Once she got sober, Rocio De Alba began noticing women trying to stop drinking or using drugs everywhere she looked. She saw them on the news, interviewed in decrepit halfway houses. She saw them in documentaries, caught in alleys and corners dying for a fix — and dying to stop. She studied their close-ups in photo essays, their faces creased and spotted, roadmaps of their worst days.
None of them looked like the women Ms. De Alba met in her recovery meetings. Nor did they look like her — a fine art photographer and busy wife and mother, raising four children in Queens.
Ms. De Alba wanted to show the public what women in long-term recovery look like in the real world. Five years after she confronted her alcoholism, a scourge since her teens, she began to approach the women she knew from her meetings.
Did they mind if she celebrated their lives in recovery?
The answer is in Ms. De Alba’s color photo project, “There is a Crack in Everything,” four years in the making and still taking shape. Her essay of environmental portraits gathers women of all demographics who have been in recovery for at least 10 years.
For visual artists, a project like this is fraught with challenges. The recovering addict in a flea-bag hotel comes with a dramatic backdrop. The recovering addict working an office job, walking the dog, doing the dishes, not so much. Not to mention some women wanted anonymity, and others a degree of privacy.
Ms. De Alba, who studied painting and photography on her own for many years before graduating from the School of Visual Arts in 2007, has taken on photo projects where she is the subject, and spent seven years on one, “Miracle Baby,” that documents her stepson since he joined the family at age 2, after her husband gained full custody. Her approach sounds deceptively simple: empower her subjects and let the process drive the story.
Ms. De Alba discussed some of the artistic and thematic challenges of her ongoing project with Evelyn Nieves. Their interview has been edited.
How did you find your subjects?
First, I conducted interviews of fellow “sisters” who believed in my objective but, most importantly, live a fulfilling, productive life regardless of economic status, race, age or sexual orientation. The only criterion was they had to be sober for 10 years or more. It seems an independent yet miraculous transformation occurs within each woman during that time period. Not everyone reaches this milestone, and even if they do, without constant vigilance a relapse is almost inevitable — in fact, some of my subjects experienced repeated relapses and near-death experiences before they found solace in recovery.
Another way I found subjects was through the director of a halfway house. One woman I had my eye on for years was “Ms. Bailey,” revered in recovery circles as one of the longest-living sober women, since 1953. I tried for three years before she agreed to share her story with me. Last year I drove to meet with her in Boston and finally had the pleasure to photograph her.
Your project celebrates women who have made it to the other side, remaining sober for at least 10 years. Yet half the images in your series thus far do not reveal faces. Most identify your subjects with initials or partial names. Why?
During our photo session my main focus is for my subject to fully comprehend my intentions, which are to celebrate her and bring social awareness to the fact that genuine recovery is achievable and exists. But the project is a collaboration of sorts. Once they agree to share their story, I ask them to select a location for the shoot. Some choose a space that brings them peace and comfort. One subject wanted to be photographed in the last place where she woke up from in a drunken stupor. This information is strictly confidential and given to me at their discretion. The same goes with respect to anonymity. It is not my place to question why they want to remain anonymous. The decision is theirs, but I can guarantee you it’s not from shame, nor does it negate such accomplishments and relentless efforts to conquer their addiction and reach, as you said, “the other side.”
What do you intend to do with this project? Exhibit? Book?
First, I need to accumulate as many stories as I can. The challenge is locating the subjects. I have applied for grants so I can travel the country and expand the diversity of the women. I’m a firm believer that not every project needs to become a book. So for now I don’t envision that path. In a perfect world, I’d travel and photograph at least 100 subjects to complete the photo portion. I’d then produce a documentary where I follow one woman the entire first year of her recovery. I want to bring balance to my project so it shows both spectrums of addiction: the celebrations of long-term sobriety alongside the painstaking journey of a woman’s first year in recovery.
Can you describe the difficulties of remaining in recovery that make sobriety such a compelling subject?
I celebrated nine years of sobriety Dec. 29, 2016. I nurture my recovery like a newborn child. I attend a 12-step program, therapy, and practice unconventional forms of meditation or prayer. People who survive the claws of addiction are considered miracles, because long-term recoveries are rare and addiction is on the rise.
For me, it’s clear the odds are against us. Ten years of recovery is nothing compared to the millions who die. And there isn’t a deficit of imagemakers covering those stories thoroughly and with visually stunning images. It is the sporadic and humble success of my exemplars that inspires my recovery and this project.
Follow @nytimesphoto on Twitter. Rocio De Alba is also on Instagram. You can also find Lens on Facebook and Instagram.
Gender differences come into play when it comes to treatment for substance abuse. Just as each patient’s needs are unique, and a treatment program must be tailored to address those particular needs, attention also must be paid to the special needs of women. What works for men in treatment doesn’t always work the same way for women. Here’s a look at some of the different needs women have in substance abuse treatment.
Context is Important
Treatment experts agree that substance abuse treatment for women needs to be approached from the perspective that includes the context of the women’s lives. These include her relationships with family, extended family, and support systems, social and economic environment, and the impact of gender and culture.
The Substance Abuse and Mental Health Services Administration (SAMHSA)/Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocols address the specific needs of women in treatment for substance abuse in Treatment Improvement Protocol (TIP) 51. While certain elements of TIP 51 are summarized here, the complete TIP is available from the SAMHSA/CSAT website (//ncadistore.samhsa.gov/catalog/productDetails.aspx?ProductID=18244).
Core Principles of Gender-Responsive Treatment
Gender is an important clinical issue in substance abuse treatment for women. There are gender differences in the development and pattern of substance use disorders and differences in treatment approaches. Researchers note that these differences begin with early risk factors for substance use and continue throughout treatment and recovery.
Core principles of gender-responsive treatment for substance abuse include:
• Recognizing the role and significance of personal relationships in women’s lives.
• Addressing the unique health concerns of women.
• Acknowledging the importance and role of socioeconomic issues and differences among women.
• Promoting cultural competency that is specific to women.
• Endorsing a developmental perspective.
• Attending to the relevance and presence of various caregiver roles that women assume throughout their lives.
• Recognizing that culturally-ascribed roles and gender expectations affect society’s attitudes toward women with substance abuse.
• Adopting a trauma-informed perspective.
• Using a strengths-based treatment model for women.
• Incorporating an integrated and multidisciplinary treatment approach for women.
• Maintaining a gender-responsive treatment environment across all settings.
• Supporting development of gender competency specific to the issues of women.
Initiation of Substance Use
Many factors influence the reasons for women’s initiation of substance use. Some of these factors are more prevalent for women than for men. Stress, negative affect, and relationships often precipitate substance use for women. Women are often introduced to substance use by a boyfriend, family member or close friend. And, although genetics may be a significant risk factor in women’s substance abuse, more evidence points to a familial influence – a combination of the effects of environment and genetics. Parental alcohol use increases the prevalence of alcohol use disorders among women by at least 50 percent. Less is known about the familial influence of illicit drugs.
Other factors associated with initiation to substance abuse include living in a chaotic, argumentative, and violent household, and/or being expected to take on the responsibilities of an adult while still a child.
• Relationships – Women are particularly affected by relationships, the status of their relationships, and the effects of substance abuse by a partner. In fact, women who abuse substances are likely to have a partner who is also a substance abuser. Some women think of shared drug use as a means of communicating and/or connecting with their partners. Drug use rituals – such as sharing needles – are often initiated by males. These put women at risk of contracting HIV/AIDS and hepatitis through needle-sharing practices and by having unprotected sex with males who inject drugs. The status of a relationship also affects substance use and potential abuse. Married women are more protected against this risk, but separated, divorced, or never-married women are at greater risk. Relationships also influence women throughout treatment and recovery.
• Other risk factors – Among the other risk factors associated with substance use and abuse are sensation-seeking, anxiety and depression, eating disorders, posttraumatic stress, and difficulty in regulating effect. Women who have a substance use disorder often have a history of trauma, including interpersonal and childhood sexual abuse. Sociocultural issues affect risk for substance use and abuse. These include experiences of discrimination, degree of acculturation, and socioeconomic status. Not only are these risk factors prominent from the beginning of substance use, but they continue to influence women’s substance use, health status, help-seeking behavior, and access to treatment.
Women’s Patterns of Substance Use
Empirical data in TIP 51 identifies 6 patterns of women’s substance use”
1. The gender gap is narrowing across ethnicities for substance use – particularly among young women.
2. Women are more likely to be initiated to substance use through a significant relationship, while marriage plays a protective role.
3. Women accelerate to injecting drugs faster than men and the rituals and high-risk behavior surrounding substance use is directly influenced by their significant relationships.
4. The earlier patterns of use for women (initiation age, amount, and frequency), are positively associated with higher risks of dependency.
5. Women are more likely to alter their substance use pattern in response to their caregiver responsibilities.
6. Women progress faster from initiation of use to developing substance-related adverse consequences.
While more men than women are substance abusers, women are as likely as men to develop a substance use disorder after initiation. Pregnant women are more likely to abstain or reduce use during pregnancy, but continued use is associated with many issues, such as less prenatal care to the potentially irreparable harm to the child from fetal exposure. Women entering treatment most often cite drug use as the main reason for admission.
Physiological Effects of Substance Use on Women
Women develop substance use disorders faster than men. Factors that influence or compound the physiological effects of drug and alcohol use on women include co-occurring conditions, health disparity, aging, developmental issues, ethnicity, and socioeconomic status. Research on the physiological effects of alcohol and illicit drugs is fairly limited and often inconclusive, there are significant differences in the way men and women metabolize alcohol. Women both suffer more complications and severe problems from alcohol use than men, and these develop more rapidly. This process is called “telescoping.”
Complications include hypertension and other cardiac-related diseases, liver disease and damage to other organs, breast and other cancers, neurological and cognitive effects, reproductive consequences, and greater susceptibility to HIV/AIDs, hepatitis and other infections and infectious diseases.
Abuse of substances such as stimulants, opioids, and some prescription and over-the-counter drugs cause adverse effects on the woman’s menstrual cycle, gastrointestinal, cardiac, and neuromuscular systems, among others. Alcohol and drug use by pregnant women is associated with numerous complications: spontaneous abortion, prematurity, low birth weight, fetal abnormities, neonatal abstinence syndrome, and premature separation of the placenta from the uterine wall. Considerable research on alcohol use and pregnant women points out the significant risk of fetal alcohol syndrome (FAS), which involves growth retardation, central nervous system and neurodevelopmental abnormalities, and craniofacial abnormalities.
Special Needs for Screening and Assessment of Women
Screening and assessment are important aspects for the consideration of treatment for women with substance use disorders. In order to obtain an accurate diagnosis and determine successful treatment, it is essential to understand the nature and extent of the woman’s substance use and its interaction with other areas of her life.
Screening is typically a brief process for identifying whether certain conditions may exist and asking questions in order to determine if a more thorough evaluation and referral is needed. In addition to drug and alcohol screening, there is also screening for co-occurring risks, conditions, or disorders. These include general mental disorders, eating disorders, mood and anxiety disorders, risk of doing harm to self or others, and history of childhood trauma or interpersonal violence.
Assessment, on the other hand, involves a detailed examination of several areas in the woman’s life in order to diagnose substance use disorders and the possible presence of co-occurring disorders. Assessment is an ongoing process, during which the counselor forms a better picture over time of the client’s issues, how they can best be addressed, and her progress during treatment. Assessment processes should also include explore the woman’s strengths, coping styles, and available support systems. Assessment also requires a thorough health assessment and medical exam.
In both screening and assessment of women with substance use and/or co-occurring disorders, the affirmation of cultural relevance and strength is important. Counselors should be sensitive to the women’s cultural beliefs and values, acculturation level, language, level of literacy, and emotional ability to respond. This helps facilitate the assessment process and engage the women in treatment.
Women’s Treatment Challenges
Women face a number of challenges or obstacles to accessing treatment. These include the stigma of substance abuse, fear of loss of child custody, few resources for women with children, lack of collaboration among social service systems, lack of culturally congruent programming, and limited options for pregnant women. Counselors can help women to overcome personal barriers to treatment such as shame and motivation, but programming/administrative policies have to address obstacles around the program structure, coordination between agencies, and services delivery to improve treatment engagement.
Effective engagement strategies have been developed in recent years, including outreach services, pretreatment intervention groups, and comprehensive and coordinated case management.
Placing women in treatment for substance abuse also involves not only her needs and severity of the disorder, but also availability of treatment facilities in the area, her financial situation, and available healthcare coverage.
Treatment levels suggested by experts include:
• Pretreatment or early intervention
• Outpatient treatment
• Intensive outpatient treatment
• Residential and inpatient treatment
• Medically-managed intensive inpatient treatment
Specific placement criteria also have to take into account pregnancy, child placement, and children services. In addition to standard care, treatment services for women have to address women’s specific needs, pregnant women, and women with children – such as life skills, family- and child-related treatment services, medical and mental health services, comprehensive and coordinated case management, and health promotion.
Active involvement by the women in all aspects of the treatment planning and placement significantly enhance the likelihood of their recovery and empowerment.
Substance Abuse Treatment for Women
Research shows that women are just as likely as men to remain in treatment once it is initiated. However, factors that appear to encourage women to stay in treatment include a collaborative therapeutic alliance, supportive therapy, onsite child care and children services, and other integrated and comprehensive treatment services.
Other important factors that improve treatment retention include the support and participation of significant others, being older, and having at least a high school education. Women who have an involvement with the criminal justice system or child protective service are also more likely to remain in treatment.
Research is limited on specific therapeutic approaches for women, other than for trauma-informed services. Recently, however, more attention is being devoted to implementation of effective women’s treatment programs across systems, emphasizing integrated care and identifying women’s specific treatment issues and needs.
Clinical strategies, treatment programming, and administrative treatment policies have to address women’s specific issues in order to adequately treat them. Gender-responsive treatment must involve a safe and non-punitive environment where the staff holds a positive and hopeful attitude toward the women and show a commitment toward learning about the women’s treatment needs, experiences, and appropriate interventions. As research, programming, and clinical experience expand along gender lines in substance abuse treatment, there will be ongoing opportunities to adapt new standards of care for women.
Women and Continuing Care
Transitioning from a more intensive level of care (active treatment) to a less intensive level of care (aftercare or continuing care) is always challenging – whether the client is a man or a woman. Evidence shows, however, that women will continue with services if they are able to stay within the same agency or the agency makes an effort to connect them to the new service provider before the transition.
As for treatment outcomes, women have comparable abstinent rates with men and are just as likely to complete treatment. Women will, however, have more positive outcomes with respect to less incarceration, higher rates of employment, and more established recovery-oriented support systems.
Relapse rates between men and women don’t differ. It is more likely that individual characteristics play a greater role in who relapses or not. There is a clear delineation between risks and triggers that make women more prone to relapse than men. Women also exhibit different behavioral and emotional responses during and after relapse. Factors precipitating women’s relapse include more interpersonal problems, anxiety and depression, severe traumatic stress reactions to early childhood trauma, and low self-worth. In addition, women who relapse lack sufficient coping skills, greater difficulty separating themselves from others who continue to use, and failure to develop new, non-using friends. Of important note is the fact that relapsing women are more likely to seek help and to have shorter relapse periods.
Study Shows Gender Differences in Painkiller Abuse
Just how do gender differences show up relative to a particular drug that’s abused? The results of a recent study (//www.healthfinder.gov/News/newsstory.aspx?docid=638574) by Harvard’s Brigham and Women’s Hospital points up the different reasons for prescription painkiller abuse by men and women. The study was comprised of non-cancer patients who took opioid painkillers for chronic pain. The painkillers included oxycodone, codeine, fentanyl, and morphine. While the men and women had similar rates of opioid abuse, their risk factors for such abuse varied by gender.
Study author Robert N. Jamison, a clinical psychologist at the Harvard Brigham and Women’s Hospital says in a press release, “Our analysis showed the drug misuse by women is motivated more by emotional issues and psychological distress while in men this behavior usually stems from problematic social and behavioral problems that lead to substance abuse.” Jamison also notes that women abusing prescription painkillers “are more likely to admit to being sexually or physically abused or have a history of psychiatric or psychological problems.”
The clinician and his colleagues recommend that women who are taking opioids for non-cancer conditions and show signs of significant affective stress receive treatment for the mood disorder and also receive counseling on the dangers of relying on opioids to improve sleep and reduce stress.