The experience of women who are in substance use disorder (SUD) and mental health (MH) treatment has long been shaped by cultural norms, historical stigma, and systemic barriers. From the marketing of “women’s tonics” in the 19th Century to modern critiques of treatment models designed primarily for men, women’s struggles and triumphs in recovery reflect a complex story. This complex trajectory highlights the urgent need for trauma-responsive, culturally relational, and gender-specific approaches to care.
Women’s experiences across history reflect how medical practices, societal roles, and family expectations intertwined to create both vulnerabilities and strengths. The way women’s pain has been understood, sometimes minimized and sometimes pathologized, provides a backdrop to current treatment approaches. The question today is not simply whether women can access care but whether the care, if provided, is responsive to their unique experiences and identities.
Historical Views: From 19th-Century Tonic Culture to Early Psychiatry
In the 1800s and early 1900s, substance use among women was often framed through a lens of morality and “hysteria.” Patent medicines such as “soothing syrups,” “nervine elixirs,” or alcohol-laced tonics, marketed directly to women, promised relief for menstrual pain, childbirth recovery, or nervous exhaustion (Courtwright, 2001). Many of these products contained opium, cocaine, or high levels of alcohol, which fostered dependency that was pathologized as a female weakness or moral failing instead of being recognized as addiction.
The paradox is striking: the same society that condemned women for alcohol or opiate use simultaneously sold them addictive substances as household remedies. This reveals an enduring tension, in which women’s suffering was commodified and their struggles with addiction were hidden or condemned. The “cult of domesticity” demanded women to appear virtuous, patient, and self-sacrificing, leaving little room for honest acknowledgment of substance misuse.
Simultaneously, women were over-represented in psychiatric institutions, where diagnoses such as “hysteria” and “neurasthenia” blurred the line between mental health struggles and gendered expectations (Showalter, 1985). Institutionalization was less about treatment than social control and served the function of disempowering women who were perceived as difficult, nonconforming, or too openly distressed. This set the stage for a treatment system that often silenced women’s voices and punished their suffering rather than treating it.
Barriers to Recovery: Then and Now
While access to care has improved, women today still face unique challenges in entering and sustaining recovery. The echoes of history remain visible through stigma, systemic inequities, and cultural expectations that shape treatment experiences.
- Stigma and Shame: Women who use substances are more harshly judged as “unfit mothers” or “immoral,” which discourages them from seeking care (Beckman & Amaro, 1986). This moral framing often delays treatment until crises occur, which reinforces cycles of secrecy and isolation.
- Caretaking Burdens: Many women avoid treatment because of childcare responsibilities or fear of losing custody (Ashley, Marsden, & Brady, 2003). Unlike men, women are disproportionately penalized for leaving children in care while they seek recovery, making treatment feel like an impossible choice between personal healing and family preservation.
- Co-Occurring Trauma: Women with SUDs have higher rates of trauma, domestic violence, and co-occurring disorders, all of which complicate engagement (Najavits, 2002). Substance use often develops as a survival strategy for unprocessed trauma, which means that treatment must do more than address chemical dependency. It must also create pathways for safety and trust.
- Economic Barriers: Limited financial independence and employment inequities make residential treatment less accessible to women. Insurance coverage gaps, lack of paid leave, and disproportionately low-paying jobs compound these barriers.
- Systemic Gaps in Care: Women often encounter fragmented systems where mental health, addiction, and primary care services are siloed. This increases dropout rates and reduces long-term recovery outcomes, as women are forced to navigate multiple disconnected programs rather than being supported through integrated, holistic care.
Taken together, these barriers reveal why many women often fall through the cracks of treatment systems built without their realities in mind.
Treatment Differences: Women vs. Men
Research underscores that women respond differently to treatment modalities than men, and gender differences extend beyond biology into social, relational, and cultural dimensions.
- Relational Approaches: Women often prioritize connection and meaning in recovery. Cultural Relational Therapy (Jordan, Kaplan, Miller, Stiver, & Surrey, 1991) highlights how growth occurs through relationships, which is a stark contrast to traditional models emphasizing rugged individualism. Women heal not in isolation but in connection, through supportive networks where authenticity and empathy are central.
- Charlotte Kasl’s Contributions: Kasl (1992) critiqued the patriarchal assumptions of 12-step programs, noting that steps requiring women to “admit powerlessness” may replicate dynamics of abuse rather than foster empowerment. She proposed The 16 Steps for Discovery and Empowerment, which is grounded in feminist and multicultural perspectives that reframe recovery as a journey of reclaiming strength and dignity rather than submitting to powerlessness.
- Cunningham’s Research: Cunningham et al. (1994) noted gender gaps in how women experience 12-step groups, finding that some elements resonate (e.g., community and mutual aid) while others alienate women with histories of oppression or trauma. For example, the emphasis on confession and making amends can trigger shame responses in women whose substance use was intertwined with abuse.
- The Jenike Curve Problem: The “Jellinek Curve,” long used to illustrate the trajectory of alcoholism and recovery, was developed based on male drinkers in mid-20th-century studies (Jellinek, 1946). Applying it uncritically to women obscures differences in progression, co-occurring disorders, and social consequences. Women often experience a “telescoping effect,” moving more quickly from first use to addiction, and their recovery trajectories are rarely linear.
- Protective Factors Unique to Women: Protective factors such as strong female peer support networks, safe housing, trauma-informed medical care, and access to reproductive health services significantly influence women’s ability to sustain recovery. These elements shift the focus from simply stopping substance use to building resilience and a community that sustains long-term healing.
Emerging Models of Gender-Responsive Care
Since the late 20th Century, treatment centers and theorists have increasingly recognized that “one size fits all” models fail women. Innovations include:
- Women-Only Programs: These provide safety and community for survivors of trauma and can help women build trust without the dynamics of gendered power imbalances that often surface in mixed-gender groups.
- Integrated Trauma and SUD Care: As pioneered by Lisa Najavits’s Seeking Safety model, combining coping skills for PTSD and substance use addresses the core reality that, for many women, trauma is not just a co-occurring disorder but a root driver of addiction.
- Culturally Relational Approaches: Emphasizing empathy, authenticity, and mutuality as central healing tools, programs grounded in relational-cultural theory focus less on compliance and more on fostering voice, choice, and connection.
- Holistic Supports: These focus on the importance of addressing parenting, housing, financial literacy, and healthcare alongside sobriety. Programs that treat recovery as a whole-life endeavor see greater retention among women.
- Protective Factors Wheel: Visual frameworks help illustrate the “ripple effect” of trauma and the constellation of supports, including spirituality, healthy family dynamics, community involvement, and positive identity development, that buffer women from relapse. The wheel highlights how recovery is sustained not only by removing substances but also by strengthening protective anchors across life domains.
Statistics: Where We Stand Today
Women represent nearly 32% of individuals with SUDs in the United States, yet they remain significantly less likely than men to enter treatment (SAMHSA, 2023). This treatment gap underscores the importance of examining not only the prevalence of SUDs among women but also the systemic barriers that keep them from accessing care.
Research shows that women with opioid use disorder face a higher risk of overdose death compared to men, largely due to the faster average progression from initiation to dependence (Becker & Koob, 2016). This heightened vulnerability illustrates the urgency of tailoring interventions that address the unique trajectories of women’s substance use.
Compounding these risks is the reality that up to 80% of women in treatment report histories of trauma or abuse (Covington, 2002). Such histories make clear that effective treatment cannot be narrowly focused on abstinence but must instead integrate trauma-informed practices that acknowledge the deep interconnection among addiction, safety, and past experiences.
Protective factors, when incorporated into treatment programming, can reduce relapse risk by as much as 40%. This finding highlights the value of comprehensive, gender-responsive approaches that extend beyond the traditional models of care.
Ultimately, these numbers confirm what women in recovery have long known: their journeys cannot be measured solely by whether or not they achieve abstinence. Recovery must also take into account trauma, safety, relationships, and the broader social conditions that shape women’s lives.
Toward Dignity and Responsiveness
Women’s stories of substance use and recovery cannot be disentangled from history, culture, and relational contexts. While marketing in the 19th Century commodified women’s pain and treatment and in the 20th Century often silenced it, today’s challenge is to create spaces where women’s voices guide recovery models. Approaches such as Cultural Relational Therapy, gender-specific programs, and feminist critiques of traditional models remind us that healing for women is deeply rooted in empowerment, connection, and dignity.
The work of scholars, clinicians, and the women in recovery themselves underscores a common truth: when treatment honors women’s lived realities and strengths, it not only promotes sobriety but also restores dignity, resilience, and hope for generations to come.
Sources:
- Ashley, O. S., Marsden, M. E., & Brady, T. M. (2003). Effectiveness of substance abuse treatment programming for women: A review. The American Journal of Drug and Alcohol Abuse, 29(1), 19–53.
- Beckman, L. J., & Amaro, H. (1986). Personal and social difficulties faced by women and men entering alcoholism treatment. Journal of Studies on Alcohol, 47(2), 135–145.
- Becker, J. B., & Koob, G. F. (2016). Sex differences in animal models: Focus on addiction. Pharmacological Reviews, 68(2), 242–263.
- Covington, S. (2002). Helping women recover: Creating gender-responsive treatment. In S. L. A. Straussner & S. Brown (Eds.), The Handbook of Addiction Treatment for Women.
- Courtwright, D. T. (2001). Forces of Habit: Drugs and the Making of the Modern World. Harvard University Press.
- Cunningham, J. A., Sobell, L. C., Sobell, M. B., & Kapur, G. (1994). Utilization of health care resources by problem drinkers: Results from a community survey. Journal of Studies on Alcohol, 55(1), 44–51.
- Jellinek, E. M. (1946). Phases in the drinking history of alcoholics: Analysis of a survey conducted by the official organ of Alcoholics Anonymous. Quarterly Journal of Studies on Alcohol, 7, 1–88.
- Jordan, J. V., Kaplan, A. G., Miller, J. B., Stiver, I. P., & Surrey, J. L. (1991). Women’s Growth in Connection: Writings from the Stone Center. Guilford Press.
- Kasl, C. (1992). Many Roads, One Journey: Moving Beyond the 12 Steps. HarperCollins.
- Najavits, L. M. (2002). Seeking Safety: A Treatment Manual for PTSD and Substance Abuse. Guilford Press.
- Showalter, E. (1985). The Female Malady: Women, Madness, and English Culture, 1830–1980. Pantheon Books.
- Substance Abuse and Mental Health Services Administration (SAMHSA). (2023). Key Substance Use and Mental Health Indicators in the United States.
