Women, intimate relationships and drug use: experiences and meanings

Abstract

Objective

To analyze the experiences and meanings of intimate relationships experienced by women in treatment due to drug consumption.

Method

This was a qualitative, descriptive and cross-sectional study developed with the participation of 21 women attended at a Psychosocial Care Center in the state of São Paulo, Brazil. The interviews were submitted to reflective thematic analysis and organized into three axes.

Results

The women reported lifelong social vulnerabilities and weaknesses in support networks that led to suffering, helplessness, and early drug use. Becoming a wife was constructed as a hope for a new way of life, though in an idealized and contrived manner. Intimate relationships proved to be central, both for experiences of increased and decreased drug use. Drug use escalated due to the need to please the partner, fulfill the role of a wife, or when faced with violence. Decreases occurred in situations where the partner provided support, assistance in accessing treatment, or when the spouse restricted their freedom. These relationships added to the vulnerabilities experienced, creating demands on healthcare and social systems.

Conclusion

Treatment should include interventions regarding women’s intimate relationships, as well as addressing gender roles and intervening intersectorially in other social determinants.

Keywords
Gender; Marriage; Mental health services; Substance-related disorders

Resumo

Objetivo

Analisar as vivências e significados dos relacionamentos afetivo-amorosos vivenciados por mulheres em tratamento devido ao consumo de drogas.

Método

Pesquisa qualitativa, descritiva e transversal desenvolvida com a participação de 21 mulheres atendidas em um Centro de Atenção Psicossocial do interior paulista. As entrevistas foram submetidas à análise temática reflexiva e organizam-se em três eixos.

Resultados

As mulheres relataram vulnerabilidades sociais ao longo da vida e fragilidades nas redes de apoio que culminaram em sofrimentos, desamparo e uso precoce de drogas. Tornar-se esposa foi construído como esperança para um novo modo de vida, porém de forma idealizada e engendrada. As relações afetivas mostraram-se centrais, tanto para experiências de aumento como de diminuição do consumo de drogas. O uso aumentou por necessidade de agradar o parceiro, cumprir o papel de esposa ou diante das violências. A diminuição ocorreu em situações de apoio do companheiro, auxílio para acessar o tratamento ou quando cônjuge restringiu sua liberdade. Esses relacionamentos se somaram às vulnerabilidades vividas produzindo demandas aos equipamentos de saúde e sociais.

Conclusão

O tratamento deve incluir intervenções sobre os relacionamentos amorosos das mulheres, assim como problematizar os papéis de gênero e interpor-se intersetorialmente entre os demais determinantes sociais.

Palavras-chave
Gender; Marriage; Mental health services; Substance-related disorders

Drug use among women is a growing phenomenon. There is evidence in the literature that women initiate abusive and problematic involvement with psychoactive substances due to experiences related to vulnerabilities in their psychosocial contexts throughout their lives. These observations were corroborated in a study on crack cocaine consumption among women in Brazil, which revealed that drug use was also associated with social vulnerabilities such as low educational attainment, lack of a source of income, unemployment, prostitution, social stigma, and so forth (Limberger et al., 2016). Other authors have additionally highlighted the impoverishment of support networks, peer pressures for consumption, and the fact of having parents and/or partners who are also users as influences for the initiation and maintenance of abusive drug use (Albuquerque & Nóbrega, 2016; Alves & Rosa, 2016). Accordingly, there is a significant consideration to be made regarding the social and relational contexts experienced by women, in which understanding the consumption of psychoactive substances is predominantly shaped by gender relations.

In this context, gender relations are historically constructed with influences from culture, which can induce and perpetuate positions and experiences that lead women to greater vulnerabilities. Regarding this theme, the gender category does not only refer to ideas, but also to institutions, structures, everyday practices, and everything that constitutes social relationships, as well as power relations based on perceived gender differences (Moraes et al., 2018). These norms, roles, and gender relations can result in suffering and influence access to services, as women are entangled in contexts of historical, social, and economic inequality and domination.

Within the spectrum of roles and cultural symbols that society conveys and envisions when referring to women, the structures of gender asymmetry also reoccur for those who use drugs, creating a landscape undermined by derogatory representations of women drug users. This culminates in the expression of prejudiced attitudes and social exclusion. When it comes to drug abuse, these women are repositioned within the social context, being identified and stigmatized as women associated with guilt and danger. Therefore, the drug use is internalized as a deviant behavior, in addition to often making it impossible to fulfill gender roles as wife, mother and family caregiver. Consequently, users tend to consume the drug in the private sphere, leading to fear of seeking help and treatment (Alves & Rosa, 2016).

In this complex scenario, social networks are often identified as potential risk factors and/or sources of protection for drug consumption (Siepmann Soccol et al., 2020). Studies have suggested the special role of family members, as well as other components of the social network, such as intimate relationships, in women’s initial engagement with substances, exerting a strong influence on them becoming abusive drug users and getting involved in situations of violence (Cugler & Figueiredo, 2021). Silva et al. (2021) found that female substance users are more likely to align their consumption patterns with those of their partners, and even escalate them. Therefore, drug abuse is associated with relationships that often reveal gender expectations and perpetuate situations of risk and vulnerability, impacting the subjectivities and mental health of the female user (Zanello, 2018).

In the international context, studies such as the one by Leukefeld et al. (2017) also found results in this direction, indicating that women’s drug use initiation, maintenance, and relapse were associated with their relationships. Therefore, the influence of social networks on consumption is a condition that can persist throughout life through marital relationships, and it is important to emphasize that in these contexts, women exist within power dynamics capable of influencing their decisions to engage in high-risk behaviors. This is evident in the social gender constructs that generate imbalances and dominations (Leukefeld et al., 2017). Gilchrist et al. (2019) highlighted the existence of complicating dynamics in relationships where both partners use psychoactive substances, making it particularly difficult for women to leave, especially when faced with experiences of psychological and physical violence. Therefore, among the participants, the need for shelter, lack of financial support, fear of retaliation, and not wanting to interfere with the well-being of their children were reported as additional reasons for not leaving relationships, even violent ones.

Considering these issues, Stanesby et al. (2018) directed the discussion towards prevention efforts involving women, where the main focus should also be on partners and the dynamics that involve those with whom they have an emotional relationship, potential gender roles, and victim-perpetrator relationships when present. This is because high-level drug consumption can have adverse consequences on marital relationships. In this regard, there are indications that couples with problematic consumption experience disruptions in their daily tasks and escalating conflicts, with low potential for mutual social and emotional support. Additionally, Radcliffe et al. (2019) emphasized the need for partners to be helped to recognize that what they see as isolated incidents of women’s substance use is actually part of a more concerning story from the women’s perspective, where they feel intimidated, dependent, and ashamed. This poses a particular challenge for research and treatment services in practice, as it requires an intervention for these men aimed at them understanding the complex interconnections between gender, violence, and substance use.

Regarding women, even though services may not be inherently equipped to handle the complexity of relationships involving alcohol use and to encompass the experiences between partners, they should direct their efforts towards understanding how drug consumption and marital dynamics interact (Wilson et al., 2020). Accordingly, within Brazilian public policies, there are regulations that structure networks for the care of consumers of harmful psychoactive substances, aiming to provide services through therapeutic, social, and preventive activities. Among these actions, the Ministry of Health Ordinance nº. 336 of 2002 stands out, which outlines the functioning of Centros de Atenção Psicossocial Álcool e Drogas (CAPS-ad, Alcohol and Drug Psychosocial Care Centers), specialized community-based mental health services. These centers also aim to understand the individual’s life history and their social determinants, including gender, situations of vulnerability, and the realms of social and affective networks (Borges et al., 2017; Ministério da Saúde, 2002).

Gender-related issues pose challenges for the care services, as the specifics of this theme are not mentioned in official documents and service practices (Alves & Rosa, 2016). In many of these services, there is a lack of activities and programs that address the needs of female clients, with the ones offered being predominantly tailored towards males (Rasch et al., 2015). Additionally, understanding and incorporating marital relationships are crucial in drug user treatment, as they provide valuable insights into the actual and potential support available, as well as women’s choices and experiential possibilities. All of this aids in the development of health interventions tailored to individual needs and realities (Borges et al., 2017).

At the national level, there are knowledge gaps regarding the marital relationships of women who engage in problematic drug use and are undergoing treatment in public services such as CAPS-ad, especially from a gender relations perspective (Alves & Rosa, 2016). In this context, the aim of this study was to analyze the experiences and meanings of intimate relationships lived by women in treatment due to drug consumption.

Method

This was a qualitative, descriptive, and cross-sectional study conducted in a CAPS-ad in the state of São Paulo, Brazil. The center’s care practices include groups and treatment approaches tailored to the female gender and their needs (such as women’s groups and groups for mothers and grandmothers). The qualitative design is justified due to its potential to provide rich and detailed insights into participants’ experiences. In the field of health, qualitative research can fill gaps left by quantitative methods by highlighting users’ and care providers’ perspectives for the understanding of the phenomena and meanings people attribute to illness and life (Day et al., 2018). Therefore, the results obtained through qualitative research can assist in constructing health guidelines, defining more effective intervention strategies, and improving the quality of care offered by providers to the community (Thorne, 2020).

Participants

A convenience sample was used, considering the ease and opportunity to approach women with problematic drug use at the CAPS-ad service. Participants were 21 female users undergoing treatment for problematic drug use. Inclusion criteria were: being over 18 years of age and taking part in activities aimed at this audience within the institution, regardless of the duration of treatment. Women were invited to participate regardless of their marital status at the time, as they were encouraged to report aspects of their intimate relationships, both past and present. Therefore, single, married, widowed, and cohabiting participants were included in the sample. All reported experiences with heterosexual relationships. Data collection was stopped when, in the researchers’ evaluation, theoretical saturation was reached – as postulated by Glaser and Strauss (1967); at this point, the sample size was determined when the information became redundant or repetitive.

Table 1 presents some sociodemographic characteristics of the participants. Names were omitted to preserve identities, with the participants represented by the letter “M” followed by the number indicative of each interview. The heterogeneity of psychoactive substances consumed by the participants should be highlighted, with alcohol being the most consumed legal drug, and cocaine and crack being the illegal ones. Eight participants were multi-users, seven consumed only alcohol, and the remaining six consumed only cocaine/crack.

Table 1
Sociodemographic characteristics of participants from the city of Ribeirão Preto, SP, Brazil

Participant	Age	Colour	Marital status	Schooling	Source of income	Residing with	Drug of preference
M1	79	White	Widow	CEE	Retired	Daughter	Alcohol
M2	42	Brown	Single	CEE	None	Shelter	Alcohol, cocaine and crack
M3	54	Brown	Separated	CEE	None	Shelter	Crack
M4	43	White	Single	CEE	None	Shelter	Alcohol, marijuana, cocaine and crack
M5	31	Brown	Married	CEE	Her husband	Husband and stepdaughter	Alcohol, cocaine and crack
M6	25	White	Single	CHS	Her father	Parents, sister and 2 children (< 18)	Cocaine, crack, marijuana and perfume launches
M7	58	Black	Married	CEE	Sickness benefit	Husband, 2 children (> 18), 2 grandchildren, 5 nephews	Alcohol
M8	30	White	Single	CEE	Children’s pension and Bolsa Família	Alone	Cocaine
M9	31	White	Cohabiting	CHS	None	Shelter	Crack
M10	34	White	Cohabiting	IEE	Her husband	Shelter	Alcohol and crack
M11	35	Brown	Single	CHS	Does odd jobs	Friend and her 2 children	Crack
M12	50	Brown	Married	IEE	Her husband	Husband and daughter	Alcohol
M13	33	Brown	Separate	CEE	Retired	Parents	Alcohol and cocaine
M14	33	Brown	Cohabiting	CEE	Her husband	Husband	Alcohol
M15	38	Black	Divorced	CEE	Her lover	Son (< 18)	Cocaine
M16	28	Black	Single	CEE	Bolsa Familia	Shelter	Cocaine
M17	56	Black	Single	IEE	Pension	2 children	Alcohol and cigarettes
M18	39	Brown	Single	IEE	None	Shelter	Alcohol, crack and cigarette
M19	62	White	Single	CHE	Retired	Uncle and nephew	Alcohol
M20	64	Brown	Married	I	Her husband	Husband	Alcohol
M21	55	Black	Separate	CEE	Does odd jobs	Alone	Alcohol

• Note: CEE: Complete Elementary Education; CHE: Complete Higher Education; CHS: Completed High School; I: Illiterate; IEE: Incomplete Elementary Education.

Instrument

A semi-structured interview script was used, with the first section focusing on sociodemographic information and preferred drugs. The second section contained questions that aimed to investigate the women’s intimate relationships throughout their lives, marital dynamics, substance use within those contexts, and the perceived impacts of conjugal experiences on their trajectories through services and institutions. The questions and interview approach were guided by gender studies and feminist research principles, which share epistemological foundations with qualitative research. Both approaches aim to gather and represent each woman’s unique perspective, giving value to their voices and meaningful experiences. The exchange and interactivity between researcher and participants were emphasized to capture the female experience, placing them as experts of their own lived experiences and minimizing potential power dynamics. This approach aimed to gather a complex and comprehensive range of subjective narratives that reveal their connections to political and social contexts, which the researcher can analyze (Neves, 2012). Questions like “When you reflect on your life and think about relationships, what comes to mind?” or “What have your relationships been like, or how would you like them to be?” are examples of questions guided by the epistemologies mentioned.

Procedures

The interviews were conducted by two researchers, both of whom were psychologists. The data collection took place from September to October 2019. The participants’ responses were audio-recorded and transcribed verbatim, with an average duration of approximately 23 minutes per interview. Participants were invited to join the study while participating in activities at the CAPS-ad, usually approached before or after women’s groups and/or mothers’ and grandmothers’ groups. During the initial data collection, participants were shown to an empty room within the service, where the research objectives and interview process were further explained. Upon acceptance, the participants provided their consent by signing the appropriate documentation. At the end of the interview, the researchers were available to address any questions or have discussions related to the project’s scope. The study received ethical approval from the Research Ethics Committee of the Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto of the University of São Paulo (CAAE nº 14968319.0.0000.5407).

For data evaluation, the interviews were subjected to reflexive thematic analysis, as proposed by Braun and Clarke (2019). This method involves constructing themes as a result of analytical and creative work performed by the researcher, involving decoding and searching for patterns of shared meanings. Themes are connected by a central concept, reflecting the data collection questions and narrating stories. The process of reflexive thematic analysis consists of the following stages: 1) familiarization with data through reading and immersion in the materials produced; 2) creation of initial codes (identifying latent or semantic aspects of content, aggregating potential meanings); 3) organizing and combining initial codes into themes and sub-themes; 4) Refining and reviewing the themes; 5) naming the themes upon which narratives were constructed, noting intersections and proximities, and analyzing each theme; 6) Writing the final report and selecting excerpts and quotes to illustrate the themes. It is important to note that, in the presentation of quotes, parentheses “(...)” were used to hide specific aspects of the results when necessary, without compromising the categories. Additionally, square brackets “[ ]” were added to provide explanations within the quotations.

Results

The analysis allowed for the construction of three main themes portrayed in the experiences and meanings of marital relationships among women seeking treatment at CAPS-ad: 1) becoming a wife: the pursuit of hope and (re)encounter with helplessness; 2) marital dynamics and their effects on drug use; 3) between support and stigma: when institutions interfere in the life of the husband and the user wife.

Becoming a wife: the pursuit of hope and the (re)encounter with helplessness

The women shared stories of lives marked by various vulnerabilities, where becoming a wife proved to be an opportunity for emotional and social transformation in the face of the many hardships they experienced. However, as their relationships progressed, they found themselves (once again) facing helplessness. They recounted experiences of silencing during childhood and adolescence, abuse, lack of family support, and discrimination. They also shared aspects related to the social class to which they belonged, where, due to low levels of education and the need to work to supplement the family income, they went through jobs with little prospects for change and advancement, along with low salaries. They had experiences working in the fields, as domestic workers, cleaners, and even prostitutes.

Given these contexts, the participants felt helpless and experienced notable suffering throughout their lives, which was also manifested through mood swings and feelings of sadness. The early use of drugs as a response to these experiences emerged, in some accounts, as a way to cope with social and emotional helplessness. In this scenario, substance abuse went hand in hand with emotional expressions, leading to impairments in daily activities. Diagnoses and treatments for psychiatric comorbidities, such as bipolar affective disorder and depression, were mentioned, along with histories of mental health hospitalizations. In light of this, the possibilities of marital relationships were seen as an alternative in the face of primary helplessness, early drug use, daily challenges, and the suffering of sadness and mood fluctuations that could lead to institutionalization.

Relationships started to be seen by them as a chance to feel noticed, protected, and loved, in addition to gaining access to material resources that were previously impossible within their realities, instilling hope in marital life. Within these relationships, idealizations and expectations of transformation were formed, whether it was the woman as an object of love and/or becoming a wife. Even in new emotional relationships, these desires persisted and were rekindled.

M14: It’s a relationship I started. I was married, he’s married too. It’s that kind of story, you know? It started as a joke, but my marriage had already ended, though I was persisting, so I wanted to separate. He paid for my divorce and has always supported me. I believed that one day he might leave his wife to be with me (...) I stopped taking birth control because I wanted to get pregnant by him. When I said I wanted to get pregnant by him, there was no turning back [laughs]. (...) But he was the one who, when I needed it the most, would talk to me, listen to me, and help me.

Becoming objects of love and wives was experienced intensely and with significant investment by these women. They placed their hopes on relational ideals that would lift them out of their previous circumstances, resulting in choices and a daily life shaped by the desires and possibilities of their husbands. Despite their own desires, these women lived their marital relationships within the confines of their husbands’ trajectories, adapting themselves while rejecting other potential occupational roles. Accordingly, financial dependence on their spouses was a common aspect for these women, as most of them lacked other sources of income. As a result, they relied on their partners for support in all aspects of life – something they interpreted as “help”. M4: “(...) he helps me. Period pads, hygiene products. There’s food, but (...) when I’m hungry, I just have to tell him, ‘I’m hungry!’”

Within these relationships, many of the study participants voiced demands and needs for recognition, respect, and affection that often went unmet by their husbands, leading to discomfort within the marital relationship and in the woman’s role as a wife. There were asymmetries in affection and the treatment demonstrated between the couples. Changes in the affection and lovingness of the partners also resulted from pregnancy and/or the birth of children. In this regard, the women spoke about the perspective that the attention once directed toward them shifted to the children, leading to new relational dynamics, as the couple’s dyad was disrupted. In an attempt to draw closer to their partners and regain their investments, there were moments when they chose to prioritize staying with their husbands over being with their children, leaving the offspring with extended family or exposing them to vulnerable contexts. On the other hand, in other situations, the partners did not present themselves as a source of support when it came to the possibility of fatherhood.

M17: [The marriage caused sadness]. It made me sad, and well, he’s a really good person, but I miss this aspect a lot, him coming to me and giving me a hug, that warm embrace I used to feel, that deep-down love, that love that came from within. I never had that from him. Even today, I see people hugging, kissing, showing that affection, and I think, ‘Oh, what if it were like that too?’ After a year of being married, I had my first child, and I even said to him, ‘Funny thing, when we were dating, you had that thing with me, showed me more affection, but now that I’ve had my first child, you’ve divided the love you had for me with him’. (...) he started to like our son more than me. It’s not that I was jealous, but I felt isolated, he wasn’t treating me well, wasn’t showing me that affection anymore.

As experiences unfolded within these relationships, some difficulties, as mentioned earlier, arose and led to shattered expectations both as wives and as women, encompassing both relational and subjective aspects. Based on this, the participants reported finding themselves once again in emotional and social helplessness, and they considered the idea of separation, however, they dismissed this due to the ideal of an “eternal marriage” and the potential impact of separation on their children. Ultimately, they resigned themselves to these contexts and often turned to (increased) drug use as a way to cope with them.

M14: My depression happened because of my marriage, but I didn’t separate because I had a young son, and I thought I’d have to go back to my parents’ house. The upbringing I had was that you get married and stay together until you die. However, I got to know drugs because I had a back problem, and they numbed the pain in my back. So, I tried them, liked them, and my experimentation led me to not leave the house [and not separate from the husband].

Marital dynamics and their effects on drug use

Staying in a marital relationship and in the role of a wife had impacts on the drug use patterns of the women. For those who were already using drugs before, continuing this use helped them fulfill the role of being a wife and looking after the home and husband, as well as alleviating the suffering that comes with that role.

M3: I saw that drugs made me feel good; I became myself again. Drugs lifted me out of depression. So, I resumed my household chores, started doing laundry, cooking, taking care of the house. That drug was nourishing and sustaining me at home.

In the questionnaires, it was observed that within the marital dynamics the partners also emerged as potential influences for experimentation and consumption of different types of drugs. Some participants, like M6, found themselves compelled to accompany and please their partners through shared drug use, as refusing the substance could be interpreted as rejecting the relationship. M6: “My drug of choice was crack cocaine, but I started with marijuana out of curiosity because my boyfriend smoked it. So, to keep up with him, to not lose him, I started smoking [marijuana]”.

Subsequently, when under the influence of drugs or faced with intense consumption, the women reported conflicts with their spouses, who were displeased with their consumption behaviors. This scenario of discontent, verbal disapproval, and physical aggression sometimes led the husbands to respond to their wives’ drug use by providing more drugs to silence them or to halt the conflicts. These interventions were carried out by the husbands in response to abusive use, yet they ended up creating further scenarios of vulnerability.

M3: The day I found this drug, I abandoned my medication treatment and started using only the drug. Initially, my husband would give me money to buy the drug because I wanted it; I was driving him crazy. But when he saw that things were getting worse, he stopped giving me money, and I started stealing from inside the house (...). [Over time], he abandoned me, left me alone, and my children abandoned me as well.

It is evident that there were consequences for the relationships, such as emotional distancing, abandonment, increased suffering for the women, and a lack of support due to the situation. The combination of drug use, marital dynamics, and violence (from both sides) thus emerged as complicating factors in the relationship and had a significant impact on the lives of these users.

M5: But I can’t [stop drinking]. I fight with my husband. Sometimes, I even hit him because I want alcohol. I start breaking things in the house. So, to prevent something bad from happening, he goes and buys more. The worst part is that I don’t just drink [a little], I drink [and] want more and more (...). That’s when I become happy. I don’t stay down like I am, sad, feeling like I want to kill myself, those kinds of things.

Therefore, ruptures, conflicts, disappointments, and abandonments within their relationships were felt by the women as fractures in their expectations and their roles as wives, serving as triggers for relapses or even an intensification of the substance use (and other suffering). In some reports, this context exposed them to vulnerabilities related to physical well-being and to their surroundings. What they felt on a subjective level spilled over into the external world through substance use and/or subjecting themselves to risks.

The conjugal emotional relationship could also act as a catalyst for changes in life, including in terms of drug use. Periods of abstinence and harm reduction were reported when their husbands positioned themselves lovingly in the interaction and offered them material support, affection, and companionship, often aligning with their romantic ideals and hopes, as expressed by M6.

M6: At the age of 18, I stopped [using drugs] because I was in a relationship, and he didn’t use. I thought my life was wonderful because I finished school. I was the top student in vocational school, and I was with a really good guy who was a teacher there. He gave me everything I wanted, he loved me, he was very affectionate, gave me flowers, made declarations of love (...) serenaded me, expensive chocolates [laughter]. He was very kind, he gave me jewelry (...) and not just because of material things, you know? Because he treated me like a princess.

Other participants recounted more realistic and less idealized experiences with their partners, like participant M4, however, these experiences also led to changes in their drug consumption.

M4: What helps me is my desire to change my life, you know? I want to take my boyfriend seriously, I want to take my kids, I want to have a normal life in sobriety (...). In this relationship I’m in, he treats me well, he understands me. He sees things in me that maybe a lot of people, like my mother and my sister, always say I don’t have. Not him! He doesn’t see me that way. He has faith in me, you know? He’s betting on me. So, that makes me want to change.

Less violent interventions in the face of intense drug use were also directed by partners, especially when they positioned themselves as support in the women’s drug use. The partners initiated and encouraged access to treatment services (such as CAPS-ad and/or inpatient treatments) to address the issue, altering the relational landscape in which the women found themselves. The participants upheld the investment in care even in the face of adversity, reduced their drug use, and embraced therapeutic approaches, creating contexts of affection with their spouses where the women felt motivated to reciprocally respond.

M13: He was the one who supported me in everything. He was the one who had me admitted, made sure I lacked nothing afterwards. He helped me and I went [for the treatment]. He spent a lot, a lot on me. There was a time when he had me admitted, but he couldn’t visit me because he fell ill. When he needed me the most, I wasn’t there, I was there [admitted]. So, today I see everything he did for me. Today, I help him, he has a knee problem, and I’m the one who has to dress his wounds, take him to the hospital sometimes to change the dressing. For me, it’s been much better [not drinking]. Both for me and for my husband (...) and I don’t want to stay away from him anymore.

It should be highlighted that some participants experienced changes and reductions in drug consumption when they were under restrictions imposed by their partners or in situations where they could not acquire the substance due to a lack of income.

M11: I don’t drink anymore because I don’t have money, I’m locked in; it’s been a month and a half without drinking (...) I don’t have a job. If I had a job, my money, my independence, I would be able to buy what I wanted, you know?

Between support and stigma: when institutions interfere in the life of the husband and the user wife

Sexual and emotional relationships leave marks on women’s stories, whether they are in a relationship or not. Being a “wife of a man” and a “wife who uses drugs”, considering the reported contexts of race, education, income, and interactions, led to limited and sometimes stigmatized paths, mainly described by the participants when they were no longer with their partners. Different marks and needs emerged that, due to the vulnerabilities these women were facing, created demands for the state and public policies to address.

A primary mark of vulnerability appeared when the option to end the relationship was chosen, accompanied by feelings of (the return of) desolation and fear. For some participants, separation followed experiences of various forms of violence over time, which were reported triggers for the termination, considering the accumulated suffering. After the separation, some women, already lacking other support networks, lost housing options and ended up homeless. The participants felt weakened by the actions of their ex-partners, who sometimes continued to perpetuate violence even after the separation. Faced with these scenarios, an escalation in drug use was triggered for some, as a way to cope with the emotions arising from both the separation itself and the acts committed by the men. Given the various circumstances of social and emotional vulnerability, coupled with expressions of helplessness linked to abusive drug use, there was a need for these demands to be absorbed and addressed through the outreach, shelter, and support services of the social welfare system. As a result, many women experienced institutional involvement that was also marked and influenced by their intimate relationships.

M16: I escaped from a relationship I had because he used to beat me a lot. He used drugs and [thought] I was getting involved with another man. So, at some point, you think about what you want for yourself. To continue living like this for three more years? So, I walked away, said goodbye, and walked out (...) I never saw him again. I’m afraid to go out on the street and run into him. Violence. It made me panic, fear to leave the gate of the shelter. I don’t have anyone here for me. Today, I sleep in the support house, in the shelter, but before all this, I went through many problems (...). It was the outreach [social services] that found me on the street, and the lady who gave me food approached me because I ran away from my husband and spent around 14 days hiding from him. I had to sleep under trees and in vacant lots, you know? Hiding so he wouldn’t find me.

The role of motherhood was another aspect compromised for many participants, who suffered interference from the legal system, which often benefited the men. Some participants stated they were separated from their children because they lived with their ex-partners. Some even lost custody of their children to fathers who were also users (and even abusers) of drugs. They reported the prevalence of stigma associated with being a drug-using mother, including within the legal system – a perception strongly internalized by them as well. The participants questioned their qualifications as mothers, and as a result of the separations, few maintained contact with their children, materializing the fears arising from separation, as discussed in the initial themes of this study.

M8: They [the children] stay with their father, who has temporary custody (...) Their father is wonderful, a very good person, hardworking, he’s never been involved with drugs. His only vice is alcohol. I don’t want my children to go through this, to see me in this state anymore. That’s why it’s better for them to be with their father than with me. It’s not good. I don’t wish this [crack addiction] on anyone, not even my worst enemy.

In this way, the marital relationships of drug-using wives revealed directions and impacts on the women’s institutional trajectories. In various services, all the complexities experienced by the women were revealed, either through access to rights or the perpetuation of stigma.

It should be noted that the participants highlighted the important role of the health services (particularly CAPS-ad) in addressing their vulnerabilities and enabling transformation, including in their intimate relationships. After the women’s involvement and ongoing support from CAPS-ad, the significance of active listening and support became apparent. There was an appeal for the service to mediate communication between participants and their partners. The women placed hope in the service and its team to facilitate certain negotiations so they could access their desires, as they struggled to do so on their own within their marital interactions. Accordingly, CAPS-ad emerged as a possibility for reclaiming autonomy, self-care, dreams, and relational patterns (especially with their partners) that are less harmful and limiting.

M5: If [CAPS-ad] could pester my husband to let me go back to school, at least (...). But every time I go to school, he says I’m looking for another man. That’s what discourages me, because I only finished sixth grade, and I hardly know how to do anything. What’s the use of me doing almost nothing?

Discussion

The purpose of this article was to analyze the experiences and meanings of intimate relationships for women undergoing treatment at CAPS-ad. In this context, the economic and social situation of poverty among the participants can be observed, aligning with indications that issues like poverty, lack of financial resources, and housing are intrinsically linked to drug use in Brazil (Limberger et al., 2016). Hogana et al. (2018) analyzed that in women, categories of race and class combine to create contexts of social vulnerability. Therefore, examining the situation of women who are drug users highlights the need to consider gender in conjunction with other social markers, such as race, class, and generation, among others, which are understood and organized within power relations (Leukefeld et al., 2017).

In turn, Souza (2016) argued that this scenario leads to the development of specific subjectivities and the adoption of behaviors that are influenced by social determinants, mainly reflecting in forms of primary and family socialization that produce different emotional, cognitive, and relational responses throughout an individual’s life. The participants reported experiences of violence and helplessness during their development, which were recurring phenomena in family relationships, as seen in the first theme. Regarding this scenario, Cugler and Figueiredo (2021) suggested in their findings that violence at a young age can be a precursor to abusive substance use and the continuation of violent experiences in adulthood.

Research indicates many differences between male and female users who engage in substance abuse, particularly concerning psychiatric comorbidities. Physical, sexual, and psychological violence have been associated with various psychiatric issues in female users, such as depression, anxiety, phobias, suicide attempts, alcohol and drug abuse, eating disorders, postpartum depression, and bipolar disorder, among others; correlations verbalized in the discourse of the female participants in this study (Albuquerque & Nóbrega, 2016; Alves & Rosa, 2016). However, attention must be paid to the fact that psychiatric categories are constructed with the attribution of certain behaviors and forms of expression of suffering, such as correlation with the female gender (for example, crying as analogous to depression), in which women express suffering and are categorized mainly due to difficulties in activities related to gender roles and caregiving (maternal and interpersonal) (Zanello, 2018).

Regarding the construction of their subjectivities, in the first theme, it can be observed how the participants were immersed in the discourse of romantic love, which positions women as dependent on men’s love to become subjective. From this perspective, women grow up in societies where prevailing discourses portray them as fragile, waiting for a man who will save them from all troubles (Zanello, 2018). Esper et al. (2013) found that the main motivation for women in treatment to reduce drug consumption (in 68.2% of cases) was to fulfill gender social roles as expected by society (wife, homemaker, and mother). Not having their own income also weakened these women because, when financially dependent on partners or ex-partners, they were often subjected to violence and unhappiness due to their inability to lead an autonomous life, thus limiting the possibilities for other social and occupational roles (Corradi-Webster, 2020).

The need for shelter, lack of financial support, fear of retaliation, and not wanting to interfere with the well-being of their children were reported by participants in this and other studies as additional reasons for not leaving relationships, even when they were violent (Gilchrist et al., 2019). With this in mind, it can be seen how the support networks of these women, beyond their spouses, are fragile and lead them to feel isolated. Therefore, the drug use by these women was caused by trajectories of exclusion and emotional and social abandonment, which imprisoned the individual much more than the substance itself (Souza, 2016).

Faced with the inclusion of these women in contexts of individual and social vulnerabilities, these stories of weakening do not allow, in some cases, for controlled and safe drug use by the women themselves (Corradi-Webster, 2020). Consequently, partners become part of this relational dyad between women and drugs and become influential in maintaining, increasing, or decreasing consumption, causing changes and interferences in consumption patterns, as seen in the second theme. Therefore, in relationships marked by conflicts and violence between spouses, the possibility of quitting or reducing drug use becomes particularly difficult, and women transition from potential victims to being involved in violence themselves (Lucchese et al., 2017; Siepmann Soccol et al., 2020). In this context, there are studies that also support the findings of this research, indicating that relationship support is an effective aspect in reducing drug use, as also highlighted in the second theme (Stanesby et al., 2018). Influences on drug consumption are affected by the perceptions (or lack thereof) of support, trust, affection, and material assistance felt by women in relation to their partners, causing them to remain in this cycle of use-abuse-non-consumption in an attempt to maintain the bond with their partners.

Therefore, the presence of a partner cannot be directly taken as a factor that increases or decreases drug use, as the subjective, relational, and contextual experiences of these women in relation to men are also at play. These experiences were verbalized in this study through dominant gender discourses, even for those who felt supported by their partners – a result that aligns with the findings of Silva et al. (2021). Intimate relationships also become influential when, for instance, they serve as sources of stress and/or contribute to drug use, resulting in difficulties in adhering to the care provided by healthcare services. On the other hand, partner support can ensure initial access to treatment in healthcare facilities, a finding also supported by this research (Stanesby et al., 2018)

It is evident that relationships can leave marks on the trajectories of these women in terms of stigma, blame, and a return to helplessness. They become referenced and judged in relation to their partners, with the failure of the relationship and its consequences often attributed to them, thereby exacerbating the disparities in power dynamics between genders (Zanello, 2018). The fact that these women had lost custody of their children due to being drug users had a detrimental effect on them, a phenomenon not as frequently observed among women from middle or upper-class backgrounds that use drugs. Because of this, there are preconceptions about motherhood in the context of drug use, as there is a strong notion that these women are incapable of caring for themselves and others (Corradi-Webster, 2020). Zanello (2018) referred to this social construct as the “maternal device”, which dictates emotions and expectations directed towards the female gender regarding the role of motherhood. This concept is often internalized by women themselves due to societal norms and even by healthcare providers in the CAPS-ad centers, as found in the investigation by Silva et al. (2018).

Some of the workers at CAPS-ad centers hold strong stereotypes of women drug users as responsible for maternal and family care, believing that they must achieve abstinence to properly fulfill this role. Additionally, these workers conceive women as inherently fragile and dependent on emotional relationships. These verbalizations run counter to the principles of support and care that should be promoted by these institutions.

Given the situations of fragility and vulnerability in which these women have found themselves, their social and support networks throughout their lives become relational, subjective, and societal obstacles. Thus, a dependence on public health and social welfare services is observed, where these women direct their appeals and treatment needs, leading to trajectories of institutional insertion and monitoring. The data indicate that the initial access to these services was due to social vulnerability and drug use. However, over time, a broader context of disruptions and difficulties emerged within the scope of care, including intimate relationships, leading to requirements for public policies. In conclusion, the treatment and institutions should assist in the reconstruction of various life spheres, preferably through intersectoral interventions and analysis of how social conditions influence behaviors and healthcare. Care and attention related to alcohol and other drugs should prioritize strengthening the potential support network for the female user, restoring weakened relationships and/or facilitating the establishment of new healthy connections (Cugler & Figueiredo, 2021).

Day et al. (2018) pointed out that issues such as stigma, motherhood, and relationships with partners and family members should be investigated to enhance adherence and address the unique demands of women. Creating spaces for discussing these issues would increase the likelihood of women reflecting on strategies and potentially redefining their consumption patterns. In this context, vulnerabilities and roles as wives should also be discussed and addressed in the services, both to involve partners in the treatment so they can contribute and share responsibility, and to encourage women to develop resources for envisioning treatment and life trajectories beyond intimate relationships (Radcliffe et al., 2019).

Based on this study, it is suggested that strategies such as couples counseling (psychoeducation, guidance-focused psychotherapy, and support, among others) should be considered as interventional possibilities within more specific therapeutic projects tailored towards women and gender relations. This approach recognizes the constructions and consequences that intimate relationships have on women’s lives and drug use patterns. Regarding interventions aimed at women, these projects should be capable of reframing their life stories and psychological distress, while also encouraging actions that promote empowerment, autonomy, financial independence, and providing guidance, approaches, and support for situations of violence and motherhood, among others.

It is important to highlight that this study had some limitations. One of them was the choice of qualitative methodology, which does not allow for the generalization of results to the population of women drug users. Additionally, the inclusion of participants in treatment at CAPS-ad who came from a specific social class proved to be another limiting factor, as drug users from different socioeconomic strata may exhibit other characteristics related to experiences in intimate relationships. This could also apply to women seeking support from other types of institutions, using other forms of treatment, and with regards to usage patterns other than abusive consumption. It is also suggested that future research could consider including men’s perspectives on their experiences in marital relationships, as well as encompassing a range of relationships beyond heterosexual unions.

Conclusion

The women in drug treatment at the Psychosocial Care Center exhibited diverse histories of social vulnerabilities throughout their lives, where intimate relationships were constructed as hopes for transformation in the face of their hardships. They became wives within an idealistic and constructed romantic framework. Additionally, they indicated an early initiation into drug use, a condition influenced and impacted by relational dynamics. There was an increase in drug consumption based on the need to fulfill the role of a wife and please their partners, as well as in situations of conflict and violence. Reduction in drug use was reported when they felt supported by their spouses, who encouraged them to seek treatment, or when facing restrictions in their freedom. With this, the maintenance (or cessation) of drug consumption occurred in an attempt to sustain the bond with their partners within the traditional model of the marital relationship constructed. It was observed that intimate relationships, as a result, played a significant role in the trajectories of these participants who were entangled in various vulnerabilities, leading to the need for support from public policies. There were repercussions and interventions from the social welfare, healthcare, and justice services, resulting in experiences ranging from stigmatization to support. Therefore, there is an urgent need for services such as CAPS-ad to be sensitive to gender issues present not only in intimate relationships but also to offer therapeutic approaches within this perspective.

• How to cite this article: Pinto, A. L. L., & Corradi-Webster, C. M. (2023). Women, intimate relationships and drug use: experiences and meanings. Estudos de Psicologia (Campinas), 40, e220130. https://doi.org/10.1590/1982-0275202340e220130en

• Support

  Conselho Nacional de Desenvolvimento Científico e Tecnológico (Process nº 316074/2021-7).

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Editor responsável

André Luiz Monezi de Andrade

Publication Dates

• Publication in this collection
  10 Nov 2023
• Date of issue
  2023

History

• Received
  11 Nov 2022
• Reviewed
  05 Apr 2023
• Accepted
  28 Sept 2023