Holly Wilson, a licensed professional counselor (LPC) candidate in Colorado, knows firsthand that women can feel disconnected or overlooked in addiction recovery programs. When she decided to seek help for alcohol dependency through 12-step and other treatment programs, Wilson kept hearing staff in these facilities talk about addiction in terms of “hitting rock bottom” and “failure” and make blanket statements such as “all addicts are liars.”
These types of statements didn’t fit Wilson’s experience, but they did add to the self-criticism she was already feeling. A self-described “high-functioning drinker,” Wilson had always been able to hold down a job and had never been cited for drunken driving. She didn’t fit the messy, drunken stereotype that many people associate with those who need treatment for addiction.
“I kept drinking for a long time because I was able to show up and look good, but I was really dying inside,” says Wilson, a member of the American Counseling Association. “I just got sick of myself and saw that I wasn’t achieving what I could.”
Declaring in treatment that “failure” had brought her to this point didn’t feel accurate or helpful, Wilson recalls. “I had to subscribe to calling myself an alcoholic and [agree to] ‘your best thinking got you here.’ It reinforced a lot of the shame that I was already feeling about myself,” she says. “I was actively seeking help and wanted to get better, and the system I experienced felt like it was forcing me into this box that I was a rock-bottom failure. … I kept hearing the message that you have to hit rock bottom before you can get well, and I thought that was really dangerous.”
The focus that some treatment programs place on admitting failure or a sense of powerlessness over a substance can alienate or even drive away female clients because many women already carry intense feelings of shame about their alcohol use, Wilson notes.
Despite Wilson’s difficult initial experience with treatment, she stuck with it and eventually found outpatient group therapy and individual therapy that felt welcoming and helped her learn more about the reasons why she drank. During her time in a women-only sober living house, she and her housemates were able to have deep and honest conversations about the trauma they had experienced — much more so than in the dialogue she’d experienced in coed groups, Wilson says.
Wilson’s recovery journey inspired her to help other women with similar experiences. After becoming a counselor and working in numerous positions in different substance use programs, she founded Women’s Recovery, an outpatient addiction treatment center for women with locations in Denver and Dillon, Colorado. Wilson serves as chief empowerment officer of the treatment center, which combines trauma-informed care with clinical treatment. The organization has a client-focused model that begins with asking clients what they want to get out of life, rather than prescribing what they should or have to do, Wilson says.
Treatment for alcoholism “doesn’t have to be through the lens of [a] power struggle over [a] substance,” Wilson says. “There is a misnomer that people have to get to rock bottom before getting help. … I would love to see a psychic shift [away from] that. It’s a problem whenever alcohol is getting in the way of things they want out of life. … The best thing we can do as counselors is shift our focus from that kind of rock-bottom-drunk perspective to an early intervention approach. We don’t have to wait until our clients lose everything and burn their life down to help.”
Multiple factors at play
Alcohol consumption and rates of alcohol use disorder among American women have been rising steadily in recent decades. Data compiled by the National Institute on Alcohol Abuse and Alcoholism indicates that although men consume more alcohol overall than women do, the gender gap is closing. In the nearly nine decades since Prohibition ended, the male-to-female ratio for measures of alcohol consumption — including prevalence and frequency, binge drinking and early onset drinking — has gradually narrowed from 3-to-1 to close to 1-to-1.
Rates of alcohol-related hospitalizations and health concerns, such as liver problems and cardiovascular disease, are also increasing for women. In an article published last year in Alcohol Research: Current Reviews, researcher Aaron White noted that “although women tend to drink less than men, a risk-severity paradox occurs wherein women suffer greater harms than men at lower levels of alcohol exposure. … Because women reach higher blood alcohol levels than do men of comparable weight, their body tissues are exposed to more alcohol and acetaldehyde, a toxic metabolite of alcohol, with each drink.”
The stress of the COVID-19 pandemic, of which women are bearing the brunt with job loss and child care and caretaking pressures, is exacerbating these trends, says Todd Lewis, an LPC who authored chapters on alcohol addiction and prescription drug addiction in the ACA-published book Treatment Strategies for Substance and Process Addictions. Alcohol is often used as a fast-acting way to temporarily ease or ignore one’s emotions or psychological pain, notes Lewis, a professor of counselor education at North Dakota State University who also sees clients at a private practice one day per week. The immense stress that many women have faced throughout the pandemic, coupled with increased isolation and the extra strain on relationships, has played a role in furthering the rise in alcohol use among women, he says.
Although many factors are at play, Sarah Moore, an LPC with a private practice in Arlington, Virginia, points to the intersection of alcohol being readily used as a coping mechanism and alcohol being widely available and interwoven into social norms and expectations. The expectation to drink can also dovetail with the pressure to be thin and other issues related to body image that women face, including disordered eating, she adds.
It’s more challenging than counselors may realize, Moore says, for emerging adults to foster and maintain social relationships through activities that don’t involve alcohol. “For a lot of 20- and 30-somethings, that [drinking alcohol] is their entire social life. Older generations may not be aware of how hard it would be to skip out, how integral that is to social situations,” she notes.
Moore, an ACA member, specializes in counseling for women, including issues related to alcohol dependency. She co-moderates a therapeutic group for women — Me, My Body and Alcohol — with Jyotika Vazirani, a psychiatric nurse practitioner and psychotherapist.
Alcohol is easily accessible and seemingly everywhere, Moore notes. It is often a part of sporting events and professional networking events, in which participation can be seen as a way to further one’s career, especially in high-pressure fields such as technology and law. The popularity of touring craft breweries and wineries also continues to grow. In many areas, alcohol can be purchased via delivery or curbside pickup at grocery or liquor stores.
One ironic aspect of American culture is that it frowns on both alcoholism and sobriety, Moore and Lewis note. “If you lose weight or quit smoking, everyone wants to know your secret,” Moore says, “but if you say you’re not drinking, they don’t know how to respond” in social settings.
And if individuals choose not to drink in social situations, they can face stigmatizing comments such as “you’re not having any fun,” Lewis adds.
In counseling, Moore role-plays and talks through scenarios with clients who have anxiety about declining alcohol at work events and in social situations because drinking has become so ingrained in these settings. She works with clients to plan and practice ways to artfully dodge questions and comments about their beverage choice.
Intertwined with trauma
All of the counselors interviewed for this article note that women who have an unhealthy relationship with alcohol often have experienced trauma in their past, are currently experiencing trauma or, in some cases, both. It is imperative that counselors are sensitive to this potential connection; use trauma-informed methods; are able to screen for posttraumatic stress disorder, intimate partner violence and abuse (physical, emotional, sexual, etc.); and know when and how to refer clients for specialized care when appropriate.
Sophie Hipke, an LPC in training at Women’s Recovery Journey, a women’s-only outpatient recovery program within the counseling clinic at Family Services of Northeast Wisconsin, says a vast majority of clients there have experienced (or are experiencing) “significant” trauma and turned to alcohol to cover up or numb painful emotions. Clients are often aware that alcohol won’t fix their problems, but they feel that it holds the promise of offering temporary relief, notes Hipke, who is training to be fully certified as a substance abuse counselor.
Many of the clients that Hipke and the counselors at Women’s Recovery Journey treat started drinking alcohol at an early age, sometimes as young as 11 or 12. For these clients, alcohol was often a way to escape an abusive household or deal with a loss or trauma, Hipke says.
“Substance use is often just a symptom, and the client has been self-medicating [to cope with] trauma or mental illness or both,” Wilson says. “We find that the majority of people who are seeking substance use disorder counseling have a reported history of trauma. There’s been a shift [among mental health practitioners] in the recent decade to recognize that it’s intertwined. … In order to really help people recover, we have to help them dig out of that trauma that has built up over time.”
For Wilson, the trauma of her brother’s death was what “pushed her over the edge” with her drinking, she says.
Clients who have a substance use disorder and a trauma history need a two-pronged approach in counseling, Wilson notes. They need to process and heal from past trauma and develop skills that allow them to deal with new traumas as they (inevitably) happen. “With both ‘big T’ trauma and ‘little t’ trauma, every person has a threshold and level of internal resiliency, and they can only take so much,” Wilson says. “If they don’t have the ability to cope as new trauma comes in, they are overwhelmed. [That’s when] we find ourselves continuing to turn to that substance over and over.”
Building rapport with clients is always an important aspect of counseling, but that is especially true with this population, Moore says. Women often feel intense amounts of pain and shame related to their trauma and alcohol dependency or addiction, so it’s vital that counselors focus on fostering a nonjudgmental and trusting relationship with these clients before delving into the hard stuff. Practitioners should also be patient, understanding that it may take these clients a long time before they feel stable enough to process their trauma, Moore advises.
Because trauma commonly dovetails with alcoholism and problem drinking in women, counselors should carefully choose treatment methods that are appropriate for this population, Moore stresses. Supports that are commonly used with male clients may not be helpful for female clients, especially if they have experienced sexual abuse or domestic violence.
Moore and the other counselors interviewed emphasize that recovery treatments that involve mixed-gender groups may not be appropriate — and could even be harmful — for female clients who have a substance use disorder. The vulnerability involved in talking about deeply personal issues that tie into their alcohol use can be triggering in coed settings for this client population, especially if they have experienced past trauma involving a man.
Counselors should thoroughly vet their local Alcoholics Anonymous (AA) chapter and other coed support groups before recommending them to female clients, Moore cautions, because these groups could exacerbate clients’ feelings of shame and possibly even retraumatize them. “AA can feel disempowering to women clients,” she says. “A lot of these women have a history of sexual trauma, and being around men is not therapeutic [for them] necessarily.” On the other hand, female-only group counseling or support groups can be powerful settings for female clients to feel supported and understood.
Lewis notes that although mutual aid groups such as AA can be a helpful supplement to counseling for some clients, practitioners should be mindful that AA’s 12-step method has a Western, patriarchal and masculine bias. The organization’s founding roots also have ties to Christianity, which can further alienate some clients, he adds.
Women for Sobriety (womenforsobriety.org) can be a helpful alternative, Lewis says. The organization’s model is based on a series of steps, like AA, but with an empowering focus, he explains.
Lifting the shame
Feelings of shame are common with women who have an unhealthy relationship with alcohol. Because of this, these clients often harbor denial or strong urges to hide their problem even from their therapist, which can affect the dynamic in counseling sessions, Moore notes. It can also cause these clients to cancel sessions or stop counseling altogether.
Moore urges counselors to be prepared for — and patient with — the resistant behaviors that this population may exhibit. “This is a challenging population to treat,” Moore acknowledges. “It [alcohol use] is something that can be a very closely guarded part of their life.”
Resistance and secrecy can be especially prevalent among female clients who are successful in their careers or who work in helping professions such as medicine or counseling, Moore says. Throughout her career in the mental health field, she says, she has witnessed many peers “quietly struggle” with alcohol misuse.
Women are often socialized to be concerned with how others might judge them, which can cause perfectionist tendencies and feelings of shame, Wilson points out. “One of the things that keeps women from getting help is that they can show up, put their best foot forward and play the part of someone who is well when they’re suffering inside. That can be really hard to break through as a counselor,” Wilson says. “Women also have an incredibly high pain threshold. We can take a lot before we break down.”
Hipke finds that women’s shame around drinking often dovetails with parenting issues and feelings of failure as a mother. Many of the clients in the recovery program where Hipke works have had child protective services involved with their family or children removed from the home because of alcohol- or substance-related offenses. These women often feel ashamed for being a burden to family or others who care for their children when they are unable to. The feeling of being a bad mother “really cuts deep for them,” Hipke says.
“Society’s expectation is that women are supposed to naturally be a good mother,” Hipke points out. “Society sees them as doing this [being addicted to alcohol] to their kids rather than doing it to themselves.”
Clients always need an atmosphere of nonjudgment in counseling, but that need is magnified exponentially for this client population because of the associated shame, Hipke says. Practitioners should be hyperaware of the language they use with these clients to ensure they are not reinforcing feelings of shame, she stresses. Counselors must also be careful not to frame a client’s situation as something that they brought on themselves. Statements that assign blame, such as “you’re choosing alcohol over your children,” are not only hurtful for these clients, Hipke says, but also carry the false message that substance use disorder is a choice.
“Be aware of how you’re talking about addiction [and] reiterate that addiction is not a choice,” Hipke urges. “We don’t see any other mental illness as a choice, but people often see addiction that way.”
Part of fostering a welcoming and nonjudgmental atmosphere in counseling is being sensitive to the needs and stressors that women might be juggling outside of counseling, such as child care or transportation. This might call for clinicians to exercise greater flexibility by offering to use telebehavioral health with these clients or allowing them to bring an infant or small child into counseling sessions when child care is unavailable.
Wilson’s facility offers group counseling both in the mornings and the evenings to accommodate clients’ schedules. “We [counselors] need to accommodate women who have a lot of balls in the air already,” she says. “There can be a lot of pressure for women to be the anchor of their family, the scheduler, and that can be something we need to be cognizant of.”
Practitioners may also need to think of creative ways to broach the subject of alcohol use with female clients in counseling sessions without being too direct or aggressive. Otherwise, these clients may stop attending. One method Moore likes is asking clients detailed questions about their sleep habits, including whether they use alcohol as a sleep aid.
“Find ways to get the conversation started early. Don’t wait for it to come up,” Moore says. “It can be hard to get an authentic answer from women regarding alcohol because of the [associated] shame. Sleep can be a good way to ask and bring it up because alcohol use can really mess up sleep.”
Lewis also urges counselors to weave assessment questions regarding alcohol use into conversation with clients rather than firing one question after another at them. This approach intersperses questions about what is happening in the client’s life beyond drinking, such as in their home and family life and relationships, he says.
Instead of asking direct questions about the quantity and frequency of their alcohol consumption, using prompts such as “What does a typical week look like for you in terms of drinking?” can offer a gentler way to query clients about their alcohol use, Lewis says.
For his doctoral dissertation, Lewis researched binge drinking among college students through the lens of Adlerian theory. He found that unhealthy relationships, including problems forming and maintaining relationships, were more often a predictor of women’s drinking behaviors than of men’s. As he points out, dependence on alcohol can cultivate an unhealthy cycle: Poor or absent relationships can contribute to alcohol use, which in turn can hinder an individual’s ability to maintain or build new relationships. So, asking female clients about their relationships and social supports can help counselors understand when further questioning about alcohol use might be needed, Lewis says.
(See the Counseling Today article “Becoming shameless” for an in-depth look at helping clients with feelings of shame.)
Equipping clients with coping mechanisms, including ways to quell critical self-talk, is another important part of working with this population. Clients will need robust, healthy coping skills as they work to eliminate alcohol consumption — the quick, accessible coping tool they have come to rely on.
Providing psychoeducation that addiction is a disease and that recovery involves rewiring one’s neural pathways for decision-making is helpful, Wilson says. Her initial work with clients includes a focus on coping mechanisms that will help them regulate their emotions. She also works to build up clients’ communication and social skills, which may be underdeveloped because of the individual’s history of trauma, mental illness and substance use.
“The only thing they’ve known to use to cope is the substance, so we need to replace that right away,” Wilson says. “We [the staff at Women’s Recovery] are big believers in skill building. We start with loading clients up with all sorts of coping and grounding skills [as well as] the message that this is going to be a lifelong journey. Clients are recovering, and it will take constant work.”
One nice thing about outpatient treatment is that clients learn to live without substance use in everyday life during treatment, Wilson notes. Clients can see what triggers come up and learn how to address them as they navigate work, family life and relationships while living at home.
Hipke notes that group counseling can also be a rich setting for female clients to learn coping mechanisms, both because they are exposed to the lessons that other women have learned during their recovery journeys and because they are provided with a safe place to strengthen their social and relationship skills.
“Group [counseling] is the most powerful part of our program. It resonates with them to hear others’ stories, helps them build bonds and also holds them accountable,” Hipke says. “It’s powerful [for clients] to know they can share stories and talk about whatever they need to, and it won’t leave the room. As a therapist, we can point things out to them all day long, but it’s so much more powerful to hear it from a peer.” Hipke has noticed that she can say something repeatedly to a client in an individual session, but it often won’t “click” until the client hears the same message in the group.
Lewis and Hipke note that in individual counseling, motivational interviewing is a useful method for building rapport and helping clients who may be resistant or ambivalent to behavioral change. This approach can also be beneficial when counseling female clients who are in denial or who have complicated feelings that are exacerbated by the stigma and shame associated with their alcohol use.
The counselors interviewed for this article also mentioned cognitive behavior therapy (CBT), Gestalt techniques and trauma-informed modalities, including eye movement desensitization and reprocessing, as being particularly helpful with this client population. Hipke says that using a strengths-based approach can also be useful, as can including a client’s partner or family in sessions, when appropriate.
Including clients’ family members or others in counseling sessions can help clear up misunderstandings and hurtful feelings that linger regarding a client’s addiction and past behavior, Hipke explains. In these cases, a counselor can act as moderator to support and guide conversations toward healing. “Having kids, parents or siblings join in on sessions for the therapist and client to be able to talk more about addiction and provide a safe and neutral space to have discussions can be very healing for both the client and their family,” she says.
These clients may also need to spend significant time working on self-talk and intrusive thoughts and learning how to deal with difficult feelings in a healthy way. With self-talk, part of the work involves helping female clients hold themselves accountable while resisting the urge to be overly critical and beat themselves up, Hipke says. Mindfulness and CBT can be particularly helpful in these areas, she adds.
Many clients, especially those with abuse histories, must unlearn behaviors they adopted over time to block out powerful emotions such as anger, sadness and happiness, Hipke says. These women often struggle to find the words to explain what they are feeling. Hipke uses an emotion wheel to help clients name their emotion, recognize how it manifests in their body and identify why it’s a difficult feeling for them to experience.
“For many clients, they were either punished or wouldn’t get their needs met if they showed emotion. … They often need to rediscover sadness or anger and realize that it’s OK to feel those emotions, or even that it’s OK to be happy. They often don’t know what to do with being happy,” Hipke says. “From there, we identify why it’s so difficult. What has led to the place where feeling sad or angry isn’t OK? And then we begin to dismantle that. Just labeling it, identifying it, is helpful — and then they can match coping skills to the emotion they are feeling.”
Preparing for relapse
When doing counseling work with women who are addicted to or dependent on alcohol, it is important to be prepared for the possibility of relapse.
It can be helpful to talk frequently about relapse prevention skills, both in group and individual counseling, Hipke says. This includes being able to recognize the signs that an individual might be headed toward relapse. She also listens for instances when clients mention going through a stressor. This presents an opportunity to offer extra support and check on how the client is coping, including asking gentle questions about the possibility of the client feeling an urge to return to substance use.
Once again, it is important for counselors to provide nonjudgmental responses, Hipke stresses. If a client relapses, counselors should normalize the experience and celebrate that the client recognized it and shared it with the therapist, she says. Women are often afraid to tell their counselor about a relapse. So, when they do, Hipke recommends that clinicians assure them that it’s not a sign of “failure,” either on the part of the client or the counselor.
Hipke also emphasizes that counselors should not take client relapses personally. “For a lot of the women [in our program], they struggle with balance in different areas of their lives. They’re not just stopping drinking, they’re making a lot of behavioral changes in their lives,” Hipke explains.
She often talks with clients about how it’s normal for relapses to occur during any kind of behavioral change. “It’s not the relapse that we want to focus on but what to do after,” Hipke says. “What can we do differently to make sure it doesn’t continue happening, [and how can we] keep [clients] from beating themselves up, because that can lead to more relapses.”
How much is too much?
Counselors shouldn’t take a one-size-fits-all approach to assessment questions about a client’s alcohol use because women form dependency on alcohol for different reasons — and in different ways — than men. Practitioners should focus more on the context and reasons why a female client drinks alcohol rather than on the quantity, says Holly Wilson, the founder and chief empowerment officer of Women’s Recovery, an outpatient substance abuse treatment program for women in Denver.
Questions about the number of drinks a client consumes also have the potential to spark countertransference issues, notes Wilson, a licensed professional counselor candidate. Counselors will have personal feelings about how many drinks are acceptable, and they must be careful not to project those assumptions onto clients.
“It doesn’t matter if you would have a problem doing what they’re doing … or [if] the quantity or frequency of the client’s drinking may be something you’re fine with, but they’re not,” Wilson says. “It doesn’t have to be according to your own personal standards of drinking or substance use.”
Instead, she advises counselors to focus on exploring the client’s relationship with alcohol. The CAGE questionnaire can be a helpful tool to use with female clients, Wilson says, because it focuses on how a person feels about their drinking. CAGE poses four questions that can prompt further dialogue with the client:
- Have you ever felt you needed to Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt Guilty about drinking?
- Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?
Here are some books that Sarah Moore uses with individual and group clients:
- “Can I Keep Drinking?: How You Can Decide When Enough is Enough” by Cyndi Turner
- “Between Breaths: A Memoir of Panic and Addiction” by Elizabeth Vargas
- “The Sober Diaries: How one woman stopped drinking and started living” by Claire Pooley
- “This Naked Mind: Control Alcohol, Find Freedom, Discover Happiness & Change Your Life” by Annie Grace
- “Quit Like a Woman: The Radical Choice to Not Drink in a Culture Obsessed with Alcohol” by Elizabeth Whitaker
Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at firstname.lastname@example.org.
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.