Postassault Substance Use and Coping: A Qualitative Study of Sexual Assault Survivors and Informal Support Providers

Abstract

This qualitative interview study examined 45 informal support dyads where a sexual assault was disclosed. Data from matched pairs of survivors and their primary informal support provider (e.g., friend, family, significant other), were used to explore the survivor-support provider (SP) perspectives of coping with assault-related distress via substance use and the effects of survivor substance use on the survivor-SP relationship. Results revealed that survivors’ use of drinking and/or drugs to cope had both positive and negative effects on survivor-SP relationships. Findings also showed that SPs play various roles in providing support to survivors who cope via substance use, including engaging in substance use with the survivor and efforts to help get help in their recovery from the assault and substance abuse. Suggestions are made for how safe spaces can be provided where survivors and supporters can get information and treatment, whether formal or informal, that addresses sexual assault, PTSD and substance abuse issues in an integrated way.

Helping a loved one manage the effects of a sexual assault can be daunting for informal support providers (SPs) and becomes even more complicated when the survivor has past or present substance use issues. Research on sexual assault and substance use issues has established linkages between the two phenomena, finding a high prevalence of co-occurrence of post-traumatic stress symptoms and problem substance use among many survivors. Studies show that some sexual assault survivors develop drinking problems following assault and use drinking to cope with distress related to the assault (Fossos et al., 2011; Ullman et al., 2013). Self-medication theory posits that survivors experiencing posttraumatic stress disorder and depressive symptoms may use alcohol or other substances to cope with negative emotions by reducing feelings of distress, which may lead to increased risk of drinking substance use problems (Miranda et al., 2002).

Risk of developing substance use coping is greater for those with a history of child sexual abuse (CSA). Survivors may be victimized repeatedly by known family perpetrators, which is highly related to psychological distress and relates to problem drinking (Grayson & Nolen-Hoeksema, 2005). CSA is also related to risk of sexual revictimization in adolescence and/or adulthood. Revictimization places survivors at greater risk for substance use issues, as multiple sexual victimization experiences increase odds of worse psychological sequelae including problem drinking (Classen, Palesh, & Aggarawal, 2005).

Research also shows that there is a vicious cycle of substance use to cope and revictimization for some survivors. This cycle is likely due to some survivors’ greater engagement in risky behavior and in alcohol-related contexts where they are more likely to be targeted by perpetrators. Once revictimized, survivors’ trauma-related symptoms may worsen, which can lead to increased self-medication through substance use (see Lorenz & Ullman, 2016 for review). Sexual assault may lead to substance use or for those who are already using, increased reliance on substances to self-medicate symptoms of PTSD, which then causes stress on their relationships with others; particularly close others like family, partners and even close friends. Davis, Taylor, and Bench’s (1995) study of 138 significant others of sexual and nonsexual assault victims found unsupportive behavior toward victims was more likely among significant others of sexual assault victims (than non-sexual assault victims) and from romantic partners than from other family members or friends, which was interpreted as being due to the greater psychological distress romantic partners experience.

While research has examined and found that substance use coping occurs for both victims of child and adult sexual assault, and leads to risk of drinking problems and revictimization (Hannan, Orcutt, Miron & Thompson, 2017; Hughes et al., 2010; Ullman, Najdowski & Filipas, 2009), little research has examined the social and relationship contexts in which assault-related aftermath occurs for survivors and their informal support networks. Research is needed to understand how relationships are affected for survivors disclosing sexual assault to partners, family, and friends as well, as very few studies have examined relationship changes following sexual assault disclosure (Ahrens & Aldana, 2012; Brookings, McEvoy, & Reed, 1994; Connop & Petrak, 2004; Moss, Frank, & Anderson, 1990) from a broad range of informal support network members. Existing studies consist of smaller studies of couples looking at how marriage and sexuality is affected by sexual assault with data on either victims’ perceptions or male partners’ perceptions, but not both. These small qualitative studies showed that men have reactions of psychological distress, guilt, self-blame, loss of trust, anger, blame of the victim, changes in their views about male sexuality, and effects on their relationship with the victim, including relationship dissolution in some cases (Brookings et al., 1994; Connop & Petrak, 2004; Moss et al., 1990; Smith, 2005). One qualitative study examined multiple informal sources of support in survivors and relationship effects from the perspective of victims (Ahrens & Aldana, 2012). They found that, following disclosure, relationships were either strengthened or remained strong. Yet, many survivors in their sample described relationships that deteriorated following disclosure, an outcome related to the quality of the relationship prior to disclosure. Findings from this study illustrate the potential complexity of relationship functioning and satisfaction surrounding disclosure, which may be further complicated by substance abuse issues. Ahrens and Aldana (2012) called on future researchers to examine relationship changes following disclosure through a dyadic lens to better understand how both the survivor and SP perceive the relationship following disclosure.

Insight into survivors’ experiences coping with sexual assault and associated substance use following assault and how others around them try to help them in responding to disclosures and survivors’ substance use and/or help-seeking efforts is needed. Survivors of sexual assault typically have symptoms of PTSD and depression and may have sexual and relationship problems resulting from their assaults, including difficulties with trust, intimacy, and engaging in sexual behavior with romantic partners (Fleming, Mullen, Sibthorpe, & Bammer, 1999; Perilloux, Duntley, & Buss, 2012). One study found a relationship between a partner’s self-reported drinking and their partner’s actual drinking. The study showed that participants with low levels of self-reported drinking reported less relationship satisfaction with partners who had problem drinking, and this effect was more pronounced for male participants (Rodriguez, Overup, & Neighbors, 2013).

Information is needed from this subset of survivors and their informal network members to better provide advice and support to both parties in dealing with the aftermath of assault and substance use concurrently. Most survivors and their SPs deal with these issues on their own and do not have access to treatments known to help women with comorbid PTSD and SUDs (Lenz et al., 2016 Najavits & Hein, 2013). Professionals and support groups may be two specific help sources that can provide information to survivors, but research and practice efforts need to account for the intersection of sexual assault and comorbid psychological symptoms and substance use problems. Typically, services for trauma treatment focus on psychological symptoms, but not substance use problems, whereas substance use treatment or 12-step programs like Alcoholics Anonymous (AA) focus on substance use without focusing on trauma exposure and its psychological and substance use effects (Schneider, 2006). This is problematic, as it has been estimated that between 41 and 66% of individuals in substance abuse treatment report experiencing a history of some form of trauma (McNeece & DiNitto, 2005). Additionally, individuals with some reported trauma also report needing a substance use program that also addresses their trauma (Patton, Snyder, & Glassman, 2013). Substance use programs that do have a trauma-informed perspective do see results. For example, in one study addressing sexual trauma of women in a substance use program, post-assessments showed decreased levels of anxiety, depression, and PTSD (Hemma, McNab, & Katz, 2018).

Following assault, it is common for survivors to turn to substances to cope with the emotional and physical effects of the assault. In the aftermath of assault, survivors tend to turn to informal support sources as well, particularly friends, family, and significant others for support. Providing positive reactions and ongoing support to a survivor can be daunting for SPs. SP’s social reactions can subsequently affect the survivor-SP relationship overall, particularly when the survivors’ coping is further complicated by substance use issues. Thus, it is important to understand how survivors and SPs perceive such substance use and how substance use, coupled with the after effects of trauma impact their relationship.

Current Study

Most research to date has focused on survivors, informal support sources, or professionals, separately. The few studies examining social support following sexual assault disclosure show that survivors and SPs do not always perceive disclosure and social reactions in the same way (Davis & Brickman, 1996; Lorenz et al., 2017). This is likely the case regarding post-assault substance use as well. Specifically, victims and supporters may agree more on SPs supportive behavior, but victims may perceive more unsupportive behavior from SPs than SPs report they gave to victims (Lorenz et al., 2017). Research has yet to study survivors and their informal support networks simultaneously to try to obtain a richer picture of the ways in which recovery unfolds in the context of relationships over time. We sought to address this gap by examining survivors’ substance use during recovery and their relationship with their primary informal support provider. This study used dyadic survivor-support provider (SP) interview data to explore the following research questions: 1) How do SPs perceive survivors’ use of substances to cope with distress related to sexual assault? 2) Do survivors and SPs differ in their assessments of the survivors’ use of substances to cope? 3) How does survivors’ use of substances affect the survivor/SP relationship?

Method

Participants

The sample of this study included adult female sexual assault survivors who disclosed their assault to an informal SP. Survivors had previously participated in a 3-year longitudinal survey (N = 1,863) regarding unwanted sexual experiences and the social reactions they received when disclosing these experiences (see Peter-Hagene & Ullman, 2016, for study description). Survivors who indicated interest in being contacted for an interview were also asked to provide contact information for a friend, family member, or significant other they told about an unwanted sexual experience. SPs were contacted later for a separate interview that focused on their experience helping the survivor. Separate interviews with survivors and SPs (N = 90) took place over 2 years, resulting in a sample of N = 45 matched pairs of survivors and SP interviews. Written informed consent was obtained for all interviews immediately prior to the interview. The study was approved by the University of Illinois at Chicago IRB.

Survivors were an average of 43 years old, ranging from ages 20 to 59 at the time of the interview. Survivors were ethnically diverse: 75% non-White (African American, Latina, Native American, or multi-racial), 18% White, non-Hispanic, 7% not reported. Approximately 60% of survivors had children. About 76% had attended or graduated from college; 24% were currently enrolled in school, and 38% were currently employed.

Regarding the assault, most survivors in this sample were assaulted by one person (n = 34; 76%). Most survivors described their relationship to the perpetrator as a stranger (n = 18; 40%), followed by a non-romantic acquaintance (n = 13; 29%), casual or first date (n = 5; 11%), romantic acquaintance (n = 5; 11%), husband (n = 2; 4%), and relative (n = 2; 4%). Perpetrators were an average of 28 years old, ranging from 16 to 55, and primarily male (n = 43; 95.6%). Approximately 42% (n = 19) of survivors were under the influence of alcohol and/or drugs at the time of the assault.

SPs were also an average of 43 years old, ranging from ages 20 to 72. Two-thirds (64%) of SPs were female, and 64% had children. Approximately 66% were non-White (African American, Latino, Native American, or multi-racial), and 19% were White, non-Hispanic. Most had attended or graduated from college (66%) and were currently employed (60%).

Survivors and support providers tended to be similar in terms of gender, race/ethnicity, and education. Approximately 64% (n = 29) of matched pairs were both female. Almost all the pairs were matching in race (82%; n = 37). Of pairs comprised of different races, two were African American/White, four were African American/Mixed-race, and one was African American/Native American. Twelve pairs (27%) differed in terms of Hispanic/Non-Hispanic ethnicity. Slightly over half (58%; n = 26) pairs indicated the same level of education.

Half of survivors and SPs (n = 23) described their relationship as “friend”. Fifteen pairs (33%) were family relationships. Parent-child relationships represented 73% of the familial matched pairs (n = 11), with sons or daughters as SPs in eight of these pairs (72%), and mother SPs in three (27%). Seven matched pairs were significant others (16%) and all were male partners to the survivor. Three (43%) of significant other pairs were married at the time of the interview.

Procedures

Semi-structured face-to-face interviews were conducted by one of three trained interviewers on the research team. Interviews lasted an average of one hour, but ranged from 30 minutes to 3 hours. Participants were compensated $30USD for the interview portion of the study. After each interview, interviewers created “summary” documents, which included interesting points, questions raised, final thoughts, and unanticipated feelings emerging from the interview. Interviews were audio-recorded, transcribed, and checked by other members of the research team. During the transcription process, brief summaries and identified patterns were added. Interviewers conducted a final review of their transcripts for accuracy. Interviewers and members of the research team met to discuss emerging themes and patterns following transcription, as an initial stage in developing the codebook.

Measures

The interview protocol for survivors and SPs focused on the survivor’s disclosure of an unwanted sexual experience, social support provided/received, and appraisals of the survivor-SP relationship. Interview participants were also asked to discuss the survivor’s post-assault experience in terms of recovery and coping, including coping methods and appraisals of the survivor’s recovery progress. The present study focused on survivor recovery. Overall, there were 20 codes under the umbrella of the “recovery” family, though the focus of this study fell onto one particular recovery code: substance use (described as: the survivor’s use of drugs and/or alcohol to cope or post-assault efforts to stay sober, from the perspective of both the survivor and SP). While the bulk of analysis focused on the substance use code, we also explored the interview content within six other codes related to recovery and substance use: relationship impact, relationship changes, maladaptive coping, adaptive coping, positive, negative, and mixed recovery appraisals, and risk avoidance/self-protective behaviors.

Data Analysis

Members of the research team summarized each interview transcript to identify patterns and themes, which were later discussed among the research team in a process similar to that of thematic analysis (Braun & Clarke, 2006). The research team conducted several trials of interview coding and refinement to develop a codebook that covered the content of individual interviews and themes reflecting the matched pair relationships. Coding trials resulted in several revisions of the codebook whereby codes were added, renamed, redefined, and/or combined. The codes were descriptive in nature and were used to summarize and describe the primary topic of the excerpt (Saldana, 2012). We examined the context of the codes by reviewing transcripts and interviewer summaries when identifying relevant interview excerpts (i.e., quotes).

We used Atlas.ti Version 7 qualitative analysis software for coding and analysis. We identified codes that made the most analytic sense of the data (termed “focused” coding; Charmaz, 2006) and used the identified codes to pair with segments of the transcript. Specifically, we selected codes that best represented what was happening in the interview text. We coded the data separately and compared our interpretations of the content with other members of the research team to achieve consensus (Eisikovits & Koren, 2010). This process took place in several stages. First, pairs of coders separately coded each interview matched pair using the codebook. Second, one coder in the pair then reviewed both coded transcripts to identify any inconsistences in the assigned codes. Third, the coders discussed these disagreements until reaching a joint consensed version by both parties (Patton, 2009). In cases where agreement was not obtained, double coding (i.e., simultaneous coding; Saldana, 2009) was used as a compromise between the two codes. Fourth, the original interviewer reviewed the coded transcript for agreement with the assigned codes. The coders and interviewer discussed any disagreements and corrected the coded transcripts until consensus was reached between the three parties. During the coding process, researchers created memos within the transcripts to highlight any relationships or inconsistencies within and between the survivor and SP interviews, or to capture unanticipated themes in the data (Charmaz, 2006). The inclusion of memos allowed coders to pay attention to the relationships between different matched pair interviews.

Analysis took place using an iterative process in several stages after coding was completed. We analyzed the interview at both the individual level and at the level of the matched pair (i.e., dyadic). First, we conducted queries in Atlas.ti software to identify the number of times each interviewee endorsed a particular code related to substance use and recovery, the survivor-SP relationship, or coping. We also noted the type of survivor-SP relationship (i.e., friend, family member, significant other). Second, like that of thematic analysis, members of the research team individually reviewed the quotes for each query in search of patterns and noteworthy findings (Braun & Clarke, 2006). Third, the team met several times to review the identified themes and patterns. During this process, we looked for similarities and contrasts within and between the 45 matched pairs in response to the proposed research questions of the present study.

Results

Results are presented in order of the research questions to present findings related to SPs’ perceptions of survivors’ post-assault substance use, comparison of survivor and SP’s perceptions of the survivors’ substance use and the role of the survivors’ post-assault substance use on the survivor-SP relationship.

How do SPs Perceive Survivors’ Use of Substances to Cope?

SPs likely vary regarding their knowledge of and involvement in the survivor’s substance use and coping in the aftermath of the assault. As one SP described, he and the survivor met when they were both engaging in substance use, and he noticed a drastic increase in the amount of alcohol the survivor was consuming after she was assaulted to the point of consistently “blacking out”. Yet, the SP explained that he never approached the survivor about her heavy drinking:

“I don’t know how you mention that you’re drinking too much to somebody who already drinks a ton. She [the survivor] already knew it was a huge problem. Like I’m not gonna tell her anything she doesn’t know. And if she doesn’t want to change it I can’t.”

– SP (FR, M, 22, WH)¹

Rather than addressing the survivor’s unhealthy coping via heavy drinking, the SP explained that he felt confronting the survivor would be pointless, but rather just tried to be there for her:

“Of course, they’re [the survivor] just going to give you the lines and they’re not gonna be able to either understand where you’re coming from or really take your advice to heart, so in a sense that just kind of being around her more, trying to make sure that she, you know, if she did get to that point [of needing help] had a way out or she had somebody else there with her.”

– SP (FR, M, 22, WH)

Overall, the SP appraised the survivor’s recovery positively based on their conversation regarding participating in this research study, a conversation that took place at a later date from the original disclosure. The SP was impressed by the survivor’s calm demeanor discussing the assault and her willingness to participate in the study. As he stated:

“She made it extremely clear to me that she was over this [the assault]. That she’s not letting this define her and she isn’t letting her make decisions for her anymore.”

– SP (FR, M, 22, WH)

Similarly, another SP discussed being aware of the survivor’s addiction, and also sharing that addiction, but not wanting to speak with the survivor about the underlying issue to her addiction – the assault:

“I guess I’m kind of scared to touch on the subject with her because I don’t want to hurt her. I feel like I am invading her privacy or trying to make her remember things that she may obviously not want to remember. So, I mean, like I said, I made sure I let her know that I’m here and that if she ever wanted to talk about it again that we can but we’ve never talked about it again.”

– SP (FR, F, 26, H)

One SP discussed not understanding what the survivor was going through, and not knowing about her substance use issues. As the survivor explained in her interview, she developed a drug addiction after the unwanted sexual experience she had as a child, and engaged in sex work to finance her addiction. While (at the time of the interview) she was six years clean, the SP (the survivor’s child) explained in her interview that she did not understand what was happening, likely because she was young at the time this was happening:

“Me and my sister didn’t know what was wrong, what was going on with her [the survivor] like why is she changing so much, why she look dazed all the time, why is she losing weight, what is going on with her. And one day my aunt sat us down and told us, you know, your mom is on drugs and that’s why she looks like that.”

– SP (F, F, 42, AA)

Another SP, a friend to the survivor, shared her perspective on the survivor’s ongoing alcohol/drug issues following molestation the survivor experienced as a child by her mother’s boyfriend:

“She did state to me that she started drinking at a young age, and the reason she did was to try and forget what happened to her, and that her mom would go out and the boyfriend would drink. I’m not sure if the mom was drinking with the boyfriend, but that’s probably what caused him to do what he did to her.”

– SP (FR, F, 50, Multi)

The SP in the quote above recognized that the survivor was always angry and had problems recovering from the abuse she experienced, and as a result, had substance abuse issues. The SP explained that she has encouraged the survivor multiple times to seek substance abuse treatment or counseling.

One SP, a friend to the survivor, spoke about how the survivor focused on limiting her alcohol use after she was assaulted to avoid possible revictimization. He explained that she regulates her drinking and implements her own strategies to prevent herself from drinking too much, such as setting a timer for when she should stop drinking.

In one matched pair of two friends, the SP showed a positive appraisal of the survivor’s alcohol use. In her interview, the survivor mentioned alcohol-involved assaults and drinking at a young age as part of the social milieu and to cope with childhood abuse. The SP went into depth regarding the survivor’s history of having neglectful and alcoholic parents, and shares that, because of this, the survivor feels that she is “doomed to be an alcoholic”. While the survivor did not share much information about her drinking habits, the SP feels that the survivor engaged in risky drinking behavior as a child but has “grown out” of these behaviors:

“She [the survivor] was younger and drinking. I don’t believe that she is an alcoholic. I guess she was afraid of turning into her parents…But she’s not engaged in that [drinking behavior] now.”

– SP (FR, F, 26, WH)

The support provider in this pair was able to take into account the survivor’s life history, trauma, and past coping. The data above represents SPs who supported a survivor through a transition from substance abuse to more adaptive forms of coping.

Do Survivors and SPs Differ in their Assessments of the Survivor’s Use of Substances to Cope?

Survivors and SPs may not always perceive the survivor’s substance use the same way. This section reveals survivors’ assessments of their substance use, as well as unprompted discussion by SPs regarding the survivor’s recovery in terms of substance use.

Most survivors described their substance use as self-medication. For example, one survivor spoke about engaging in substance use to ignore her emotional pain because she had no one to turn to for support:

“I couldn’t talk to her [her guardian/roommate]. So, I did something to self-medicate a lot to ignore it or forget it until the next time I needed to self-medicate, whatever the situation was.”

– S (SO, F, 42, AA)

Another survivor described not having access to medical care to receive medications that she probably needed for her manic/depressive episodes, so had to turn to alcohol and drugs to cope, which, as she explained, caused her to do some “really stupid things”. Conversely, one survivor was prescribed anti-psychotic medicine, but did not like the effects, so decided to stop taking the medicine and self-medicate with binge drinking. She explained that she and one of her friends went on a 2-year drinking binge, which helped her to cope with her depression and avoid dealing with the emotions associated with the unwanted sexual experience.

Another survivor described a situation where she was revictimized, but numb to the severity of the assault because she was heavily using drugs and alcohol on a regular basis to cope with the original assault that occurred when she was younger. She further described that she had been in a relationship with an older man (30s) when she was young (14). Given this age difference, even if not illegal at age 14, this may well have been a predatory relationship. When he left her, she discussed having a “nervous breakdown” that led her to cocaine use because she didn’t have anyone to turn to for support at the time. The survivor engaged in ongoing drug and alcohol abuse as part of her previous romantic relationship and to cope with the abuse she experienced throughout her life. As she explained, she wanted to be intoxicated to numb herself, find distraction, and not be held accountable for her actions. Yet, she also felt that most of the bad things that happened in her life (e.g., abusive relationships, assaults) were because of her drinking. This survivors’ SP – her significant other – explained that when he met the survivor she was engaging in heavy drinking behaviors, which, as he explains, was placing herself in risky situations. Both the survivor and SP explained in their interview that the SP helped the survivor to stop drinking at the start of their relationship:

“One of my first steps in having a relationship with (survivor) was my effort in helping her not to do that [be in risky situations]. And that meant not drinking at all, which, you know, she no longer has been for many years now. Currently not binge drinking which is what I am talking about.”

– SP (SO, M, 55, WH)

“When I met (SP) he really helped me with stability, structure. I left the cocaine behind and got into acting and singing…(SP) he helped me get a computer, we bought a car together, we moved in together, he got me to stop drinking.”

– S (SO, F, 45, U)

The survivor went on to explain that she still struggles with marijuana use, but is thankful that the SP has been there for her. Similarly, another survivor spoke about how she was heavily drinking and in denial, but then met the SP (her significant other) who helped her to open up about dealing with the assault and her alcohol issue. Both the survivor and SP talk about how the SP helped her to confront her issues and transition into counseling.

“He (the SP) caught me drinking once in the middle of the night when he was sleeping.”

– S (SO, F, 23, WH)

“I didn’t feel devoid of information. She [the survivor] had no problem telling me most things. It was more of seeing her mental state change and from the very beginning [of the relationship] she had a lot of vices that I was helping her get off, let alone nightmares and different anxiety attacks. She stopped smoking about the time we were meeting, but she was having very severe alcoholism problems at that time. And there were times she’d sneak bottles of liquor into the bed and sneak those at night. She was leaning on me because she could not control herself and she knew that.”

– SP (SO, M, 26, WH)

Similar to the survivor quoted above, another survivor spoke about the numbing feeling she experienced when self-medicating after the assault. Since this survivor stopped drinking, she acknowledged that what happened to her was sexual assault and has been adaptively coping with the emotions associated with her delayed acknowledgment in the form of formal support:

“I thought it was normal, you know, you just let a guy have sex with you, you just have sex and that’s just what you do for them to like you but then I realized after five years. So, when I got sober which now I’m five and a half years sober, I’m addressing these things because it wasn’t until I got with the therapist that she just dug in deep, deep, deep, and so I didn’t know that all of this stuff was not normal.”

– S (FR, F, 43, AA)

Another survivor discussed her ongoing struggle with substance use, particularly that she is angry about the assault and angry that she is addicted to drugs because of it:

“I’m just angry. I’m angry about something and part of the reason what brings out the sadness is because I can’t act on it. I can’t do anything. There’s nothing I can do about what anyone did to me…I can’t do anything about the way my family treated me. I can’t do anything about my drinking when I was a teenager, my drug use. I’m angry because I’m a drug addict. Right now, I’m battling smoking cigarettes…. But I’ve battled a lot of demons and I feel like it was all because of my childhood.”

– S (FR, F, 41, AA)

The survivor above was 42 days clean and still struggling with her recovery at the time of the interview. She mentioned her failed attempts at Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) and that these programs may have failed her because they did not force her to address the full context of her situation – particularly the lack of support from her family since her unwanted sexual experience from her childhood. However, the survivor spoke about how the SP has been helpful with her recovery by always checking on her. As the SP explained, she understands where the survivor’s addiction stems from and is supportive in her recovery:

“You know, how you can just feel worthless and no good, so for her being so young I can understand how she probably went through a lot of the stuff she went through and I can understand like how women can go to addiction trying to soothe themselves, thinking they worthless anyway…As far as her [the survivors] addictions and stuff, drugs were her major problem, I think she’s doing very well with that. But like other parts of her life, she, you know, she’s working on it.”

– SP (FR, F, 60, AA)

Another SP explained that she still provides support to the survivor regarding her child sexual abuse CSA experience:

“It’s been a while since we talked about the rape or the molestation, you know, the child abuse, the rape, you know, she’s had a lot of drama in her life, and she’s came through a lot of drama, when she drinks or she breaks down, she brings it up.”

– SP (FR, F, 50, Multi)

In this matched pair, the SP helped the survivor realize that she had a substance abuse issue. While the survivor explained that she speaks openly about her abuse history, the SP stated that the survivor only brings it up when she is drinking. The survivor was still working on her drug/alcohol addiction, and, as the SP explained in her interview, the survivor had recently told her that she was not ready to enter substance abuse treatment. The survivor described her ongoing battle in coping and recovery:

“I have the right to be angry. I have the right to hate. I have the right to struggle with my emotions. So that’s a battle I have to fight within myself. And every day it’s a struggle of whether or not I’m going to win or whether or not I’m gonna let the Devil win and every day I have to struggle with that even now that I’m not, you know what I’m saying, I’m in a safe place…I still have to struggle with the way I used to feel and if I’m gonna let that break me one day and take me back to drugs. And every day is a different struggle but so far I’m winning and that’s all that matters.”

– S (FR, F, 30, AA)

The survivor in the above quote explained how helpful it was to share her story and learn that struggling with substance use post-assault is normal, that many women turn to alcohol or drugs to cope. However, the survivor’s appraisal of her substance abuse issues was more positive than the SP’s, where the SP seemed to feel that the survivor needs treatment. Yet, the survivor acknowledged her struggle, but spoke about having a good handle on her recovery (“winning”) and had positive outlets in the form of speaking with other survivors.

A significant other matched pair interview revealed inconsistencies in the survivor and SP’s perceptions of the survivor’s post-assault alcohol use. The survivor and SP started their relationship while the survivor was still struggling to cope with the unwanted sexual experience. As she explained, she loved the SP and wanted to give the relationship her best try even though she was not ready to engage in sexual behaviors. Though they were in a romantic relationship, at the time of the interview they defined their relationship as “friend”. In her interview, the survivor discussed drinking to numb herself to engage in sexual behaviors with her partner:

“I didn’t want to have the feeling I had when I was being raped. I didn’t want to hurt. I didn’t want her to touch me in certain ways…so I would drink, drink, drink alcohol any time before we would have sex…I would drink so I wouldn’t have to feel.”

– S (FR, F, 41, AA)

However, the SP did not speak to these issues and it was unclear if the survivor ever divulged this information to the SP. In her interview, the SP discussed how the survivor is a recovering addict. The SP explained that she has encouraged the survivor to seek formal help several times to assist with recovery from the assault and substance use, but does not think the survivor has done so yet.

The mother of one survivor explained in her interview how proud she was to see her daughter and her daughter’s husband getting sober. The survivor engaged in drug and alcohol use to self-medicate following an unwanted sexual experience:

“I guess the drugs and alcohol mostly covered that up, you know, when stuff happened I just continued to use, use, use, drink, drink, and it covered it up.”

– S (F, F, 49, AA)

The survivor explained that now that she is sober, she is no longer numb and therefore scared of being revictimized, and prays that she will stay sober and prays that she will not be assaulted again. As the SP explained, the survivor was unhealthily thin and addicted to drugs, but she knew that the survivor would stop using when she was ready. Once she got sober, the SP was ecstatic:

“I couldn’t believe it. They [the survivor and her husband] started going to church every Sunday with me. They started going to meetings right around the corner here and I was so proud.”

– SP (F, F, 72, AA)

The SP discussed feeling that the survivor no longer struggles with her addiction and is recovered from the assault, and as such, they no longer discuss these issues anymore.

How do Survivors’ Use of Substances Affect the Survivor/SP Relationship?

Changes in a survivor’s level of substance use following assault can spark positive or negative changes in the survivor’s relationship, particularly with individuals who provide ongoing support and care to the survivor. This section explores how survivors and SPs discuss the changes in their relationship as a result of the survivor’s substance use.

Some survivors and SPs used substances together as part of their relationship. One survivor remarked how her significant other introduced her to cocaine. In another situation, the survivor and SP engaged in substance use together, but also sobered up together, which suggests a significant change in the tone of the relationship because their relationship no longer centered around alcohol or drug use as it had before. Rather, the couple together altered their lifestyle to include other (sober) activities. At the point of the interview, neither party had consumed alcohol in a decade. The SP mentioned the level of mutual support that was necessary to make sobriety possible for them. Another matched pair both described how they were currently struggling with addiction, where the survivor described their friendship as “dysfunctional” due to their substance use:

“Yeah, we still can still go to work, go to school, go to church, and appear that everything is fine. But at home, we’re like, drunks.”

– S (FR, F, 24, AA)

However, the SP explained that they are no longer engaging in this heavy drinking, but she did so for experimental reasons, as part of their social network (i.e., social binge drinking), but recognized that the survivor was also engaging in binge drinking to cope with the assault. The SP explained feeling like knowing that the survivor was coping via substance use, and engaging in this substance use together had brought them closer because the survivor trusted her with this information, and continues to turn to her for support even though they no longer drink together.

In another matched pair who engaged in alcohol use together, and worked to get sober together, the SP – a significant other to the survivor – described their relationship as stronger because they worked together to be sober. In this situation, the survivor engaged in alcohol use to self-medicate but went to rehab to address these issues because, as she explained, she lost control and did not enjoy how she behaved when she was intoxicated. However, the SP was not ready to stop drinking when the survivor went to rehab, and continued drinking. Eventually, he realized that when she arrived home, he could not drink around her out of fear of triggering her, and therefore decided to sober up as well. At the time of the interview, the survivor was three years sober. On the contrary, the SP expressed in his interview, that despite their strong support network, he fears that she might relapse at some point and has a long road of recovery ahead.

One matched pair discussed their journey in helping the survivor to get sober, and while the survivor still engages in recreational marijuana use, she has been off cocaine and avoided heavy drinking for several years now. While they worked together as a couple to help the survivor adaptively cope and recover from her substance abuse issues, the survivor discussed feeling that she and the SP are growing apart:

“I feel like we’re growing apart because we’re two different people. I was always telling the girls everybody has stepping stones, sometimes people are good for you and then you outgrow them.”

– S (SO, F, 45, U)

This survivor explained that she felt the SP may have entered her life to help her get her life on track, deal with the emotional pain from her abusive past, and help her get sober, but now may need to go their separate ways.

Relationship changes can also occur when SP’s feel fatigued from providing ongoing support to the survivor. For example, in one matched pair, the survivor and SP began a romantic relationship when the survivor was still struggling to cope with the assault. The survivor disclosed to the SP at the beginning of the relationship, and as both parties explained, the SP was very supportive to the survivor. The SP explained in her interview that after learning about the assault, she encouraged the survivor to seek formal help, and later after realizing the survivor had an alcohol issue, encouraged her to seek formal help for that as well. However, the SP explained that during their relationship, she kept encouraging the survivor to seek help, and the survivor kept putting it off and (to her knowledge) never did. This became a point of tension in their relationship, because as the SP recalled, she did not feel equipped to provide that level of support to the survivor, was feeling fatigued from the ongoing support she could provide, and was struggling herself to witness the issues the survivor was facing. As such, the SP ended their romantic relationship until the survivor could manage on her own without having to rely so heavily on the SP, though they both expressed wanting to be romantically involved again.

Post-assault substance use can be particularly harmful for survivors who are mothers and have young children to care for. Several SPs who were children of survivors were “parentified” after the mother’s assault (see Lorenz et al., 2017), but in the context of post-assault substance use, this can be further complicated. For example, one SP – the daughter of the survivor – spoke about her experience witnessing her mother intoxicated in the aftermath of the assault. The SP recalled that as a child she was tasked with taking care of the household and she appeared to resent the fact that she was forced to mature quickly as result of her mother’s addiction:

“She [the survivor] used to be high telling me thank you, you know, for taking care of the kids, whatever, but, tell me something but you never explain to me like why I had to take on that role. I didn’t really have no childhood. You know? That’s why I had my son at such a late age.”

– SP (F, F, 35, AA)

The SP discussed being able to understand why she was forced into that role after her mother disclosed that she was assaulted by her previous romantic partner – the father of the SP’s brother. The SP explained that she pushed her mom to sobriety when she dragged her home from the location where she used drugs, and though she is now sober, she still takes care of her today. The SP mentioned that she has forgiven her mother for putting her in a position of early maturation. The survivor explained that she is sober, but did not go into depth regarding her history of substance abuse issues or parentification of her daughter. The survivor explained that her relationship with her daughter is not as good as she would like it to be, describing her daughter as “controlling” and “in her business”, likely stemming from her concern for her mother. Overall, the mother’s substance use negatively affected the mother/daughter relationship, and affected how the SP lives her life today.

While substance use to cope with assault can prompt changes with SPs, ongoing substance use can also create changes in the survivor’s other relationships. For example, one matched pair began as close friends and then grew romantically involved (about 6 years prior to the interview). The survivor had experienced CSA by her grandfather and since then had struggled with substance abuse issues. Both the survivor and SP explained that disclosing to the SP has brought their relationship closer and that the SP helped the survivor to recover from the assault and overcome her substance abuse issues. While the survivor/SP relationship grew closer during the survivor’s recovery, the survivor explained in her interview that – because of her substance use – she has no relationship with her children. As she explained, she had her children when she was a teenager and addicted to drugs/alcohol, and left them with their father because she “didn’t feel like the children deserved to be around me [the survivor] in that state…they didn’t deserve the lifestyle I was leading” and as such, her children refuse to speak to her. While the survivor felt that she was making the responsible – but difficult – decision at the time, she still is faced with the consequence of having severed relationships with her children.

Recovery can also mean avoiding certain people and places and avoiding use of substances. While some survivors may turn to alcohol to cope, others choose to avoid alcohol completely to minimize the risk of future assault. This was the case for several survivors in this sample, who avoided substance use following alcohol-involved assaults in order to avoid risky situations and possible revictimization. As explained by one survivor:

“I do know that alcohol was involved [with the assault] and to this day, I don’t drink.”

– S (F, F, 59, AA)

The above quote represents sentiments shared by several survivors who endured alcohol-involved assaults. This type of change in behavior or lifestyle can lead to shifts in survivors’ relationships with the SP or other members of her social network. For example, one survivor spoke about gravitating toward unstable, toxic relationships characterized by unwanted sexual experiences and substance abuse. She explained that she has been trying to make positive changes in her life, including avoiding drugs and alcohol:

“I avoid a lot of social situations because they’re being just too much emphasis on alcohol and I’m at the point in my life right now where if I see that something’s affecting my body in a negative way and I’m trying to get off, you know.”

– S (FR, F, 25, Multi)

The survivor in the quote above went on to explain that avoiding substances has caused a resurfacing of emotions, leading to a change in her energy and overall feelings. Due to this change, her relationship with the SP – her friend and roommate – has improved. Conversely, one survivor explained that she started drinking when she was 3 years old when her parents would give her alcohol as a reward, and from that point has struggled with alcohol addiction issues, particularly in using alcohol to suppress her PTSD symptoms from her unwanted sexual experiences. Since she has stopped drinking (5 years sober at the time of the interview), her friends are not as accepting of her:

“Even now my childhood friends that I’m still really good friends with, cool with a lot of them still have a hard time accepting that I’m an alcoholic so they thought that was who I was and who I am. When I put down the drugs and alcohol, there was a lot of people that didn’t want to receive me sober and I had to do a lot of eliminating. They preferred me to be that (survivor) because that’s the only (survivor) they know.”

– S (FR, F, 43, AA)

The survivor in the above quote relied heavily on her therapist for support, but the quote above raises the question of who the survivor’s informal support network is, if her friends do not want to be involved in her life outside of drinking. However, this survivor still maintains a friendship with the SP, who shared in her interview that she feels the survivor is recovered, though their friendship is not as strong as it once was. This was a similar situation to another survivor, who began a romantic relationship with the SP and stopped engaging in substance use with her friends. As the SP explained, “the minute she changed from that [substance using], all her friends went away.” Again, this illustrates relationship changes that occur outside of the survivor-SP dyad.

Another survivor spoke about, after many failed attempts, making a serious lifestyle change to finally get sober. This survivor had suffered several unwanted sexual experiences, including assaults in the context of sex work, intimate partner relationships, and acquaintances beginning when she was 18, and engaged in heavy alcohol/drug use for about 15 years. The survivor cut ties with anyone she felt might hinder her sobriety and moved to a different neighborhood. Both the survivor and SP in this pair explained that they met attending college classes (about 5 years prior to the interview). As the SP discussed, she and the survivor met when they were both at a point in their lives when they were working to put substance abuse issues behind them and work towards a healthier lifestyle, which since becoming friends they have worked on together through a mutually-supportive friendship. This matched pair highlights the importance of healthy, supportive relationships in making positive life changes toward recovery.

Discussion

The present study of victim-informal supporter dyads examined how survivors’ substance use is impacted by sexual assaults and the ways in which this factor affects survivors’ coping, recovery, risk-taking and relationships with friends, family, and significant others. This is the first study of survivor-informal SP dyads to examine these issues in a way that illuminates how substance use affects not only survivors but also their recovery process in the context of their relationships, as well as how their SPs are affected by and attempt to respond to their substance use following sexual assault. Several patterns were revealed in these interviews.

First, some SPs of survivors who abuse substances appear to be less likely to push for substance abuse help-seeking because they do not want to exacerbate pain for survivors. This indicates that efforts to educate SPs should address how to deal with substance use/abuse issues related to survivors but also the effects on themselves (i.e., AA or other support). Clearly, this is more complex than dealing with responding to sexual or assault or substance use issues alone, so more skill and support may be necessary to deal with and respond to both.

As documented in the separate literatures on sexual assault and substance use, individuals affected by each of these issues can lead to positive and negative effects on close relationships of survivors (Ahrens & Aldana, 2012; Brookings, McEvoy, & Reed, 1994; Connop & Petrak, 2004; Moss, Frank, & Anderson, 1990). More broadly, survivors may experience voluntary and/or involuntary changes in their social networks if they are disbelieved or the persons around them cannot deal with the assault or its effects. This has been more studied in the substance abuse literature where it is known that those who are drinking/using substances may need to avoid those network members and find sober, supportive non-substance using networks to enhance their recovery and avoid relapse. Unfortunately, this may involve losing close friends and others who provide support, so treatment providers need to help survivors navigate which relationships they can keep, and which ones are too harmful to realistically do so, where they have the choice. Brown and colleagues (2015) explain that treatment providers may simply advocate women leaving substance using networks, yet some women may be in circumstances where they cannot simply leave family or friends and where those relationships are more mixed, making it more appropriate in some cases to set limits and manage those relationships in ways that are heathier for them. Sexual assault survivors’ relationships are challenged also by the assaults, and substance use issues only add to that and make it much more difficult, particularly to maintain romantic relationships. Thus, survivors and supporters need much more support from individual and couple counselors, 12-step programs, and formal treatment providers for substance use issues to be able to navigate relationships where assault and post-assault substance use are co-occurring.

With regard to formal support groups like NA and AA, we found survivors were mixed with some saying they worked for them, but not others. For example, one survivor did not feel accepted into these programs but turned to church instead and that worked for her. This also illustrates the important role that faith and spirituality can have in recovery, as well as the positive support networks that are often associated with being involved in religious communities. Research on 12-step and other support groups also shows that increased social support, sponsors, and likely resulting feelings of belonging appear to be key aspects of what make them effective at protecting against relapse (Tonigan & Rice, 2010; Kelly et al., 20111; Kaskutas, Bond, & Humphreys, 2002). This study’s findings illustrate the need to have substance use groups that address the unique needs of sexual assault survivors. Recognizing this need, some clinicians have offered training and guides to professionals, sponsors and other helpers to address trauma in the context of working 12-step programs (Marich, 2012). Such groups should be professionally led by those who are knowledgeable and experienced in both sexual trauma and substance abuse treatment issues in women. Programs for women with dual disorders are so important for addressing trauma and the results of it comprehensively, and research shows they can be effective for women with PTSD and SUDs (Lenz et al 2016; Najavits & Hein, 2013), a population that has high rates of sexual abuse and assault.

Recent research on attitudes towards 12-step groups shows that women with PTSD and SUDs want trauma and PTSD, not just SUD, addressed in self-help and that is preferable to simply having women-only groups (Najavits, de Haan, & Kok, 2015). Our study suggests that we need more research regarding what it is that makes NA and AA programs useful to some survivors but not others, which was also recommended by Najavits and colleagues (2015). Perhaps women-only groups that acknowledge and/or incorporate the role of trauma can be most helpful for survivors in providing a safe space that addresses how women are impacted by sexual abuse and assault. Research shows that women-only AA groups are helpful to some women (Sanders, 2009), but research has yet to look specifically at how issues related to how (and if) trauma is dealt with, to the extent that it is, in those groups and/or between survivors and their 12-step sponsors. For many women, professionally led groups that deal with issues of dual disorders and trauma comprehensively may be needed, so survivors not only have individual therapy for themselves and trauma-specific treatment, but can also share with other women who have similar comorbidities.

Many survivors in our study have sexual abuse histories that led them into the vicious cycle of risky sex and substance use, where they were taken advantage of at a young age by older men or raped. After that, they were unable to set boundaries and/or simply did not know that unwanted sex was not normal, so they continued to be victimized. Whether this was unwanted or not, often such experiences are harmful, and young girls who may think they are valued by older men, later regret such relationships and realize they were actually exploited (Phillips, 1999). Clearly, CSA survivors are at greater risk for drinking to self-medicate, and face greater risk of PTSD, depression, and suicidality (Paolucci, Genuis, & Violato, 2001; Ullman, 2016), given their greater likelihood of being revictimized and the betrayal trauma many experience by older parent or parent-like figures (e.g., much older boyfriends/partners) who exploit them when they are young and vulnerable and cannot protect themselves.

Professionals can help SPs to encourage survivors to seek formal substance abuse and mental formal help, given that SPs are unlikely to be able to cope with all of these issues and effectively help survivors and take care of themselves. Survivors and SPs need information and services specific to assault-related substance abuse and how to effectively cope. For example, one SP explained that the survivor tries to curb her drinking by setting timers telling her when it is time to stop drinking. However, such examples show an underlying need to address the issues of trauma and substance abuse as well as to make resources available to help the survivor and the SP to assist her in doing so.

Our data show that relationship partners can help to positively influence women’s sobriety. Male partners’ drinking appears to have a greater effect on women’s drinking, especially early on in relationships than women’s drinking has on their male partners (Leonard & Mudar, 2004). This is illustrated in several of our interviews where male partners influenced survivors to seek help who previously were not willing to do so. There is a clear need for positive support sources for survivors that reinforce and support their recovery from trauma and sobriety and that do not trigger them into risk-taking behavior and relapse.

Unfortunately, some survivors were drawn into substance use by their partners and the couple used substances together. In our data, these couples eventually got sober together, too, but their relationship changed due to the refocusing of their relationship on a healthy lifestyle rather than substance use – which sometimes was positive (i.e., mutually supportive relationship) but not always (e.g., one survivor who was ready to “move on” because she learned that she and the SP were not the same people, and felt that she and SP found each other to get sober together but that was their only role in life together). In such cases, the relationship may serve as a catalyst to get sober for survivors and/or SPs, but after that is achieved, the partners may not have further motivation to stay together, which may be because substance use was what drew and/or kept them together or the growth in becoming sober made them recognize differences that led them to move apart in life.

Using the same dyadic interview sample, Lorenz and colleagues (2017) noted a ‘parentification’ effect among parent-child matched pairs, where the child (SP) felt obligated to take on adult or parent responsibilities before they were ready to do so. Lorenz and colleagues (2017) observed this effect in examining social reactions in general, though we also observed a similar pattern specific to substance use issues in the present study. Children of survivors felt obligated to quickly mature and care for their mother following disclosure due to the emotional effects of being assaulted, but in cases where the mother engaged in heavy substance use to cope with the assault, the child needed to physically care for the mother and their household as well. This illustrates that the parentification effect can be further complicated by substance abuse issues. Again, this is an important pattern for practitioners to consider because SPs experience this in addition to any secondary trauma, which could potentially cause greater damage to the survivor-SP relationship, as well as adverse mental health outcomes for SPs as they mature into adults. Consistent with the literature, our data also show that survivors use substances to self-medicate via drinking or drug use – to suppress emotions like depression. Self-medication via drinking and/or drug use is problematic, as it is only a temporary solution and can worsen the symptomatology, particularly for survivors who were prescribed medications to assist with psychotic symptoms, depression, etc. but did not like the effects of the medication so turned to alcohol/substances instead, which also increases odds of alcohol problems (Robinson et al., 2009). This pattern suggests that better therapy and/or medication is needed to help survivors to adhere to treatment without side-effects that may lead them to prefer alcohol or other drugs.

Limitations

This study used a small, volunteer, convenience sample of dyadic matched pairs that were more positive in their relationships by virtue of still being in relationships and willing to do interviews on this topic. Interviews of SP’s were primarily about their relationships with survivors, as they were recruited via survivors, so less focus was on SPs and future dyadic studies should ask SPs more about their own experiences. Only one SP was interviewed for each survivor, but survivors often told multiple sources, so broader social networks warrant future study. With the retrospective design, 12 years on average had elapsed since assaults (M = 12.3; SD = 11.7), which may have influenced accounts by survivors and SPs.

SP’s may have been cautious about what they said about survivors, even though confidentiality was promised. Some pairs may have talked to each other about the study, which may have affected their discussions about sexual assault and relationships. Talking about sexual assault appears to be helpful to survivors with few reporting negative effects of study participation and some positive effects on help-seeking (Kirkner, Relyea, & Ullman, in press), so this may be an opportunity for relationship partners to reflect on this topic and their relationships.

Future research is needed in larger samples of survivor-SP dyads and/or their broader informal social networks to better understand how to help them navigate the impact of sexual assault. Despite these limitations, the present study provides a rich understanding of the ways in which recovery unfolds in the context of relationships over time by examining substance use, recovery, and informal relationships from a dyadic perspective.