“The relationship changed because I had changed”: Experiences and perceptions of friendships between women treated for substance use disorder in women-only residential programs

Abstract

Historically, the notion of friendships between women has been replete with negative myths and perceptions. However, studies show that friendships between women contribute to their wellbeing as a source of support and empowerment. Social support is known to be a key factor during recovery from a substance use disorder (SUD). Previous studies have examined a variety of relationships, but less attention has been paid to friendships between women with SUD. This qualitative study examined the perceptions and experiences of friendship of 14 women who recovered from a SUD and were treated in women-only residential treatment programs (RTP) in Israel. Content analysis revealed four categories that paralleled their linear life-course from childhood to adulthood: social rejection and the longing for connection and acceptance, interest-based versus non-interest-based friendships, being distant versus becoming close, and friendships with “normative” women versus friendships with “clean addicts.” Each category is situated on a conceptual axis representing the tension between trust and mistrust, the unifying theme. These findings are best understood within the framework of relational cultural theory (RCT), which emphasizes the importance of relationships in people's lives. Therapists should consider the positive impact of friendships between women, as a theme during the therapy process.

Keywords

friendship women recovery relational cultural theory substance use disorder Israel

Friendship is a voluntary connection based on choice that involves affection, trust, and mutuality between individuals (Blieszner, 2014). Historically, friendships between women tend to be framed with negative characteristics such as mistrust, hostility, and competition (Knickmeyer et al., 2002). To challenge these perceptions, feminist researchers have shown that friendships between women contribute to their wellbeing (Powers et al., 2009) and physical health (Yang et al., 2016), and can be a source of support and empowerment (Orbach & Eichenbaum, 1987) while providing a space for identity establishment and confirmation (Kaeppel et al., 2020; Rind, 2002).

Gender-responsive treatment approaches for women with a SUD have been proposed to better meet women's needs than a generic treatment approach (Grella, 2008). This treatment is characterized by a women-only setting, a relational approach, trauma-informed therapy, and holistic services (Ashley et al., 2003). In women-only treatment programs, women can form relationships that can serve as a source of support (Neale et al., 2018). Despite acknowledgement of the role of social support in the recovery from a SUD (Cloud & Granfield, 2008), and recognition of the importance of women-only treatment programs, there is scant research on friendships between women with a life history of a SUD diagnosis (i.e., individuals diagnosed as having had a SUD some time in their lives). The goal of the current study was to bridge this gap, and contribute to theory and treatment approaches for women with a SUD.

Friendship between women

Friendships between women are plagued by enduring myths and negative perceptions (Glover et al., 2015; Knickmeyer et al., 2002). These include claims that women are not worthy of each other's trust (Dickey, 1998), the notion that women are “natural” enemies (Knickmeyer et al., 2002), and that they compete over “their men” and are thus hostile to each other (Rind, 2002). Even female talk itself is considered to be gossipy and malicious (Johnson & Aries, 1983). O’Connor (1992) argued that friendships reflect the cultural and social ideology in which they occur. Thus, social perceptions of friendships between women are likely to affect these relationships.

By contrast, feminist scholars have argued that this imagined hostility between women derives from sexist views which ignore the true sources of oppression and thus blur the dynamics of inequality (Brown, 2013). Rich (1986) suggested that men are afraid of women who are connected to each other because they see this as a threat to the phallic world and their privileges. Despite these negative social perceptions, studies of friendship between women have shown that it contributes to their wellbeing and health (Yang et al., 2016). For example, in a study of women who were physically, mentally, or sexually abused in childhood, support from friends helped to moderate depression (Powers et al., 2009).

In friendships with women, women can create a space in which they feel liberated from their social roles as employees, mothers, or partners (Rind, 2002), and feel free of gender stereotypes and behave in a way that is not considered “feminine” (Green, 1998), which enables them to construct their autonomy, individuality, and identity (Kaeppel et al., 2020). Thus, the space between women can create a counter-narrative in neoliberal times (Martinussen et al., 2020). Beyond these personal aspects, sharing experiences raises awareness of their collective nature (Bachmann, 2014), and thus may have a political potential that can lead to social change (Devere & Smith, 2010).

It has been argued that a girl's initial connection with her mother constructs her needs and expectations in relationships with women in adulthood (Orbach & Eichenbaum, 1987). For example, in a study conducted in Montreal on 31 couples, their daughters, and the daughters’ best friends that examined friendship quality in adolescence and adulthood, positive mother–daughter communication predicted a higher level of these daughters’ perception of female friends’ support in adulthood (Baril et al., 2009).

Women's socioeconomic status and ethnicity also influence their opportunities to form friendships with other women (Castañeda & Burns-Glover, 2017; Greif & Sharpe, 2010). For women from marginalized groups, limited time, money, and mobility may constrain their social circles and obligate them to rely on their immediate environment of neighbors and family alone (Sloan et al., 1996).

Women with a substance use disorder and gender-responsive treatment

Addiction manifests in different ways between genders (Grella, 2008; McHugh et al., 2018). Studies have shown that gender plays an important role in the etiology of addiction, its characteristics, barriers to treatment, treatment outcomes, and recovery needs (Becker et al., 2016; Huhn & Dunn, 2020). The etiology of drug use among women is commonly attributed to child abuse and neglect, and sexual abuse in particular (Leppard et al., 2018). An Israeli study of 104 women with a heroin addiction treated in a methadone clinic found that all of them had been sexually abused as children, and that 54.2% reported symptoms that exceeded the DSM-IV criteria for posttraumatic stress disorder (PTSD; Schiff et al., 2010).

Compared to men with a SUD, women are diagnosed with more comorbidities, and tend to pay for drugs through sex work, which is also traumatic (United Nations Office on Drugs and Crime, 2016). To a greater extent than men, women with a SUD tend to live with a partner who is also addicted, and tend to point to this relationship as the cause of onset of use or as a stressor (Beijer et al., 2018; Tuchman, 2010). Women with a SUD report conflicts with family members, lack of family support, and loneliness (Tracy et al., 2016). Thus, problems in relationships and their role in the dynamics of addiction are central issues in the treatment and recovery of women (Covington, 2008).

The growing awareness of the characteristics and needs of women with a SUD, in addition to the low participation and high dropout rates of women in traditional settings, prompted the development of gender-responsive treatment programs designed to better suit their needs (Greenfield et al., 2007; McCrady et al., 2020). In contrast to common treatment approaches to addictions based on medical models and a hierarchy in relations, gender-responsive programs are characterized by a relational approach, holistic services, women-only settings, and trauma-informed therapy models that take the social context of women's addiction into account (Grella, 2008). These programs are based on a relational model that views addiction as a problem of disconnection, such as interpersonal violence, sexual abuse, and others (Hartling, 2003). In this model, substance abuse in women is seen as an attempt to facilitate connections in an abusive environment and/or as a mechanism to cope with the consequences of past trauma (Hartling, 2003).

In gender-responsive programs, the staff is composed of women who provide a strong female presence, which can be an empowering role model for women in therapy (Grella, 2015; Pelissier & Jones, 2005). For example, in a qualitative study on a women-only program in the UK (Neale et al., 2018), participants had more positive opinions about treatment compared to their initial expectations; they agreed that the absence of men made it possible to share difficult life experiences such as sexual assault and prostitution; viewed other women as a source of identification and support; and formed friendships with other women that lasted after treatment. At the same time, some women noted the complexities associated with intrusive behaviors, difficulty trusting others, conflicts, and problems relating to women from different backgrounds.

Women with a substance use disorder and social support: Risk and protective factors

A useful framework for understanding social support is Cloud and Granfield's (2008) recovery capital model. Social capital is one of the four components of the model, and is defined as resources that help individuals initiate and sustain recovery from a SUD. Studies of women with a SUD have reported a positive association between social support and length of residency in treatment (Davis & Jason, 2005), successful treatment completion (Lewandowski & Hill, 2009), fewer relapses, and a higher likelihood of abstaining from drugs (Brown & Riley, 2005; Stevens et al., 2015). Social support has also been associated with lower levels of depression and anxiety, was a possible moderator of posttraumatic symptoms (Walker, 2011), and contributed to a sense of empowerment (Barringer et al., 2017).

Several studies exploring social support for women with a SUD have examined friendships in the context of recovery. Davis and Jason (2005) found that during treatment, women rely primarily on friends (women and men), unlike men, who rely on their family as their primary source of support. A study comparing pre- and posttreatment support systems found that after treatment, there was a significant increase in women's perceptions of the support they received from their friends (Lewandowski & Hill, 2009). Another study found that after treatment, women tended to distance themselves from friends who use drugs, and made new friends (Neale et al., 2014). A study examining differences in the social support systems of women with a SUD before, during, and after treatment found that 2 years after treatment, women had a broader support system, as well as more relationships with nonusers than in their pretreatment period (Brown & Riley, 2005).

The current study

Establishing and maintaining meaningful relationships was shown to be a crucial part of women's recovery from substance abuse (Tracy et al., 2016). In women-only programs, women were reported to form new meaningful, mutual, empowering relationships with other women (Neale et al., 2018). However, friendships between women and their importance to women with a lifetime history of a SUD diagnosis are understudied. To fill this gap, the current study explored the experiences of friendship between women enrolled in women-only residential treatment programs (RTP), and the meaning they ascribed to these friendships.

This study was conducted in Israel, where women's gender role remains centered on being wives and mothers (Fogiel-Bijaoui & Rutlinger-Reiner, 2013). In the specific context of women's substance abuse in Israel, as in other countries, shame and guilt were also found to be related to their “failure” to fulfill normative social expectations as mothers and wives (Gueta & Addad, 2014).

In Israel, the recommended treatment approach for women with a SUD is gender-responsive and trauma-informed (Ministry of Social Affairs and Social Services, 2017). In 2020, women constituted 20% of all patients, compared to 8% in 2010 (Committee Against Drugs and Alcohol, 2016; Ministry of Social Affairs and Social Services, 2020). This increase may be due to greater awareness and responsiveness of service and treatment providers to women's needs.

Method

This qualitative study employed a naturalistic method that takes a holistic approach to human experiences (Lincoln & Guba, 1985). It is grounded in the ontological assumption that phenomena should be understood in the context in which they unfold, and that experiences and perceptions of individuals are multiple and constructed. This is in line with principles deriving from feminist approaches that highlight connections as a primary theme in female research methodology (Davis, 1986), involving contextual research that explores relationships between the person and the environment. Hence, these approaches are suitable for probing friendships, a type of connection that constitutes an integral part of women's day-to-day lives and can be best understood through an examination of the social context in which they take place (O’Connor, 1992). Here, women-only RTP provides a specifically female context to probe this issue. Since investigating the concept of friendships in women who have experienced social marginalization and prejudices may affect the way they perceive friendships, the women-only RTP context made it imperative to listen to these women's voices, stories, feelings, and thoughts, which can yield rich, dense data as suggested by feminist approaches (Beckman, 2014).

Participants

Fourteen women (M_age = 34.3, SD = 9.46; range: 21–60) treated in the four RTP for women in Israel were interviewed individually. The eligibility criteria were: women who had been diagnosed as having a lifetime history of a SUD, who had not used any drug for at least 6 months prior to the interview, and had been treated for at least 6 months in a women-only RTP.

Eight women were immigrants from the former Soviet Union (FSU) who had come to Israel as children or adolescents. Twenty-two percent of all patients diagnosed with SUD in Israel are immigrants from the FSU (Ministry of Social Affairs and Social Services, 2017). The average age at onset of drug use was 17.61 (SD = 1.82; range: 14–21). The time spent in RTP ranged from 7 to 14 months. The participants had completed treatment in the RTP 6 months to 3 years prior to the interviews.

Procedure

After obtaining their initial consent, the first author called potential participants to provide further information about the study and to offer to meet them at a time and place of their choosing where they would feel comfortable sharing personal information. The interviews were conducted in participants’ homes, cafes, or parks. All the interviews took place in Hebrew and were translated into English after content analysis. Informed consent was obtained from all participants. Full confidentiality was explicitly stated on the consent form and was explained verbally. The study protocol was approved by the Institutional Review Board of Tel Aviv University. All the names presented in the findings are pseudonyms.

Semistructured face-to-face interviews conducted by the first author were utilized to probe participants’ experiences and the meaning they attach to them. Based on the notion of “ethics of care” (Gilligan, 2016), we attempted to minimize the hierarchy throughout the process by viewing participants as active collaborators (Beckman, 2014).

The interview started with a general question, “Please describe what comes to mind regarding friendships with women in your life,” to allow participants to share their experiences, feelings, and thoughts in a nonconstrictive way (Brinkman, 2014). The interview included a set of questions such as “Tell me about your relationships with female friends from childhood to this day” and “Tell me about the relationship with other women in residential care.” The interviews were audio recorded and transcribed later with the participants’ consent. After transcribing, the recordings were deleted.

Note that recruitment was challenging since we aimed to interview participants after completing their RTP. The recruitment process lasted until data saturation was achieved; that is, when the criteria for the breadth and depth of participants’ perceptions and experiences were met (Bowen, 2008).

Data analysis

A six-step content analysis was conducted (Elo & Kyngäs, 2007; Graneheim & Lundman, 2004). First, we read all the interviews several times, to get a sense of the whole. Second, we chose three interviews which were noticeably different in content, and coded each of them inductively (Elo & Kyngas, 2007), which resulted in 362 codes. This inductive coding approach related to the content manifest to “let the text talk” (Graneheim & Lundman, 2004), to get a fine-grained sense of the women's descriptions where they are able to reflect their authentic voices in terms of the way they perceived and experienced friendships with other women, without the premature judgment or pervasive stereotypes (Gilligan, 1995; Taylor et al., 1995) that surround women with a SUD. Third, we grouped the codes according to their content similarities and differences into 52 categories and subcategories, which were again condensed into 26 categories. The remaining 11 interviews were coded according to these categories. If new content emerged, it was coded and labeled accordingly. Fourth, the tentative categories were discussed by the authors and relabeled. These categories were then grouped and clustered into four large categories, which emerged as chronologically parallel to four key periods in participants’ lives. These periods reflected different meanings and experiences of friendships with women. Finally, these categories and the associations between them were subsumed into one holistic theme that captured participants’ main underlying meaning on an interpretative level (Graneheim & Lundman, 2004).

To enhance trustworthiness of the findings, several steps were taken. The two researchers coded the text independently. Their codes were then compared to guarantee that they reflected the participants’ experiences and meaning-making in relation to the research question, and were thus credible (Graneheim & Lundman, 2004; Lincoln & Guba, 1985). The researchers discussed the categories identified in each stage until each category was considered to be sufficiently comprehensive. We adopted the principle of “showing rather than telling” (Tracy, 2010) by providing rich, detailed quotes. The complete procedure and context are described below. Given the importance we ascribed to female friendships, we were aware of the ways our own perceptions and experiences could influence the interviews and the content analysis. To remain alert to the influence of these perceptions, we maintained ongoing discussions between us on the topic of female friendships, and shared our stories, experiences, feelings, and thoughts. This reflexive process helped us define our positionality in relation to the research process (Beckman, 2014), and our different way of understanding what the participants were conveying.

Findings

Four categories that corresponded to four key periods in the lives of the participants, and which paralleled their stages of substance use and recovery, were identified: (a) Social rejection and the longing for connection and acceptance, relating to friendships during childhood and adolescence; (b) interest-based friendships versus non-interest-based friendships, a category that corresponded to the period of drug use; (c) being distant versus becoming close, which described relationships during the RTP; (d) friendships with “normative” women versus friendships with “clean addicts,” a category that characterized the recovery process. The overarching theme that united the four categories was situated on an axis ranging from mistrust to trust, where each period and corresponding category reflected aspects ranging on this axis.

Social rejection and the longing for connection and acceptance

The participants characterized their childhood and adolescence in terms of their feelings of rejection by their family and a sense of being different from their peers, while seeking out connections and acceptance. The source of rejection appeared to have been associated with factors such as living in poverty, being an immigrant (for several women), or their complex relationship with their mothers, which led to a lack of trust and by extension a lack of interest in the company of other girls, an unwillingness to identify with them, and sometimes with femininity. Dana described how she lost trust in women because of her complex relationship with her mother:
I think that addicted women and women in general … uh …women that have experienced sexual abuse or something like that in their lives—I don’t think women were a strong point for them. In other words, someone who experienced that is someone who was hurt by their mother. Her mother was not there for her … The feminine side was not strong enough. Because if it had been, the damage would be fixed and somehow, she would be better able to get through it because there was a mother to talk to. [If] there was a mother that … listens, that accepts, that hugs … uh … So I think that everything is a result of that. Uh … it's as if … what is your first experience as a child in the world? It is your mother … Your mother represents a feminine figure. And when she is not there for you, in my opinion, it is very difficult … uh … to have a strong relationship because you think that you can’t depend on her; it's like you didn’t have it then, so why should you have it with someone else of that gender.
In addition to lack of trust, participants mentioned being rejected or ostracized by other girls their age. As Daphna described: “So that's it. That leaves scars. You experience all kinds of scars, exclusion at school, a fat child, everything combined.” Daphna thus shared her experiences of being excluded and rejected by other girls in school because of her weight.

Their lack of trust in girls and women and the exclusion from the company of girls led some of the participants to become friendly with boys. Dayana, who immigrated to Israel at a young age, described feelings of social difference and social rejection from the company of girls because of her background of being an immigrant from the former Soviet Union: “Then I came here, it was very difficult for me to adjust to Israeli society because I was the stinky Russian, I was the one who ate pork” (which is not considered kosher). This led her to establish friendships with boys. She said that she mimicked male behavior because she did not meet the social standards expected of girls:
Only boys, all the time … Behaving like a man in every way, like an adolescent boy—not a girl. I hated women. Why did I hate them? Because I couldn’t be beautiful like them and thin like them and wear [designer] Diesel [jeans] like them. I couldn’t be the prom queen and I couldn’t go to clubs because I was very fat. Who would want to go out with me?
Similar to the way Dayana adopted “masculine” behavior, Valeria stated that she wanted to hide her femininity: “During that period, it was also hard for me to put on a skirt and emphasize my femininity. I would dress like a boy because I wanted to be in their group.” This was Valeria's way of exemplifying her wishes to belong to the boys’ circle.

Participants said that despite these relationships with boys, they still suffered from loneliness. For example, Dayana described how drugs replaced friends: “There was a stage when ecstasy and crystal became my best friends, I disconnected from everyone.” For Dayana, as for other participants, loneliness was part of the backdrop leading to the initial use of drugs.

“Interest”-based friendships versus “non-interest”-based friendships

This category covers the women's drug use period. The women defined their friendships at that period as interest-based, which emerged as social relationships centered on drugs and were engaged in solely and deliberately to get drugs, money, or connect with drug dealers or men who pay for sex. As Valeria stated: “They were friends for drug use who were not real friends. They were the people you hang out with because you have an interest in getting the best drugs at the best price.” These types of relationships were not built on genuine trust and could be viewed as exploitive.

Sofia stated that most relationships during her period of drug use were with men and implied that they involved sex in exchange for drugs. She said that friendships with women were irrelevant since they could not be leveraged to obtain drugs:
During my drug use, there were mainly men. Just men. Why am I saying “mainly”? All of them were men. It was … It didn’t have anything to do with friendship … it wasn’t friendship but my circle consisted of men. Because … you know—drugs—and where am I going to get them and if I hang out with a girl what is there in it for me? Basically nothing … So … let's say it was preferable for me that way. That is friendship with … what is it called? It's in exchange for something.
Alongside these interest-based relationships, participants also recalled friendships, mostly with one woman, that were not based on interest, some of whom were users and others not. Like a beacon of light in the darkness, in their lowest phases of drug use, they would contemplate engaging in a different quality of relationship with a woman friend. These relationships were exceptional moments in a life of chaos, and involved manifestations of concern, trust, protection, assistance, and even help in attempts at rehab.

The participants’ initial narratives suggested that friendships and drugs are incompatible, but as the interviews progressed, this narrative began to fissure and stories about relationships with women participants could rely on came to the fore. For example, Dayana described a relationship in the prostitution context that was different in that it was not interest-based:
Dayana: There was a friend who … even though we used together she never let anyone touch me when I was already “submerged” [under the influence of drugs] and I didn’t let anyone touch her. She was a true friend who I really loved and still do, and she really loved me.

Interviewer: You said before that there was no drug-related friendship; there was only interest, but you loved her. What made this possible?

Dayana: I’ll tell you why. We didn’t mix drugs and the relationship. She was working [in prostitution] on her corner and I was working on mine. It was a kind of reciprocity. She wasn’t being nice to get something from me because she could have gotten the same thing … She didn’t need me for drugs because she already had some.

Some of the participants described more complex relationships that included tensions between trust, care, and reciprocity on the one hand, and the need to get drugs on the other. Daphna said that she also ended up dragging the friend she lived with into taking drugs, even though she loved and respected her:

She also got into it. Totally. It's as if I got her into it further and further and I just used her, I totally used her. I really loved her as a friend, but the drug use was more powerful. It really was.

Nika, who came from a low socioeconomic background, described how she had friends who bought her drugs, tickets to parties, and food in exchange for her company: “They knew that if I was with them, I was the entertainment but they were funding it. I was some kind of performer for them. No problem—drugs, money, alcohol—if they paid I would join them.” Nika's description emphasizes interest-based friendship characterized by performing in exchange for drugs and money.

Being distant versus becoming close

This category reflected a turning point in the meaning of participants’ friendships with women and the way participants experienced them, and related mainly to the time spent in the RTP. During this period, the participants developed new ways of being in a relationship with women friends, which continued to be part of their lives after treatment. The women began RTP with feelings of mistrust, and, at times, disgust towards other women. Gradually, during the treatment process, they started to develop relationships based on similarities, a feeling of closeness, and trust. Thus, the RTP constituted a kind of laboratory for working on relationships and trust-building. The process of changing their relationships with other women was inseparable from the internal processes of change related to acceptance, self-love, and dealing with old patterns leading to changes in identity. For some participants, this change resulted in a disconnect from old friends and the formation of new relationships with women. For others, the change in attitudes toward friendship also occurred within existing relationships such as childhood friends and friends from the drug context who had recovered. These relationships included components such as the sharing of emotions, authenticity, trust, lack of exploitation, availability, and reciprocity.

Some participants described the beginning of therapy in the RTP as eliciting feelings of disgust towards other women. Shani, for example said: “at the beginning, I felt disgusted with her and I wasn’t prepared to understand it … I wasn’t prepared to understand that she was sick like me. I stole, but she sold her body, for me that was weakness.” Shani was thus expressing the distance she felt from other women in the RTP.

The participants described how their relationships with other women in the RTP were an important factor in their recovery. Sofia, for example, described how a friend in therapy told her that she had exploited her, and how this constituted a milestone in her therapeutic process:
And then she told me … “all that time you used me.” That killed me. As if I didn’t know that I was doing that, but no one had ever told me that to my face. That was where my therapy really took off.
The participants described how social relationships developed, and the ways in which these relationships helped them persevere in therapy. Valeria, for example, described her relationship with a friend in RTP: “There was a good connection between us. We encouraged and supported one another. We had a relationship of cooperation, understanding, and identification, and gave each other strength.”

Similar depictions of helping others persevere in therapy through connection, understanding, trust, similarity, identification, and their acknowledgment were also present in other participants’ narratives: “There was a great deal of honesty among the women. There was a lot of strength and power. They did not give up on one another easily” (Daphna). Dayana described how acceptance on the part of a friend she met in the RTP was an important part of her recovery process:
She heard my life story, which was very similar to hers. She did not judge me. She accepted me as I am … something that I could not do for myself. She loved me without teeth. She loved me fat, thin—it did not matter to her. She liked talking with me … We learned from one another and today she is a good friend and I won’t abandon her … It was worth everything.
The women also described how the nature of the friendships with women that began during the period of therapy extended to other relationships after RTP. These friendships were experienced as intimate and trustworthy. Some of the women maintained the friendships made during therapy. Others renewed relationships with childhood friends, or friends who had used drugs and recovered, or made new female friends in 12-step groups or at work.

Daphna, for example, described renewing contact with a friend she had used with:

The relationship changed because I had changed. I did not see myself … I did not see anything. I saw the food; I saw the drugs. Today, I see her as the person she is. I connect with her. So, ah … this is really special.

Daphna thus made it clear how personal change and the ability to be in a relationship allowed her to reconnect with a friend from the past. Thus, the ability to see the other in relationships with women was related to the ability to see oneself. Daphna described her connections with friends from the RTP:
Friendships which are very, very strong. A few months ago … all the girls met at a café, and it was like we had never been apart. It's like friends from the army. It is the same thing. Ah … It was very strong. It is really … these are girls that I can talk to about anything—it does not matter what. They will always be there and … ah … it is like something very deep. Very, very deep. As if we were together in the same womb. Really.
Jasmin said that, while taking drugs, she was used to managing on her own, she did not let anyone into her house and did not trust friends to help, so she gradually drifted apart. Today, after therapy, she is in contact with women from the RTP:
I was used to being that way … So, really, I shared this with the girls … and I felt bad about it and it brought up the past for me and ah … all sorts of things like that … to say that I’m hurt, that I am worried; like to say those things, to express them … That it is OK that they worry about me and give me some kind of response and I won’t let them down and the world won’t come to an end. That is the main change, I think.

Friendships with “normative” women versus friendships with “clean addicts”

This category related to the period after RTP. The participants discussed the advantages and disadvantages of friendships with women who did not use drugs, as compared to former addicts who were “clean.” Participants used the slang term “normative” to describe a person without a past of substance use disorder.

In friendships with women who did not use drugs, the participants considered they had found a bridge to society, a source of learning, direction, and inspiration. However, in friendships of this type, they did not always feel identification or that the friend would understand what they had gone through. By contrast, in friendships with former addicts, they found similarities, common issues, and the type of support they needed. Anna indicated, “It is easier with my [female] friends, who were in treatment with me, easier to understand each other,” exemplifying the complexities of friendships with non-drug-users.

At the same time, in friendships with “clean” addicts, the women expressed fear that the friend would return to drugs and drag them into using again. Valeria described this complexity:
It is difficult to build a connection with clean addicts because even when we do the work [treatment] … and we try to be OK, we still have a perverted way of thinking and a lack of stability. And then there is the problem that if we try to be with normative people, we feel they don’t really understand somehow. When we are with clean addicts like ourselves, there is understanding, but also instability.

Shani described the difficulty of trusting a friend who might relapse and drag her back into drugs:

If you don’t build for yourself—in my opinion, OK?—a “clean” life, your best friends, your activities, everything, everything you do, you can’t hold on, there is no such thing, in the end everyone relapses. So, let's say that you [turning to the interviewer] are my friend from therapy and both of us are clean. Let's say that you are “down” or you have gone through something sensitive and you are going to use, and I am with you … I immediately will be dragged down with you, right away there will be a problem. It's a problem.

At the same time, the participants felt they received better support from their clean addict friends. Daphna compared the support she received from both types of friendships:
So, Maya [the friend who did not use drugs] cannot always understand addiction and the things that I’m dealing with. She doesn’t fully identify with me. She can’t really understand things the other girls understand. Even her reaction … the reaction that I need—I can’t get it from someone normative. The response that I need is to give me a hug and to listen to me and that's it. I don’t need to be analyzed and that … just let it go. It's like I need to share. They [clean addicts] will tell me “we love you, everything is all right.” If I want advice, I ask for it.

Dafna also talked about the importance of a connection with a woman who didn’t use drugs:
In recent months, I have become more open to normative [women] because in some way I understand that I also need to be in contact with normative women to get a different perspective on life. More normative. Because at the end of the day, I want to integrate into normative society. It's a need. It is my need. I really want to be normal in the end.

Another complexity related to friends who do not use drugs is that they drink. Luba mentioned the need for distance from her friends at work because they drink alcohol, and she does not want to reveal herself as a “clean addict”:
You see, I met some girls from the factory, it is also a problem, because they go out, they probably … they drink, they smoke there, so where I would hang out? So, I come up with excuses that I can’t go. First time, second time, third time, then they stop inviting me, so where can I meet friends?

Yet another difficulty establishing friendships with women who did not use drugs was the lack of understanding of the spiritual elements of recovery and the new perceptions of life formed during that process. As Dayana stated:
I am healthy. I am alive. I can tell you today—Look, the sun is out. I can see it with the eyes of someone sane. Where will you find something like this? If you say that to a normative [woman], she will say: “she's crazy, send her to the Abarbanel psychiatric department [a psychiatric facility in Israel].” A normative [woman] won’t understand you. She can feel your pain. She can cry, but that will be out of pity.

Discussion

This study examined the notion of friendships between women with a SUD who were treated in women-only RTP, and the meanings and experiences they attributed to these friendships. The findings reinforce the notion that social support is important to a healthy recovery (Cloud & Granfield, 2008), and help us better understand the ways in which women's friendships are formed in the specific context of substance abuse. The study described the patterns of change in women's friendships from childhood, through treatment, to life after the RTP. Four major categories emerged from the content analysis, corresponding to four periods in life; the axis linking them expresses the tension from mistrust to trust in friendships with women.

Three main insights can be derived from the findings. The first is women's longing for a connection with other women, even when the history of their relationships with women is rooted in vulnerability. The second, interwoven with the first, is the issue of trust. The third addresses the importance of creating friendships between women during the recovery process.

The first insight corresponds to relational cultural theory (RCT), which emphasizes the importance of relationships in women's lives (Jordan, 2001) and also draws on notions of female psychology (Chodorow, 1978). RCT posits that women derive a sense of value from active participation in relationships (Miller, 2008), and that the development of women's identity from childhood to adulthood (as shaped through the relationship with the mother) revolves around trying to maintain a connection rather than separation (Gilligan, 1993).

RCT, as other psychological theories, considers that psychological problems such as depression, anxiety, addictions, and others result from a crisis in the early relationship (Surrey, 1991). Girls who have been neglected or abused try to stay connected to objects that are significant to them at all costs.

In the context of addiction, this theory views drug use as one way these women try to maintain relationships in an abusive environment (Covington & Surrey, 1997). According to Hartling (2003), substance abuse is a disease of disconnection that can be caused by severe violations of the self. As was shown in the first theme, the participants started using drugs when they found themselves relatively alone and disconnected from their families and peer group. Substance abuse is also a mechanism to deal with the consequences of trauma (Hartling, 2003). All the women in this study reported a past of sexual and/or family abuse; hence, drug use may have been a result of this violation.

Women's longing for a connection, despite the abuse they experienced as children, was present in each category. Based on the notion that women's identity is structured and shaped within relationships (Surrey, 1991), the findings here showed that the women longed for connections for psychological survival, even under the most difficult circumstances. Longing for a connection and the initial ability to be in a relationship and to trust were present before entering the RTP, and developed during the therapeutic process, in part by being closer to other women. The therapy process itself is rooted in the ability to form a mutual, trusting relationship with other women. In the third theme, the women emphasized the extent to which the relationships and friendships they formed with other women in the RTP were a crucial part of their recovery process. As one of the core components of RCT, relationships can thus have a therapeutic potential (Hartling, 2003).

The second insight is related to the centrality of trust as expressed in the tension between the longing for a relationship and the difficulty of trusting another person. Previous research on women with a SUD (Henderson & Boyd, 1997; Kreis et al., 2016; Neale et al., 2018) has also addressed the issue of trust. For example, in a study by Neale et al. (2018) that examined whether women preferred to be treated in women-only settings, 19 women stated that they started therapy from a position of mistrust towards other women, which related to a history of abusive relationships. The Neale et al. (2018) study also found that the experience of women with SUD in a women-only setting was complex. The current findings extend that study by providing a broader description of the change processes women go through in treatment in relation to other women, and how women draw on this experience and form friendships with women in recovery, months and even years after completing RTP.

The third insight relates to the importance of making connections with nonusers after treatment. Interestingly, our interviewees used the term “normative” to refer to women who do not use drugs, and used the term “not normative” to describe women who have drug addictions. This terminology may be ascribed to an internalization of the social stigma directed towards them as women who are addicted to drugs, a process known as “self-stigma” (Corrigan et al., 2017). Alternatively, the participants may view women who do not use drugs as a bridge to society at large, and as a way to be reintegrated into the community. Hence, social ties are essential to this stage in recovery and can be seen as “bridging social capital” between the recovering person and society (Lyons & Lurigio, 2010).

Limitations

This study was conducted in Israel; hence, studies of other cultural groups could lead to different findings. This study probed the experiences and perceptions of friendships among women with a SUD who were treated in women-only RTP, so further investigation is needed in other treatment settings such as day centers and outpatient units.

Future directions

This study is one of the first to examine friendships between women with a SUD. As shown in the findings, the changes in women's friendships during and after treatment also relate to how they perceived and experienced the quality of these relationships. These findings can be further explored through quantitative research methods. Friendships between women with a SUD could also be examined in the context of outpatient units and mixed gender settings. Finally, the women in this study were marginalized, first as women but also as immigrants and as women who live in poverty. Future research should examine the ways in which marginalization impacts women's friendships in the context of substance abuse.

Implications for practice

This study highlights the potential of women-only settings to build meaningful relationships inside and outside RTP. Therapists and staff working with women with a SUD can benefit from the description of these processes and should take the issue of friendships between women into consideration as one of the key factors related to their recovery. The findings can enable therapists to better understand the dynamics between trust and mistrust. Women with a SUD should be encouraged to discuss the roles of female friendships in therapy, address the sources of mistrust, and work for change in the context of friendships between women.

Another implication emerging from the implementation of RCT therapy is the use of “discrepant relational images” instead of women's relational images (Jordan, 2018). Relational images are inner constructions and expectations formed on the basis of experiences in relationships, whereas discrepant relational images are exceptions to the dominant relational images. Thus, therapists can encourage clients to find images to contradict disruptive relational images to bolster their sense of hope and connection. As we showed in the second theme, even during the drug use period, the women had at least one authentic female friendship. This experience can be used in therapy as a discrepant relational image, to instill hope in women's ability to form authentic mutual relationships with other women in their life.

Thus, overall, the longing for a connection motivated the participants to maintain friendships with other women throughout their lives. The possibility of forming meaningful friendships was mainly concretized during the RTP. These findings may help professionals understand the importance of the issue of friendship between women for women with a SUD, and better promote supportive and beneficial female relationships.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was supported by the Israel Authority for Prevention of Violence, Alcohol, and Drug Abuse. This authority played no role in the study design or the collection, analysis, and interpretation of the data, the writing of the manuscript, or the decision to submit the paper for publication.

ORCID iD

Belle Gavriel-Fried

Author Biographies

Jenia Kelner is a social worker. She earned her BA and MA from Tel Aviv University. She currently works with international students at Tel Aviv University. She also conducts quantitative research in the field of addictions and gender.

Belle Gavriel-Fried is an Associate Professor and the Head of the Addiction and Recovery Lab at the Bob Shapell School of Social Work at Tel Aviv University. She specializes in the psycho-social factors that enhance and hinder recovery from addictions through qualitative and quantitative research methods.

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