Many distinct but interconnected processes emerged as being important to women's addiction recovery. For the purposes of this discussion and consistent with the findings of the meta-synthesis, recovery is not simply a process of reducing use of drugs and alcohol or attaining abstinence from drugs and alcohol. Rather, recovery is regarded as a process of "re-covering" oneself, that is, as a process of personal and individualized growth that unfolds along a continuum, leading to a higher quality of life [47, 48].
Through involvement in programs, women developed an enhanced sense of self. Development of a sense of self-worth is notable as women with substance use issues tend to have low levels of self-esteem  and pregnant women and mothers, in particular, experience stigma that negatively impacts their self-worth [50, 51]. Along with an improved self-worth, the development of a non-addict identity is an important aspect of recovery [52, 53]. Mothers with substance use issues often experience difficulties in developing a maternal identity, which is related to limited care giving experience, a focus on one's own needs for recovery, and addressing only the non-emotional needs of children . The meta-synthesis revealed that integrated treatment programs support women in defining self in other roles, including self as mother.
As part of the recovery process, and related to the development of a non-addict identify, women also developed a capacity for relationships with their children and with others internal and external to the treatment program. This is an important aspect of recovery because women who use substances often have histories of physical, sexual or emotional abuse as children [54, 55]. These histories, along with socioeconomic circumstances and characteristics of drug-exposed children, can negatively affect parenting practices . In addition, women with substance use issues often continue to experience abuse beyond childhood , which may negatively impact their abilities to engage in adult relationships.
Another finding of the meta-sythesis was that women developed personal agency through integrated treatment program involvement. Other first person accounts similarly describe people in recovery as active agents of change in their lives rather than passive recipients of services . This cognitive resource plays an important role in promoting healthy behaviours, including continued abstinence . As reflected in the findings of the meta-synthesis, an aspect of developing personal agency in recovery is learning and being able to implement adaptive coping strategies as alternatives to substance to cope with stress . The lives of women with substance use issues tend to be characterized by chronic life stress related to issues such as abuse and traumatization, single parenting, inadequate income, family or social problems, health problems, and removal of children from the home [49, 58]. Because stress can trigger relapse, adaptive coping strategies are key resources that promote maintenance of recovery [47, 59].
The finding that women experienced the giving and receiving of social support within integrated treatment programs is noteworthy as women who use substances often experience social isolation and limited social support [49, 60]. Social support, including that of peers and helping professionals, is a key resource in recovery [47, 48, 61, 62]. As suggested by the meta-synthesis findings, social support may act to buffer against stress, a notion espoused by Tucker and colleagues  who found that women with greater social support reported less substance use. It is essential that women have social support systems that are constructive and provide support without enabling drug use . Moreover, as noted by Kellogg and Kreek , a constructive social setting enables women to develop relational or interpersonal aspects of their self-identity, a component of self-development that emerged in the meta-synthesis.
Getting women to engage and participate in recovery activities is a first step to treatment retention and longer-term outcomes [38, 65]. Because staff members are key actors in this process , the finding that women engaged with program staff is important. Therapeutic relationships were characterized by acceptance, a non-judgmental attitude, openness, empathy, and respect. In a recent study, stronger therapeutic engagement, specifically program participation and rapport with staff, was found to be associated with higher treatment motivation and readiness and to better psychosocial functioning (e.g., higher self-esteem, self-efficacy, decision making, social consciousness) .
Therapeutic engagement with staff and the support of women with shared experiences facilitated self-disclosure of histories of neglect and abuse and substance use-related issues. In a study of women in recovery, "breaking the silence" by discussing abuse experiences assisted them in reshaping their sense of self and connecting to others . Altering one's concept of self and committing to a newly established sense of identify was seen as integral to the process of recovery. Women in this study also reported that they began to understand their behaviour patterns, which enabled them to take action.
Recognizing destructiveness patterns was a theme revealed by the meta-synthesis. It is consistent with the concept of "truthful self-nurturing" that was identified by Kearney  as the basic process of women's addiction recovery in a review of 10 study reports of recovery processes. As she noted, women developed insight into the consequences of substance use, including harms to their children, and a gradual realization that alcohol and drug use caused more distress than it relieved. "Giving in to the hard truths" enabled women to engage in more healthful ways of caring for themselves and to develop positive relationships (p. 503) . They became aware of the need for behaviour change, and while often women initially focused on simple goals such as eating and obtaining shelter, they progressed to more complex long-term goals .
Goal setting was another theme that emerged from the meta-synthesis. The ability to engage in future-oriented, goal-directed behaviour is central to the recovery process in substance use treatment . Programs that are supportive and goal-directed demonstrate improved treatment participation and better outcomes [52, 69]. The need for women to act in a consistent self-directed manner to achieve goals underscores the importance of personal agency .
The qualitative meta-synthesis highlighted the motivating presence of children for women to remain in integrated treatment programs. The meta-analysis of quantitative studies of integrated treatment programs we conducted (unpublished data) revealed that, relative to non-integrated programs, having children present increases client engagement, possibly because pregnancy-, parenting-, and child-related services increase maternal motivation to actively engage and remain in treatment . Creamer and McMurtrie  commented that women in treatment often have difficulty or are unwilling to separate themselves from their role as mother to focus exclusively on their own needs. They, too, identified that children can be motivators for staying in treatment. Moreover, because mothering can build self-esteem , the presence of children also contributes to women's development of sense of self.
The findings regarding outcomes are consistent with previous reviews and meta-analyses of quantitative studies in supporting the effectiveness of integrated programs in improving maternal engagement, substance use, and well-being. This qualitative meta-synthesis also identified positive outcomes of integrated programs for parenting knowledge, skills, and confidence, as well as child development and behaviour and the parent-child relationship. The lack of attention to child outcomes is an important omission of the qualitative studies conducted to date, especially given that integrated programs are designed to meet the needs of women and their children.
Strengths of this meta-synthesis include the use of: a systematic and comprehensive search strategy; criteria that were congruent with the defined purposes of the synthesis to make inclusion decisions; and a quality assessment checklist developed by the National Institute for Health and Clinical Excellence (NICE) . Several of the studies were determined to be of high quality, and lower rankings tended to represent an absence of information (e.g. research methods unclear, study limitations not reported, inadequate discussion of study limitations) rather than explicit methodological inadequacies. Details about themes and verbatim quotes were extracted from the documents. These data were then synthesized using a systematic and iterative process to create high-order constructs or themes that reflected women's experiences. Finally, two of the authors independently determined whether reports met inclusion criteria, assessed quality, and analyzed the extracted data, with decisions made by consensus when there were differences. While we anticipated that conducting a thematic analysis of the studies in chronological order would capture developments in knowledge, we found no discernable developmental patterns. This most likely is related to the wide diversity in study aims and research methods.
The main limitation of this meta-synthesis is that it relied on data derived predominantly from simple qualitative descriptive studies. Within the hierarchy of qualitative evidence , descriptive studies are a weaker type of evidence compared to conceptual studies or generalizable qualitative studies conducted using more theoretical approaches such as grounded theory or phenomenology. Descriptive studies can confirm and describe characteristics of a phenomenon within a specific population and highlight context-specific issues, but may have limited transferability to contexts outside of the original study and limited utility for evidence-informed practice and policy development. While it has been argued that it is inappropriate to synthesize the findings of qualitative studies that have been carried out in diverse contexts and to generalize across studies, qualitative meta-syntheses can produce new understandings through conceptual development of shared meanings or generative mechanisms [22, 72].