Choose who’s in your circle: how women’s relationship actions during and following residential treatment help create recovery-oriented networks

Abstract

Women in recovery from substance use disorders often have difficulty establishing recovery-supportive networks. This exploratory study uses qualitative thematic analysis to examine how 88 women in recovery describe the actions they take to manage their personal social networks 12 months after intake into residential substance use treatment. Participants describe disconnecting or limiting contact with recovery-endangering people and adding recovery-supportive people to their networks as primary relationship actions for maintaining recovery. Their actions to build recovery-supportive networks can provide a focus for clinical work to help them become integrated into their communities.

“You gotta just choose certain people to be in your circle.”

–29-year-old African American woman

Women make up about one third of the 1.84 million admissions for substance use disorder treatment in the United States (SAMHSA, 2014). Women in early recovery, particularly those from low-income households, face a number of challenges. Managing their personal social networks (PSNs) so they can avoid substance use in their first year of sobriety is primary (El-Bassel, Chen, & Cooper, 1998; Falkin & Strauss, 2003; Tracy, Munson, Peterson, & Floersch, 2010). Women in residential substance use treatment may represent a more vulnerable population with less recovery-supportive PSNs than those in outpatient treatment (Min et al., 2013). Subsequently, a major focus for women’s substance use disorder (SUD) treatment involves creating stable, healthy relationships within their personal social networks. Adding to the current body of knowledge, this study describes the actions women take to promote recovery-supportive PSNs 12 months after entering residential SUD treatment.

Women’s Recovery Networks

Both practice experience and research literature indicate that in general, having more network members who are supportive of sobriety is related to a greater ability to maintain sobriety (Bond, Kaskutas, & Weisner, 2003; Laudet & Stanick, 2010; Soyez, Leon, Broekaert, & Rosseel, 2006), increased length of abstinence (Mutschler, et al., 2013), and increased abstinence self-efficacy, or confidence in one’s ability to refrain from drug use (Laudet & Stanick, 2010). The converse is also true: Having substance users in the network significantly increases relapse risk (Broome, Simpson, & Joe, 2002; Day, et al., 2013).

Women, however, often enter recovery with multiple layers of social disadvantage that lead to social networks that are less supportive of recovery. The first layer, substance use, can lead them to have fragile networks during recovery that provide insufficient social support as a result of having disconnected ties with others, either during substance use or after quitting substance use (Trulsson & Hedin, 2004). Likewise, women in recovery have described having network members who are simultaneously sources of vital support and potential relapse triggers, making it difficult to fully disconnect from recovery-endangering relationships (Tracy et al., 2010).

Family, intimate partners, and close friends are common sources for a woman’s introduction and perpetuation of substance use; these same people are often also sources of exposure to trauma (Center for Substance Abuse Treatment, 2009; Velez et al., 2006), potentially exacerbating stress and conflict rather than providing recovery support. Women with a history of trauma exposure report having difficulty disconnecting ties with network members who use substances (Sun, 2007), creating new recovery-supportive relationships (Min, Tracy, & Park, 2014), and overall difficulty managing the closeness and boundaries in the relationships in their networks for recovery success (Cloitre, Miranda, Stovall-McClough, & Han, 2005). This second layer of disadvantage can compound the social network problems resulting from substance use, and a woman who experienced trauma may enter treatment with a more fragile PSN, placing her at a higher risk of relapse unless she strengthens the ties with sources of recovery support (El-Bassel et al., 1998).

Finally, women in residential SUD treatment such as inpatient rehab enter with significantly higher numbers of substance users in their networks, including more people they had used with previously, and significantly less support for their recovery than women in outpatient treatment. These differences persist with only gradual improvements over the first year of recovery (Min et al., 2013). Thus, women who require residential treatment, and particularly those with a history of trauma, may represent a more vulnerable population in need of greater intervention for creating stable, recovery-supportive social networks. This need raises the question of how women in early recovery, and particularly those in residential treatment, form sobriety-oriented networks.

Creating Recovery-Supportive Networks

Recovery from substance abuse requires a woman not only to learn strategies for sobriety maintenance, but also to develop a social network that supports those strategies (Harris, Fallot, & Berley, 2005). This can include developing new nonusing network relationships; learning to set limits with people who may hinder their efforts at recovery (Brown, Tracy, Jun, Park, & Min, 2015); engaging with various community activities such as recovery-oriented activities or treatment, work, school, church, and other community institutions (Dominguez & Watkins, 2003); and support from self-help groups such as 12-step programs (Acier, Nadeau, & Landry, 2011; Groh, Jason, & Keys, 2008). All of these actions can be helpful in increasing the number of abstinence-supportive network members and in providing the support the person’s existing network lacks.

Aims

A social network consists of the ties between a given set of individuals, and a personal social network includes those ties in relation to a particular focal person (Borgatti, Everett, & Johnson, 2018; Scott, 2017)—in this case, the woman in recovery. Studies looking at women’s social networks in recovery primarily focus on the “what” and “who” of the networks as quantitative attributes, who is in the network, what types of social support are available, and factors influencing relapse, and ignore the heterogeneity and complexity of the network (Stone, Jason, Light, & Stevens, 2016). As stated previously, the people in women’s networks often play dual roles of providing support while endangering recovery, necessitating a more nuanced, less quantitative view that examines the “how,” or the specific actions that women take to manage their relationships within their social network. Stone et al. (2016) call for more examination of the mechanisms of change in social networks during recovery in order to create more useful research models and identify intervention targets. This exploratory study seeks to provide this examination by focusing on the following questions: How do women in recovery from SUDs describe the actions they take to manage the relationships in their personal social network? How do they describe the resulting changes that occur in their networks?

Method

Research Design and Sampling

This study uses thematic analysis of qualitative data selected from the NIDA-funded study The Role of Personal Social Networks in Post Treatment Functioning (R01 DA022994–01A2). Data were collected from May 2009 through April 2013 from women in treatment at one residential and two intensive outpatient, county-funded, women-only substance abuse treatment programs in a Midwestern city. Women were eligible for the study if they were 18 years of age or older, had been in treatment at study initiation for one continuous week, and had a DSM-IV diagnosis of substance dependence. Exclusion criteria included a diagnosis of or taking medication for a psychotic disorder. We collected data at 1 week after treatment program intake, 1 month, 6, and 12 months post-intake using a computer-assisted, in-person interview. Data collected at each time point included qualitative data, clinical diagnoses and scales, social support characteristics, and network compositional and structural data, using Egonet software (available from sourceforge.net/projects/egonet; McCarty, 2002; McCarty, Molina, Aguilar, & Rota, 2007).

Participants

The 88 women in this study ranged in age from 18–55. Nearly two thirds identified as African American, about 30% identified as White, and about 3% identified as Asian, Native American, or Other. The majority of the women had at least one co-occurring mental health disorder, and nearly half reported using substances at some point between the start of the study and the final interview. Table 1 presents sample characteristics in full.

Table 1.

Sample Characteristics (N = 88)

		N	%	M (SD)
Mean age (range 18–55)		88		37.01 (10.11)
HS or equivalent education		50	56.8
Race
	African American	58	65.9
	White	27	30.7
	Other	3	3.4
Co-occurring mental health disorder		65	73.9
	Generalized anxiety	14
	Post-traumatic stress disorder	29
	Major depression	50
	Dysthymia	4
	Mania	22
	Hypomania	6
Mean score on Trauma Symptom Checklist (max 120)		88		47.31 (20.72)
Substance use since last interview		43	48.9
Discharge disposition
	Dropped out	38
	Completed treatment successfully	29
	Referred to other treatment	18	20.5

The study team focused the analysis on the 88 women receiving residential treatment who provided qualitative data at 12 months post-treatment intake. While we coded all data, saturation was achieved by roughly the halfway point for each transcript during open coding using this sample, and the sample size was considered sufficient for this analysis.

We analyzed selected quantitative data for the sample population to provide a demographic and clinical description of the study participants. These quantitative variables included age in years; race (White, African American, and Other); completion of at least a high school education (yes/no); self-reported substance use since the previous interview (yes/no); co-occurring mental health diagnosis as assessed by the Computerized Diagnostic Interview Schedule (Robins et al., 1999; yes/no); score on the Trauma Symptom Checklist with a range of 0–120, higher scores representing higher trauma symptomatology (TSC; Briere, 1996); legal involvement (on probation, parole, or awaiting sentencing), and the discharge disposition (completed treatment, referred to other treatment, dropped out).

Thirty-six women who were in residential treatment at the start of the study dropped out prior to the 12-month interview, and their cases were compared with those in this sample. Those who completed the 12-month interview were more likely to identify as African American and more likely to have lower educational levels than those who dropped out. There were no significant differences between the two groups on age, mean score on the TSC, presence or type of co-occurring disorder, or their treatment disposition.

This study was approved by our university’s Institutional Review Board, which also approved the parent study protocol of obtaining signed, written, informed consent and the provision of a $35 gift card and travel expense reimbursement at each interview for respondents. A Certificate of Confidentiality was obtained from the Department of Health and Human Services.

The Questionnaire

Three of the open-ended questions we asked at the 12-month interview were grouped around the primary theme of social network change. The relevant study questions posed to respondents are as follows:

1. We’d like to know your thoughts on how your social network may have changed since the last time we talked.

2. What about the number of people in your network? Is your network bigger, smaller, or the same size as before? Why is this so?

3. Are the people in your network the same people or different people from before?

We conducted all open coding and analysis using ATLAS.Ti, version 7.5.10 (2017). Following the framework outlined in Fereday and Muir-Cochrane (2006), we analyzed the responses to these questions thematically, using a combination of both deductive and inductive approaches. We created an a priori template, based on the three open-ended questions listed above, and included “overall network change” (better, worse, the same), “change in network size” (larger, smaller, same size), “network stability” (are the people in the network “new,” “different,” or “the same”), “change in network composition” (categories of relationships, substance users or sober network members, supportive or unsupportive network members). Figure 1 presents a graphical representation of this a priori thematic tree. This template was used as a guide, but responses were coded for the research questions inductively, using a broad interpretation of each question to avoid missing any potentially related themes. Coding within this hybrid deductive/inductive approach proceeded iteratively and recursively so that as themes were identified, they were added to the template and were then coded for within all transcripts.

Figure 1:

A priori thematic coding struvture

In the next stage, we organized the open codes thematically and merged codes that were conceptually similar and concluded with the synthesis and organization of a theme tree. This theme tree was refined and restructured based on a review of both the literature and the data. We analyzed the resulting thematic structure to provide the frequency, intensity, and co-occurrence of codes. A graphical representation of this emergent thematic tree is presented in Figure 2.

Figure 2:

Emergent thematic coding structure

The code refining process utilized three coders. First, a primary coder coded all responses based on the structure outlined above. Next, two additional coders coded a 25% sample of responses from each transcript and compared and refined the code structure until 75% agreement was reached. The primary coder then re-coded the full transcript using the refined structure, and repeated the process of code comparison and refinement with a 10% sample of each transcript.

Results

Emergent Themes

Despite the interview questions centering on perceptions of network change, the women talked mostly about their own actions and activities in relation to those perceived changes. Thus, the theme of “relationship actions” quickly emerged as the dominant theme in the analysis. This theme was defined as actions the women reported taking to manage relationships within their networks, particularly those they reported had helped or hindered their recovery. The concept of “personal changes” emerged in relation to this theme, and included involvement in recovery support groups and community activities, employment, and descriptions of personal growth experiences.

Relatedly, “engagement in community activities,” emerged from the data. Many of the codes in these themes were interrelated. Their discussion of these topics was so correlated that separate reporting of the themes became difficult; therefore, the results centered on the relationship actions the women shared, followed by engagement in community activities and personal growth reported in relation to relationship actions. A list of these relationship action and personal growth codes and themes, including code counts and occurrence percentages, are shown in Table 2.

Table 2:

Code Counts by Theme

Theme	Code	Total a	% b
Relationship actions	Deliberately disconnected relationship	34	12.9
	Chose to have less contact	16	6.1
	Staying away from negative people	7	2.7
	Staying away from people doing drugs	27	10.2
	Focus on family	9	3.4
	Adding people to network	43	16.3
	Don’t want new people	5	1.9
	Trying to regain relationships	5	1.9
	Change in interactions with others = Isolating	23	8.7
	Change in interactions with others = More	15	5.7
	Attending recovery meetings	30	11.4
	Involvement in work, school, or community activities	26	9.9
Personal growth	Personal growth and self-awareness	30	11.4
	Trying to stay clean	7	2.7

^aTotal possible count for each code is the number of participants (88) times the number of primary documents (3) = 264; codes may co-occur with other codes.

^bPercentages obtained by dividing the observed count for the code by the total possible count, and provide a measure of intensity.

Relationship Actions

Limiting contact and deliberate disconnection

Prominent in the theme of relationship actions were those codes concerning actions that women reported taking to limit the contact they had with network members. “Choose to have less contact” represented actions that a woman described as “staying away from,” or “not spending as much time around” certain people, for example: “[My network is] different. I’m staying away from people doing drugs.” Relatedly, “Deliberately disconnected relationships” was coded when the women indicated that they had actively severed a tie: “[My network] is smaller. I don’t talk to my dad. I really don’t talk to my little sister much. And I stopped talking to some people.”

The women often specified the network member’s characteristics as a context for limiting contact or disconnecting from the relationship. Common rationales were coded “staying away from negative people,” and “staying away from people doing drugs.” Women indicated their network members’ substance use as a motivation for limiting contact: “[I’m] staying away from certain people. Staying away from people with alcohol and drug problems and negative people,” or for completely disconnecting: “I have stopped talking to those who drink or use.” Similarly, network members’ lack of supportiveness was cited as a reason for disconnecting: “I chose to stop talking to my dad because he gossips, he talks about me when he should be proud of me.”

Isolating

The act of isolating presented as both a risk and protective factor among the women. For some participants, isolating was described as a problem, often related to a return to substance use: “[My network] is smaller because I isolate when I use. When I was in AA I hung out with a lot more positive people. I isolate more. I hang out with using people. I need to stop and regroup and get some help. It sucks being high.” However, many of the women framed isolation in positive terms, and described it as a means of protection from recovery-threatening activities or people while they focused on their sobriety: “I guess I don’t go out as much. I never go to bars anymore. I talk to my friends on the phone. I guess in a way I have withdrawn. I’m trying to focus more on me and when I get that settled, then I can feel better about sharing myself with others.” Another woman reported that, while her network size had increased, she was using isolation to limit the type of people she allowed into her network: “[My network is] bigger, I am self-isolating and bringing only sober people into my life.”

Maintaining and strengthening existing relationships

Some of the women reported that they were focused on improving existing ties within the network by maintaining current relationships or by strengthening ties: “I am trying to grow the relationships that I have currently. I’m not trying to cultivate new ones at this time.” This focus on strengthening ties was coded, “trying to regain relationships,” and often occurred in conjunction with a change in who the women were choosing to interact with: “I have gotten a lot more involved with my family and supportive friends who don’t use and stayed away from friends who use.” Many of the women who talked about focusing on existing network ties spoke of it in relation to family, and these responses were coded with “focus on family.” One woman stated, “I am trying to reconnect with the family that I already have,” and “[I am] spending more time with family—children and grandchildren. My life is very centered around my family.”

New relationships

Based on the interview questions regarding whether the people in the women’s network were different or the same, we expected that many women would talk about the new people in their networks. As with other network change codes, however, they spoke about the actions they took to gain new network members, which was coded, “adding people to the network.” Interestingly, the women rarely talked about adding people to the network without also talking about disconnecting or limiting contact with other network members: “I tried to get rid of the friends who I let bring me down. The people I currently surround myself with are mainly people from recovery.” Participants also discussed the action of adding someone to their network in terms of what that relationship offered to them, and these quotes were given codes such as “positive network members” or “sober network members.” As one woman said, “[I am] not hanging out with people who use. I tried that, I got rid of them, but I have been meeting a lot of people at meetings who are supportive.”

Involvement in community activities

A driving force for changes in the network was becoming involved in school, starting employment, and attending religious services or other community activities. These concepts were coded “involvement in work/school/community.” Emerging from participation in these activities were new relationships. One woman who had returned to school said, “I interact more socially since being in school because I am interacting with my classmates. I have good classmates so my social network is building up.” Another participant talked about how her employment had brought new people into her network: “I’ve stepped out of my comfort zone and I am meeting people from all different walks of life. Especially, with this new work program I am meeting a lot of new people.” The women also identified religious activities as places to expand their networks: “[My network is] bigger because I started attending church and a whole lot of networking. I do a lot of volunteer work.”

Treatment and support group involvement

Women frequently discussed engagement in either peer-led or formal recovery activities. Two codes represented this concept: “attending recovery meetings,” and “relationships from recovery.” Women often linked engagement in recovery activities to both network change and personal benefit: “[My network] is bigger, cos I go to meetings, new people, I get to pick and choose from AA who’s best for me and who is not best for me.” They also viewed these new relationships as supportive of their recovery: “At NA meetings I meet new people who are supportive,” and “through AA and rehab I have met some really great people that help me to stay strong.”

Personal growth

In addition to talking about external social structures to build recovery-supportive networks, the women talked about internal changes, or personal growth. “Personal growth” captured expressions of insights or internal changes within the self, and can be seen in the following quotes: “I’m more patient, more attentive to listen, and think before I speak;” “I am trusting more people, opening up more;” and “I am more aware of people, I learned I love people.” As can be seen here, many of the quotes coded “personal growth” also related to being more open to connections to others. This newfound openness to social connections was coded “change in interaction style: more social,” and is exemplified by these quotes: “I’m very more open and social with people;” and “I’ve stepped out of my comfort zone and I am meeting people from all different walks of life.”

For many of the participants, this opportunity to describe and talk about their personal network relationships was perhaps the first time they could honestly evaluate their relationships in a nonjudgmental setting. As one woman commented, referring to the research interviewers, “You guys made me realize how I have to pick the people who are good for you to hang … with and not.” This type of self-awareness regarding the effect of their social network on their recovery was echoed in a number of other responses from the women. Some talked about actively changing their networks to be more recovery-supportive overall: “[My network is] way different because I...surround myself with positivity.” Others recognized the negative impact their existing PSN could have on their recovery: “My understanding of recovery is that it is an active change…and if I am not connecting the dots—that social part of me—then I’m not gonna grow or change.” These vibrant descriptions of relationship actions provided by the women in the study underscore the developing awareness women have of the influence of relationships on their early recovery.

Discussion

This preliminary qualitative content analysis resonates with what is commonly known in clinical knowledge: that changing your personal social network (PSN) can contribute to a successful recovery from a substance use disorder. However, there has been little research into the specific actions that women can take to effect this change within their network. The findings presented here contribute new information to the field’s current understanding of the influence of PSNs on SUD residential treatment by providing some insight into the mechanisms of change within social networks, an area that has been identified as needing further study (Stone et al., 2016). These results suggest that these relationship actions are specific ways that women can manage changes in their networks to create recovery-supportive network connections. These strategies include limiting the amount of contact the woman has with people they view as recovery-endangering, cutting ties completely with some network members, isolating themselves from others, focusing on existing supportive relationships, and cultivating new relationships, often through involvement with employment, school, community activities, or recovery-oriented activities.

Implications for Practice and Research

This study suggests that even simple personal social network assessments, such as network maps and sociograms, can help people identify recovery risks and strengths existing in their networks. At a minimum, a social network assessment ought to be routinely conducted during residential treatment intake and assessment. Network assessments—who is in the network, how network members are connected to each other and the types of support available within and provided by the network—completed at key points in the treatment process can reveal changes in networks over time and strengths and limitations at various stages of treatment. For some clients, the primary network issue may be having a small, limited network. Other clients may be severely isolated with virtually no network resources. Still others may be involved with a highly connected network that is not supportive of recovery. A detailed social network assessment could lead to interventions individually targeted to these types of networks.

Clients may be urged to sever ties with those who threaten their recovery during treatment in order to maintain sobriety, but women may find such a complete severing of ties impractical due to a perceived need to rely on those ties for basic needs and survival (Sun, 2007; Tracy et al., 2010), escape from loneliness (Harris et al., 2005), or out of a sense of obligation to family (Stone, Jason, Stevens, & Light, 2014). This study identified that a common strategy among women in recovery is to limit their contact with recovery-endangering individuals rather than end the relationship. The actions to manage change in relationships described by the women provide a description of specific interpersonal skills, or a preliminary “curriculum,” of ways to effect changes in personal social networks while in recovery. Network therapies for substance use disorders, such as that of Copello, Orford, Hodgson, and Tober (2009), draw upon a curriculum of core skills including communication, coping, enhancing social support, and network-based relapse management (p. 62) and elective skills, such as increasing pleasant and joint activities, active development of positive supports, and minimizing support for problem drinking (p. 105).

Based on the types of actions to manage change in networks described by these women, treatment practitioners may want to impart skills in network-focused treatment sessions to promote protective isolation, such as deliberately disconnecting, choosing to have less contact, or staying away from negative people. These types of actions to minimize support for problem drinking or drug use (Copello et al., 2009) are often difficult for female clients to initiate, and the skills building could focus on brainstorming possible actions and role playing as practice in a safe treatment setting before carrying out the action in the real-world network.

Likewise, the skills to add or enlarge a network, such as focusing on family, regaining relationships, or changing interaction style, provide a roadmap to creating changes in personal networks while at the same time promoting an empowerment- and strengths-based approach to network changes. The same actions to manage change in relationships may not work or be appropriate for all women in substance abuse treatment; having a menu of options allows for a more individualized approach to network change. The practitioner’s knowledge of resources available in the community such as self-help groups may also be valuable in helping clients enlarge their network resources that are supportive of recovery.

Involvement in recovery meetings is shown to be related to positive outcomes in recovery (Bassuk, Hanson, Greene, Richard, & Laudet, 2016) and is often encouraged as a part of SUD treatment. Beyond merely attending recovery meetings or other community activities, women discussed the importance of the relationships formed in community spaces as important, and this may be a critical part of creating a recovery-supportive social network. Future qualitative research may want to explore how such connections are related to long-term sobriety and recovery.

The women in this study reported creating new ties during recovery primarily through their engagement in sobriety support groups, employment, school, or religious activities. While echoing clinical knowledge and previous research regarding engagement with recovery support groups (Bassuk et al., 2016), this finding shows how women may fill gaps in their social networks with new, recovery-supportive ties. Theoretical frameworks that address addiction theory and social networks, such as recovery capital (Cloud & Granfield, 2008) or the transactional theory of stress and coping (Lazarus & Folkman, 1984), focus in part on this balancing act of minimizing the effect of stressors in the social network while maximizing the effect of recovery supports, and this study provides some additional support to these frameworks.

Limitations and Further Research

The women in this study were primarily low-income and African American, and all were engaged in residential treatment. Further research is needed to determine how these findings apply to more diverse populations and treatment modalities, such as intensive outpatient programs. In this study, some women volunteered that they attended AA or NA support groups, but the participants were not asked to specify what type of recovery activity in which they engaged in the prompts. As there may be some variation in the support received through different types of support groups and programs, this would be an interesting avenue for exploration. Studies should also connect how internal processes such as self-efficacy and managing the influence of mental health problems or traumatic symptoms influence a woman’s ability to engage in recovery-supportive relationship actions. Overall, more research is needed on what specific patterns of relationships within the personal social network support or threaten recovery, how those patterns change over time, and what changes lead to greater recovery success.

This study was an analysis of previously collected data with emergent primary themes that reflected responses beyond the set of open-ended questions asked of the participants. Thus, there was no opportunity for deeper exploration of these themes, including how the women saw the connections between their actions and their sobriety. However, this presents an opportunity for future research to explore more deeply and directly how women use these relationship actions to manage the ties in their social networks during recovery. Similarly, the parent study chose to exclude participants with psychotic disorders and to use DSM diagnostic criteria to describe the sample. As nearly 75% of the sample had a co-occurring disorder, this was a limitation that was at odds with the holistic, person-centered approach used in this study. Exploration of alternate ways to describe samples in similar studies is recommended.

Conclusion

This qualitative study addressed a research gap by examining the specific actions that women in residential treatment told us they take to manage their relationships within their social network during the early recovery period. The women voiced how they limited relationships when those relationships could not be eliminated altogether. Women also described how they added to their networks by using community resources to fill in gaps in their networks. Changing a personal social network is not always an easy thing to do and takes a great deal of courage and persistence, as these women describe; however, such changes may be key to maintaining an enduring recovery. This examination provides specific approaches that practitioners can take to help women develop more recovery supportive networks.