A Qualitative Exploration of Women’s Lives and Resilience in Substance Use Disorder Recovery

Abstract

Objective

This study sought to explore constructs of the Whole Health resilience model to identify potential intervention and local research opportunities as a precursor to intervention development, as well as to describe women’s resilience in Substance Use Disorder (SUD) recovery including current strengths, coping, self-care, needs and priorities in the context of their everyday lives.

Methods

Qualitative data were collected from December 2018 to January 2020 in the Mid-South United States. In-depth interviews of 17 women age 25 to 65 years in SUD recovery for 2 weeks or longer were conducted in 9 different settings including a Medication Assisted Treatment (MAT) hospital setting, a MAT pilot program in a community corrections setting, an incarceration re-entry residential program, community-based peer support organizations (eg, Narcotics Anonymous, Alcoholics Anonymous), a residential SUD treatment facility and a yoga teachers’ online group. These data were analyzed with a hybrid approach (inductive and deductive coding).

Results

The major themes that emerged from the analysis included social support, individual-level cognitive and spiritual strategies; self-care; stressors, priorities, needs, and self-care barriers and trauma. In this context, women needed a wide range of support including treatment of severe physical injuries, professional psychological support, help with restoring relationships, SUD treatment and recovery services, job training and coaching, health insurance advice, transportation, intimate partner violence (IPV) counseling and housing. Peer-support groups and faith communities were instrumental in many (but not all) of these women’s lives in recovery—a gap was identified for women who did not have social support from these groups.

Conclusion

These data highlight the need for developing interventions for women in SUD recovery that take a holistic view of resilience life areas, as well as integrate professional services, family support, community support and approach care as wrap-around support that includes integration of social services to meet women’s basic needs.

Introduction

Women are at increased risk for substance use disorder (SUD) and co-occurring mental illness in the United States with significant increases in serious mental illness, depressive episodes, marijuana and methamphetamine use and opioid use.¹ Lifetime exposure to trauma, including Adverse Childhood Experiences (ACEs) and subsequent vulnerability, increases the likelihood of developing an SUD.² A study of 20 000 women in the United States found that women who experienced violence were nearly 2.5 times more likely to develop an SUD.³ Studies report that 80% to 90% of women who are in SUD treatment have had violence exposure in their lifetimes.⁴ The intersection of violence, trauma and SUD in women is well documented,⁵ and necessitates providing gender-responsive, trauma-informed and integrated interventions for SUD treatment and recovery services for women.⁶ Developing integrated SUD interventions requires exploratory research to identify potential opportunities and barriers, as well as insight into the complex lives of women in SUD recovery, which is defined as “a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life.”⁷ Therefore, this study aimed to describe women’s resilience in SUD recovery and strengths, coping, self-care, needs and priorities within the context of their everyday lives.

Resilience is defined by the US Substance Abuse and Mental Health Services Administration (SAMHSA) as “the context-specific ability to respond to stress, anxiety, trauma, crisis, or disaster […, which] develops over time and is the culmination of multiple internal and external factors. For those who develop mental health and/or SUDs, the influence of both internal development and external environments converge to either promote or restrict the development of personal resilience.”⁸ The Whole Health Resilience (WHR)⁹ model is emblematic of this approach as it represents a range of internal and external constructs (eg, coping, strengths, environment, community). A comparative study of the use of the WHR model in a community mental health setting to address mental health, substance use and physical health showed decreased hospitalizations, emergency department visits, office visits and overall Medicare expenditures.¹⁰ Although formal tests of the WHR model against other approaches are sparse, the WHR has demonstrated promising evidence of its ability to guide programming that supports resilience in SUD recovery populations. In this study, we sought to explore constructs of the WHR model to identify potential intervention and research opportunities in the local context as a precursor to intervention development.

Materials and Methods

A qualitative research design, informed by interpretive description,¹¹ which included applying a priori constructs and allowing inductive codes to arise from the narrative, aimed to better understand women’s experiences of SUD recovery including their stress, coping, self-care, strengths, priorities, needs and other contextual factors related to recovery from a WHR perspective. This was part of a larger study on the acceptability and feasibility of yoga as a potential adjunctive self-care intervention in SUD treatment and recovery.

In-person interviews took place from December 2018 to January 2020 in the Mid-South United States. We recruited women who had been in SUD recovery for 2 weeks or longer from a medication-assisted treatment (MAT) hospital setting, a MAT pilot program in a community corrections setting, an incarceration re-entry residential program, community-based peer support organizations (eg, Narcotics Anonymous [NA], Alcoholics Anonymous [AA]), a residential SUD treatment facility and an online yoga teachers’ group. Private rooms in the recruitment locations or in community organizations such as public libraries served as the interview setting. Recruitment methods included posters, provider referrals, snowball recruitment (eg, participants referred by providers or other participants), as well as in-person presentations and recruitment during or after the SUD treatment and recovery meetings in the clinic and community settings.

We used purposive sampling to recruit women age 18 to 65 years in early recovery (2 weeks minimum) or later recovery (more than a year), and broadly representative of racial/ethnic groups. The University of Arkansas for Medical Sciences Institutional Review Board (IRB) reviewed and approved the study protocol. Written consent was waived by the IRB to protect the anonymity of the participants. Each participant gave verbal consent after reviewing the consent information document, which was documented by the researcher in a process note.

Data Collection and Analysis Methodology

A semi-structured interview guide was informed by the WHR model. The in-depth interviews integrated contextual factors related to stress, coping, resilience and recovery, as aligned with the WHR model life areas (social support, cognitive strategies, environmental factors) (see Table 1).

Table 1.

Interview Guide Questions Related to Whole Health Resilience

Global opening question: We know that recovery is a complex process for women. Everyone’s experiences are different. We would like to know more about what has helped you in your recovery, as well as what else influences your recovery. Would you please tell me about what your life is like in recovery? Feel free to give me as much or as little detail as you want.
What kind of exercise do you enjoy? Can you exercise where you live?	Physical Activity
What is it like where you live? How much do you feel supported emotionally where you live?	Physical Environment Emotional Environment
How does service/helping others affect your recovery?	Advocacy/Service to Others
What are your dreams and goals?	Personal Life Development
What is your work life like?	Work Life Development Co-Worker Relationships
What are your eating habits like?	Healthy Eating
How are you sleeping?	Sleep
What are your family relationships like? How are your family relationships supportive/not supportive of your recovery?	Family Relationships
What are your friendships like? How are they supportive/not supportive of your recovery?	Friend Relationships
In what ways does spirituality or your religious practices support your recovery?	Spiritual Beliefs Spiritual Practices
What are some of the ways of thinking that help you with your recovery?	Optimism-Positive Expectations
How do you relax?	Cognitive Skills-Avoid Negative
Are there other ways you experience healing?	Relaxing Healing

Following the interviews, a questionnaire was administered to collect demographic information (age, race/ethnicity, socioeconomic status, etc.) and exposure to adverse childhood experiences using the Adverse Childhood Experiences scale,¹² a 10-item scale measuring abuse, neglect and household dysfunction.

The interviews were audio recorded and transcribed verbatim. The first 3 interview transcripts were reviewed and memoed to address potential gaps in the interview technique. After the first 5 interviews were conducted, data collection paused as the codebook was developed using inductive and deductive coding. Then, 2 rounds of iterative coding and comparing emerging sub-codes produced the final codebook. All of the interviews were then re-coded with the final version of the codebook. The hybrid thematic analysis¹³ began by applying a priori codes that organized the coded segments into broad codes, which was largely directed by the interview guide itself and helped to organize the first round of analysis into pragmatic buckets of coded segments. The a priori deductive codes and the data-driven, inductive codes and sub-codes were then interpreted together. Subsequently, the sub-codes were organized into themes with interpretive inductive analysis. The resulting sub-codes were then organized into larger themes that aligned with the WHR model.

Results

Participant Demographics

A total of 17 women ranging in age from 25 to 65 years participated in the study. Although incarceration exposure was not directly elicited, more than half of the participants shared that they had been incarcerated in their lifetime (n = 9), some of whom had also participated in re-entry programming in the past (n = 6). Table 2 summarizes participant demographics.

Table 2.

Participant Demographics (N = 17)

Variable	Participants n (%)
Median age (years)	41.5
Age range (years)	40 (25 to 65)
Race/Ethnicity
White	11 (64.7)
Black, African-American	4 (23.5)
Latina/White or Black, African-American/White	2 (11.8)
Education
Less than high school degree	1 (5.9)
High school degree or equivalent (GED)	1 (5.9)
Some college	15 (88.2)
Employment status
Employed, full-time	5 (29.4)
Employed, part-time	3 (17.6)
Not employed, looking for work	3 (17.6)
Homemaker	3 (17.6)
Disabled, not able to work	3 (17.6)
Annual household income from all sources
Less than $15,000	6 (35.3)
Between $15,000 and $34,999	9 (52.9)
$35,000 or more	2 (11.8)
Drug of choice (more than one could be selected)
Opiates/Opioids/Heroin	10 (58.8)
Stimulants	6 (35.3)
Marijuana, Alcohol	8 (47.1)
Currently in SUD treatment	10 (62.5)
Previous treatment history
Inpatient	7 (64.7)
Outpatient	8 (47.1)
None	5 (29.4)
Length of recovery
Less than one year	8 (47.1)
More than one year	9 (52.9)
ACEs
Median	4
Range	7

Abbreviations: ACE, adverse childhood experiences; SUD, substance use disorder.

[Insert Table 2]

Themes

From the hybrid analysis, 5 themes emerged. The first 2 themes—“stressors, priorities, needs, and self-care barriers” and “trauma” are discussed below and outlined in Table 3. Of the themes, ³—“social support,” “individual-level spiritual/cognitive strategies” and “self-care”—align with the WHR model constructs. Social support aligns with WHR interpersonal relationship categories such as family, friend, co-work relationships, advocacy, spiritual practices (eg, attending church) and advocacy. Individual-level spiritual and cognitive strategies are a blend of the WHR constructs of optimism, cognitive skills, and spiritual beliefs/practices. Self-care includes many of the resilience areas in the WHR that are not related to professional therapy or social support, including physical activity, healthy eating, sleep, relaxing and healing. Table 3 includes the hybrid development of the themes and exemplar quotes.

Table 3.

Themes: Stressors, Priorities, Needs, Self-Care Barriers and Trauma

WHR Themes	Deductive Code	Inductive Codes and Patterns	Supporting Statement
Stressors, Priorities, Needs, and Self-Care Barriers	Stressors	Children/family/partner Finances/resources/housing Anxiety/grief /loneliness/ confusion/anger/fear of groups/stigma	“First on my list is getting a job, then continuing with my GED. Also, I have some failure to appears…that I’m wanting to get taken care of so I can get my driver’s license back, and transportation. I need to get a vehicle. I know I’m gonna save up for that.”
	Priorities	Finances/housing/transportation Family Recovery/herself/school/health Faith/God	“Recovery first. God. Taking care of my bills. Then my family and friends.”
	Needs	Money/health insurance/food stamps/transportation Family mediation/Emotional support Treatment closer to home/Extended recovery services
	Self-care Barriers	Putting others first/family/caretaking Partner Resources/money/transportation
Trauma	Stressors/life in recovery	Trauma/panic attacks/paranoia/PTSD	“I was kidnapped and it [drugs] was brought into my life. It was put in my food and my drink and so, then I got addicted, but for me, it’s not about that part. The reason for it being difficult is the aftereffects of my abuse that I had, so yeah. That’s why it’s difficult for me.”

Trauma

Trauma and its consequences were apparent in direct narratives of interpersonal violence. While we did not probe directly for trauma histories, these narratives arose in conversation about stress, injuries—or in response to the global opening question (see Table 1). Many of the participants described complex post-traumatic stress disorder (PTSD) symptoms resulting from events such as long-term spousal abuse, childhood sexual abuse, and kidnapping. The ACEs questionnaire also revealed childhood exposure to trauma (neglect, abuse, etc.). Of the participants, 2 reported being diagnosed with PTSD. In addition, anxiety, loneliness, anger, fear, paranoia and grief were woven throughout the participants’ narratives.

Some of the participants identified trauma as the underlying cause of their addiction—and perceived that their SUD would be improved if they could come to terms with their trauma histories. In the context of many of the SUD treatment programs there was mention of trauma and intimate personal violence (IPV) therapy programming, while participants recruited from community-based locations were less likely to report use of professional psychological services. In a few cases, participants in community settings were in the process of arranging appointments for therapy.

Stressors, Priorities, Needs, and Self-Care Barriers

The women’s narratives of life in SUD recovery elucidated complex and challenging circumstances that complicated their recovery. Every participant balanced financial and caretaking responsibilities while attempting to take care of themselves, as well as prioritizing sobriety. When asked about their priorities, participants reported finances, housing, recovery, faith in God and family, in a variety of combinations. Many also acknowledged efforts to prioritize their own self-care, although some reported not finding the time or being able to take care of themselves.

Relationships and caretaking were noted by the majority of the participants as stressors. Partnerships with women in recovery or partners who were part of their drug-using history were reported as complicated and stressful. Restoring relationships with children who had been damaged by the respondents’ substance use was also reported as stressful by many of the participants. Women described a variety of other relationship stressors such as needing to distance themselves from drug-using friends, and there was a gap in time until new friendships formed.

Cutting across all the patterns of self-care barriers and needs was the struggle for more financial security, health insurance, food stamps and transportation. Many of the women reported working or having worked 2 or more jobs. Others received disability or were in the process of applying for it, having sustained injuries from violence and car accidents.

For women re-entering the community from incarceration, there were additional challenges, including not being eligible for food stamps on release from prison because of felonies or losing state health insurance after becoming employed. Financial needs extended to women’s partners, spouses, NA sponsees, children and grandchildren. In addition to the highly prioritized financial and resource needs described above, the majority of women also described experiencing stigma, and 2 participants additionally reported that they perceived stigma from their primary care providers. The majority of the participants also expressed needing help with relationship support, extended recovery services and treatment closer to home.

A number of participants in MAT treatment expressed the need for education about MAT for primary care providers, family and the general public. Many hid their treatment from their families, friends and employers. Finally, many of the participants expressed the need for SUD treatment services in more convenient locations, as well as often lacking resources such as transportation or time.

Social Support: Emotional and Informational

Social support (eg, interpersonal, emotional, advice) was the most prevalent theme that emerged from the participants’ answers. Emotional social support was derived from relationships with families, NA/AA sponsors and therapists. Friendships at work were also mentioned as supportive by a few of the women. Professional counseling for women with access to it was noted as instrumental in supporting recovery, particularly related to learning cognitive techniques (eg, positive reappraisal) and relaxation techniques (eg, mindful breathing). The majority of women also identified group social support received from daily, weekly or occasional NA/AA group meetings. In addition, there were some mixed results regarding social support received in groups, related to fear and anxiety of participating in groups, as well as unwanted male sexual attention in AA/NA meetings.

Also related to professional care was the value of medication to help manage anxiety. Medication in the context of MAT, as well as medications for anxiety and depression, were mentioned as an aid in coping in recovery.

I think the first time I tried recovery without the methadone, I was just—it was so difficult—like they were trying to teach me coping skills and stuff, but I was just struggling so bad with not having—I don’t know. It’s like I couldn’t clear my head enough to learn what they were trying to teach me. Here, it’s like the methadone is taking the edge off and helping me learn all this stuff and then hopefully I can get off that, and then still really know what they were saying. It’s like it didn’t click before. (White woman, 32 years of age)

The majority of the participants also reported social support related to religiosity, such as attending church; although a few of the participants identified avoiding church for various reasons (1 woman due to trauma experienced in that setting). Religious and spiritual practices that could be viewed as intrapersonal strategies are discussed in the next section. A couple of participants who were not connected to a peer-support recovery group or a church and who lived alone expressed loneliness.

Just loneliness, that’s another obstacle to deal with, tryin’ to do the right thing and not fall. ‘Cause it’s easy to go even to a new place and fall into the same crowd of people that you were around before. I mean, it’s beneficial to be lonely for a while until you get some good friends in your circle. (African-American woman, 30 years of age)

Spiritual and Cognitive Individual-Level Strategies

The second most salient theme was individual-level strategies that included both secular and religious psychological strategies. Religious/spiritual practices such as personal prayer, reading the Bible, meditation, and reading from NA’s “The Basic Text” were mentioned. The most prevalent intrapersonal-level cognitive strategies described by the women were “thought stopping” or “thought switching” or consciously directing thoughts to more positive topics, or in some cases, perspective taking by acknowledging their progress. Positive thinking, positive self-talk, and self-soothing were also mentioned by several of the participants. When women were asked about their strengths, they identified their families as motivating factors, as well as their renewed self-esteem in recovery and determination.

Self-Care

Self-care was probed directly and through questions related to the WHR construct “health promoting behaviors” (see Table 1). Prioritizing themselves was a common refrain—and many of the women found it difficult to find time for themselves. Half of the participants replied “walking” as the most common answer to what kind of exercise they participated in. Some women with athletic backgrounds also replied “running” (n = 6). Others highlighted spending time outdoors as a way to relieve stress, by walking or, as 1 participant reported, fishing. Additional physical activities mentioned included basketball, volleyball, cardio- or weight-training, jujitsu, yoga and Zumba.

Many participants reported physical injuries (broken wrists, ribs and spines; stenosis; missing lumbar disks; knee injuries; knife wounds; and spinal rods), some of which precluded full participation in physical activities. Some could only walk (not run), while some found walking to be too strenuous. Because this was part of a larger study assessing the acceptability of yoga, when asked, participants expressed moderate interest (“I wouldn’t mind trying it.” [African-American woman, 25 years old]) to strong interest in beginning yoga (“I’m really interested in it.” [White woman, 38 years old]), and also highlighted their concerns about being able to participate because of their injuries and physical condition.

In addition to exercise, participants talked about beauty/grooming when probed about self-care. For example, many participants mentioned clothes shopping, manicures, pedicures, wearing make-up and getting their hair done, while others mentioned eating out with friends. Some mentioned that not spending money on drugs gave them extra cash to spend on trips to the hair and nail salon, stores, and restaurants. Questions about “self-care” or “taking care of oneself” usually resulted in these kinds of activities, which require money, while questions regarding how to cope with stress elicited more answers related to exercise, bathing, creative endeavors and healthy eating.

The Figure depicts the 3 themes of social support, intrapersonal spiritual and cognitive strategies, and self-care in their approximate proportion to their mention in these data, offering an overview of the make-up of resilience in this sample of women (N = 17). The Figure was developed by approximating the code counts and grouping the codes into thematic groups in relationship to each other in order to visualize the complexity of women’s resilience. Table 4 contains a summary of the themes with the corresponding subcodes that were developed.

Figure.

Representation of Women’s SUD Recovery in Whole Health Resilience Model (N = 17)

Table 4.

Resilience Themes

WHR Themes	Deductive Code	Inductive Codes	Supporting Statement
Social Support Individual-Level Spiritual and Cognitive Strategies Self-Care	Coping/relationships/professional care/relaxing/healing/cognitive skills/religious coping/advocacy	Relationships/counselors/family/NA meetings	“Now that I’m in recovery, I get to talk to counselors and different people that—they don’t judge me. They understand me, and they give me positive feedback.“
		Religious/spiritual coping/meditation/breathing	“I was going to church, and then I got kind of bad off into addiction, so I quit going. Since I’ve been in recovery I haven’t really started back going to church or anything. Spiritually, I feel like I have a connection with God and I pray and everything, but I haven’t felt ready to go back to church yet.“
		Cognitive strategies	“Well, it’s like you’re turning on a light switch. When I start having thoughts of my sister and everything surrounding her death, I can replace it. It’s like turning on a light switch. Replace it with something else, like a good memory.
		Walking/sports/time outdoors	“Ever since I’ve started my recovery I’ve been walking every day, a little bit more every day. I’m lucky that I live in an area, I walk my son to school and home, instead of driving ‘cause it’s not that far.“
		Creativity/journaling	“Meditation, journaling and talking to my sponsor. Those are my biggest tools.”
		Medication	“I have terrible anxiety over anything and everything for a long time. I’ve done way better recently. I’ve done a lot of—well, I got on medication, which has helped, and then also some mindfulness and some breathing techniques that I’ve learned that have helped, but I think what led to my issues was my anxiety.“
	Strengths/cognitive skills/optimism/advocacy	Children/family	“I have to find something more that I love than pills, and it’s my kids.”
		Determination/willingness/responsibility/independence	“That’s probably a strength of mine as well, just drive or determination just to not ever go backwards.”
		Advocacy/compassion/empathy	“I like to think I have empathy today, ‘cause I’ve been through a lot. Like a lot of people have when they’re coming in. I can put myself there. I can impart experience, strength, and hope to help people get past things, if they’re open to that.”
		Positive attitude/self-worth/faith	“The fact that I have a big self-worth. When I was doing drugs, the people that I was around, they would talk to me or treat me like I was nobody.. …My greatest strength is my self-worth. I know that I’m somebody, yeah.”
	Self-care/physical activity/nutrition/sleep/rest	Time for self/prioritize her own goals	“Just having my peace time, my inner peace, I always make time to have time just for myself.”
		Body care/exercise/healthy cooking/rest	“Over the last—in this three year process I’ve learned how to take care of my body better through nutrition and through exercising. I actually pay attention to those things now. I think that’s a lot of self-care that I do is just cooking for me and my family and things like that.“
		Shopping/nails/hair/makeup/eat out	“Start doing my hair. I have a different style every week. I do my nails. I make sure they’re polished. Do my toes. I go shopping. When I was doing drugs, none of that. Every money that I got, I wanted to get high with it. Now, I get to do things to make me feel good. Makeup — I started wearing makeup.“

Discussion

These data demonstrate the complexity of resilience of women in SUD recovery, many of whom have co-occurring mental health conditions and who face an “assemblage of disadvantage”¹⁴—or a confluence of structural (eg, poverty, access to care) and biographical (eg, trauma) forces that often problematize recovery. This study also verifies previous findings of perceived stigma of both accessing care,¹⁵ and more broadly of being a former substance user in recovery.¹⁶

While there are a plethora of studies of self-care for chronic illnesses such as cardiovascular disease and stroke, less has been published about the specific area of self-care in SUD recovery among women.¹⁷ Data from our study highlight similar self-care topics noted in the chronic disease arena such as diet and exercise, with exercise being more salient. In other research, self-care in SUD recovery has been defined as a mindful awareness of emotional and physical triggers and direct processing of the information to avoid relapse.¹⁸

This definition of self-care falls within the WHR area of cognitive skills and mindful awareness, and in our study, the participants’ narratives were abundantly filled by themes of emotional awareness, but less of subtle physical awareness other than pain and limitations of physical injuries. In addition, women in this study were not always clear about the question of self-care, and asked for clarification. Self-care strategies were better elicited by prompts about how to cope with stress. The nascent literature on chronic disease management and SUD recovery taken with these data point to an opening for interventions that more explicitly define and address self-care in this population, particularly in how self-care relates directly to SUD recovery.

There was a strong representation of religious and spiritual coping for SUD recovery within these data—both on the individual and interpersonal level—which is documented in the literature.¹⁹ Spiritual and religious coping have been documented in the violence recovery literature as well.²⁰ Recent research showed that adjunctive participation in AA to SUD treatment was mediated by an increase of spirituality/religiosity, by decreasing negative affect (eg, negative emotional states).²¹ There was also evidence in these data that the participants’ relationships with their churches were complex and sometimes problematic. Further research of women’s relationships with their faith communities along the continuum of SUD recovery could inform intervention development to meet the needs of women in recovery within these contexts.

In addition, for women who did not have a faith community or support from an NA/AA group, there was a gap in time before new relationships were formed. The literature offers evidence that the lack of social support following incarceration can exacerbate negative mental health outcomes, particularly among individuals who have experienced trauma.²² In addition, social support during recovery is an important protective factor for preventing SUD relapse.²³ For example, women who attended AA groups in addition to an IPV intervention (ie, Seeking Safety) reported decreased alcohol use at the end of the study period.²⁴ Previous research found a positive impact on tobacco abstinence with the implementation of a social support intervention among underserved women.²⁵ Our data highlights a timeframe of need and the potential for an innovative social support intervention to bolster SUD outcomes in the local context, especially following incarceration.

While there is acknowledgment of gender-responsive and gender-specific SUD treatment options in the literature,²⁶ these data highlight the priority of creating more treatment and recovery service options that integrate the specific needs of women while intervening on trauma and the resulting psychological and physical wounds and co-occurring mental health disorders. In particular, the WHR model for this study provides a framework to explore the multiple life areas and needs, including employment, housing, transportation, treatment and recovery support, as well as integrative health components supportive of quality of life in recovery such as physical activity, religiosity/spirituality, sleep and nutrition. Overall recommendations include being cognizant that earlier stages of recovery and treatment require an intensive amount of effort to maintain sobriety and avoid relapse. For example, many of the women sought jobs based on what would allow them to attend daily NA/AA meetings, which in some cases meant 2 part-time jobs. Research has shown that unmet basic needs such as jobs and housing can limit involvement in SUD treatment.²⁷ As such, any interventions must take into account the limited resources and time women have, as well as the recovery strategies that support them.

While one of the re-entry programs in this study did provide integrated interventions on multiple levels (ie, job training, housing, trauma therapy, yoga, nutrition education and relapse prevention), other SUD treatment programs did not offer holistic intervention components to the same extent. Some literature supports the idea that non-addiction-specific measures such as nutrition and physical activity correlate with poor quality of life in recovery,²⁸ which are reflected in these data and are potential points of intervention. A report on the study of the “Very Integrated Program” for smoking cessation, nutrition, physical activity, and SUD treatment highlights early attempts of clinical care using an integrated model.²⁹ Future research could help identify WHR life areas and integrative health practices that not only bolster substance use outcomes, but also improve quality of life measures that support recovery.

In addition, research practitioners, policy makers and payers could further explore the effectiveness of integrated care models for women in SUD recovery. While these models present a number of challenges to the current healthcare systems (eg, payment structures), some innovative programs such as the University of Vermont Comprehensive Pain Program³⁰ have used integrated care to provide care to patients with complex needs such as patients who experience pain. In particular, such a model would be appropriate for the women in our sample, many of whom struggled with comorbid SUD and pain.

As the WHR model is a strengths-based and person-centered model, interventions ought to take into account women’s individual strengths and the importance of choice. These qualities also are reflected in the US Substance Abuse and Mental Health Services guidelines for Trauma Informed Care,³¹ which are important to integrate into recovery services. In addition, interventions that incorporate physical activity need to carefully consider the potential for physical injuries sustained from victimization (eg, IPV services need to be integrated into recovery services).

Conclusion

The major themes that emerged from the hybrid analysis included: social support, individual-level cognitive and spiritual strategies; self-care; stressors, priorities, needs, and self-care barriers and trauma. Within this context women needed a wide range of support, including treatment of severe physical injuries, professional psychological support, help with restoring relationships, SUD treatment and recovery services, job training and coaching, health insurance advice, transportation, IPV counseling and housing. Peer-support groups and faith communities are instrumental in many (but not all) of these women’s lives in recovery—yet a gap of need was identified for women who do not have social support from these groups. Intervention development could be aided by integrating the WHR model, as the model outlines professional services, family and community support, and self-care as avenues to recovery.

Study Strengths and Limitations

This study gathered a diversity of perspectives from 9 different sites, which is a particular strength. While the variety of settings does offer the possibility of multiple viewpoints, we acknowledge the potential for selection bias. A further limitation is that this study did not reach women who did not seek treatment. Finally, these data are not generalizable and apply only to the local context.

Biographies

Margaret M. Gorvine, PhD, CHES, E-RYT

Tiffany F. Haynes, PhD

S. Alexandra Marshall, PhD, MPH, CPH, CHES

Cari J. Clark, ScD, MPH, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia.

Nakita N. Lovelady, PhD, MPH

Nickolas D. Zaller, PhD; Department of Health Behavior and Health Education, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas.