Book Review

Substance and Shadow: Women and addiction in the United States

N Engl J Med 1997; 337:57July 3, 1997

Article

Substance and Shadow: Women and addiction in the United States
By Stephen R. Kandall, with the assistance of Jennifer Petrillo. 353 pp. Cambridge, Mass., Harvard University Press, 1996. $29.95. ISBN: 0-674-85360-1

As a neonatologist specializing in the treatment of drug-exposed babies, Dr. Stephen Kandall was asked to testify for the defense in the case of Jennifer Johnson, a young woman charged with “delivery” of a controlled substance, cocaine, to her baby through the umbilical cord. His distress at the outcome of the case — Johnson was convicted — moved Dr. Kandall to write this book.

Substance and Shadow presents a social history of addiction in women, including the evolution of attitudes and treatments, and a policy prescription for the care of addicted women. As a historical account, the book succeeds. It is a well-researched chronology of women's use of and dependence on drugs, starting with the 19th century, when the majority of opium addicts were women who obtained the drug legally from physicians, druggists, or charlatans.

For readers interested in the development of federal treatment and research programs for women or personal accounts by addicted women, Substance and Shadow is an excellent source of references. Particularly rich are the early chapters, which document the major role of iatrogenesis in drug abuse and dependence among women at the turn of the century.

The book then addresses the unique needs of addicted women during pregnancy, the postpartum period, and early motherhood. Their traumatic experiences of sexual assault while intoxicated or in the course of exchanging sex for drugs may also require special attention. However, in trying to establish the meaningful clinical distinctions between men and women, Dr. Kandall lapses into gratuitous discussions of nondifferences. He emphasizes, for example, that many women feel acute shame over their lost promise or suffer guilt over neglecting children and family. But men too experience profound emotional distress when they relinquish themselves to drugs, and Dr. Kandall does a disservice to true sex differences and the implications they have for treatment by intimating that addicted women somehow suffer more keenly than men.

Although the author writes approvingly of the popular “women's health” approach to treatment (i.e., programs only for female patients and programs run solely by and for women), he bases his impression on scattered examples. At present, there is no mature literature on the benefits, drawbacks, and optimal design of such gender-specific programs. What previous studies have shown, however, is that the longer an addict (male or female) stays in treatment, the better he or she does. Dr. Kandall mentions this crucial rule but does not adequately explore strategies for improving retention — perhaps the greatest challenge to clinicians.

Substance and Shadow also fails to grapple with complicated policy issues, such as coercive treatment of addicts during pregnancy and after childbirth and the nature of sanctions, both criminal and civil, in modifying their behavior and helping them become better parents. At times, necessary detail is glossed over. For example, Kandall promotes needle exchange but gives no hint of the debate over the interpretation of needle-exchange research.

Throughout the book Dr. Kandall repeats his view that addicted women are victims of society — “united in a punishing sisterhood” — sounding more like a social advocate than a scholar. And his obvious impatience with those who cast a judgmental eye on drug-abusing or drug-dependent mothers precludes a head-on confrontation with the inescapable fact that these women, as agonized and deserving of help as they are, frequently fail as parents.

With growing evidence that a lack of parental supervision is a major factor in the development of delinquency and drug use in the next generation, the child-welfare system must inevitably be involved. Yet Dr. Kandall virtually ignores this reality. For example, his omission of an excellent policy book called When Drug Addicts Have Children: Reorienting Child Welfare's Response (D. Besharov, ed. Washington, D.C.: American Enterprise Institute and Child Welfare League of America, 1994) prompted me to wonder how many other good studies were selectively omitted because they did not align with the author's slant.

A detailed exploration of the ways that clinicians can collaborate with authorities (e.g., child-protective services, the criminal-justice system) would have been most welcome. But Dr. Kandall views addicted mothers as an “oppressed” class that has turned to drugs because of “the stresses they face — minority status, reduced economic, social and political expectations.” Thus, it is not surprising that fear of blaming the victim would make him shy away from endorsing sanctions. This is unfortunate, since there is ample research to show that addicts legally compelled to complete treatment do as well as or better than those who volunteer.

In all, Substance and Shadow offers a solid, useful chronology of women's involvement with drugs and society's response to it; I will use it often for reference purposes. However, readers looking for a fresh perspective and nuanced consideration of policy issues will be disappointed.

Sally Satel, M.D.
Yale University School of Medicine, New Haven, CT 06510

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