Every Picture Tells a Story: Images of Women’s Recovery.
A Constructivist Grounded Theory of Women’s Recovery from Alcohol Addiction.
This study explored the meaning that women addicted to alcohol attributed to their decisions to maintain their recovery while engaging with drug and alcohol services. Women, alcohol, alcohol-use disorders (AUDs) and addiction are under-researched areas when compared to the number and range of studies on male alcohol consumption and its related harms. Research increasingly suggests that recovery from alcohol addiction is a possibility, but current understanding of the process of recovery remains limited and consequently service provision may lack appropriate support structures.
Key words: women, alcohol, addiction, maintenance, recovery, alcoholic, sobriety.
This research utilised a constructivist grounded theory methodology to analyse data collected from 10 female participants currently in the maintenance phase of recovery from alcohol addiction in the North East of England. Interviews were conducted using participant-driven photo elicitation; selected images formed the foundation of the semi-structured discussions. Following initial data analysis, a focus group comprising of professionals working in alcohol and addiction services discussed the initial research findings in order to confirm or refute there credibility.
The findings revealed three emergent core categories that support female maintenance in recovery: 1) thought changes, including towards alcohol, towards self and towards life; 2) lifestyle changes, consisting of keeping busy and aspects of self-improvement; 3) supportive networks, encompassing building appropriate social networks and the importance of recovery support. Subsequently, an emergent grounded theory of female maintenance in recovery from addiction was developed (Appendix A).
The findings served to highlight some relevant areas wherein changes could be made to service development and implementation in order to best meet the specific needs of this client group, thus facilitating long and stable recovery. This study suggests a move away from the acute treatment model for addiction of brier, time-limited therapy, towards a model of sustained, on-going and life-long recovery management. This article suggests a perspective on recovery that supports a process of second-order change; that is, change that shifts beyond managing addictive thoughts and behaviours and challenges the client to re-examine and re-define aspects of their identity.
Historically, research and treatment models for alcohol addiction and alcohol-use disorders (AUDs) have been based on a male model. Service organisation and treatment provision were tailored to meet the needs of men and substance abuse was generally considered a male problem. It is only more recently that female rates of substance misuse have reached a level similar to those of men (2,3). Consequently, researchers have begun to recognise the importance of understanding and meeting the specific needs of women with AUDs.
It is estimated that women currently make up one-third of the UK population with alcohol-related problems; nearly half of those have problems with additional substances (4,5). Women who encounter problems with alcohol use report symptoms of greater severity and experience substantially greater health-related consequences when compared to men (6). In addition, research suggests that women’s alcohol-use related problems appear to interfere with effective functionality in more areas of life than men’s (7). Statistically, women are older than men when they develop a pattern of regular and harmful alcohol use. However, once this pattern has become established, women tend to encounter problems with greater rapidity and intensity than men (2).
Women are more likely to encounter barriers that prevent them from seeking support from relevant services or from maintaining their recovery upon commencement of treatment (6,8). Reasons cited by women as likely to prevent them from seeking or maintaining treatment include: family responsibilities, shame and guilt, and co-occurring mental illness (6). Recent research suggests that women experiencing AUD’s are less likely to enter treatment when compared to their male counterparts. Additionally, it has been suggested that women are almost twice as likely to withdraw from treatment when compared to men (9).
This research identifies women as a resource of valuable information regarding the maintenance of recovery from addiction to alcohol and how women may come to understand and define their recovery. The aim of this study was to explore the lived-experiences of women who have maintained their recover, in excess of six months, in order to gain an understanding as to how recovery is viewed and to determine the processes that have enabled them to achieve the transition from alcohol dependence to maintenance in recovery. The research question asked how chronic alcohol-dependent women in recovery experienced the transition from alcohol dependence into recovery, and how they understand and maintain their recovery.
This study has served to further highlight the integral nature and importance of identity change in individuals who successfully navigate the transition from addiction to recovery, with particular reference to the maintenance stage. Each of the women who took part in this research described the changes that they had made in the way that they thought about their addiction, their addictive behaviours and the subsequent consequences of each. As part of this process it would seem that they each developed a renewed sense of identity consisting of alternative perspectives, lifestyle choices and effective support networks which may be regarded as ‘second-order changes’.
Second-order change affects how a person experiences and makes sense of their world, their relationships and their experiences, including how they come to comprehend themselves. During the maintenance stage of recovery, clients are likely to be more responsive to supportive therapeutic interventions due to the stability of their abstinence (6). Therefore, once the client has reached this stage appropriate support structures should aim to scaffold the client in experiencing and maintaining behavioural change.
Addictions treatment is often a frustrating process as progress is often thwarted by lapse or relapse and clients may feel demoralised by the very repetitious nature of such a process (10). It has been suggested that clients who struggle with chronic alcohol addiction issues may persist in a cycle of substance use, treatment, recovery, and relapse for over a decade (10). Consequently, services are potentially faced with multiple treatment admissions. This article suggests that support in thought and behaviour modification is just the beginning, not the end point of the process of recovery. Professionals working in the recovery field should be acutely aware of the changes in thoughts and behaviours as well as the potential for exponential growth in other areas of the client’s lives that may help them to maintain those changes and enter long-term, stable recovery.
This study has elected to employ a qualitative, grounded theory approach (11,12) as it has been suggested that qualitative approaches may more accurately and successfully reveal the ‘lived experience’ of addiction and recovery through the rich narrative of participants (13). This study aims to develop a protocol/model for successful support in the maintenance stage of recovery from alcohol addiction, resulting in more effective counselling and therapeutic intervention. Consequently, qualitative research is particularly appropriate for exploratory work that is inductive and aimed at gathering rich and descriptive information upon which theory may be built (14).
Grounded theory is a methodological approach that has previously been employed in the area of addiction in the development of treatment plans for problem gambling (15) and in raising the profile of the lesbian population in the field of substance misuse (16). The aforementioned studies and the majority of qualitative studies in psychology have used interview data as the central method of data collection (17). Given the context of addiction and recovery and, as has been noted in previous studies, solely verbal accounts can elicit responses that couch the subjective experiences of the participants in the language of the recovery setting or group dynamic in which they are engaging (18,19). In this study, one of the key aims is to explore the extent to which the use of photographic representation may enrich and complement material gained through the interview process.
A constructivist grounded theory analysis was conducted of ten female participants’ (Mage=33 years, SD=8 years, age range: 21-46) descriptions of their life-experiences in terms of the transition from consuming harmful levels of alcohol, to addiction, moving into recovery and maintenance which was delineated as being longer than six months. Participants were not required to have met any medically assessed or recognised diagnostic criteria, but were self-identified as being chronically dependent upon alcohol over a prolonged period of time (in excess of six years). The main aims of this research were to capture and develop a deeper understanding of the views and experiences of women who perceived themselves as being in recovery from addiction, while offering suggestions for service development and implementation.
Participants were recruited from a voluntary drug and alcohol service in the North East of England which offers an initial assessment followed by group and one to one recovery and motivationally organised sessions; the aims of these being to develop self-reliance and empowerment through psycho-education and cognitive-behavioural interventions. All of the participants had abstained from the consumption of alcohol for at least six months having previously described themselves as ‘alcoholic’ or ‘addicted to alcohol.’ Participants were selected using purposive sampling in order to focus on the particular characteristics of this specific group. The nature of purposive sampling in this case was extreme or deviant sampling thus providing insight into the phenomenon of addiction and recovery through the unique lens of the addict in recovery.
Participants were asked to capture ten images that represented aspects of addiction and/or recovery which held significance for them. Given the availability and prevalence of photographic devices in the form of mobile phones, tablets and digital cameras, participants were given freedom of choice regarding the type of instrument that they used to gain their images. This proved to be problematic for one participant who was provided with a digital camera for the duration of the study. Participants were given complete autonomy over image selection which allowed them to explore their uniquely subjective experience of maintenance in recovery without the potential for data pollution due to researcher bias.
Participant-led photo-elicitation interviews were conducted in a private therapy room at the drug and alcohol service utilised throughout this study at a time that was most convenient for the client. Each interview lasted between 42 and 63 minutes with a mean length of 46 minutes. Images captured by the participants were collated and printed by the author; these were then used to form the basis of the semi-structured interview process. Interviews were conducted when participants were in the maintenance stage of their recovery through self-report and/or as identified by their professional case worker. The images were discussed in the order in which they were captured as this was conducive to reflecting the process of recovery that the participant had experienced thus far. Participants were asked to explain to the researcher what each photograph represented and the reasons for its inclusion in the data set. Each interview was recorded via Dictaphone and transcribed verbatim by the researcher. During initial data analysis, each transcript was analysed by an independent colleague who had no vested interest in the outcomes of the research.
The key findings from this study were presented verbally in summative form to a focus group comprised of five professionals working in the substance misuse field (service manager, assistant psychologist, social worker, recovery coach, voluntary counsellor). The individuals who participated in the focus group had not been part of the individual interview process. During the focus group, participants were encouraged to openly discuss and debate the findings and to contribute their subjective perspectives and opinions from both a professional and personal standpoint. The focus group lasted 1 hour and was facilitated by the researcher. The focus group was recorded via Dictaphone and transcribed verbatim to facilitate a thematic analysis (20); during the discussion, the researcher collated brief notes in order to capture any emergent themes.
In adherence to grounded theory procedures, data analysis began after the initial interview and continued in an iterative manner until all of the interviews had been completed (21). Following the interview process, the researcher reflected on the content of the session and made notes of any initial emergent themes or concepts that could be explored in subsequent interviews. In order to begin the process of categorical identification, the author began with initial line-by-line open coding to identify concepts, their properties and dimensions. The raw interview data was broken down and assigned a descriptive label which was referred to as a code. Each code was extracted and compared with other codes to determine potential similarities and highlight differences. Codes with similar meanings were linked together to create concepts that form the foundations of the emergent grounded theory. As an example, data that was coded as pertaining to ‘lifestyle change’ were examined to ascertain ‘best fit’ under separate categories of lifestyle change. As data analysis progressed, a greater number of categories were identified, and through a process of constant comparative analysis, were either assigned to an existing category based on similarities to the concepts in that category or formed the basis of an emergent (new) category. Each category was given a descriptive label that referred to the core nature of conceptual data in order to assist in the process of categorisation.
As key concepts were identified, data analysis evolved to focus on axial coding, which involves reassembling the data in order to identify relationships between the open codes (21). Concepts that were identified during the process of open coding were refined into potential sub-categories that provide a more complete explanation of the processes involved in maintaining recovery from alcohol addiction that eventually provided the foundation for emergent core theoretical categories. Throughout the process of axial coding, the data was continuously compared and contrasted with previous data sets. The final stage of data analysis consisted of selective coding wherein key themes were established as the core categories with lower-order sub-categories integrated and arranged to explain and support the concepts that emerged from the initial open coding procedure (21).
A range of tools were used in order to ensure methodological rigour as well as support the process of data analysis. The author kept analytic memos and a reflexive journal in order to record subjective developments in understanding and interpretation of the data. It has been suggested that memo writing is fundamental in helping researchers to organise their thoughts and reactions to the data as well as aiding in understanding through encouraging reflexivity, clarification, category saturation, and concept development (22). The researcher also used diagrams which served to visually represent the data and emerging themes throughout the process of data-analysis which allowed the author to think theoretically rather than descriptively. A thorough literature review was also delayed in order to foster a more inductive research approach and, once the initial data collection and analysis were completed, an exhaustive literature review was conducted to further inform and illuminate data analysis and subsequent interpretation (22).
Three core categories were identified following data analysis: changes in thought, lifestyle changes, and developing supportive networks. The themes that emerged during the analysis were organised into a hierarchical system and were presented as: core categories, sub-categories and concepts. A diagrammatical representation of the relationships between the three core categories, seven categories and thirty three concepts are presented in figure 1.
Core category 1: Thought changes
Each of the participants described the changes in thought that had taken place during the maintenance phase of their recovery. The core category of ‘thought changes’ was further supported by three sub categories: ‘towards alcohol’, ‘towards self’ and, ‘towards life’. The women discussed how they had had come to think differently about alcohol through learning about and coping with their cravings for continued alcohol use. The women each described how they felt that they could now face the world and make decisions more effectively while in sobriety. These shifts in perspective had allowed the women to maintain their recovery as they had gained insight into the consequences of their continued alcohol consumption and had made a conscious decision to change. Many of the participants provided examples of a projected, future self that appeared as separate and distinct from the person that they had once been. All of the participants could envisage a future and although many could not describe this potential future in detail, they were all adamant that alcohol would still have no place in their lives. When participants described the chaotic events that were predominantly linked to their historic drinking habits there appeared to be a loss or lack of control, which at this stage in their recovery they had begun to reclaim.
Claire: Things are actually starting to turn around. It’s been slow and more often than not it’s been painful. But you know what? My future is mine. It’s up to me and there’s no drink making the choices for me. I’m filling my life with other things. I can see a future now and I’m sober and surrounded by the things that matter like family and friends. The future for me isn’t about stuff anymore and having material things. It’s about making better choices and making happier memories.
Each of the women described a number of changes that had occurred in the way that they viewed themselves. They stated that theses altered perspectives had contributed to their ability to maintain their recovery from addiction to alcohol. They discussed how they had come to accept the past through learning about self and self-forgiveness and how they had developed improved levels of self-esteem through recognising the achievements that they had made in recovery and beyond.
Core category 2: Lifestyle changes
Each of the participants explained how they had instigated a range of lifestyle adaptations that they believed were pertinent in maintaining their recovery from alcohol addiction. Two sub-categories emerged from the data analysis: ‘keeping busy’, and, ‘self-improvement’.
Each of the women described the importance of avoiding boredom as part of successfully maintaining their recovery; where previously their addictive thoughts and behaviours had consumed their daily lives they now chose to fill the void of addiction with more productive activities. They also talked about wanting to feel ‘of use’ and to have purpose in their lives as well as highlighting the notion that this had provided them with an enhanced sense of identity and self-worth. Interestingly, many of the participants had taken up hobbies and pastimes that were new and not related to their previous alcoholic lives and many of these activities involved creative or physical activity with a focus on the self and renewed identity. Many of the women discussed the ways in which they had improved their sense of self while in the maintenance stage of recovery. They described an enhanced sense of concern with regard to their health; they had elected to eat more healthily while generally looking after themselves with greater care.
Some of the women discussed training or further education opportunities that they were interested in pursuing and how such opportunities had assisted in filling their time more productively as well as enhancing their sense of self-worth.
Lisa: I think you need to have a goal, something to set your sights on and to aim for. I go to college now and the end point for that will be to get back into work. These are the things that keep me focussed and push me forwards.
Every participant discussed how they would like to use their experiences of recovery to offer support to those who may find themselves in a similar situation. Many were engaged in voluntary activities linked to the drug and alcohol service as they hoped to gain further knowledge and experience in the addictions field. This not only allowed them to remain active, but also provided them with a range of meaningful and fulfilling options and opportunities that helped maintain their recovery.
Core category 3: Supportive networks
Participants described the importance of developing and maintaining supportive networks in order for them to more successfully maintain their recovery. Two sub-categories were identified during the data analysis: ‘building social-networks’, and ‘recovery support.’
All of the women described the different challenges that they had faced when choosing to leave behind previous social networks when they entered recovery. Many of their historic networks had served to actively support their alcoholic behaviours and in leaving these behind, many of the participants felt an intense sense of abandonment and isolation. During the maintenance phase of recovery, the women discussed the problems that they had initially faced when attempting to form new bonds and friendships with non-alcoholics and non-drinkers. The women described feeling culturally at odds with those around them and feeling and this was something that they all described as being difficult to come to terms with. However, the women all described a sense of pride in the efforts that they had made to improve their relationships with family and friends and in the improvements that this had made to their lives and to the lives of others around them.
Louise: It’s a different world for me now. I have a relationship with my family that I didn’t think I’d ever get back. My mam speaks to me and we go out and have lunch together at least once a week and that’s pretty amazing since we didn’t speak to each other for more than a year. I see my brother now and that’s the best. He’s got kids and I get to spend time with them all together. It’s like having a family for the first time since I don’t know when.
While all of the women recognised the importance of gaining support during their recovery, some highlighted the challenges that they faced when being open about their problems. Challenges included a sense of shame and guilt as well as fear of judgement and concern that they would lose their children. Having struggled to overcome these barriers, they all felt empowered by the fact that they had entered recovery and managed to maintain their sobriety.
Each of the participants described how they had valued the support provided by other women in recovery which included a sense of shared experience, a lack of judgement and learning from one another. A sense of similarity was discussed by all of the women as they highlighted the importance of recognising that they were not suffering in isolation, but there were others who were experiencing the world in a similar way.
Following the initial phase of data collection and analysis, a focus group was organised and attended by five professionals, who currently work with people in recovery from alcohol misuse. The focus group met for one hour and the session was facilitated by the researcher. Participants were asked to debate three initial propositions that were developed from the initial core categories, sub-categories and concepts. The propositions were: 1) people in recovery who engage in meaningful activity are more likely to maintain their recovery, 2) people who are provided with support in developing positive social networks are more likely to maintain their recovery and, 3) people who are provided with psychological support to understand and deal with the consequences of their addiction are more likely to maintain their recovery. In summary, the participants from the initial focus group were supportive of the initial findings from the interview data and offered some suggestions for potential service development. For the purposes of this article a summative version of the focus group findings is available in figure 2.
Despite existing theories and scientific perspectives that have attempted to explore the experience of alcohol-use disorders, the decisions made by people as to why they choose to maintain their sobriety whilst in specialist programmes remains a subjective human experience; an experience that is wholly lived by the individual engaged in the process. It remains, that only a small percentage of women with AUD’s actually engage and remain within specialist services (23,24). Considering the low levels of engagement and retention in alcohol services, there is minimal research which explores the subjective reasons for this phenomenon, particularly when it comes to the views and experiences of women with AUD’s (25). This research provides valuable contributions to the existing literature and knowledge around the phenomenon of subjective female recovery.
This article explores the subjective experience of the maintenance stage of recovery from alcohol dependence within a specific socio-cultural context; the findings were brought together to develop a constructivist grounded theory of maintenance in recovery from alcohol addiction which is presented in figure 3. In an effort to ensure that all instances of potential variation were accounted for, the researcher spent a great deal of time immersed in the data. Constant comparison and negative case analysis were employed with regularity to continually create links between categories, sub-categories and concepts (22,26). A selection of potential models were considered and discussed with the research supervisor prior to final theory development. The author supports the view that this model successfully and succinctly draws together all of the key concepts that emerged from the process of data analysis.
The findings support the assumption that there are more commonalities than differences within female maintenance of recovery from alcohol addiction (6,10,27). The support of treatment services and self-help groups may be perceived as additional resources that serve to assist the individual in achieving stable, long-term recovery, particularly if similar resources are missing in daily life. Since one of the key aims for women in recovery would appear to be a societal re-integration, the input from professional services tends to be less important as women come to rely on other resources as they gradually become available outside of service provision.
Multiple maintenance factors and strategies that contribute to the stabilisation of recovery from alcohol addiction and AUD’s were identified. This study served to highlight the subjective relevance and interplay between factors and resources that influence maintenance in recovery. Recovery appears over time as an interaction between individual action, societal reaction and subsequent positive and negative life events.
The process of identity change during the maintenance stage of recovery is supported by this research. Current literature highlights the importance of constructing a new identity during the maintenance stage that is in contrast with the addict identity, coupled with an awareness and dissatisfaction with the addict identity (28,29). All of the women who took part in this study described the changes that they had made in the way that they thought about their addiction and its consequences. They each described a process in which they came to recognise their ‘damaged identity’ and subsequently they reclaimed or established a new substitute identity which could be built upon during the latter stages of recovery and re-integration.
The women who took part in this study had made a decision to access treatment services and initiate their recovery as a consequence of their addictive thoughts and behaviours. Their addict identity had reached a point of crisis with other competing identities such as being a mother, a carer or a wife. It was in learning to understand and more effectively cope with these consequences during the maintenance stage that each woman began to notice a positive shift in identity and self-worth. Their awareness of remaining sober began to impact on the way they interpreted and interacted with the world and others (2). Unresolved feelings of shame and a burgeoning awareness of guilt, through self-reflection, were no longer barriers to a successful life. Each of the women described an enhanced sense of self-efficacy and self-worth as they felt able to help others and effectively ‘give something back.’ These feelings not only increased their motivation to remain sober, but reduced the negative impact of self-internalisation. Following an assimilation of the concept of being and remaining sober, the women had learned to differentiate themselves from their addiction by regarding sobriety as a ‘quality of life’ choice. It would seem that if recovery maintenance is to be achievable and effective then women require a range of support structures: psychological support in managing conflicts of identity, support in developing and maintaining appropriate and effective support networks and support in initiating adaptive lifestyle choices.
This study is primarily limited by its sample size of ten participants (excluding focus group), which may have an impact on the generalisability of the findings (30). However, for a grounded theory study it is generally viewed appropriate to work with ten participants provided sufficient contextualisation has been provided (31). All of the participants reported that they had been in stable recovery and had not consumed alcohol for at least thirty days in the last six months. However, this research did not employ any formal measures to ensure that their self-reported levels of alcohol consumption were accurate at the time of interview. Although it should be noted that the overriding intention of this research was to gain a better understanding of the experiences of women in recovery and not to ascertain the authenticity of their addiction, future studies may consider the application of more stringent tests to accurately identify previous and current alcohol use.
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Figures and Tables
Figure 1 Core categories, sub-categories and concepts
Figure 2 Focus group findings
Proposition 1: People who partake in fulfilling and meaningful activity are more likely to maintain their recovery.
All of the members of the focus group supported this proposition.
Nikki: A lot of the people who come here often want a quick fix. In my experience it’s part of the alcoholic mind-set to always look to what’s next. Once they get beyond the confusion and gain more of a sense of who they are and what they want they see that there are so many other things that they could do with their time. Unless the alcohol is replaced by something else, then they often struggle. I think it’s also about taking on new activities that had no place when they were drinking. Something new and removed from alcohol.
David: Sometimes people start to question why they’ve bothered to do this, because stopping drinking has left a hole, a gap. The people who start to realise that they can do other things get better.
Proposition 2: People who are provided with support in developing positive social networks are more likely to maintain their recovery.
This was something that the members of the focus group strongly agreed with.
Amy: There’s a lot to learn for people in recovery. They may have lost contact with people whom they value in their lives. Establishing new relationships with friends and the wider community can be really powerful but it’s also about re-connecting with family again and developing trust and accepting yourself. Without those things I think it could be really difficult to move on.
Louise: I think a lot of the power comes from being among a set of people who understand and accept you for just being who you are. You’re not viewed as the bad person all of the time, but someone who is dealing with a problem in the best way that they can while trying to better themselves.
Proposition 3: People who are provided with psychological support to understand and deal with the consequences of their addiction are more likely to remain in recovery.
Megan: I know the pressure that services are under to just get people discharged as soon as they’ve stopped drinking for a few weeks, but that just doesn’t work. We try and work with people for a longer period of time so that they can get a better handle on stuff. The issues that they may not have had time to deal with are often the issues that are fuelling the need to drink in the first place and if they don’t get addressed then the chances are they’ll come back through those doors.
Each of the participants supported the suggestion that appropriate psychological support should be offered in order to meet the specific needs of the individual depending upon the stage of recovery that they are in.
Nikki: Psychological help needs to be at different levels. Sometimes people need help to cope with the day to day stuff and that seems to happen pretty early on in recovery. Like bills and sorting out social services. The deeper level stuff comes later in maintenance I’d say. We can look at the root causes of the addiction when people are ready and I think that’s fundamental. If we think about providing value as a service it’s about getting the timing of the psychological support right because it might support the cycle better and stop people going through the service just to come back again.
To conclude, the researcher felt that all of the propositions that were presented to the focus group were wholly supported.
Figure 3 Grounded theory of maintenance in recovery from alcohol addiction
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