “I’m not used to this stuff. I never had to do this. There’re millions people that do this all the time, but it’s all new to me. I’m excited to do it. It’s gonna be my life. This is what life is about . . . . I can do it! It’s not easy. This is a big change, ‘cause I have been so used to living one way . . . . and then now I have to work for everything that I need. I went from one lifestyle where I didn’t have responsibilities to now I have to be responsible.”

Analysis:

What may face a substance-abusing mother in recovery is a harsh reality and a long way to go, as well as an opportunity of living a new, healthy life. A practitioner should continue to enhance both the internal and external resources of the woman after formal treatment and during aftercare [30]. The external resources with respect to housing, employment, and independence are critical [31]. The internal resources of the woman with respect to life skills and a sense of hope, responsibility, and self-efficacy are equally essential.