January 2003			Utter Anxiety The Soul of Programming	E Line Sports Q&A Classes From the Field First-Person Letters Huskiana
		A Common Journey to Addiction Women addicts often share a troubling distinction: a history of abuse. By Hortensia Amaro CThe joyful afternoon she turned five, Diana blew out a big pink candle at the top of a creamy cake while her parents, relatives, and friends sang “Happy Birthday” amid a swirl of balloons, games, and toys. She had no idea what lay ahead. That night, as Diana slept, her drunken father came into her bedroom and awakened her. From then on, for as long as she lived at home, Diana was terrified of her father and what he did to her at night while her mother was asleep or herself too drunk to protect her daughter. The abuse continued for years. We see many little girls like Diana when they reach their late teens or early twenties, filled with pain, confusion, and anxiety, and seeking treatment for drug addiction. It’s estimated that over 5.5 million women in the United States are addicted to alcohol and/or drugs. Of those who enter substance-abuse treatment programs, over 50 percent were abused as children. Nearly all have experienced abuse as adults. For Diana and most women like her, psychological trauma manifests itself in an almost constant state of arousal and hypervigilance, as well as in sleep disorders, impaired cognitive functioning, and an inability to trust others. Studies show that normal brain function is affected by psychological trauma, sometimes for many years after the last abuse event. Abused women experience disproportionately high rates of chronic health problems, headaches, and abdominal and pelvic pain, among other physical ailments. They make disproportionately large numbers of emergency-room visits. They also suffer many mental health problems, such as clinical depression, and anxiety and eating disorders. The betrayal by her own father, the sense of being without the protection of an adult, and the feeling of “having done something so terribly wrong” that she “deserved” what was happening to her led Diana to try again and again to escape from reality. She ran away from home at sixteen. While living on the streets, she met an older man who promised to take care of her. He introduced her to crack. At first, their life together seemed like a party. He supplied her with crack every day. Diana felt she finally had the love and protection she had longed for. She seemed almost to forget her troubled past. Soon, however, her sunken pale face wore the signs of physical addiction. Though the causal relationship between sexual or physical abuse and addiction remains under debate, increasing evidence points to the fact that women with a history of post-traumatic stress are three to four times more likely to become addicted to drugs. Clearly, women with a history of abuse are at increased risk for becoming addicted to alcohol or drugs. The high they seek is a way of self-medicating emotional or spiritual pain. Studies show that drugs and alcohol affect several of the brain’s neurotransmitters, the chemicals that carry messages from one nerve cell to another and from one section of the brain to another. These messengers control urges related to survival—such as eating, drinking, and engaging in sex—that result in pleasure. Normally, the brain “turns off” these urges once they’ve been satisfied. But it appears continued drug use affects the normal satiety response, leading a user to continue to seek out and use drugs. Over time, as the function of dopamine and other neurotransmitters grows dysfunctional, a user needs drugs to feel “normal.” Scientists have yet to determine how long it takes the brain to recover from addiction or, indeed, whether it ever does. Studies using brain-imaging techniques currently suggest that, even after the last use of a drug, the brain continues to show abnormalities. Two years after they met, Diana’s partner forced her to become a prostitute to support both of their drug habits. Again she found herself the victim of sexual and physical abuse, the situation she’d sought to escape by running away from home. Diana was constantly exhausted, and felt ashamed and unworthy. To escape the misery, she turned to injecting heroin. Unprotected heterosexual sex with her partner and customers had put her at risk for HIV infection for nearly two years. Sharing needles now upped the risk even more. Injection drug use or unprotected heterosexual sex accounts for 80 percent of cases of U.S. women diagnosed with AIDS and 56 percent of those who test positive for HIV. Of those who don’t know the source of their HIV transmission, close to another 20 percent may have been infected through a sex partner. Though estimates vary according to geography, of all the U.S. drug users who enter drug treatment—both men and women—approximately 17 percent are infected with HIV. In the Northeast, the rates are much higher; for example, 37 percent of users entering treatment in New York City test positive for HIV. Further, during vaginal sex, the virus is more effectively transmitted by men to women than women to men, placing women at disproportionate risk. Overall, one in five persons diagnosed with AIDS is a woman, and women with AIDS are disproportionately black (63 percent) and Hispanic (18 percent). At eighteen, after her partner brutally beat her and pushed her down a flight of stairs, Diana ended up in an emergency room with severe internal injuries. Studies of ER admissions show that 50 percent of women seeking emergency care have a history of abuse. Other studies indicate that 39 percent of women patients seen in family-practice settings have suffered abuse at some point in their lives. So have 50 percent seen in outpatient mental health clinics, and 64 percent seen in inpatient mental health facilities. Despite these numbers, health-care providers seldom ask women whether they have been abused, even when their injuries or symptoms would suggest it. Most medical personnel are not trained to identify women with an abuse history, and also lack the resources to intervene and refer such women to services. Over the next several years, Diana was seen many times by health-care providers. Her last visit to an ER came at 3 a.m., just after she was arrested for trying to buy drugs from an undercover policeman. She had been beaten hours before by someone who stole her evening’s earnings. Her eyes were swollen, her face was bruised, and she had two broken ribs. Now, at an upcoming court hearing, she would face the possibility of going to jail and losing custody of her two children, ages four and three. Diana had entered a world where the criminal justice system and child protective services would have control over her life. Finally, she would have to seek treatment. But what treatments work best for women like Diana? At the Institute on Urban Health Research, we are investigating the best methods for treating addiction, as well as other health problems, such as HIV and asthma. Though the institute was founded at Northeastern just last year, our research into addiction and abuse stretches back twenty years. In over eleven studies—using a variety of approaches, including both quantitative and qualitative methods—we have investigated the prevalence and consequences of various forms of abuse—emotional, physical, and sexual—in both childhood and adulthood, among various populations. For instance, two mid-1980s studies of women in prenatal care revealed that 7 percent reported physical abuse during their pregnancy. Compared with their peers, these women were 2.6 times more likely to have had a history of depression, 3.8 times more likely to have made suicide attempts, 2.3 times more likely to have had sexually transmitted diseases, and 2.3 times more likely to report little or no emotional support during pregnancy. They were also 1.9 times more likely to use alcohol during pregnancy and 2.5 times more likely to have a partner who used multiple illicit drugs. Another study, of adolescent mothers in prenatal care, verified these findings. To learn more about the roles male partners and abuse play in the lives of women drug users, we conducted a study that used a life-history approach, gathering stories that added to our understanding of the quantitative data. We discovered male partners occupy a critical role in women’s initiation into hard drugs and the progression of their addiction. Women often said they began using drugs to be close to their partners, to hang out with them and be part of their social circle. For many women, starting and continuing to use drugs happen within the context of a love or sexual relationship—a love-drug connection different from the context reported for men, who are most often introduced to drugs by male friends. Though a relationship with a male partner rarely includes violence at the start, it often becomes extremely violent. Women addicts’ stories reveal patterns of ongoing abuse at the hands of male partners. And women who turn to prostitution to support their habit often experience severe violence from male customers as well. Yet the “power of love,” as one respondent put it, makes it difficult for women to leave their male partners. The man may be the father of the woman’s children. The woman’s perception that she and her partner have survived difficult times together may work as another powerful factor that keeps them connected despite the abuse. Armed with all this data—and working with a framework of women’s relational psychological development proposed by Jean Baker Miller and her Wellesley College colleagues—in 1996 we developed a treatment program called Entre Familia. Entre Familia is a yearlong family-oriented, culturally specific residential substance-abuse treatment program for Latina mothers and their children. The program is designed to help women gain skills that allow them to avoid relapse, build healthy relationships, and develop emotional and economic stability. We have discovered that Entre Familia women have endured, in large proportion, the kinds of problems we expected to find. Our five-year studies show many clients report an abuse history, including psychological abuse (79 percent), physical abuse (79 percent), and sexual abuse (58 percent). A large majority also have a history of diagnosed medical problems (74 percent) and mental health problems (87 percent). When interviewed six months and twelve months after discharge from treatment, these women tend to show statistically and clinically significant improvement in the major indicators of recovery: staying drug-free, having a job or being enrolled in school, getting off welfare, and not engaging in criminal activities. The most significant predictor of treatment success, we found, is length of treatment. Those who stay in treatment at least six months are nearly four times more likely to stay off drugs than those who receive only thirty days of treatment. To further improve treatment outcomes, we are currently completing a study that tests the effectiveness of an enhanced model of care against the standard substance-abuse treatment. The new model—aimed at Latina, African-American, and white women who are receiving methadone maintenance for opiate addiction, or outpatient or residential treatment for substance abuse—integrates intensive mental health services and trauma treatment into the women’s care. In addition, we have just received funding for another study, which will assess how effectively stress-reduction techniques and spiritual support work as part of our enhanced treatment model. Previous studies have documented the critical role stress plays in substance-abuse initiation and relapse. And the role of spirituality in coping with chronic health conditions, including addiction, is attracting an increasing amount of scientific exploration. By continuing to investigate research avenues and treatment efforts, we hope to learn how to give abused women like Diana their strongest chance to get off—and stay off—drugs and alcohol. Hortensia Amaro is the Distinguished Professor of Counseling and Applied Psychology at Bouvé College of Health Sciences and the director of the Institute on Urban Health Research.