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Hordes of angry women wrote to me after the publication of Woman of Substances: A Journey into Drugs, Alcohol and Treatment. It wasn’t me they were mad at. The book is the accumulation of eight years’ research into the trauma, misogyny (often that “internalised” bad boy) and mental-health issues that can lie behind women’s problematic substance use. My social-media inboxes became a kind of safe harbour for readers to dock their most rageful thoughts.
I’ll be honest, I found it exhausting to read these messages during a press period where I was asked, relentlessly, about the four pages of my book that spoke of my own childhood trauma. “Maintain the rage!” one woman wrote. I aged ten years wondering if I possibly could. The common denominator in all these messages was that the owners had felt catastrophically disempowered, often around ownership of their bodies. These were women literate in mental health, so they probably knew well that anger is the emotion that shelters shame, fear and rejection. It feels empowering, but it’s transference all the same.
All this ties into a thesis that arose out of Woman of Substances: that the body becomes our battlefield. Some men will find this a familiar concept too, but women, from a young age, are conditioned to be the diplomats, the carers, the ones who absorb the blame. And so a woman who is distressed might stage a silent rebellion through her body. At one end of the scale, she chops off her hair after a breakup. At the other end, she puts her foot to the accelerator and drives her body into the ground, startling bystanders. Parents, newspapers and police press conferences may warn her of the dangers of getting paralytic, but at least when she raises that bottle to her lips or inhales on a pipe, it’s her executive decision.
I argue that there’s a key triumvirate of self-destructive behaviours; or maladaptive coping strategies, as they’re more diplomatically known. As well as problematic substance use, there’s eating disorders and self-harm. The three can often rotate – one popping up like Whac-A-Mole the moment another is smacked down – or they can coexist. Through their physicality they offer relief from intrusive, circular thoughts. But they’re imbued with violence. Drinking feels like drowning oneself. Taking drugs feels like obliteration. Self-harm takes the focus of pain from the emotions to a precise point on the body. Throwing up is the literal purging of shame.
These behaviours are often in part down to the exploration of self-loathing, but I also posit that any act of aggression against the body is an act of regaining ownership of it, just as when a person inflicts violence upon another, they now wield the power. To decide to harm oneself can be particularly appealing to an adolescent with no autonomy, or to a person who has experienced childhood sexual abuse, or to someone who has been shamed for their sexuality, or to one who endured endless medical procedures when young, or to anyone who feels that their body has been co-opted by everyone else.
When I started drinking at thirteen, I retreated inside my body. I stopped using it – for sport, for games, for affection – and I only did things to it.
My teens were a distilled version of the War on Drugs: all prohibition and punitive measures. My mother made me sign a four-page contract without my lawyer present, packed with clauses that prohibited my favourite activities. A curfew was established that only allowed me to walk home from school at a brisk pace. Allowances were made for small privileges in exchange for lengthy chores. The lock on my door was removed, as was the red light bulb in my room; apparently it didn’t look groovy and psychedelic – it made the house look like a brothel.
From this point on, alcohol became a form of psychic emancipation. I was blind drunk every day after school. How was I managing it? Nobody knew. I was the Criss Angel of drinking. Every time the key to the drinks cabinet was hidden, I’d pride myself on finding it. In Dad’s desk drawer? Laughable. Behind the salt cellar? Come on. After a while I got my own key cut at the cobbler’s on Slough High Street so that I didn’t need to bother playing the game. When I was finally rumbled and forced to hand that over, I resorted to Dad’s terrible home-brew in the shed, which yeastily expanded the gut and sent one into quite the stupor. Tiring of that, I just broke into the cabinet with an icing spatula.
“It’s like you WANT to get caught,” Mum would snap, amending the contract at the kitchen table.
As the jaws clamped tighter around me, autonomy was achieved through more imaginative methods. Every time I felt enraged I got another hole punched in my ear. When I started getting frisked at the front door as I left, I’d buzz-cut another few inches of hair off my scalp when I got home. At school, I noticed that my friend was whittling away into her arm with her set of compasses during maths class. I pulled up my sleeve and showed her my own homework.
Mutilating the body may be a silent act, but it literally scores a story into the skin. Over the decades there have been varying explanations for self-harm, from hysteria in the late nineteenth century, to suicide ideation in the ‘50s, to rote diagnoses of borderline personality disorder (known by many in the medical profession as the “dustbin diagnosis”, into which difficult women are chucked) from around the 1980s onwards.
In her 2017 book Psyche on the Skin: A History of Self-Harm, Sarah Chaney was critical that psychiatry “has largely suggested narratives framed in clinical, biomedical or individual terms.” Often, she points out, “this ignores the things that happen to people or the environments they live in. Poverty, homelessness, abuse, racism, oppression.” Certainly, the DSM – the standard classification of mental disorders used by many mental health professionals – tends to pathologise as mental disorders women’s responses to the specific challenges they face in patriarchal society. (Perhaps that’s because there are only four women among the twenty-four-strong taskforce behind the latest edition.)
In the 1964 autobiographical novel I Never Promised You a Rose Garden by Joanna Greenberg (writing as Hannah Green), teenager Deborah is admitted to a mental-health facility for three years. There, she is constantly monitored because of her propensity to express her anger through self-mutilation. She seizes back control by creating a secret world – with even its own calendar and measure of time – where they cannot interfere with her. This desire for agency is echoed in much of Sylvia Plath’s work, including the poem Stings. Plath – who had expressed suicide ideation since childhood – wrote, “It is almost over. I am in control”.
There will always be those who view self-harm less as the individual asserting control over themselves than an unforgivable stab at eliciting attention – which is then all the more stubbornly withheld. For Woman of Substances, I interviewed Dr Ben Sessa, a Bristol-based child psychiatrist who also conducts clinical trials in MDMA-assisted psychotherapy with alcohol-dependent adult clients. They’re twin interests, in his view. He told me, “We have all these sentimental feelings for little children who are being abused and hurt, but then we don’t accept what happens to them when they grow up, when they display antisocial behaviours. It’s a sloppy understanding of developmental psychology.”
Sessa gives the example of visiting a fifteen-year-old girl in casualty after she’s self-harmed with an overdose. “The nurses will say: ‘Don’t let her get one over you; she’s a manipulator, an attention seeker.’ I hate that term, ‘attention seeker’. I go up to this kid and say, ‘Good for you for seeking attention. You deserve attention. You have my attention.’ It’s a recognition that they’re not bad people; they’re the most vulnerable people. These are natural adaptive responses to pain.”
It’s eating disorders that can have the most complex relationship with substance use. Research from Columbia University has found that three per cent of the general population have eating disorders, but when we narrow that population down to people with problematic substance use, the figure rises to thirty-five per cent.
The shared risk factors include low self-esteem, depression, anxiety or impulsivity; unhealthy parental behaviours; peer and social pressures; and a history of sexual or physical abuse. As journalist Kelsey Osgood writes in her memoir How to Disappear Completely: On Modern Anorexia, “It never occurred to me to try to lose weight in any healthy way, or to strive for a body that ‘looked good’. I wanted to be repulsively thin.”
When substance use and an eating disorder occur together, the individual’s inner struggle can quickly escalate to a crisis. Most eating-disorder wards and drug-and-alcohol facilities are separate services and each is generally unequipped to treat a dual diagnosis, let alone an additional mental illness and history of trauma. So someone presenting with both will fall between the cracks. Both issues can be life-threatening and require intensive therapy, despite which there will be high relapse rates.
It was a combination of bulimia and alcohol poisoning that Amy Winehouse’s brother Alex attributes her death to. Winehouse had a terrific self-awareness, analysing her behaviour and motives in depth in her lyrics, but she also had no control left over her life. She was hopelessly entwined with the needs of another person with problematic use – her husband – and was bundled off planes and onto stages by her management. She was hemmed in at home by the paparazzi. There was no period factored in for recovery. By the time she refused to sing at the ill-fated Belgrade concert and instead took a seat on the stage, she was practically a prisoner of her schedule. Her body, which made newspaper headlines, became a very public act of defiance.
In many ways, her situation isn’t unusual. Girls are hounded by their own self-inflicted paparazzi: Instagram, Snapchat, other social media. They’re compelled, pressured and shamed into capturing themselves as a commodity in every waking hour. In this sense, an eating disorder can be reframed by the individual as a magnificent feat of endurance, as can slicing the skin or drinking like a lemming off a cliff. Look what I can do, it says.
As well as the more obvious desire not to grow outwards, an eating disorder can signify a desire not to grow up. Just as losing oneself in substances guarantees arrested development, so becoming smaller freezes the advent of adulthood. That can be appealing to one who feels that childhood didn’t go the way it ought to have. In the case of those who have received unwanted attention as children, getting thinner suggests a desire to disappear from view altogether: If I starve myself, nobody will notice me. If I overeat, no one will want to touch me and I’ll become invisible.
There’s a further complication with women’s bodies, this time accidental, not deliberate, and that’s the hormonal mayhem inflicted by taking substances or dramatically losing weight. Alcohol raises oestrogen levels, which can contribute to panic attacks, poor memory, anxiety and depression. In one study, blood and urine oestrogen levels increased up to thirty-two per cent in women who drank just two drinks a day.
The flipside is that women suffering low progesterone might be attracted to alcohol and benzodiazepines such as Xanax, because these substances can quell anxiety. But there’s no literature for the laywoman on this matter; only scientific papers that take some unearthing and decoding.
That’s the effect of substances on hormones, but the reverse is also significant – hormones affect a woman’s response to substances. In week one of her cycle, the menstrual phase, fatigue is likely to hasten the effects of drugs and alcohol. In week two, the follicular phase, oestrogen levels rise along with impulsivity, making women more prone to benders and relapses. Oestrogen is also thought to sensitise the brain to THC – the psychoactive component of cannabis – and in general slows down the elimination of substances from the body. In week three, the ovulatory phase, there’s an influx of progesterone, which tempers the individual’s interest in substances. In week four, the luteal phase, oestrogen and testosterone plunge. There may be a craving for alcohol, as there is for carbohydrates in general.
Having reached the proverbial rock bottom, I quit drinking for eight years before cautiously reintroducing alcohol. Now, drinking doesn’t feel like self-harm; the emphasis is on enjoyment. Having more than three in a row, in fact, fills me with horror as my edges start to blur. It’s hard to imagine that getting shitfaced had like being in control, but then, harming myself had felt like action in place of the passivity I felt as a depressed adolescent.
Now I had to rethink my relationship with my body. Sport put me in control in an entirely different way (with endorphins replacing the ding-ding-ding dopamine-kick of drugs) and getting stronger and stronger feels like the greatest way of achieving agency. Naturally, it’s all become very addictive.
Remembering to use the body instead of do things to it is a pretty common awakening when people tackle their substance use. I’ve got a friend who stopped shooting speed and now has her own yoga centre. Another is a competing body builder who gets the same gory enjoyment out of her four a.m. starts and rations of food as she did with her four a.m. crashes and lines of coke. It all taps into the same grizzly capacity for endurance. Similarly, many quitters turn to running. They’ve got a head start with their all-or-nothing mindset.
For some women, particularly those who have been in abusive relationships, empowerment begins with being put in touch with services that allow them to control their own finances and with agencies that help them restore order in their lives and visualise a new self. For those seeking treatment, a program that encourages self-reliance could be a better fit than one that relies on surrender to a higher power.
One alternative to AA/NA is Women for Sobriety (WFS). There are thirteen acceptance statements in its “New Life” programme, and instead of introducing herself as an alcohol or addict, a woman states her name and something positive about herself. Similarly, SMART Recovery offers meetings that focus on the individual’s own resources to tackle upcoming challenges or meet goals (full disclosure, I’m on the board of the Australian outpost of SMART).
Even with the best-laid plans, if a person has the kind of triggering incident that makes them feel out of control, they’re likely to whip out one of their old, comforting behaviours – scoring the skin, purging, or getting obliterated. It’s as though they’re falling back into a lover’s arms. That’s why it’s important that treatment programs and professionals reframe “relapse” so that it’s not a source of further anguish. Lessons could be learned from the world of business, where mistakes are viewed as learning opportunities – and as inevitable. Self-flagellation is the last thing that’s needed.