Drug Abuse

Introduction

In 1987 I began working as a psychologist at a women's crisis centre in Amsterdam. Users of the centre were all female hard drug-users and, with a few exceptions, were also daily involved in prostitution. During my time at the Women Crisis Centre (in short: VKC), I discovered that these women were classed either as being untreatable, or as victims of a male-dominated society. Neither of these viewpoints was very helpful to the women themselves.

When I started at the VKC, I had only common sense knowledge about addiction and heroine prostitutes. I believed these women were indifferent to treatment and would never talk about their past or their feelings to a middle-class academic like myself. I was wrong. These women were just as ready to talk about the things that bothered them as were the patients I had treated in a regular psychiatric hospital in the city of Delft. Besides that, the female hard drug-user appeared to have a lot in common with the ordinary psychiatric patient. And yet she was never seen as such. She was seen as a drug addict, who was a prostitute into the bargain, and as such, untreatable.

This last presumption was challenged by the foundation of the VKC in 1987, a short term, in-patient crisis centre with a capacity for six women at a time. My experience of the VKC taught me that the female hard drug-user is not just a drug addict, she is a female drug addict, and that this makes a great deal of difference; being a female druguser, she is down-trodden in her social position even more than a male hard drug-user; furthermore not only is she addicted to drugs, she also suffers from severe psychological problems which were often pre-existent to the drug-use, and, last but not least, she has often experienced different sorts of childhood traumas to male drug-users. Women are four or five times more likely to be the victim of sexual abuse than men (Soman, 1991). It is this complicated nature of the female hard drug-user which needs to be taken into account if a relevant treatment model is to be provided. The aim of this present study is to investigate the psycho-social characteristics of female drug- users in order to ascertain whether or not it is possible to provide some suggestions for treatment of this 'untreatable' group.

Female-male differences

At the time we started this study of female drug-users they were categorized as "Extremely Problematic Drug-users", just like the male drug addicts who caused trouble on the streets of Amsterdam. They were referred to as the 'hard core' of female drugusers. Local authority of the city of Amsterdam estimates that some 400 women are 'hard core' female drug-users. There were several treatment programmes for this group, all of which were tailored to the drug addict - who was, not very surprisingly, supposed to be male. The VKC was the only centre which provided feminist therapy, albeit in a rather rudimentary form. Judging from the scientific literature, there was no good reason at all to put every drug addict, be it male or female, in the same box.

Research has shown that the problems of female hard drug- users are different from those faced by their male counterparts. Rosenbaum (1981) observed that female drugusers cite family problems as a reason for becoming addicted; few male drug-users give a similar reason. She also found in her study of female hard drug-users that more than twice as many women as men became dependent on heroine after initial use, and moreover, that women proceeded more swiftly to regular daily use than men.

Contrary to what is known about male drug-users, female hard drug-users often have a history of childhood physical and sexual abuse (Cohen & Densen-Gerber, 1982, Roshenow et al., 1988, Silbert & Pines, 1981). It seems that they often use hard drugs as a way of providing relief from painful feelings; they use drugs as a way - albeit an ineffective one - of coping with problems, conflicts concerning gender-identity and negative effects of childhood traumas.

It is not only with regard to childhood traumas that female drug-users differ from male hard drug-users; they also differ with regard to the route to addiction. Researchers (Hser et al., 1987) maintain that the initial use of heroine by a woman is highly influenced by a man, especially a sexual partner, who is often a daily heroine user. Men also start using drugs because male-friends use them, though they never report a spouse or partner's use of drugs as a reason why they began to use drugs (Hser et al, 1987).

Moreover, female and male hard drug-users have a completely different life-style. More than three-quarters of hard drug using women are involved in prostitution as a way of buying drugs (Keesmaat, 1989); the majority of male drug-users gain money through dealing, theft, burglary, fraud and other criminal offences (Swierstra, 1990). According to Grapendaal, Leuw and Nelen (1991), more than half of the drug-users had already committed a criminal offence before they became addicted, 28% became criminals after they had become addicted and a minority of 21% did not commit any crimes.

Because women are involved in prostitution, they do not take part in criminal activities on a large scale. The economics of hard drug-use, e.g. prostitution, vastly influence the way a female hard drug-user lives. For instance, if she has no access to an area where prostitution is tolerated she will be harassed by the police and exposed to danger from her clients.

Research also indicates that women drug-users suffer from more health and dental problems than their male counterparts (Rosenbaum & Murphy, 1987).

Researchers (Ettore, 1992, Reed, 1987, Beschner & Thompson, 1981) observe that present substance abuse treatment programmes and the current perspective on addiction - as illness with important psycho-social aspects (Leuw, 1991) - are resistant to the notion of gender as well as to an approach sensitive to the needs of women. Some researchers (e.g. Beschner & Thompson 1981) suppose that treatment centres lack the knowledge, skills and motivation to provide women-oriented services. Reed (1987) however does not totally agree with this opinion:

While this may be the case in many instances, a more fundamental obstacle has been the failure to recognize how much existing intervention models and treatment organizations were designed for men.

Because there are many differences between male and female drug-users, it is important to investigate the psycho-social characteristics of the female drug-users, the differences and the heterogeneity among them as group.

Outline

It used to be impossible for the traditional drug dependence treatment programmes to reach and treat the group of female hard drug-users, lacking as they did an approach sensitive to the women's needs. The VKC was founded in 1987 in order to reach this target group and to motivate them for treatment. We started to study what kind of psycho-social characteristics the group presented, what kind of social position they occupied, what the function was of female hard drug-use, what kind of background these women had, what kind of childhood traumas they had experienced and what kind of psychopathology they suffered from.

From the beginning it was clear that, in order to gain the research data, a women sensitive approach was needed. The so-called objective psychological questionnaires or diagnostic interviews could not provide data concerning paths to addiction and prostitution, childhood experiences and traumas and women's social position. Moreover, as Van de Berg & Blom (1987) also point out, in the case of female hard drug-users, the traditional methods that could normally be applied to analyze a group or a subculture fail, because they do not form a subculture or a group; they form, rather, a disjointed gathering of separate individuals, all of them working alone and living in social isolation. Van de Berg & Blom turned to the separate life-histories of the individual women in order to gain some insight in their motives and important decisions.

In the present study I have combined data-gathering based on individual life-histories with more objective, empirical research. The present study is, therefore, divided into two parts: the first part consisting of a qualitative analysis of data which is based on life-histories and semi-structured interview and the second part consisting of a quantitative analysis of scores on psychological questionnaires, of data obtained from the semi- structured interview and of data from the diagnostic interview.

The first part of present study explores the following questions:

1.   What are the background characteristics of female hard drug-users in general; what are their particular routes to addiction and prostitution, what kind of drugs do they use, what kind of prostitution are they involved in and how might the legal context of drugs and prostitution be defined? (chapter one)

2.   How might a general framework of female drug-use be developed from a gender perspective? (chapter two)

3.   How do the background characteristics of the research subject compare to the data of female drug-users in general? (chapter three)

4.   Applying the general framework developed in chapter two, which kind of survival strategies might be discerned among the research subjects? (chapter four)

I shall begin by considering at close hand the first part of the present study and subsequently explain the second part of the study as well as the research questions of the second part.

First part of this study

The first part of this study consists of background characteristics, a general framework of female drug-use and an application of these two angles in the chapters three and four to the group of female hard drug-users that were treated between June 1988 and August 1989 in the VKC.

The first chapter is divided into the following subsections. First, the chapter starts with a general description of female drug-users' demographic characteristics, based on the data of a survey among 202 male and female drug- users (Korf & Hoogenhout, 1990). Second, in order to gain an insight into the process of getting addicted and becoming a prostitute, I describe the diverse routes to prostitution and addiction, which are published by Van de Berg & Blom in their study of heroine prostitutes (Van de Berg & Blom, 1987).

Drug-use and prostitution form the focus of the life of the so-called hard-core female drug-user. I describe the drug-use, based on the survey by Korf & Hoogenhout (1990). In addition to drug-use I describe prostitution, the difference between a "common" prostitute and a streetwalker and also the risk of AIDS. The data is based on literature (Vanwesenbeeck et al., 1989, Keesmaat, 1989, James & Meyerding, 1977, James, 1980, Day & Ward, 1990, Hoek et al, 1989, 1990, Hartgers, 1992).

The main part of the life of the female hard drug-users takes place on the wrong side of the law. For this reason I found it necessary to discuss the legal context of drugs (Baanders, 1989, Grapendual et al., 1991, Swierstra, 1990, Derks & Hoekstra, 1991) and prostitution (Haveman & Wijers, 1992, Altink, 1992, Hes, 1992).

chapter two is devoted to a gender perspective on female drug-use. This is necessary because current perspectives on addiction - be they biological, psychoanalytical or psychological- do not consider the notion of gender (Berrigde & Edwards, 1987, Dole & Nyswander, 1965, 1980, Walburg, 1980, Derks & Hoekstra, 1991, Stanton & Todd, 1982, Meyer, 1986). The notion of 'gender' as recently developed in women studies and post-structuralism points to the symbolic female-male difference. The idea of 'gender' relates to the historical and cultural dimension of the distinction between the sexes (Nicolai, 1992 a). I have tried to develop a gender perspective on female drug-use by borrowing data for a general context of female gender identity (Kaplan, 1991).

Kaplan (1991), a leading American psychoanalyst, has made a study of perversion as an expression of pathology of gender within the social context of patriarchal society. Traditionally, the concept of perversion is applied to bizarre or unusual sexual behaviour by males. Less than one percent of the cases cited as sexual perversion have been of females (Kaplan, 1991). However, with another understanding of the idea of perversion - perversion not only as an expression of pathology of sexuality, but also of gender-pathology - the female perversion is born. In the case of male perversions, the spotlight is on sexuality, but behind the idol of masculinity are unconscious forbidden wishes to be a passive, submissive, denigrated woman, humiliated by a dominating force, the law, or the phallus of the father. Male exhibitionists show their genital, exhibit their power with the purpose of keeping other feelings of inferiority, of castration anxiety at bay.

Kaplan supposes that women's psychological disorders reflect pathologies of gender identities. Gender-identity points to the individual way a woman experiences the female-male difference, her history of socialisation in a male-dominated society and her individual identification with social gender stereotypes. The pathologies of gender identities come into being when a woman fails to cope effectively with childhood traumas and can only survive by enlisting social gender stereotypes and identifying strongly with feminine virtues such as passivity, cleanliness, purity, kindness, concern for others and submission. An example of this extreme identification with feminine virtues is the anorectic woman. Contrarily, the prostitute is an example of rejection of feminine virtues. Resistance against social stereotyping and identification show the same process: social gender identity determines the gender identity of an individual woman.

Women use psychological strategies that enlist social gender stereotypes as a way of surviving childhood traumas. These perverse strategies have nothing to do with kinky sex (for example fetishism as a male perversion), but result from a combination of a social gender stereotype of femininity and a personal solution to childhood trauma. I will briefly illustrate this rather abstract theory with an example. Kaplan herself leaves drug-use aside, but she does briefly comment on prostitution, saying something about the kinship between frigidity and prostitution, referring to a paper by Abraham (1920) on the female castration complex. Although she does not refer to prostitution in the context of drug-use, her example of the kinship of prostitution and frigidity makes clear what, in her view, is a perverse strategy. Kaplan:

By taking the active, dominating role and appearing to care about sex as much as or even more than a man, the prostitute, who is typically frigid despite her outward appearance of active sexual interest, is making conscious what is unconscious in her proper, middle-class sisters - the wish to be more than a man and more sexually potent than a man.(p.180)

Kaplan concludes that frigidity concerns a frustration of masculine wishes and penis envy to be sure, but is also about the anxiety of exhibiting active sexual desire in a male-dominated society. Between parentheses it could be remarked that Kaplan does not refer - as others do - to women who are sexually abused as a child and later become a prostitute. She does not include in her psychoanalytical theory the perspective of dissociation as part of the negative psychological after-effects of traumatic events.

chapter three is devoted to the question of whether or not the general characteristics presented in chapter one also apply to the group of female drug-users in treatment. The chapter describes the characteristic features of the female hard drug-users in treatment, the route to addiction and prostitution, drug-use, and prostitution in relation to the general data of samples of women who use hard drugs. This chapter gives insight into the question of whether the research subjects present a special group of female hard drug- users or whether they could be seen as representative of the general group of female hard drug-users. The research is based on the individual life histories of the 52 research subjects, the semi-structured interview (see appendix two) and the data that was standardly gathered at admission.

In chapter four I consider at close hand what the coping strategies are within the general framework of female hard drug-use as a female perversion. The point of departure is that two important gender identity conflicts occur in women's lives that could be related to women's drug-use: the conflict of whether or not to adapt to social gender stereotypes and the conflict of whether or not one is in control of one's own life. These gender identity conflicts can result in four strategies that will be illustrated with case material.

Second part of this study: the empirical research

In the empirical research part I investigate the kind of childhood traumas the research subjects were subjected to and the psychopathology that exists among the research subjects. The relationship between sexual abuse and prostitution has already been the subject of research (Silbert & Pines, 1983, James & Meyerding, 1977). Some authors mention that female drug addicts have a history of childhood sexual abuse (Carson, Coucil & Volk, 1988, Cohen & Densen-Gerber, 1982, Roshenow 1988, Corbett & Devine, 1988, Schaap, 1988).

There is considerable evidence to suggest that drug-users - male and female - suffer some kind of psychiatric disorder.

Rounsaville (1982) showed that a psychiatric disorder could be detected among 70% of the drug addicts. Mclellan et al. (1984) demonstrated that the severity of psychiatric illness could predict treatment outcome. Recent American research among substance abusers (Rounsaville et al. 1982; Ross et al. 1988; Khantzian and Treece, 1985) diagnoses mostly affective disorders (40 to 60%) and anxiety disorders (10 to 17%).

Dutch research among 203 drug-users found that 37.5% of the subjects experienced anxiety disorders and 15% affective disorders (Van Limbeek et al., 1991). In research among 152 drug-users resident at a detoxification clinic Hendriks (1990) diagnosed that 60% was suffering from a personality disorder (an anti-social personality), 37% was depressed, 25% had agoraphobia, 26% a social phobia and 18% a panic disorder. There are three possible hypotheses for the co-existence of drug-use, prostitution and psychological complaints.

The first hypothesis considers the question whether or not psychiatric disorders follow or precede drug-use or whether there is no relation between psychopathology and drug-use. This first hypothesis is subdivided into the following five possible relationships. Psychiatric disorders precede drug-use (Khantzian, 1985), pre-existing psychopathology is a risk factor and drugs may be used as a kind of self-medication; psychiatric disorders emerge as a consequence of addiction (Weissman et al, 1977; Grant et al., 1978; psychopathology modifies the course of an addictive disorder; psychopathological conditions occur in addicted individuals with no greater frequency than in the general population, suggesting that the psychiatric disorder and the addictive disorder are not specifically related.

The second hypothesis is Kaplan's hypothesis. According to Kaplan (1991) pathologies of gender identity that are related to childhood traumas can cause different psychological strategies. Contrary to the first hypothesis, Kaplan presumes that women's psychological problems and complaints are related to their position within the social context of patriarchal society.

The third hypothesis supposes that psychological complaints (including drug-use and prostitution) are linked to sexual and/or physical childhood traumas (Carson, Coucil & Volk, 1988, Cohen & Densen-Gerber, 1982, Roshenow 1988, Corbett & Devine, 1988, Schaap, 1988).

According to Meyer (1986), who classified the possible relationships (and one non relationship) between psychopathology and addictive disorders as summarized in hypothesis one above, the relationship between psychopathology and addiction is another example of the Chicken and the Egg. No one has as yet produced the final statement about this issue.

I have chosen a conceptual framework that aims to understand addiction as a survival strategy. This viewpoint does not exclude any one of the above possible relationships between addiction and psychopathology. Female drug-use is to be understood within the context of women's socialization, gender-identity and social position. I will therefore focus on explanation two, that connects addiction to childhood traumas and gender-identity. Hypothesis two includes hypothesis three, in the sense that psychological complaints can be subsumed under the category 'psychological strategies' and physical and sexual abuse under the category 'childhood traumas'.

Research design

In the present study female drug-use is understood as a psychological strategy to enlist the use of social gender stereotypes in order to survive childhood traumas. In the second part of the present study I investigate the childhood traumas experienced by the research subjects as well as the psychopathology (besides addiction) found among them. Furthermore I shall investigate whether or not childhood traumas and psychopathology could be used as categories to divide the group of research subjects into subgroups. Since the entire group of female hard drug users at the VKC was initially regarded as being untreatable, I found it worthwhile to analyze whether some women among them were easier to motivate to undergo treatment, or whether some women were in need of other treatment services other than those the VKC could supply.

I would like to emphasize that this study is not a treatment-effectivity study. It is much too early to measure the treatment outcome of the Women Crisis Centre. The goal of this study is to explore the characteristics of female hard drug- users, to understand female drug-use, to describe the characteristics of female drug-users in treatment, to analyze the relationship between psycho-diagnostic variables, childhood traumas and treatment needs and where possible to give some recommendations for treatment services.

The empirical research took place between June 1988 and August 1989, with a follow-up measurement in August 1990. The research subjects (n=52) are women who use hard drugs and are involved in prostitution. They were admitted to the VKC between June 1988 and August 1989, because they had been heavily addicted to hard drugs over a prolonged period and were in crisis.

The goals of the VKC in 1987 were to give shelter, offer crisis-intervention and refer women to treatment centres.

Because referral to other centres was only possible when women were both in need of and motivated to undergo treatment I investigated whether childhood traumas and psychopathology predicted the treatment needs of the women. My clinical impression was that women who had, for example, experienced the childhood trauma of incest and also suffered from posttraumatic stress disorder returned to the VKC more quickly than women who had experienced other traumatic events and presented a different psychopathology. In the statistical analysis I used the following as outcome variables: 'time between discharge and first re-admission within one year' and 'number of readmissions within one year'. These variables are supposed to indicate the treatment needs of the women who stayed at the Crisis Centre. The variables of 'childhood traumas' and 'psychopathology' are used as predictor variables. The prediction analysis is based on the statistical method of multiple regression analysis (see chapter five, the methods section).

The variables of childhood trauma and psychopathology were measured at the time of the client's admittance by making an inventory of childhood traumas and by administering psychological questionnaires (Beck Depression Inventory (BDI) and Symptoms Check List (SCL-90)) and making a diagnosis.

Initially I tried to measure the improvement of the clients by administering the same psychological questionnaires (BDI and SCL-90) upon discharge. This research design failed, because almost half of the group of female drug-users did not feel motivated to fill out questionnaires at the moment of discharge. Sometimes they also had to leave in a hurry or were forced to leave because, for example, they had used hard drugs in the building.

As mentioned above, I also chose two other outcome variables: 'time between discharge and first re-admission' and 'number of re-admissions'. The advantage of these outcome variables is that they could always be registered, regardless of whether a women left in a hurry, was forced to leave or otherwise. Another advantage is that these variables may also provide an impression of the treatment needs of a female drug-user. For instance, if a female drug-user quickly returns to the VKC after discharge, she makes clear that she is in need of further treatment and is not able to cope with her problems without the VKC's support. A speedy return to the VKC and a number of readmissions within a year might indicate motivation for further treatment.

In the present study 'crisis intervention', operationalized as 'length of stay at the VKC' is statistically conceived as an interacting variable.

The second part of the present study investigated the following questions:

1.   What is the frequency of the childhood traumas among the research subjects, what is the average number of childhood traumas they have experienced, and what are the predictive qualities of the childhood traumas, separately and in total? (chapter five)

2.   What kind of psychopathology is found among the research subjects and what are the predictive qualities of the different psychological variables, separately and in total? (chapter six)

3.   Is there evidence for cohesion between childhood traumas and psychopathology and what are the relative predictive qualities of the separate variables and the two sets of variables as a whole? (chapter six)

The investigation into the occurrence of childhood traumas and psychopathology is based on 52 research subjects admitted to the VKC between June 1988 and August 1989. The predictive analysis of childhood traumas and psychopathology refers only to those research subjects who are readmitted (n = 26) within a year after discharge (readmission before August 1990)

The research chapters devoted to childhood traumas and psychopathology give a brief overview of the relevant literature. This is followed by a research design. In the methods section the background characteristics of the subjects are given, the setting, the assessment and the procedure of data-gathering and data-analysis is explained. Next, the results are given and discussed.

Short comments

The chapters of the research part (chapters 5 and 6) have some overlap, because the methods of research are repeated in each research chapter.

Some of the results are typical for this group of women, who are chronically in crisis, use hard drugs and work as prostitutes and therefore are not representative for all women, or all female drug or substance users. However, some issues are part of every women's life, such as gender-identity, coping strategies, socialisation, childhood traumas, loss, dependency and pleasure.

The research setting VKC

In 1987 female drug therapists in Amsterdam took the initiative of developing a feminist crisis intervention centre for female hard drug-users (VKC). Their initiative was a response to recent treatment failures with this particular group. As I mentioned earlier, drug using prostitutes were seen as extremely problematic drug abusers, because they could not be reached and treated by the traditional drug dependence treatment programmes. The female drug therapists who took the initiative of developing a women's crisis centre founded the VKC based on women-oriented criteria as formulated by Reed (1987). Women-oriented drug dependent treatment services:

-   intend to address women's treatment needs;

-   reduce barriers to recovery from drug dependence that are more likely to occur for women;

-   deliver the services in a context that is compatible with women's styles and orientations and is safe from exploitation;

-   take into account women's roles, socialization and relative status in a larger culture. To illustrate the kind of problems the VKC is confronted with I shall conclude this introduction with the life-history of one of the first clients of the VKC.

Her story is typical for the women who are admitted to the Centre and it is this kind of story that inspired the foundation of the VKC.

Rosa's life history

A therapist of the 'Stichting Drugshulpverlening Amsterdam' referred Rosa, a 22 year old woman of foreign origin, to the VKC because she had recently been raped and physically abused. She was raped when sexual intercourse took place against her wishes. She had agreed to follow a man in his car and to satisfy him by hand. He took her far out of the city, raped her and manhandled her. Later, after she had gone to the police, they told her that the man was wanted for the murder of a heroine prostitute.

Rosa was very distressed. Why was she alive and the other woman dead? She is ashamed of herself. Why did this happen to her? At night she sleeps with the light on, straight up in bed She suffers from nightmares. During the day she reads violent comic books and watches television.

Rosa is on methadon-maintenance treatment. Prior to admission she used heroine and cocaine.

A deprived background

Rosa is a child from her father's second marriage. Her mother happens to be mentally ill and could not care for her. During the first year after she was born, she was taken care of by a female cousin. When this cousin departed for Canada, an aunt reared her. When Rosa was twelve, she returned to her father who had just entered his third marriage. Rosa stayed with him and his wife until she was fourteen.

When she was eight years old, Rosa witnessed her mother chasing her brother with an axe.

At the age of twelve, a class-mate tried to rape her. She was raped by an acquaintance when she was fourteen years old. Her father was adamant she should report the rape to the police, but she did not dare. Her brother, who knew the perpetrator, was in jail, awaiting trial for murder. He pleaded not to identify the perpetrator, because the perpetrator could betray him. After the rape, Rosa became ill and stayed in bed. Her half-sisters said to her: " You will like sex when you are older." What became of Rosa?

Rosa did not stay at home. Between the ages of fourteen and eighteen she lived with foster parents. At the age of eighteen she started using drugs and became homeless. Now, when I ask her about her future, she says: "a woman has three choices: she can either become a prostitute or she can go out stealing or she can seduce a man who is a dealer". Rosa feels she has no choice: she will always remain a victim. Her treatment need was to get some rest. After she got some rest, she departed She stayed for some time with a man and now and then she is readmitted. Only a low threshold programme is possible for her, because she refuses to give up drugs.

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