and strength beyond what many could have ever believed or imagined. So many have found that ...... parenting, partner relationship, and overall communication. An individual who is ...... fulfillment, differentiation of self, and interaction style.
THE INFLUENCE OF ADDICTION RECOVERY ON COUPLE RELATIONSHIPS: A QUALITATIVE EXAMINATION THROUGH A BOWENIAN LENS
A Dissertation Presented to The Graduate Faculty of The University of Akron
In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy
Cheryl L. Thomas May, 2012
THE INFLUENCE OF ADDICTION RECOVERY ON COUPLE RELATIONSHIPS: A QUALITATIVE EXAMINATION THROUGH A BOWENIAN LENS
Cheryl L. Thomas
Dissertation Approved:
Accepted:
_______________________________ Advisor Patricia Parr, Ph.D.
_______________________________ Department Chair Karin Jordan, Ph.D.
_______________________________ Committee Member Pamela Schulze, Ph.D.
_______________________________ Dean of the College Mark D. Shermis, Ph.D.
_______________________________ Committee Member Karin Jordan, Ph.D.
_______________________________ Dean of the Graduate School George R. Newkome, Ph.D.
_______________________________ Committee Member John Queener, Ph.D.
_______________________________ Date
_______________________________ Committee Member Cynthia Reynolds, Ph.D.
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ABSTRACT The purpose of this study was to gain a better understanding of the impact of addiction recovery, such as treatment and self-help support group influence on the couple relationship. Researchers have investigated behavioral couple therapy, family relationship theory, and individual and group therapy. Few have delved into couple recovery and their experiences. A qualitative phenomenological method was implemented in this study with five voluntary couples that met the criteria. They participated in an in-depth, conjoint interview. The in-depth interviews asked questions to get to couple interactions in connectedness, triangulation, and distancing, observed through Bowenian Theory. Murray Bowen’s Transgenerational Theory: Differentiation of Self was the lens used in viewing the lived experiences reported by the participants. This theory also served in analyzing those experiences the couples shared. Analysis of those experiences brought to light four common themes among the recovering couples: Emotional Change, Interdependent Interactions, Cultivated Communication, and Treatment Dilemmas. The information gleaned from this study is valuable to many disciplines that include clinicians (marriage and family therapists, counselors, social workers, and chemical dependency counselors), clergy, researchers, and laypersons.
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DEDICATION I am dedicating this dissertation to individuals and their partners recovering from alcoholism/addiction. Your journeys of recovery created a path filled with hope, courage, and strength beyond what many could have ever believed or imagined. So many have found that path and maintained it. I also dedicate this work to individuals and families who still struggle with active addiction in their lives, may they find the path of recovery that so many others have found.
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ACKNOWLEDGEMENTS This dissertation would not exist, if the couples had not volunteered to be a part of it. I so appreciate their willingness to open up, to share a story of love, strength, and courage about their recoveries. I would like to thank my family for their love, support, and mostly their understanding and patience through the completion of this dissertation and doctoral program. My husband, Jeff, who was tirelessly supportive, doing laundry, meals, and edit suggestions (you are great with words!), but more importantly, how he would push me to work in those times I wanted to do anything but write! My children—I appreciate how my children and step-children have the ability to be focused and to make positive choices in their own lives—problems with them would have definitely gotten in the way of my finishing this work. My parents and my brother, well, they have been there through it all for me, so I am going back to the times when I was a single mom, starting all of this. I could never find the words to describe a mom and dad that have been more caring and supportive than Mom and Denny. I could not recount the number of hours they have helped with my children, running them back and forth to practice, picking them up from school when they were under the weather, and just providing them the support and love they also provided me. I would like to recognize my friends who were such wonderful, confidantes in letting me blow off steam, laugh, cry, or just be crazy, which seems to happen when one v
takes on such a huge project. They too understood when I had those times when my life was being consumed with writing, instead of spending time with them. A special thank you to my friends Shea and Joanne. Dr. Patricia Parr, whose dedication and encouragement from the start of this project offered support, feedback, and kindness that propelled me in my weekly writing. Also, great thanks to my dissertation committee: Dr. Pamela Schulze, Dr. Karin Jordan, Dr. John Queener, and Dr. Cynthia Reynolds who provided positive feedback, expertise, and guidance for this project. Finally, I am going to give gratitude to God, my father. I give Him the glory for rescuing me from the darkness of addiction and providing me the strength to do my part. I often lean on the portion of the prayer recited among the self-help support groups that will continue to guide me in my future endeavors: God, Grant me the Serenity To accept the things I cannot change; Courage to change the things I can; And wisdom to know the difference. --Reinhold Niebuhr
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TABLE OF CONTENTS Page LIST OF TABLES ............................................................................................................ xii CHAPTER I. THE PROBLEM.............................................................................................................. 1 Introduction ............................................................................................................ 1 Statement of the Problem ........................................................................................ 3 Purpose of the Study ............................................................................................... 8 Research Questions ................................................................................................. 8 Operational Definitions ........................................................................................... 9 Disease Concept Controversy ............................................................................... 11 Parameters of the Study ........................................................................................ 13 Chapter Summary ................................................................................................. 13 II. LITERATURE REVIEW ...................................................................................... 15 Family and Addiction ............................................................................................ 16 Systems Theory ..................................................................................................... 16 Bowen’s Theoretical Concepts.............................................................................. 18 Alcoholism Theoretical Foundations .................................................................... 22 Differentiation of Self ........................................................................................... 25
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Recovery.................................................................................................................. 31 Impact of Addiction on Intimate Relationship ........................................................ 35 Co-Dependency ....................................................................................................... 35 Role of Partner in Addiction ................................................................................... 36 Treatment Modalities .............................................................................................. 37 Group and Individual Therapy ................................................................................ 38 Self-Help Support Groups ....................................................................................... 40 Family Treatment Models Reviewed ...................................................................... 43 Couples Therapy ..................................................................................................... 45 Impact of Therapies on Relationship and Partner .................................................. 50 Partner Included in Treatment Processes ............................................................... 51 Chapter Summary ................................................................................................... 56 III. METHODS AND PROCEDURES............................................................................ 59 Restatement of Purpose........................................................................................... 59 Research Design...................................................................................................... 60 Research Questions ................................................................................................. 61 Questionnaire and Interview Questions .................................................................. 63 Participants .............................................................................................................. 64 Informed Consent.................................................................................................... 66 Participant Demographics ....................................................................................... 66 Data Management ................................................................................................... 71 Data Collection and Organization ........................................................................... 71 Data Analysis .......................................................................................................... 72 viii
Measures of Soundness ........................................................................................... 72 Risks, Benefits, & Ethics ........................................................................................ 74 Risks to Participants ................................................................................................ 74 Benefits to Participants ........................................................................................... 75 Ethical Principles .................................................................................................... 76 Chapter Summary ................................................................................................... 77 IV. RESULTS ................................................................................................................... 78 Overview Themes of Couple Recovery ................................................................... 80 Theme One: Emotional Change ............................................................................... 82 Theme Two: Interdependent Interactions ................................................................ 85 Theme Three: Cultivated Communication............................................................... 91 Theme Four: Treatment Dilemmas .......................................................................... 97 V. DISCUSSION ............................................................................................................ 106 Summary, Implications, and Discussion ................................................................ 106 Summary of the Study ........................................................................................... 106 The Four Themes and Transgenerational Theory .................................................. 108 Existing Research and the Four Themes ................................................................ 113 Member Checks ..................................................................................................... 116 Limitations ............................................................................................................. 118 Implications for Clinical Practice .......................................................................... 120 Future Research Implications ................................................................................ 121 Researcher Transformation .................................................................................... 123 REFERENCES ............................................................................................................... 126 ix
APPENDICES ................................................................................................................ 132 APPENDIX A: INTERVIEW QUESTION GUIDE .............................................. 133 APPENDIX B: DSM-IV-TR DIAGNOSES ........................................................... 134 APPENDIX C: DEMOGRAPHIC SURVEY ......................................................... 136 APPENDIX D: FLYER TO RECRUIT PARTICIPANTS .................................... 138 APPENDIX E: INFORMED CONSENT TO ACT AS RESEARCH PARTICIPANT ................................................................................................... 140 APPENDIX F: PHONE INTERVIEW GUIDE ..................................................... 145 APPENDIX G: COUNSELING AGENCY REFERRAL LIST ............................. 147 APPENDIX H: IRB APPROVAL LETTER .......................................................... 148
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LIST OF TABLES Table
Page
1. Participant Demographics ....................................................................................... 70 2. Member Check Responses ..................................................................................... 117
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CHAPTER I THE PROBLEM Introduction For the spouse, it is so very lonely, that sense of feeling completely out of control, believing there is nowhere to turn and no person who can truly understand. Oh, there are people around that care, but part of the delusion is that no one could possibly really help. Addiction is a dark and lonely disease that slowly steals the life of not only the addict, but also those closest to him/her—the spouse, the children. It quietly destroys loving couples and eventually their families. Many are just surviving by the time help is sought. In troubled families the bodies and faces tell of their plight. Bodies are either stiff and tight, or slouchy. Faces look sullen, or sad, or blank like masks. Eyes look down and past people. Ears obviously don’t hear. Voices are either harsh and strident, or barely audible. There is little evidence of friendship among individual family members, little joy in one another. The family seems to stay together through duty, with people just trying to tolerate one another (Satir, 1972, p 11). My personal story also reflects the common pain of addiction. When I began the journey as a doctoral student in marriage and family therapy, I knew that I would eventually work with couples that have had alcoholism or addiction impact their lives. I did not imagine, though, that one of the very first couples that I would encounter in a practicum experience would mirror my own prior life events so closely. My first husband and my children’s father, has struggled with an addiction to crack cocaine for more than half of his life. For the six years we lived together as husband and wife, with two 1
children, he was in and out of jail and rehabilitation—more than a dozen times. In all of those times, only one of the rehabilitation programs offered anything for the spouse. If I wanted to visit him, I had to go to a group about enabling and codependency. This lead me to the meetings of Al Anon, which were helpful in dealing with some of my own anxieties, but the concepts they were sharing did not quite sink in for me. It seemed to lack the “connection” with my husband in the recovery process that I so desired (even through the times when he had some periods of sobriety). I was always supportive and optimistic, as his wife, but the trauma of incessant relapse kept etching away at my resolve. I had an immature belief that he could one day overcome it, and that he and I would someday work together helping others who had similar struggles. I had always been strong for the both of us. I took up the slack in many areas that my husband lacked, whether it was household duties, spending time with the children, or even holding jobs. I was being a good enabler and it was taking its toll. What I did not realize, however, was that eventually the addiction would bring me to a level of loneliness, unimaginable pain, and hopelessness that was just too much to take. He was on a binge, and he had been gone for days, and that is when I called my parents to bring the truck. I packed up and left with our children. A short amount of time passed before I took the children for counseling and began going to counseling myself. This was a start; however, four years later, we were still separated. A part of me still had hope, but he had not changed in those four years, with the exception of getting worse in his addiction. I finally admitted that divorce was the only solution. I began a Masters program, got involved in a church community, and felt better about myself, but I also feared moving on to other relationships. For me, I thought 2
there was no hope. If I just poured myself into helping the children, maybe they could have a chance for happier and healthier lives and relationships than I had. Once in the Doctoral program, I learned about interaction of systems with the family. I then questioned—why had there not been more help for couples when my husband went off to rehabilitation? It was not long before the opportunity to work with couples in the chemical dependency rehabilitation setting for my internship came along. I noticed that couples seemed to have similar feelings and experiences I had encountered. Partners who attended Al Anon, seemed to be detached from their significant other, possibly feeling as I had, disconnected from her/his companion attempting recovery. Because of my own personal experiences and those experiences of couples in my clinical work, my direction for a research topic began to emerge. Upon further exploration I discovered that there was very little research on couples in recovery; hence, my path for this study. And so arose the inspiring journey in addiction recovery and the couple relationship--couples allowing me to hear about their journeys together. Statement of the Problem Not only have my personal experiences spawned ideas for this study, but also, my understanding of the major concepts of Marriage and Family Counseling/Therapy and Theory have further refined my direction. It is important to have a brief understanding of the systemic assumptions. The assumptions of systems theory include the idea that all parts of a system are interconnected, and must be viewed as the whole; a behavior affects its environment, while the environment will also affect the system; and lastly, a system is a way of knowing (White & Klein, 2002). For example, if a parent in the family system is struggling with addiction, various areas of that person’s life will be impacted including 3
parenting, partner relationship, and overall communication. An individual who is healthier, in recovery, for example, would be healthier in those areas. Each of the examples here are interconnected systems, each clashing one with another. The assumptions or goals of Bowen Theory are succinctly noted in Nichols & Schwartz (2004) and based on family of origin, nuclear family, triangulation, process and structure of emotional reactivity. Family systems therapy assumes that improvement in any of the subsystems translates to improvement in the entire system, i.e. the recovering couple will be better parents and the children’s behavior will improve (see Chapter II, Bowen, 1974 for more informed examples). There are few statistics available specific to the number of couples and families that are affected by addiction. However, one addiction study supported a need for working with couples and families indicative of the statistics surrounding children and parental substance use. According to the Office of Applied Studies (2008) the following results from the National Survey on Drug Use and Health (NSDUH) on substance abuse reported: Combined data from 2002 to 2007 indicate that over 8.3 million children under the age of 18 (11.9 percent) lived with at least one parent who was dependent on or abused alcohol or an illicit drug in the last year; Of these [SIC, the combined data], over 7.3 million (10.3 percent) lived with a parent who was dependent on or abused alcohol, and about 2.1 million (3.0 percent) lived with a parent who was dependent on or abused illicit drugs; About 5.4 million children under 18 years of age lived with a father who met the criteria for past year substance dependence or abuse, and 3.4 million lived with a mother who met the criteria (Office of Applied Studies, 2008). These statistics suggest an extensive number of families have been impacted by addiction. The National Survey on Drug Use and Health (NSDUH, 2003) reported that in
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2002 almost 5 million adults were alcohol dependent or alcohol-abusing and had a child under the age of 18 in their home (Office of Applied Studies, OAS, 2003). Statistics specific to couples were elusive, however, AA Grapevine (2005), a website page, about membership statistics in Alcoholics Anonymous helped shed more light on those that attend. The 2004 survey indicated that AA members were comprised of the following (http://www.boosk.com/aastats/): women 35%, men 65%, marital status—married 38%, single 29%, divorced 24%, widowed 4%, and separated 5%. The website did not provide a percentage of life-long partners. These research statistics stated that 36% maintained a sobriety period of more than 10 years. With addiction encountering so many families and married partners in recovery, a better understanding of recovery in the couple relationship needed to be investigated. Because children may not have a complete understanding of recovery, I decided to exclude them from this research and allow those that parents to speak about their recovery in regards to the perceived impact on the children. Also, research on adult children of alcoholics (see McGuinness, 1999) has been more common. Another important reason to exclude children was the participant potential to limit discussion of certain topics because of the presence of children. The current literature on couples in recovery is limited to a primary focus on behavioral couple therapy (Fals-Stewart, O’Farrell, Birchler, Córdova, & Kelley, 2005; McCrady, Stout, Noel, Abrams, & Nelson, 1991). Fals-Stewart and colleagues (2005) discuss the importance for implementing behavioral couple therapy in treatment of addiction. McCrady et al. (1991) evaluated the outcomes of treatment, but viewed couples only in behavioral treatment situations. Recovery in general has yet to be 5
specifically defined for the individual; therefore, remains as unclear for the couple relationship (Gagne, White, & Anthony, 2007). Gagne and fellows (2007) reviewed recovery literature observing the mental illness and addiction fields. In the addiction field, Gagne et al. (2007) described research that recovery acted as a change transformation in the addict. Findings indicated a movement toward the need for the addiction field to define the recovery process and connection of that process to the family. Gagne and researchers (2007) also discussed a “recovery vision” that would need to include a research shift from a pathology focus to a long-term process of recovery. This research team suggested that the fields of mental health and addiction systems should work at blending for improvement in services, strategies, and supports (Gagne et al., 2007). These authors did not acknowledge couple recovery, supporting the need for the efforts of better understanding recovery from a relational perspective and further enhancement for family involvement in recovery. There are various studies on behavioral couple addiction therapy (Fals-Stewart, O’Farrell, & Birchler, 2004; Fals-Stewart et al., 2005; McCrady, et al., 1991) with few examining the long-term emotional implications for the couple relationships or recovery’s influence (Raganathan, 2004; Martin, 1999). Martin (1999) observed longterm recovery and the couple relationship. It was a narrative study in discovery of the language the couple utilized over the years devoted to recovery from addiction during their relationship with little richness of the couple stories elaborated on in the data. Several others studies viewed differentiation of self (a balance of connectedness and autonomy in the couple relationship) and the transgenerational transmission (passing 6
behavioral characteristics from one generation to the next) (McGuinness, 1999; Hobby, 2004), but less on observing Bowenian theory or constructs, such as, emotional triangles and emotional cutoff (Prest, 1991). These studies indicated a lack in the current research, providing the basic purpose of this study--the couple relationship, recovery tools, and Bowen concepts of connectedness, triangulation, and distancing. Typically addiction has been treated as an individual disease (Jellinek, 1960; FalsStewart, et al., 2004), however, in the last thirty years, it has been recognized that family treatment may be as good or better of an option for treatment (Bowen, 1974; O’Farrell & Fals-Stewart, 1999, 2001; McCrady & Epstein, 1995). Bowen (1974) theorized that alcoholism is one symptom of family problems in connectedness, triangulation, and transmitting dysfunctional anxiety from one generation to the next. He provided a foundation for viewing the family differently, conceptualizing family structure with addiction, rather than the individual, and developing solutions. Few studies have asked the couples how these areas have been influenced by recovery. O’Farrell and Fals-Stewart (1999, 2001) viewed addiction from a behavioral couple treatment perspective. The foundation for addiction treatment has behavioral underpinnings—change the behavior and the symptoms subside. The researchers focused on establishing that couples treated for addiction could have greater results in addiction treatment. McCrady and Epstein (1995) also researched treatment with the couple rather than just the individual. However, these studies lacked analysis of couples in longer-term recovery or post treatment. When addiction is the problem, the family systems approach is one avenue for treating and conceptualizing the entire family system. Although today, there are more 7
options for treatment, an area lacking in study in addiction and treatment research is the couple relationship in the process of recovery from addiction. This study examined the couple relationship and the disease of addiction, specifically, the influence of recovery on the relationship. A more extensive review of the literature and research critique is in Chapter II. Purpose of the Study The purpose of this study was to gain a better understanding of couples recovering from addiction, which was derived from Bowen Theoretical concepts (Bowen, 1966; 1974; 1976; 1978). According to the research highlighted thus far, little is known about the influence of the recovery process on the couple relationship specifically to differentiation of self, emotional connectedness/cut-off, triangulation (bringing others into the family system), treatments utilized, and support groups. Research Questions The gap in literature evolved into several questions. The questions were derived through observation of literature, theory, and clinical interactions observed. The questions were geared toward understanding the nature of the couple in their times together, times apart, and overall strengths in recovery. There were two general questions as the focus of this research: What have couples experienced in terms of addiction recovery? What contexts or situations have influenced couples experiences of addiction recovery? The following questions were derived from Bowen’s Transgenerational Theory (Bowen, 1966): (a) In what ways has a couple experienced recoveries together or apart? (b) How have partners been impacted by addiction recovery? (c) What is the perceived impact of self-help support groups (i.e. AA on couple relationship from each partner’s 8
perspective)? (d) How has specific treatment, counseling, or any therapy (i.e. residential or intensive outpatient treatment) of the addict impacted them as a couple? (e) What has helped them change together? (f) How has differentiation of self (connectedness/separateness, triangles, cutoff) been impacted in the process of recovery? It is anticipated that results from this study will not only fill a gap in the literature, but also inform clinicians and researchers about addiction recovery in the couple relationship and provide information for future directions for treatment and recovery. Operational Definitions In this dissertation, the terms alcoholic and addict were used as synonymous terms. Alcoholics are addicted to alcohol. The term addict includes abuse of all other chemicals. In the literature review authors may have varied references to describe a person struggling in addiction, which include the terms alcoholic, substance abuser, chemically dependent, substance dependent, or addict. It is important to note that triangulation was discussed in two ways in this study. First, as a portion of Bowen Theory, in which a person/thing may be brought into the couple relationship to deflate anxiety (triangulation). It typically serves in many cases as a dysfunctional problem. Alcohol may also be considered as a triangle in the relationship (Bowen, 1974). Triangulation is also used in the methods and procedures of qualitative inquiry (Creswell, 2007). This triangulation entails analyzing the results (in this case the interview answers) by comparing it to any current research and theory (in this case Bowen Theory and any study on recovery or couple therapy). In terms of recovery and substance abuse/addiction, Gagne et al. (2007) discuss that there is no specific definition of recovery. In this study, recovery will be interpreted 9
through the social construction of reality theory (Berger & Luckman, 1966). The core of social constructionism is based on how the individual, or in this case, the couple views their own reality of what recovery is in this study. The operational definitions were used in selecting or limiting a couple’s participation in the study. Once initial contact was established, each were screened to determine that the pairs met the following criteria: Recovering alcoholic/addict: Any person considered by oneself or by a professional as having a dependency or substance abuse problem or diagnosis. Recovering was defined as having one or more years clean from any mindaltering substances (see Disease Concept Controversy). Recovering Partner: During the active addiction phase, the individuals needed to have known the recovering alcoholic/prior to sobriety. The partners in this study may or may not fit the idea of codependency. He or she may or may not have considered one’s self as co-dependent. The recovering partner may or may not have abused substances. Support Groups: The addict and/or partner sought self-help support from addiction. The support may include but not be limited to the following: Alcoholics Anonymous, Al-Anon, Narcotics Anonymous, Cocaine Anonymous, or Recovering Couples Anonymous. Treatment: The addict sought a form of individual treatment that included residential, non-intensive outpatient, intensive outpatient, counseling, therapy, or pastoral counseling at any time during the recovery process. The couple may or may not have had some type of couple treatment. 10
Limited Couples: Couples were not included when either partner had a current or within the last year active substance abuse or addiction problem. Neither partner was in any current formal treatment. No separated or divorced couples were included. Disease Concept Controversy Historically, there are three principles that have influenced addiction: the immoral or sin based—choice in behavior; addiction as a disease—illness; and addiction as maladaptive behavior—no right or wrong in morality (Thombs, 2006). The immoral conduct is based on person’s belief system or moral conduct. Drinking heavily and using a drug is wrong, so punishment is logical in treating the problem. There are three disadvantages to immoral conduct: (a) science indicates a variety of influences to the etiology of addiction (b) it is unclear that addiction was something chosen (c) history suggests that punishment is ineffective (Thombs, 2006). Addiction as a disease involves the idea that the extreme consumption of alcohol or drugs illuminates symptoms of an illness. The individual is not conflicted, evil, or irresponsible, just ill. Disadvantages of this perception are stated by Thombs (2006, p. 8), “Briefly, several of the key concepts of the disease models have not held up under scientific scrutiny. For example, the loss-ofcontrol hypothesis, the supposedly progressive course of alcoholism, and the belief that a return to controlled drinking is impossible are all propositions that have been seriously challenged by scientific investigations.” He also states that the treatment community is either unaware or chooses to ignore that the disease concepts have not been supported by research. The final position is that addiction is a maladaptive behavior—a learned, behavioral disorder. Morality has nothing to do with addiction. Addiction is not out of 11
control. Simply, the person struggling with addiction is a victim of “destructive learning conditions.” No one judges the individual and interventions are based on changing behaviors and learning the new behaviors to create overall change. A disadvantage discussed was that interventions are evaluation focused and labor intensive (Thombs, 2006). These controversial principles of addiction just discussed will not be further explored here since any such study could be an entirely separate dissertation (Clark, 1975; Flavin & Morse, 1991). These controversies will occasionally come up in treatment groups from the clients or partners. Agencies may adapt to a variety of tools in assisting the client to better understand that substance abuse as a disease. If it is a disease, it is therefore treatable. For the sake of less complication, this researcher assumes the disease concept and use of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) (2000) diagnoses of substances dependencies and abuses. There are 11 classes of substances in which the manual includes as follows: “alcohol; amphetamine or similarly acting sympathomimetics; caffeine; cannabis; cocaine; hallucinogens; inhalants; nicotine; opioids; phencyclidine (PCP) or similarly acting arylcyclohexylamines; and sedatives, hypnotics, or anxiolytics” (American Psychiatric Association (APA), 2000, p.191). In diagnosing a person with substance dependence, he must have three out of the seven criteria within a 12-month period which include: tolerance; withdrawal; inability to control use; unsuccessful in cutting down or quitting use; significant amount of time spent in obtaining, using and recovering from effects of the substance; given up important work, social, or recreational activities; and continues despite having a physical or 12
psychological problem worsened or caused by the substance use (APA, 2000 see Appendix A). If someone does not meet the criteria for substance dependence, then the criteria for substance abuse would be considered. For a substance abuse diagnosis, one out of the four criteria need to be met within a 12-month period which include: recurrent use of a substance results in failure to fulfill obligations at work, school, or home; recurrent substance use in situations that are physically hazardous; recurrent substancerelated legal problems; and continued substance use despite continued social or interpersonal problems caused or made worse by use. (APA, 2000 see Appendix A). Bowen (1974) in his work with families and alcoholism did not mention the disease controversy. He simply focused on the family interactions and how they fed into the continued drinking (see Alcoholism Theoretical Foundations). The addiction field tends to accept both the disease concept and the familial interactions approach (Thombs, 2006). In working with the couples in this research, my view also encompassed both. Parameters of the Study The participants in this study were couples in the Northeastern Ohio area that fit the operational definitions of the study. The couples may not be a representative group in generalizing across populations due to the size of the sample. The couples were selected through area self-help support group organizations and individuals in recovery. Chapter Summary The primary focus of this chapter oriented the reader to addiction concepts observed in this study. The problem highlighted the need to better understand recovery in the couple relationship. A range of literature noted research has focused on behavioral couple’s therapy, some aspects of Bowen theory, but minimal on the couple’s perspective 13
to recovery. The literature reviewed indicated that couples have not been given a voice in recovery, self-help support groups, or how recovery has impacted connectedness in their relationships. Little is known about the influence of recovery practices on the couple relationship, their connectedness, distancing, triangulation of others into the relationship. This research has provided a voice for them to tell their own stories. This qualitative phenomenology offered the couple that voice together in the shared experience of their recovery story. Information gleaned from this research may help researchers and clinicians in adding to recovery research from a relational perspective. This research was intended to promote additional quantitative and qualitative studies on the recovering couple.
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CHAPTER II LITERATURE REVIEW There has been limited research on recovery and couples. The approach of treatment and recovery has primarily been on the alcoholic/addict (Jellinek, 1946; 1960). Treat the disease, remain abstinent from all substances, then problem behaviors and symptoms will dissipate. Some early alcoholism/addiction studies focused on the impact of the family and identifying role dysfunctions (Satir, 1972; Bowen, 1974). Others of these studies focused on the partner and family problems of co-dependency (Subby & Friel, 1984; Koffinke, 1991; Lawson & Lawson, 1998), family rules (Barnard, 1981), family of origin (Framo, 1976; Fogarty, 1976), and family roles (Satir, 1972; Deutsch, 1982). It has been only over the last decade that researchers have begun to focus recovery from addiction with their partners in behavioral couple’s therapy (O’Farrell , Hooley, Fals-Stewart, & Cutter, 1998; Fals-Stewart et al., 2005; Birchler, Doumas, & Fals-Stewart, 1999). As this dissertation relates to understanding the experience of addiction recovery with focus on self-help support groups and individual treatment with the individual and his/her partner, the following literature review explored those studies and theories related to this population. Other aspects of therapy were included since recovery can be best understood as only a part of the context of the treatment practices in addiction/alcoholism recovery.
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This review of the literature prefaces investigating the phenomenon of couple addiction/alcoholism recovery. Several themes were explored in this literature review so that the research into addiction/alcoholism and couple recovery could be better understood. Principal research studies were discussed, reviewed, and critiqued. The foundations explored here included: (a) family and addiction; systems theory; Bowen’s theoretical concepts, and alcoholism theoretical foundations (b) differentiation of self research (c) recovery (d) the impact of addiction on relationships; codependency; role of partner in addiction (e) treatment modalities; self-help support groups; family treatment models reviewed; couples therapy (f) impact of therapies on relationship and partner; partner included in treatment process. Family and Addiction There were several nuances to consider about addiction impact on the family. Systems Theory, Bowen Theoretical Concepts, and Alcoholism Theoretical Foundations were outlined in this segment. The theory involved in this section created the lens of viewing couples in recovery for this research project. Systems Theory Systems theory evolved from the intellectual traditions of the organic and evolutionary perspective of Herbert Spencer (1880) and influences of the information processing of data from inventions of telecommunications such as the telegraph, telephone, and other technologies during World War II. Norbert Wiener in 1948 published cybernetics and control systems to explain the systems approach (White & Klein, 2002). This paved the way into viewing humanity and its environment in much the same way—the system is a whole of all of its parts. According to White & Klein (2002, 16
p. 124), the assumptions of systems theory include the following: (a) system elements are interconnected, (b) systems can only be understood as wholes, (c) all systems affect themselves through environmental feedback, and (d) systems are not reality, rather a way of knowing. In the 1960s family therapists introduced this concept of systems to family therapy. The systems approach with treatment emphasized continual patterns of interactions between clients and close family members. Rather than working with the family, based on causality of the problems, the present and observable behavior and interactions became the focus (White & Klein, 2002). General systems theory later evolved into the family systems theory, which highlighted relational patterns within families (Bowen, 1974). Bowen’s hypothesis was that the family system interacts and reacts with each individual in the system. He described this family system in comparison to the human body and its organs. This system, automatic in response, controls the environment. He explained that the healthy organ functions among other organs very smoothly, even compensating and increasing functions for an organ that is not running as healthily or as smoothly as it should. The body may go through various states of dysfunction from mild to more severe illness depending on the levels of functioning in the organs. Whatever the case, an organ that over-functions for another over a long period of time is not easily returned to normal. Applying this analogy to the family system the result is similar. As one member exhibits dysfunctional behavior, the others overcompensate to make up for that member’s lack of involvement in family dynamics or tasks. Bowenian concepts are compatible with how the family interacts when alcoholism is involved (Bowen, 1974).
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Bowen’s Theoretical Concepts In 1966 Bowen wrote in a seminal article, his interconnecting concepts of his Transgenerational Theory. They are as follows: differentiation of self, triangulation, nuclear family emotional process, family projection process, multigenerational transmission process, and sibling position (Bowen, 1966). He later added emotional cutoff, and societal emotional process (Bowen, 1976; Bowen, 1978). There were three examined in this study—differentiation of self, since it is the foundation, triangulation, and cutoff or distancing, since there are limited studies with these two other concepts. Differentiation of self is the foundation for all the other concepts. It is one’s ability to think, reflect, and process a response, not just react to emotional pressures or interaction with a family member (Bowen, 1978; Kerr & Bowen, 1988). The degree of anxiety combined with the degree of integration within the self is a key to understanding differentiation. Even when anxious, one is capable of being wise in decisions. People who are differentiated are balanced in how they think and feel. They are able to take a definite stand on how they think, what they believe, and any actions that follow. They are able to balance a connection with family of origin and nuclear family. Undifferentiated self demonstrates lack of control in one’s emotions, driven in reaction to the people around them. They exhibit submissiveness or defiance. They struggle with their own independence or autonomy, more likely to have emotional or intellectual fusion. This means they will describe what they think with how they feel mimicking what they have heard from others. They either agree with everything or argue with everything. Emotional distancing or fusion with family of origin will be evidenced or observed in those lacking in differentiation (Bowen, 1966; Bowen, 1978). 18
The evidence of the lack of differentiation works in this way with families where alcoholism or addiction is active. Each member would play some part in the interactions with each other around the symptoms of addiction. When anxiety is high, each member would anxiously take a part in a role causing a pattern that repeats consistently (Bowen, 1974). Codependency would be an example of family member’s reaction to the active substance user. Raganathan (2004) described several codependent traits, which assist in describing the lack in differentiation. The author discussed how family members attempt to control the addicted person for which they have no power and lose control over their own behavior for which their own lives mimic the addict’s unmanageability. Other codependent traits include loss of daily structure, personal care neglect, physical problems (often caused from high anxiety), blaming others, and overall involvement in unproductive activities (Ranganathan, 2004) like consistently calling the cell phone of the substance abuser to see where s/he is and what s/he is doing. Emotional triangles evolve from the pressure of anxiety. If two people have unresolved issues with elevated anxiety, rather than consistently arguing, one or both may seek input from another person or object at an attempt to decrease anxiety. This third person/object becomes triangulated into the couple relationship. A temporary triangle will push the two to resolve their issues such as an advising friend or counselor, whereas a consistent triangulated individual may create a fixed pattern. The fixed pattern of triangulating a person/object would displace the anxiety from the couple relationship diffusing it to the third party/object. Alcohol or substance use could be that third object in the relationship. The goal for the couple is to decrease the anxiety. When anxiety becomes too great, a person outside the family may be triangulated in. Another form of a 19
triangle can occur if the other in some way is not meeting the partner’s needs. For example, if a husband decides to work late at the office regularly, a wife might pour more time and energy into one of the children, creating a triangle (Bowen, 1966; Bowen, 1978). Nichols and Schwartz stated, “Triangulation lets off steam but freezes conflict in place. It isn’t so much that complaining or seeking solace is wrong, but rather that triangles become chronic diversions that undermine relationships” (Nichols & Schwartz, 2004, p. 122). Triangulation may play out in many ways with family members struggling with either addiction or any other dysfunction. Satir (1972) describes “universal patterns of response people use” in communication patterns produced in troubled families. The placater tries to please, apologizes, never disagrees, and feels little value of self (martyrlike). The blamer finds fault, dictates and acts superior. He too feels little value of self, but acts out by using power or bullying. The computer is never wrong, reasonable calm, cool, and collected. Feelings are checked. Voice is monotone. The distracter depends on irrelevant words and actions to whatever is going on in a situation often ignoring what is happening. Lastly, survival roles adopted into the addiction field are the chief enabler, the family hero, the scapegoat, the lost child, and the mascot (Deutsch, 1982). These roles also provide a structure enacting triangulation. Deutsch discusses the chemically dependent person, the chief enabler (typically the partner), the family hero (one of the children—a parentified role), the scapegoat (the negative attention), the lost child (invisible), and the mascot (the clown). Many of these roles involve triangulation as obvious (overt) or less obvious (covert) interactions within the family dynamics. The 20
alcoholic coming home intoxicated will over-exaggerate (by yelling and creating a scene) the scapegoat’s acting out behavior (skipping a class at school) in order to take the attention off the fact that mom or dad has come home drunk again. The family hero might try to win the alcoholic’s attention by becoming the “perfect” child (getting his attention to show yet another A on a school project). The partner of the alcoholic may develop a relationship with one of the children as a confidante (divulging too much information to the child or giving the child equal power to the parent). The children may not understand these roles as they are often an expectation by the parents or themselves. Each assumes the role and can stay in it most, if not all, of their lives if no help is sought. Emotional cutoff is the way families manage differentiation generationally. It becomes the way the individual might manage anxiety and unresolved emotional issues with parents. If fusion is greater between parents and children, then there is greater chance of emotional cutoff, moving away, or avoiding personal conversations. Some will believe their cutoff is a sign of maturity. Evidence of emotional cutoff may also be exhibited through avoiding discussion of highly sensitive issues (Bowen, 1978). An example of emotional cutoff that might be observed in the alcoholic family would be the scapegoat role earlier mentioned. Once the scapegoat reaches the age of 18, he will likely find some way of “escape” from the family. He may find himself moving into his own place or a friend’s house. He may, because of continued negative acting out, have an unexpected pregnancy or incarceration. Although these behaviors have consequences to the entire family, the member that practices emotional cutoff or distancing will not seek help from the family of origin seeking one’s own way.
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Alcoholism Theoretical Foundations As earlier mentioned, Murray Bowen is one of the founders that paved the way for utilizing family systems theory and systems therapy to conceptualize and treat alcoholism within the family setting. He described the applied theory in his 1974 seminal article discussing the functioning of each of the family members as they react emotionally to their own anxiety of living with an alcoholic stated “Systems theory assumes that all important people in the family unit play a part in the way family members function in relation to each other and in the way the symptom finally erupts. The part that each person plays comes about by each ‘being himself.’ [sic] The symptom of excessive drinking occurs when family anxiety is high. The appearance of the symptom stirs even higher anxiety in those dependent on the one who drinks. The higher the anxiety, the more the other family members react by anxiously doing more of what they are already doing. The process of drinking can become a chronic pattern.” (Bowen, 1974, p. 115) In comparing the family system to the human organ system, Bowen developed terms to guide the research. He hypothesized that when the function of a bodily organ became dysfunctional, other organs worked harder to compensate for the lacking functions. He suggested it was similar with the family member of an alcoholic. Members work to compensate for the lack, but the dysfunctional organ does not get better and the other organs are weakened because of the compensation. Furthermore, he stated, “How does alcoholism fit into systems concepts? From a systems viewpoint, alcoholism is one of the common human dysfunctions. As a dysfunction, it exists in the context of an imbalance in functioning in the total family system. From a theoretical viewpoint, every important family member plays a part in the dysfunction of the dysfunctional member” (Bowen, 1974, p. 117).
Every family member plays a role in the dysfunction. Conceptually, he discussed the importance of the degree of differentiation of self. Differentiation of self is the degree that the person has a grounded sense of self—others having less influence on his values,
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principles, or decisions. This degree of differentiation of self is based on the type of relationship the person has with his/her parents, the level of differentiation his/her parents experienced, and how he handles any “unresolved attachment” with his/her parents during the young adulthood stage. For example, if there are periods of non-drinking or decreased crisis, symptoms are less likely to be produced in the family members. Symptoms and decreased flexibility will project into anxiety or increased tension. If there are a greater number of adaptive patterns, then dysfunction is greater. Finally, the more emotionally disconnected a nuclear family is from parental families, the greater the incidence of symptoms and problems (Bowen, 1974). Bowen summed it up with discussion of the clinical setting. He examined level of decreased functioning or impairment in the alcoholic. Rather than viewing this member in the intensity of alcoholism, he examined the level of differentiation of self, if higher the outcome of therapy would be improved. He also examined the level of anxiety. Family members most dependent on the alcoholic would show increased levels of anxiety. With this increased anxiety came an increased threat or fear, in turn, overcompensating. He stated, “The more the family is threatened, the more anxious they get, the more they become critical, the greater the emotional isolation, the more the alcoholic drinks, the higher the anxiety, the greater the criticism and emotional distance, the more the drinking, et cetera, in an emotional escalation that makes the problem worse and both sides more rigidly self-righteous. Anything that can interrupt the spiraling anxiety will be helpful” (Bowen, 1974, p.121).
He also wrote that just one family member willing to step out of the anxiously, overcompensating role can have a significant influence toward de-escalating the anxiety. Bowen described working toward increasing the emotional connectedness among a
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couple, which in turn would assist in stopping the drinking. Over-functioning is another important interaction that he stressed. He explained that it was easier to engage an overfunctioning partner to do less than it was to get the under-functioning partner to do more. Lastly, on an outcome level, when both partners were willing, eager, and engaged they did better than when just one partner in the couple system engaged in the process, which indicated the importance of conjoint therapy rather than individual therapy (Bowen, 1974). Bowen’s ultimate goal in his family therapy work was to help each of the family members reach a higher level of differentiation of self. He explained, The basic effort of this therapeutic system is to help individual family members toward a higher level of differentiation of self. An emotional system operates with a delicately balanced equilibrium in which each devotes a certain amount of being and self to the welfare and well-being of the others. In a state of disequilibrium, the family system operates automatically to restore the former togetherness equilibrium, though this be at the expense of some. When an individual moves toward a higher level of differentiation of self, it disturbs the equilibrium and the togetherness forces oppose with vigor (Bowen, 1966, p. 367). These aspects of Bowen’s theory discussed above were examined with the sample of couples in this research. Differentiation of self, emotional distancing, and triangulation (adding another relationship for further dysfunction) were viewed through the lived experiences of the couples in the recovery process, specifically, the impact of self-help support groups, treatment options, and the experience of recovery. Bowen’s conceptualization of addiction indicated that through the addiction there is interaction with the couple system. Recovery also would maintain those interactions, supporting the need for this investigation—viewing recovery through the Bowenian lens.
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Differentiation of Self Some researchers have examined differentiation of self in individuals. McGuinness (1999) [see critique] examined adult children of alcoholics (ACAs) and their marital partners (sample size 101 couples) quantitatively using the variables of need fulfillment, differentiation of self, and interaction style. She hypothesized that the marital partner that had an alcoholic parent would have higher levels of unfulfilled needs, lower levels of differentiation of self, and would score higher on factors one and two of the dominance-accommodation scale than their partners, adult children of non-alcoholic parents (ACNAs). This author used a descriptive comparative design, with selfadministered questionnaires. The results of the study indicated no significance in the differences between the two groups. The results for interaction styles indicated lack of significant differences between ACAs and ACNAs on interaction and emotional need fulfillment. This did not support her hypothesis. She stated that this sample of marital partners might be examples of resilient adult children of alcoholics, perceiving their interaction and emotional needs as being met by their partner, rather than having unfulfilled needs as she hypothesized. Critique: McGuinness Differentiation of self results indicated no significant differences between ACAs and ACNAs. Her explanation was that the sample must have greater developmental maturity, capacity to learn and adapt, and strength from adversity. She reported that levels of differentiation was supported in Bowen’s Theory, “Moreover this lack of difference between ACAs and ACNAs in levels of differentiation provides additional support for Kerr and Bowen’s (1988) contention that levels of differentiation may vary 25
among children raised in a family with an alcoholic parent, as well as among alcoholics, and that individuals with higher levels of differentiation are better able to thoughtfully manage life’s problems and diseases that may arise” (McGuinness, 1999, p. 92). She also noted that individual psychotherapy and treatment might have impacted the levels of differentiation, which were better than she had anticipated. Those who achieved positives from the results seemed to maintain better levels of differentiation of self than was expected related to unanticipated factors of individual growth. Another of the findings indicated a lack of statistical significance between ACAs and ACNAs correlation between interaction and emotional needs and differentiation of self. Again, she provided an explanation of support for differentiation of self theory— partners at similar levels mirroring similar satisfaction, which concluded that her sample had both ACAs and ACNAs at similar levels of differentiation. One final result indicated no significant differences between dominance and accommodation until viewing gender. Wives in this sample, who were highly educated, were more dominant and less accommodating than their husbands in interaction style. This could have been an indication of a sample not easily generalized, according to McGuinness (1999). Although the hypotheses did not have support from the findings, McGuinness’ study did support the Bowenian concept of differentiation of self, through her study of the couple relationship by their similarities. She had anticipated that the ACAs and ACNAs would be different, but Bowen indicated that couples would be attracted to each other because of similar levels of differentiation. She viewed couples whose parents were alcoholic. Although the study supported aspects of differentiation of self, it did not discuss recovery or any use of support groups that may have been a part of the lack of 26
significant differences throughout the data. She did however consider that individual treatment might have confounded the data to some degree. The data was also a quantitative study, which may not get to the depth of the qualitative analysis. Her hypotheses also focus on one aspect of the theory lacking analysis of treatment and selfhelp support groups. Another researcher, Hobby (2004) [see critique] studied a quantitative comparison of adult daughters of alcoholic fathers (ADAs) and adult daughters of nonalcoholic fathers (non-ADAs). She examined the transmission of relationship behaviors from fathers and daughters to those daughters within their own marital/couple relationship— Bowen’s concepts of differentiation of self. There were 101 female participants who were in a committed relationship for at least one year and who had lived with their father for at least 10 years during childhood. She used the California Inventory for Family Assessment (CIFA), which assesses behaviors in the following three theoretical domains: closeness-care-giving, openness of communication, and intrusiveness. Hobby stated, “In this study, consistent with Bowen theory, higher levels of closeness-caregiving and openness of communication, and lower levels of intrusiveness, were interpreted as signs of greater differentiation of self” (Hobby, 2004, p.2). Critique: Hobby The results of this study indicated that “ADAs (adult daughters of alcoholic fathers) experienced less warmth, time together, nurturance, consistency, openness/selfdisclosure, and more anger-aggression and conflict-avoidance from their fathers than did non-ADAs.” In the ADA group there were higher rates of alcoholism/problem drinking, higher rates of violence, financial crisis, and sexual abuse as compared to non-ADAs. 27
There were no significant differences between the two groups (alcoholic vs. nonalcoholic fathers) in terms of separation anxiety, possessiveness/jealousy, emotional inter-reactivity, projective mystification, and authority/dominance, which contradicted prior research. Lastly, results of this study did not show significant differences in ADAs and nonADAs in their behaviors toward their partner. Consistent with Bowenian theory correlational findings did indicate moderate “associations between differentiation of one’s father (in terms of father’s behavior toward daughter during childhood) and differentiation of self (in terms of daughter’s behavior toward her partner/spouse currently)” (Hobby, 2004, p.3). However, overall findings indicated a more positive outcome than Bowen’s theory of differentiation suggested. The positive outcome was that ADA’s relationship with their father did not indefinitely determine the quality of a future committed relationship with a partner. The degree of intergenerational transmission was also not as great of a degree as the Bowen theory implied, according to Hobby (2004, p. 36). She reported, “the findings of this study partially contradicted Bowen’s theories and instead suggested that an individual can have a differentiated self in some relationships but not in other relationships, which also appeared to be an encouraging conclusion for adult children of alcoholics” (Hobby, 2004, p. 36-37). The limitations of Hobby’s study supported directions for future research. The author pointed out that sampling broader demographics would be useful, since it was limited to the female heterosexual population ages 20-50 in a current committed relationship residing in the United States. The sample also included 70% white and 30% non-white participants, which may not have been a good representation to the general 28
population of women. There was also a limitation to the sample size in general, which the author did not mention. A sample size of a total of 101 participants was considerably small for a quantitative study. Also, this study only observed at participants whose fathers were alcoholics. The dynamics may show a difference if either the mother or both parents were alcoholics. Another limitation of Hobby’s study was that she examined the couple’s relationship in regards to differentiation of self, but more in the intergeneration transmission (the pressure on the relationship from one generation to the next). She did not examine triangulation or emotional cutoff aspects of the theory. She also did not view the influence of various forms of support group and treatment to the current couple relationship and descriptions of levels of differentiation of self with overall recovery in the couple relationship. One study examined alcoholic and non-alcoholic couples. Prest (1991) [see critique] studied in a quantitative and qualitative comparison of the alcoholic and nonalcoholic couples in family of origin, dyadic relationship, and the level of codependence. The level of codependence was measured through the use of Bowen’s aspects of family of origin and differentiation of self theory. He had two phases in the study, Phase I and II, quantitative and qualitative, respectively. The two comparison groups of 60 subjects per group each contained 30 couples (120 subjects), white, heterosexual, and married age 3050. Critique: Prest Results in Phase I supported Bowen’s theory of partnering with those people similar to themselves in interpersonal functioning and differentiation of self. However, some findings were exceptions between the two groups. The first was the perception of 29
husbands in the comparison group. They scored higher on perception of triangulation in family of origin, which contradicted Bowen’s theory. Wives’ codependency scores were also significantly higher scores than husbands in the comparison group, not in the alcoholic group. He contended that feminist theory of pathology of women might have been a repercussion of the significance between groups. However, since the findings did not show up in the clinical group also, he stated, “Codependence may be ‘fostered’ by differing factors in the two populations; social gendering and spousal relationship roles and dynamics in the former, family of origin dysfunction in the latter” (Prest, 1991, p. 195). In other words, other factors may foster codependency besides addiction. Finally, for Phase I, the study indicated that there were some significant differences between the two groups, mostly in family of origin and codependency. The alcoholic group indicated significantly higher levels of intergenerational intimidation, lower levels of intergenerational intimacy and individuation, lower levels of spousal intimacy, spousal individuation, personal authority, and higher levels of nuclear family triangulation (Prest, 1991). The Phase II of the study examined a smaller sample of nine couples from the original 60 in which he completed qualitative semi-structured interviews (three groups of three). These nine couples reported varying levels of codependence a high, low, or difference as termed by Prest. The low group was low in spousal codependency scores; the high group was high in spousal codependency scores; and the difference group was differing in codependency scores. He reported that the low group (low codependency) described more positive family of origin experiences such as strong, communicative, supportive relationship with parent. They also discussed values and ideals. In the high 30
group, the family of origin experiences was described by alcoholism, divorce, family disruption, and difficulty managing anxiety. The difference group described a combination of the other two group’s stories indicating the mixed levels of codependency within the couple relationship. Overall implications discussed by Prest (1991) indicated that his research helped to bring a better understanding of codependency in the relationship context. He wrote that his study could be used to explain codependence, addictive/compulsive behaviors, and interactional patterns. He also explained that codependency is connected to the family of origin context and the emotional systems supporting Transgenerational Theory. Although, this study did not specifically measure differentiation of self, but utilized codependency as a factor in examining alcoholic couples, his research supported aspects of Bowen’s Family Systems Theory in family of origin and differentiation of self context. His mixed methods approach supported the need to further understand this theory with alcoholic couples in recovery and implications for future research and treatment. Recovery Recovery has been a term used in both the mental health and addictions fields. The following study analyzes the meaning of recovery in both the fields of mental health and addiction in a review (Gagne, White, & Anthony, 2007) [see critique]. The review highlighted mental health research, longitudinal outcome studies. The overview of the outcome therapy indicated that people with mental health illnesses were improving over time. According to Gagne et al. (2007), many policies and practices of recovery have moved through state mental health systems even though there is no set definition of 31
recovery. In the addiction field, Gagne et al. (2007) described recovery as change transformation in the addict. These researchers discovered a movement in addiction studies to better define recovery along with a better way to connect the recovery process to family. Overall findings from the mental health field indicated that the mental health system is working toward including community support services to help enhance recovery for the person suffering mental illness. The addiction field has little in on-going community support. Both the mental health and addiction fields need to work at helping individuals to have “on-going recovery support services” (Gagne et al., 2007). The recommendation included in this research was that professionals, family members, and peers provide support. Finally, the authors discussed implications for future directions of the “recovery vision” that included directions of research to shift from a pathology focus to long-term processes of recovery. Also, that mental health and addiction fields must work at blending their efforts to have more significance in services, strategies, and supports (Gagne et al., 2007). Critique: Gagne, White, and Anthony Recovery was not defined in this study. The article grasped the concept that recovery is perhaps more a process than an end-point. Maybe this could be the reason for so many viewpoints of recovery. Defining recovery, perhaps, is more conducive to the individual and/or couple from their own reality, the social construction of reality (Berger & Luckman, 1966). Gagne and colleagues (2007) did not discuss couple recovery, which supports the efforts for better understanding recovery in the relational perspective.
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Petroni and researchers (2003) [see critique] examined the recovery periods of couples for an understanding of the similarities and differences between alcoholics and co-alcoholics (partners of alcoholics) over three recovery periods. The purpose of the study examined the data in alcoholism long-term recovery. The study was a secondary analysis of the data collected from the Family Recovery Project (FRP) at the Mental Research Institute in Palo Alto, California. The authors stated that “the purpose of the study was to contribute empirical data to the current fund of knowledge in the area of long-term recovery, via the Koss-Butcher (K-B) and Lachar-Wrobel (L-W) Critical Item (CI) sets from the Minnesota Multiphasic Personality Inventory 2 (MMPI-2)” (Petroni et al., 2003, p.42). The independent variables they controlled for were gender, relationship to alcohol (user of it or not), and time period in recovery. They compared recovery periods from zero to five years (Recovery Period 1), five to ten years (Recovery Period 2), and ten plus years (Recovery Period 3) examining male vs. female alcoholics, male vs. female co-alcoholics, male alcoholics vs. male co-alcoholics, female alcoholics vs. female co-alcoholics, and male co-alcoholics vs. female co-alcoholics. For each variable, results were analyzed. Recovery Period 1: Male vs. Female Alcoholics indicated one difference in CI, males tended toward more deviant behavior, specifically paranoid ideation. For Male vs. Female Co-Alcoholics did not significantly differ in CIs in any category. In comparing the Male Alcoholics vs. Male Co-Alcoholics, Male Alcoholics indicated more CIs than Co-Alcoholics on Situational Stress. Substance Abuse items did not indicate differences between the either from the items or the increased denial from both groups. Mental Conflict items were higher for the male alcoholics in concentrating, focus on task, and 33
details. In comparing Female Alcoholics to Female Co- Alcoholics, female alcoholics indicated higher CIs on Anxiety and Tension. Co-Alcoholics were higher on the Family Conflict items. In the subsequent periods 2 and 3 some of the results indicated more similarities for male and female alcoholics and co-alcoholics. Eventually leading to the idea overall that as recovery progresses, the experience for all involved becomes more similar (Petroni et al., 2003). Critique: Petroni, Allyn-Byrd, and Lewis In critiquing this study, this article presented a challenge in extracting information. The article totaled 15 pages, which 10 of those pages totaled more than 60% of the article in detailed results. It would have been helpful if there were tables showing any trends or comparisons and more than a paragraph for implications and conclusions respectively. That being said, there have been so few articles on couples and recovery, this article did indicate change in the individuals over time toward becoming more alike in recovery. What it did not do was delve into the lived-experiences of couples and recovery. Another researcher, Martin (1999) examined six couples in a qualitative and narrative study that had experienced aspects of recovery from addiction. She examined the “processes of relational healing in couples with one partner recovering from alcoholism or other psychoactive substance dependence.” She discovered key words of recovery that couples commonly used among themselves including fear, love, work, honesty, synonyms for gratitude, loss of control, and detachment. Other similar language included that of twelve-step programs and spirituality.
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Implications for further research included comparing such couples with other nonrecovering couples or utilizing a different sample of recovering couples. Martin’s (1999) research established an in-depth examination of recovering couples literature and theory, but did not seem to reach the depths in the conclusions expected from the participants’ stories. However, the stories she shared of relational healing revealed key terminology among couples experiencing recovery. Lastly, the author did not utilize Bowenian lens in observing couple relationships. Impact of Addiction on Relationship There are some areas researchers have discussed concerning the impact of addiction on the couple relationship. This section outlines two basic areas researched concerning that impact. Co-dependency and the role of partners in addiction were highlighted. Co-dependency Families operate daily to keep a sense of balance in relationships. When there is a family dealing with some type of a crisis, such as alcoholism/addiction, the members still attempt to work at that balance. Usually, the tools families use to maintain balances are survival (i.e. Blamer Satir, 1972; i.e. Family hero Deutsh, 1982), which they learned in their families of origin (Bowen, 1966; 1978). According to Bowen theory the overall functioning of codependent family members would be described as lacking differentiation of self. Differentiation of self could be translated into common terms used in the addictions recovery field known as enabling and codependency. Ranganathan (2004) discussed future challenges to families and alcoholism in his article based on review of prior research. He described that in the transitioning family 35
there are more women working, a greater number of dual income parents, and an increase in the number of alcoholics, having greater repercussions on the family. Concerns of codependency and enabling supported his suggestion that individual-oriented addictions treatment should shift to family-oriented treatment. He reviewed how each of these behaviors became an innate part of the survival tools the family uses to keep the family together, which in turn family members often suffer with stress-related illness. One author delved into specific characteristics of the codependent, which are highlighted as follows: caretaking, low self-worth, repression, obsession, controlling, denial, dependency, poor communication, weak boundaries, lack of trust, anger, sex problems, and progression. The progressive characteristic of codependency may involve feelings of depression or lethargy, isolation, loss of routine, hopelessness, thoughts of suicide, become addicted, or violent (Beattie, 1987). The information she developed is utilized in the literature for those seeking self-help. In critique, she does apprise that the information comes from the many years of experience in the field with little empirical support. Role of Partner in Addiction Goldberg (1985) developed four dynamics of alcoholism/addiction while working in over 130 cases of alcoholism/addiction and 68 couples focusing treatment on addiction. The author reported that in every case of working with couples and alcoholism that every spouse in some way contributed to the substance abuse. The author discovered that the alcoholic and spouse participated in four dynamics. The first dynamic described was called shared addiction. This dynamic emphasized the need for clinicians to assess the spouse for substance abuse because of the high rate of partners also using substances. 36
If one partner is in treatment while the other is drinking, then this could sway the recovery of the partner. The second dynamic exposed was quid pro quo. This is the even exchange of one thing for something else. This idea explained that it is like a covert (unspoken rule) pact a couple makes in the process of the relationship. While one spouse distances, the other presents as the alcoholic or the workaholic. Both partners quietly agree in order to avoid conflict and intimate contact. The third dynamic was caretaking. This occurs when the non-alcoholic partner receives rewards or advantages, which may have included feelings of power and worth, from taking care of the sick partner. This may or may not have occurred at a conscious level. The last dynamic was sado-masochism. The partner of the alcoholic would allow aggressive, violent, and abusive behavior. Ultimately, the partner would end up staying in the relationship blaming the violence on the disease of addiction. He would not be that way if he did not drink so much, would be the rationalization. The dynamics described by Goldberg (1985) indicate how the partner of an alcoholic/addict can be misguided by addiction. His work with couples shows the intricate link of behaviors in couple relationships and the need in working with the couple through the treatment process for greater success. His research, however, did not indicate the dynamic relational influence in the recovery process; supporting the need for further understanding recovery from addiction in the couple relationship. Treatment Modalities Treatment available for substance abuse/addiction is typically varied within facilities, which include non-intensive outpatient groups, intensive outpatient groups, residential groups, individual sessions, and family/couple treatment as adjunct to the 37
other treatments. Research in this section includes group and individual therapy, self-help support groups (not considered to be formal treatment), family treatment models, and couples therapy. Group and Individual Therapy Many treatment programs view alcohol and addiction recovery from the behavioral aspect of addiction treatment through the Transtheoretical Model stages-ofchange model, a behavioral approach, developed by Prochaska and DiClemente (1982, 1983, & 1986) and Prochaska, Norcross, and DiClemente (1994). The individual evolves through a series of stages: (1) precontemplation, in which the individual is not considering change at all; (2) contemplation, in which the individual is considering changes in behavior; (3) preparation, in which the individual makes plans to take action; (4) action, in which the individual changes the behavior and begins to become stable in changes; (5) maintenance, in which the individual remains stable in the changes made for several months; (6) termination or recycle (relapse), in which the individual remains abstinent from chemicals or relapses, needing to begin the stages over. The stages of change allow the individual to view where he is at from an objective view. It also provides hope in the event that there is a relapse with another starting point. Often the stages can be utilized in both group and individual therapies. Finally, O’Farrell and FalsStewart (1999) also applied the assumptions of the stages of change model in working with couples and families in behavioral family/couples therapy. There have been some studies of group therapy that focused on the codependent. One study examined the importance of the relationship aspect of recovery, which was entitled Symptom Reduction and Enhancement of Psychosocial Functioning Utilizing a 38
Relational Group Treatment Program for Dependent/Codependent Population (Byrne, Edmundson, & Rankin, 2005) [see critique]. These researchers investigated a therapeutic group of 52 subjects with the treatment process focus on past and present relationships. As stated, “The purpose of this project was to examine whether a closed-ended treatment group focusing primarily on past and current significant relationships (i.e., patterns of relating) would significantly reduce psychiatric symptoms associated with anxiety and depressive disorders as well as improve perceptions of self-efficacy and interpersonal patterns of relating” (Byrne et al., 2005, p. 71). The hypothesis was that clients would report those symptoms of anxiety and depression as significantly decreased as well as a report of improved interpersonal efficacy in relationships maintaining these characteristics at a six-month follow up. Critique: Byrne, Edmondson, and Rankin Findings in the study supported their hypothesis. The findings indicated that past and current relationships being the focus in group therapy decreased the symptoms of anxiety and depression while also enhancing a sense of interpersonal efficacy in relationships. Also, this treatment was maintained at the six-month follow up. Byrne et al. (2005) also analyzed the aspects of the group therapy that were helpful which included the following: the structure and content were significant; characteristics of group process (imitative learning, universality); and specific skill building curriculum (family of origin and patterns of relating). Overall, this study supported the way people can change and grow in a psychotherapeutic group along with the importance of focusing on relationships:
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“Groups place primary emphasis on establishing and developing the group’s identity and intermember relationships while at the same time focusing attention on individual growth. It is this balance between experiences with community and attention to self-change that provides an amplified and distinctive learning field. The group experience allows members to access the thinking of a number of people promoting collaborative knowledge. Interpersonal learning available through group process provides corrective emotional experiences and the opportunity to identify aspects of self in others” (Byrne, et al., 2005, p.82). One critique is that although one focus of the study is relational, only the individual is reporting the need, not the partners together, supporting the need to have both partners heard in the recovery process. Self-Help Support Groups There have been few studies examining support groups and their influence on the family or couple relationships. In this section there will be studies highlighted about AA and Al-Anon. This first study examined couples and support groups in a clinical trial. McCrady, Epstein, and Hirsch (1996) [see critique] studied AA-related behaviors during treatment. There were 90 couples randomly assigned to one of three treatments: 1) Alcohol-focused behavioral marital therapy (ABMT) (n=30), 2) ABMT plus AA/AlAnon (AA/ABMT) (n= 31), 3) ABMT plus relapse prevention (RP/ABMT) (n=29). The researchers delved into specific areas that related to implementing AA-involved treatment with the following key areas of measurement: compliance, use of skills taught during the treatment, and the nature and extent of involvement with AA during the active phase of treatment (p. 605). Uniquely, they wanted to view this with couples that participated in AA and Al-Anon. They also measured treatment attrition, number of treatment sessions attended, attendance to AA and Al-Anon, use of skills from AA and Al-Anon, compliance with homework, and drinking during treatment.
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Critique: McCrady, Epstein, and Hirsch Findings for this study indicated that the clinical trial study, first of all, could be used to study the effectiveness of AA. Next, standardized treatment utilizing both AA and Al-Anon as an aspect of treatment was also effective in spawning AA involvement. The researchers also found the AA/ABMT groups were more likely to attend more AA and Al-Anon meetings. Those most involved also reported prior attendance to the AA meetings before treatment began. However, among the therapeutic groups studied, there were not statistical differences among Al-Anon attending partners in regards to Al-Anonrelated skills. Those partners that were less compliant with condition-specific homework attended fewer Al-Anon meetings. The findings pointed toward little differential involvement in Al-Anon meetings suggesting that post treatment results could not be interpreted as effective for Al-Anon as an element of treatment (McCrady et al., 1996). Some limitations of the McCrady et al. (1996) study did little to portray the impact of AA on treatment. However, the researchers never made it clear as to why they were including the partners and their attendance to Al-Anon. The study may have been done without the partners first, then a later study done with the partners with explanation. The findings for the partners attendance to Al-Anon was found to be of little difference among the three groups, perhaps because researchers were not certain as to what they were examining by including the couples. Possibly, the partners participating in the study felt unsure of their own part in the treatment as well. This may have been reason for lack of participation in the condition-specific homework, indicating less compliance. Those partners may also have been expecting a different outcome with treatment, perhaps an outcome of a better relationship with their partner. These aspects were not discussed in 41
the findings or the limitations of the study. Perhaps this qualitative inquiry helped to bridge the gap in the literature by directly asking couples to share their experiences about the processes of recovery. Another study (Friedemann, 1996) [see critique] investigated those family members that attended Al-Anon and their perception of inner-city indigent substance abusers. The exploratory pilot study viewed the perceived family functioning from those members that attended Al-Anon compared to those who did not at three different intervals—beginning residential treatment, ending residential treatment, then one month later. There were 78 subjects in the final sample: 39 residents and 39 family members of which 36 attended Al-Anon (18 residents and 18 family members). The control group consisted of 42 subjects (21 residents and 21 family members). None of which were participating in formal treatment or Al-Anon. (Friedemann, 1996). Critique: Friedemann The results indicated that the two groups posited differences on family satisfaction scores. The Al-Anon group showed more satisfaction than the control group, which may have been a function of Al-Anon attendance and positive feedback in that group. The study highlighted a positive feature of supporting, as Friedemann put it, a “systemic view of the family and the proposition that if a positive change happens in a subsystem, such as new hope and a belief in one’s ability to manage one’s life and the family, it has the potential to affect interpersonal family system processes as well” (Friedemann, 1996, p. 133). Another area was the family perceptions of stability and growth. Stability was greater than growth. Finally, family perception of recovery tended
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to decrease in the follow-up, most likely because several of those in the residential treatment program relapsed, according to Friedemann. Although the study (Friedemann, 1996) did not focus on the couple relationship, it did view the family system and support group involvement on family members in the treatment and recovery of the loved one in treatment. There is a need for further research on the couple and how support groups influence their relationships. One area not studied in the support group studies on addiction and recovery is increase of emotional connectedness, triangulation, and differentiation of self since those groups are individually focused. Bowen (1974) described working toward improving differentiation of self-utilizing family/couple focus rather than the individual focus. Further research of the self-help group influence on recovery was needed in this area. Family Treatment Models Reviewed O’Farrell and Fals-Stewart (1999) reviewed three specific treatment models that have been developed over several decades: family disease model, family systems models, and behavioral models. This review was utilized in treating the family/couple with the addict to move them into the action stage of the stages of change. These authors believe that the family disease model comes out of the self-help support group Alcoholics Anonymous, which was founded in 1934. By 1949, the family organization called AlAnon was founded to provide support for family and friends of alcoholics. Black (1987) and Wegsheider (1981) specifically focused on the children raised in alcoholic families and the impact on their adult lives. Other authors have also examined the family symptoms that manifest within the family members (Beattie, 1987; Schaef, 1986). Positives from the family disease model 43
include understanding how codependency, enabling, and family role functions are also symptoms within themselves. A focus of this model was to treat the family members separately. Family members were provided psycho educational information and self-help group support. They were encouraged to focus on learning how to cope with living with a family member actively using/drinking rather than providing an intervention. O’Farrell and Fals-Stewart (1999) did not, however, mention that this approach may have spurned the idea that codependent and enabling family members may take much of the blame when provided this information. O’Farrell and Fals-Stewart (1999) described that the family systems models became a force in the 1970s and 1980s, and a more integrated focus on the addiction and the family. The authors stated: “The family systems approach to treating substance abuse focuses on the interactional rather than the individual level. Thus, identifying and addressing underlying family issues or processes that have necessitated the development of the substance abuse in one or more family members are crucial to therapy. From a family systems perspective, drug or alcohol use by a family member serves an important function for the family, helping to maintain homeostasis of the family system (i.e., balance, stability, and equilibrium). It is assumed that the family’s organization (i.e., structure and function) helps to maintain homeostasis and that family members will resist changes that threaten homeostasis” (O’Farrell & FalsStewart, 1999, p. 290). Their view of addiction within the family system focused on roles, rules, behavior, and boundaries. These researchers (1999) then discussed behavioral marital and family therapy for substance abuse as a model, which is reflected from learning theory. This approach included the social learning theory of stimulus-response models of operant and classical conditioning. This model has been the most frequently used approach with alcoholic
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couples. They reviewed several areas of research such as marital communication and (Hersen, Miller, & Eisler, 1973; Billings, Kessler, Gomberg, & Weiner, 1979) reinforcement patterns observed (McCrady, 1986; McCrady & Epstein, 1995). In summing it up, they concluded that there was “substantial research” that supported the approach of family based treatment along with the individual suffering from addiction. O’Farrell and Fals-Stewart (1999) found the need in working with couples and addiction. They provided a foundation for the importance of those addicted to substances and in relationships with significant others, a need for the research. The approach in their research, however, was a perusal of the literature. They did not ask those involved. This qualitative inquiry did that. Couples Therapy Although there has been emergent research and treatment models indicating that couples therapy may improve treatment outcome of addiction/alcoholism (McCrady & Epstein, 1995; O’Farrell & Fals-Stewart, 1999), it would seem many treatment facilities do not fully implement this type of treatment to provide the most benefits for their clients. Fals-Stewart & Birchler (2001) [see critique] conducted a national survey of treatment and use of couple therapy. In the introduction, there is discussion of the empirical support of behavioral couple therapy (BCT), the technique these researchers have chosen as the basis for their practice and research. The purpose of their study was to investigate substance abuse treatment programs, nationally, to indicate whether couple therapy (whether it was BCT or not) was being provided as part of treatment. They also wanted to
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know if treatment providers were aware of BCT and its effectiveness. Lastly, they wanted to know why they did not use BCT, for those that utilized another couple treatment orientation (Fals-Stewart & Birchler, 2001). The Fals-Stewart and Birchler (2001) study examined individual programs from the National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs from Substance Abuse and Mental Health Services Administration (SAMHSA). The programs provided services that included outpatient programs treating adults. Out of 8,742 programs 800 programs were randomly selected for the survey. There were 569 (71%) programs that indicated having clients eligible for couple treatment: 398 (70%) of the 569 programs agreed to complete the telephone survey. The authors stated, “although not by design, at least one program from each state was included” (Fals-Stewart & Birchler, 2001, p.278). One of the findings from the national survey indicated that only four of the treatment programs reported using behavioral oriented couple therapy, while none reported using BCT specifically. Less than 5% were aware that BCT was available for use with couples. The authors discussed how BCT has the greatest empirical support, but it was utilized the least. Most of those interviewed indicated they offered general couples counseling (47%) or disease-model couples counseling (43%). The mean number of couples sessions provided within the programs was about 3.1. Interviewees were provided materials on the effectiveness of BCT with a brief description of the process of BCT. Even after this material was provided more than 70% still indicated their
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unwillingness to utilize BCT—with most common reasons as being too intensive and more stand-alone rather than as adjunct to other treatments provided (Fals-Stewart & Birchler, 2001). Fals-Stewart and colleague (2001) determined that there is a gap between research and practice and two tasks need to be a part of the movement from the two—barriers to implementation and developing mechanisms and strategies to reduce or eliminate barriers. The barriers they discussed included the following: limited communication between treatment providers and investigators; BCT implements too many sessions or needs to be primary treatment; limited populations in prior BCT research; information about BCT has not been well distributed and; BCT is not compatible with the diseasemodel treatments (Fals-Stewart & Birchler, 2001). Critique: Fals-Stewart and Birchler In critiquing the study findings, there are a number of limitations not discussed in regards to why agencies did not utilize BCT. Perhaps training was lacking or it did not fit with the therapist theoretical orientation. Also, client ability to be involved in more treatment beyond the groups and individual therapy they were already participating in may have created another barrier (i.e. client’s unwillingness to include partner in treatment; time constraints). Lastly, this particular study examined programs by interviewing program directors. Asking the client and their partner’s perspectives could be helpful in identifying further needs specific to BCT in the addiction treatment process and recovery. Fals-Stewart, O’Farrell, Birchler, Córdova, and Kelley, (2005) discussed the theoretical rationale for behavioral couple therapy involvement with substance abuse 47
treatment. According to prior research, couple and family oriented treatment has resulted in increased abstinence for alcoholism and drug abuse (O’Farrell & Fals-Stewart, 2001; Stanton & Shadish, 1997). Fals-Stewart, et al. (2005) perused prior studies in behavior couples therapy (BCT) for alcohol and drug abuse. They stated that there was a variety of antecedent conditions and reinforcing consequences of substance abuse within the interactional patterns of the family, specifically, the couple relationship. The antecedent conditions included poor communication and problem solving, arguing, financial stressors, and nagging. The consequences included both the negative and the positive terms giving such examples as disapproving comments, multiple problems with children, and increased stress for all within the family. As in the family therapy arena, they too conceptualize the interactional patterns around substance/alcohol abuse as a whole, considering all family interactions, not to blame those family members, but to identify and treat the whole system to achieve abstinence from substances. The authors stated, “Taken as a whole, the strong interrelationship between substance use and family interaction would suggest that interventions that address only one aspect of this relationship would be less optimal. However, traditional interventions for substance abuse, which focus largely on the individual substance-abusing patient, often do just that” (Fals-Stewart et al., 2005, p. 231). The main fundamental assumptions of BCT included two thoughts: (1) family (usually a spouse) rewarded abstinence and (2) antecedents were reduced if the relationship distress and conflict were also reduced. The authors, Fals-Stewart et al. (2005) then identified and discussed the BCT treatment components which comprised of methods used to address substance use, to enhance relationship functioning, couple based relapse prevention planning, and session 48
structure and treatment duration. This study reviewed the positive influence of BCT on the addicted population. In conclusion, Fals-Stewart et al. believe that researchers will continue focusing on the BCT intervention methods for providing better services. Clinicians will work in goals to implement BCT as an aspect of the treatment process for those couples that can benefit from it. Critique: Fals-Stewart, O’Farrell, Birchler, Córdova, and Kelley In critique of this research, the investigators viewed BCT primarily, not looking at other forms of couple therapy. It would have been helpful if they included a review of some other theoretical perspectives. Possibly, there had been little done at the time. There have been few studies that brush the surface of recovery and the couple relationship. This study examined treatment with the couple, not recovery. One aspect of couple treatment in addiction often overlooked has been the female alcoholic with the non-substance abusing male partner (Fals-Stewart, Birchler, & Kelley, 2006) [see critique]. Fals-Stewart et al. (2006) studied this relationship dynamic with a sample of heterosexual couples (N = 138) where the married or cohabiting woman was entering treatment for an alcohol use disorder. Some of the variables examined included relationship adjustment, marital happiness, spousal violence, session compliance, and satisfaction with treatment. For the comparison, the researchers randomly assigned participants into 1 of 3 equally intensive interventions: (a) behavioral couples therapy plus individual-based treatment (BCT), (b) individual based treatment only (IBT), or (c) psycho educational attention control treatment (PACT). The results as reported by Fals-Stewart et al. (2006) supported better outcomes for BCT plus individual than for the IBT and PACT treatment groups. Specifically, the 49
results for BCT were more effective in relationship adjustment (dyadic adjustment was higher over the 12 months following treatment) and improving outcomes of different dimensions of drinking behavior (fewer days drinking). Relationship happiness was also at high levels utilizing BCT over the IBT or PACT. Women also reported fewer negative consequences in interpersonal and social responsibility as a result of drinking during the year after treatment than women in IBT or PACT. Another important finding was that partners that received BCT compared to those receiving IBT or PACT reported fewer days of episodes of partner violence in both male-to-female and female-to-male aggression. Critique: Fals-Stewart, Birchler, and Kelley One limitation Fals-Stewart et al., (2006) determined in their study was that like other prior studies, in the follow-up of treatment, BCT also declined in effectiveness over time. They stated, “more attention needs to be given to developing and using methods to maintain gains over a longer period of time after BCT is completed” (Fals-Stewart et al., 2006, p. 589). This supported the qualitative inquiry here, by finding out directly from those couples that have been successful in the recovery process what had actually worked for them and what had not. Impact of Therapies on Relationship and Partner Several investigations inquired about couple relationships and treatment. The research detailed in this section highlighted those studies partners were involved. This section contains critique of that research.
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Partner Included in Treatment Processes One study focused on the expressed emotion of partners and relapse after treatment. O’Farrell, Hooley, Fals-Stewart, and Cutter (1998) [see critique] examined expressed emotion (EE) in 86 (78 men and 8 women) alcoholic patients and their spouses. Prior studies of expressed emotion in family members of schizophrenic patients had been done supporting that when there was evidence of expressed emotion, there was a higher rate of relapse of the patient. The expressed emotion included talking negatively, emotional over-involvement, and speaking critically (Kavanagh, 1992; Parker & HadziPavlovic, 1990). O’Farrell et al. (1998) wanted to decrease the likelihood of relapse in the alcoholic patient when the family had high EE. They believed behavioral marital therapy (BMT) along with Antabuse (prescribed by a doctor and to cause vomiting if the patient drinks any alcohol) to curb the likelihood of drinking, may decrease the level of EE along with the level of relapse. Critique: O’Farrell, Hooley, Fals-Stewart, & Cutter In discussing the results, the authors stated that there was “predictive validity of EE to a new diagnostic group. Alcoholic patients with high EE spouses were more likely to relapse, had a shorter time to relapse, and spent a greater percentage of days drinking in the 12 months after BMT than did their counterparts with low EE spouses” (O’Farrell et al., 1998, p. 750). Other findings indicated that a spouse that was angry and critical about past drinking could still have had those same feelings even after BMT, which seemed to increase the likelihood of relapse. The authors noted that the increased critical behavior by the spouse might be from disappointment that BMT was utilized but their partner still relapsed. In describing the effect size, O’Farrell et al. (1998) explained that 51
the expressed emotion in alcoholic couples appears to be greater in strength than of those expressed emotions with schizophrenia patients in prior research. They determined that this should be a cautious indication since relapse can be defined in so many various avenues. The limitations discussed by O’Farrell et al. (1998) included the sample size (n=86) may not have allowed for generalizing the study to a heterogeneous sample. Another was that BMT was different in the overall context of the study—prior expressed emotion studies looked at schizophrenia and other mood disorders, which examined family members, in general, not the couple relationship. BMT may have reduced the expressed emotion and criticism influencing the results to an extent. Another limitation may have been any undiagnosed mental health disorders that could have influenced the results. Lastly, the sample size of the number of women alcoholics was a limitation, indicating the need to do further research on women alcoholics and their male partners in expressed emotion. This study was helpful in indicating the relapse potential of addiction when the spouse has higher expressed emotion. In investigating expressed emotion and follow up on relapse, this research by O’Farrell et al. (1998) indicated the impact of treatment and potential recovery has on the partner of an alcoholic, which further supported the need to interview couples concerning their own perspectives on treatment and recovery in a qualitative venue. One group of researchers examined effectiveness of alcohol treatment that included the spouse (McCrady et al., 1991) [see critique]. The purpose of their study was to evaluate treatment effectiveness and comparing the treatment interventions. There 52
were 45 alcoholics and their partners in three separate groups of outpatient behavioral treatment situations (McCrady, 1991). The groups were separated into the minimal spouse involvement group (MSI, n-14), alcohol-focused spouse involvement group (AFSI n-12) and alcohol-focused spouse involvement plus behavioral marital therapy (ABMT n-19). Each member of the group had follow-up contact at six, twelve, and eighteen months. The alcoholic was given a Breathalyzer and blood screen (for liver functioning) analyses at various times and follow-ups. Requests for any driving under the influence infractions were also documented. Each couple was measured in marital satisfaction, psychological functioning, and occupational functioning at each of the interval follow-ups. Critique: McCrady, Stout, Noel, Abrams, & Nelson Results of the study indicated that MSI and AFSI had worsened in drinking behaviors during the follow-up periods, while the ABMT group improved in abstinence from alcohol over the follow-up visits. All three groups were similar in their stability of legal and employment issues, but marital separations were at a lower rate with those that received marital therapy. The marital therapy group also rated higher on their marital satisfaction measures. The authors pointed out that marriages do not just improve if you treat the alcoholism individually, but marital therapy will improve the overall outcomes. Results in psychological functioning indicated that the ABMT group that received marital therapy, had increases in positive affect and decreases in negative affect compared to the other groups (McCrady et al., 1991). The authors reviewed the possibilities as to why the differences existed among the groups. They explained that each group was taught the same skills to achieve abstinence, 53
but the marital therapy group received information on how to improve their relationship, which may have contributed to their greater levels of marital satisfaction. One aspect they pointed out as a surprising finding was that all three of the groups were similar in the number of relapses, but the ABMT group seemed to have better skills of communication and coping, yielding the higher results on the scales of satisfaction and psychological functioning. In general review of the study, the authors determined, “The overall pattern of results suggests that adding marital therapy as one component of an outpatient behavioral alcoholism treatment program will enhance treatment outcomes, in terms of treatment compliance, subjects' ability to cope with drinking, marital stability and satisfaction, and subjective well-being” (McCrady et al., 1991, p.1423). The study indicated that information was lacking regarding the couples behavior in helping themselves improve over time. The qualitative nature of this study could assist in answering such a question. One outcome study examined relapse among married/cohabiting substanceabusing patients and “perceived criticism (PC)” (Fals-Stewart, O’Farrell, & Hooley, 2001) [see critique]. The researchers examined the contribution of PC to the prediction of relapse. The prior studies they reviewed had examined levels of expressed emotions (O’Farrell, et al. 1998), which they stated is a very costly form of measurement toward outcome studies in addiction couples treatment. Expressed emotions are similar to perceived criticism, but less costly by using three methods of measure: (1) the PC (perceived criticism), which was one 10-point Likert scale question “How critical is your spouse of you? (2) the Dyadic Adjustment Scale (DAS), and (3) the Timeline Followback Interview (TLFB). 54
Critique: Fals-Stewart, O’Farrell, & Hooley Fals-Stewart et al. (2001) analyzed three predictions from a sample size of N = 106. The hypotheses studied were as follows: 1) increased levels of PC from spouse will be linked with a greater likelihood of relapse, more use of substance, and short time span to relapse after behavioral couples therapy; 2) PC as a predictor for relapse over other predictors such as demographics and drug problem severity; 3) dyadic adjustment and PC are related—the greater PC from a spouse, increase in couple distress, therefore, an increase in substance use (predicting that PC may be a greater predicting factor for relapse than dyadic adjustment). The findings supported their hypotheses. Fals-Stewart et al. (2001) results indicated that similarly to expressed emotion correlation to relapse, so also was PC. Higher PC scores coincided to increased likelihood of relapse, shorter time to relapse post treatment, and fewer days abstinent during the 12 months following treatment, which also persisted after dyadic adjustment levels were controlled. These findings also supported the controls for demographics and drug use severity. They pointed out that PC indicated that other events in the marriage and issues involving the spouse were reasons often given as the cause of relapse by the patient (Fals-Stewart et al., 2001). In critiquing Fals-Stewart et al. (2001), a first glance could invite criticism toward blame of the partner for the patient relapsing into use; however, the authors did point this out as part of the overall discussion. They conferred that a spouse might have unrealistic expectations for treatment and might not understand fully the potential and possibilities of relapse. They also discussed how the relapse itself established a critical nature in the spouse, who might feel very disappointed that their partner did not abstain from 55
substances. Fals-Stewart et al. (2001) also noted that PC was simply what the patient perceived, not an actual measurement of criticism or hostility, which did not completely account for a patient who might be overly sensitive. They did not formally interview the couples in a qualitative way, which may have gleaned further information. This study supported that couples can fall into interactional patterns that lead to relapse. It also supported the idea that a more detailed picture is needed from the couples for greater understanding of the recovery process. Chapter Summary Described in this chapter was an extensive review of the literature of couples and recovery. There has been minimal research on recovery with couples and present research has focused on the heterosexual couples in treatment. First explored were the foundations of family and addiction—the theoretical foundations of the research. Systems theory (the root of family systems theory), Bowen’s theoretical concepts, and his view of alcoholism in the family system were all examined in detail. These theories exhibit the foundation for investigating couples and their experiences with recovery. One interesting aspect Bowen’s theory that rose out of the review included studies on differentiation of self. The studies observed in this chapter brought out the overarching quantitative studies that observed portions of the theory—mostly transgenerational (the passing on of dysfunction from one generation to the next). However, the studies did not focus extensively on emotional connectedness/distancing and triangulation in the recovery process, which supported the need to examine them in this study.
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Recovery was also examined. The literature reviewed in this section brought further attention to the need for speaking with couples in recovery. One article determined the overall need for defining recovery in both the mental health and addiction fields (Gagne et al., 2007). The addiction field supported the importance of relational (family/couple) treatment needed as part of defining recovery. This article did not however, specifically focus on couples and recovery. It looked at the overall fields that view recovery and reviewed what lacks. One study (Petroni et al., 2003) simply examined recovery periods up to ten plus years with findings that indicated the longer someone is in recovery the more similar experiences of the alcoholic and the co-alcoholic (partner). They compared the individuals recoveries through an analysis of two separate surveys within the MMPI-2, but did not delve into recovery stories or link them in any way as couples in the conclusion. Martin (1999) examined in a dissertation, relational healing in recovery from addiction. She reported her observations in their language, but fell short in the interpretations to themes. These articles touch some surface content of the ideology of recovery, but lack information about the impact of treatment, self-help supports, and how couples talk about their connectedness and separateness in their recovery processes. The next section in this chapter highlighted the impact of addiction on relationships. Codependency and a partner’s role in addiction were viewed. These were included as important pieces to addiction literature. Partners are impacted by addiction. Treatment programs may have a family piece that allows family to at least be educated, but have not developed how the partners navigate through recovery. 57
Treatment modalities from the literature were also included in examining works. This was important since various portions of treatment may have influenced the couples being interviewed. The treatment modalities viewed in this research included individual, group, self-help support groups (many consider this a form of continued treatment after formal treatment is completed), family treatment modals, and couples therapy. Finally, the impact of therapies on the relationship and partner was highlighted in this review of literature. The articles in this section examined the partner’s view of therapy through expressed emotions (O’Farrell et al., 1998), effectiveness of alcohol treatment when the spouse was included (McCrady et al., 1991), and perceived criticism as a prediction of relapse (Fals-Stewart et al., 2001). All of these studies included partner view, but all were included in the process of active treatment or shortly after. This dissertation attempted to inquire more deeply into the recovery process.
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CHAPTER III METHODS AND PROCEDURES Restatement of Purpose The purpose of this study was to gain a better understanding of couples in recovery from addiction. As discussed in Chapter II, little is known about the impact of the recovery process on the couple relationship. Bowen (1966; 1974; 1978) theory helps to explain the impact of addiction on the family. Some research examined self-help support group influence in the family setting (Friedemann, 1996) but few have examined these group influences on the couple relationship (McCrady, Epstein, & Hirsch, 1996). Research associated with couples and addiction has usually examined behavioral therapy with couples in addiction treatment, not the recovery process post-treatment (FalsStewart & Birchler, 2001; McCrady & Epstein, 1995; Fals-Stewart et al., 2005). In treating addiction there are various modalities that have been utilized including individual, group, and family treatment. The present study was designed to provide a better understanding of what couples are experiencing together in the recovery coping process. The use of the phenomenological methods enabled the researcher to better construct the meanings of couples in recovery (Boss, Dahl, & Kaplan, 1996). As clinicians and researchers delve into and evaluate new directions in the treatment of addiction, exploring the experiences of couples in the recovery process can provide
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context for the needs of those in treatment for their addiction. This qualitative analysis explored the experiences of couples in the recovery process and examined the details of their stories. Research Design The phenomenological approach (Moustakas, 1994; Creswell, 2007) was implemented in exploring couples and addiction recovery. Moustakas (1994) labeled four overall procedures or requirements in a phenomenological inquiry that include methods of preparation, data collection, organization of data, and analysis of data. Moustakas (1994) also outlined the following processes as aspects of the phenomenological model: epoche, phenomenological reduction (see process under data collection/analysis), imaginative variation (utilizing cluster of meanings), and synthesis of composite textural and composite structural descriptions (uses descriptions for meanings). The epoche epoch process was used to engage and create rapport with the participants. The researcher sets aside pre-judgments and bias, therefore, no hypotheses were developed apriori. Throughout the research process, efforts were made to follow a philosophy proposed by Boss et al. (1996). They described the seven philosophical assumptions of phenomenological family therapy research applied to this study. The relational nature of this inquiry makes the application of these assumptions appropriate, even though members of the family beyond the couple were not included in the study. The abbreviated assumptions are stated as follows (Boss et al., 1996), p. 85-86: • • •
Knowledge is socially constructed and therefore inherently tentative and incomplete. Researchers are not separate from the phenomena they study (subjectivity rather than objectivity of the researcher is recognized). Knowledge can be gained from art as well as science. 60
• •
• •
Bias is inherent in all research regardless of method used. Common, everyday knowledge about family worlds is epistemologically important (there is no hierarchy with the participant and researcher as far as who is the expert). Language and meaning of everyday life are significant. Objects, events or situations can mean a variety of things to a variety of people in the family.
These assumptions were considered in all aspects of meeting with the participants for interview, data analyses, and written portions. Triangulation in this study has two separate definitions: one theoretical and the other methodological. Bowen theory (1974) discusses the triangulation of other family members into the couple relationship, which can be considered a dysfunction. In this chapter, triangulation means a comparison of the data to other sources improving the validity (Creswell, 2007). In data analysis, it is the process used in supporting a more sound or credible study. Research Questions Couples in recovery were interviewed with in-depth, open-ended questions inquiring about their own experiences in the recovery process. Choudhuri, Glauser, and Peregoy (2004, p. 445) state, “The task of the qualitative researcher is to restructure and clarify data to offer a narrative that captures the essence of participants’ individual and collective stories.” In qualitative studies the goal is to develop descriptions and a mutual shaping rather than causal relationships (Lincoln & Guba, 1985). Hypotheses may be used to make predictions, but research questions will lead to the rich, thick descriptions of participant experiences (Creswell, 2007). Creswell (2007) demonstrated that there should be two broad and general questions with other open-ended questions to follow. In this study, those two general questions were: What have couples experienced in terms of addiction recovery? What 61
contexts or situations have influenced their experiences of addiction recovery? In addition to general questions, specific research questions were derived from Bowen Transgenerational Theory concepts. The principles of differentiation of self, connectedness, triangulation, and cut-off/distancing provided the guide for the researcher development of the following questions: (a) In what ways have a partners experienced recovery together or apart? (b) How has each partner been impacted by addiction recovery? (c) What is the perceived impact of self-help support groups (i.e. AA on couple relationship from each partner’s perspective)? (d) How has specific treatment, counseling, or any therapy (i.e. residential or intensive outpatient treatment) of the addict impacted them as a couple? (e) What has helped them change together? (f) How has differentiation of self (connectedness/separateness, triangles, cutoff) been impacted in the process of recovery? The questions in this study were developed by considering the personal history and lived experiences of the research participants with the goal of developing rich, thick descriptions in the data. As Moustakas (1994) stated the questions should: (1) seek to reveal meanings of lived experiences; (2) seek to uncover qualitative rather than quantitative aspects of behaviors and experience; (3) engage research participants with sustained personal and passionate involvement; (4) not seek to predict causal relationships; and (5) highlight vivid descriptions and experiences rather than ratings or scores. This was accomplished by stating the questions in such a way that participants were asked “how” or “what” rather than “why” to establish the meanings and experiences rather than causal.
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Questionnaire and Interview Questions Interviews of couples along with a demographic questionnaire (Appendix C) were used to provide further understanding of recovering couple experiences with the following questions. Each partner filled out the demographic questionnaire prior to the interview. The below interview questions were presented to each of the couples in a conjoint interview process. (Appendix A): 1. Tell me about your experience during the process of recovery. 2. How have you been able to stay connected? Explain your times alone, independent of each other? 3. How have you as partners been impacted by recovery from addiction? 4. How have self-help support groups impacted your relationship (i.e. AA on couple relationship from each partner’s perspective)? 5. How has specific treatment, counseling, or therapy (i.e. residential or intensive outpatient treatment) of the addict impacted you as a couple? 6. What has helped you change together? 7. During the process of recovery who or what else seems to have been involved in your relationship? 8. What mechanisms do you use to distance yourself from your spouse or others? The open-ended nature of the questions allowed for in-depth, rich, text and information to be gathered to obtain information for the purpose of examining their experiences together in recovery. Each interview was approximately 60 minutes. Pilot Test of Interview Questions In a pilot test of the questions, the researcher presented the questions to a couple not meeting the participant definitions to ensure clarity and understanding of the questions. A couple volunteered filling out all of the paperwork. Once presented the questions, each participant seemed to grasp understanding of the questions as they answered appropriately. The questions were then used in the study.
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Participants Boss et al. (1996) briefly discussed the sampling procedure for a phenomenological research approach. It is typical to have a small number of participants for the study. The small sample size is conducive to getting to meanings and experiences descriptions of those participating in the research (Boss et al., 1996). The sample size for this study consisted of five couples in recovery that fit the criteria. Participant Selection Another aspect of methods preparation is locating and selecting research participants. In qualitative inquiry it has been described as an in-depth sampling of a small number of participants (Patton, 1990). Creswell (2007, p. 128) discussed purposeful sampling strategies for a phenomenological study, “It is essential that all participants have experience of the phenomenon being studied.” He also explained that all the participants need to fit the study criteria—“criterion sampling.” Self-help support group meetings provided greater access to individuals who met the criterion of recovery, in a relationship, and may have participated in formal treatment. Patton (1990, p.169) stated that purposeful sampling allows for “information-rich cases whose study will illuminate the questions.” Purposeful sampling here means having basic criterion decided before selecting your sample (Creswell, 2007). Purpose sampling was used in this study. Flyers and informed consents (Appendix D and E respectively) were handed out at area self-help support meetings and events to individuals. Participants also volunteered through referral. Five couples volunteered that met the criteria.
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Once initial contact was established, the couple had to fit the following criteria to be a part of the research sample: Recovering alcoholic/addict: Any person considered by oneself or by a professional as having a dependency or substance abuse problem or diagnosis. Recovering was defined as having one or more years clean from any mindaltering substances (see Disease Concept Controversy). Recovering Partner: During the active addiction phase, the individuals needed to have known the recovering alcoholic/prior to sobriety. The partners in this study may or may not fit the idea of codependency. He or she may or may not have considered one’s self as co-dependent. The recovering partner may or may not have abused substances. Support Groups: The addict and/or partner sought self-help support from addiction. The support may include but not be limited to the following: Alcoholics Anonymous, Al-Anon, Narcotics Anonymous, Cocaine Anonymous, or Recovering Couples Anonymous. Treatment: The addict sought a form of individual treatment that included residential, non-intensive outpatient, intensive outpatient, counseling, therapy, or pastoral counseling at any time during the recovery process. The couple may or may not have had some type of couple treatment. Limited Couples: Couples were not included when either partner had a current or within the last year active substance abuse or addiction problem. Neither partner was in any current formal treatment. No separated or divorced couples were included. 65
Once a couple volunteered, meeting the above sample parameters, the researcher contacted them and scheduled the interview. From an initial phone interview (Appendix F), the researcher confirmed that the couples volunteering were appropriate to the research being conducted of couples in recovery being studied. The participants were given an opening statement explaining their role in the research as co-researchers, the amount of time anticipated for their involvement, and informed consent (Appendix E). A meeting was then scheduled where informed consent forms were reviewed and signed. Informed Consent Informed consent included the following requirements as well as any additional from the Institutional Review Board (IRB) such as the following (Creswell, 2007, p. 123): • • • • •
the right of the participants to voluntarily withdraw from the study at any time the central purpose of the study and the procedures to be used in data collection comments about protecting the confidentiality of the respondents a statement about known risks associated with participation in the study (if any) the expected benefits to accrue to the participants in the study the signature of the participant as well as the researcher
Another consideration of informed consent included providing information for counseling/treatment referrals should any topics produce individual stress, relational conflict, or a concern for relapse into using. The participants were provided a list of referrals (Appendix G). Participant Demographics Participants completed a basic demographic questionnaire (Appendix C) before the interview (Appendix F). The following profiles were developed using that 66
information. All of the couples that volunteered for the study were Caucasian, heterosexual couples with three or more years in recovery from the Northeast Ohio area. None had used any alcohol or drugs within the last year. Each couple was intact with no current separation. The couple was included in this research if they had known one another while one partner was actively using. All of the participants reported involvement in twelve-step, self-help groups. Couple descriptive details of demographics are presented and outlined in Table 1. Recovering Couple One Bob (age 66) and Stacy (age 49) was a recovering couple that met while Bob had been working an AA program and Stacy was still actively using. He had been in recovery for 25 years, while she had been in recovery more than 10 years. Both attend AA meetings, apart from one another, working separate recovery programs. At the time of the interview Bob and Stacy had been married for 9 plus years. He was Master’s level educated, while she attended some college. He was retired working part-time and Stacy was fulltime employed. Both had grown children (from prior relationships) no longer living at home. They had a combined income exceeding $50,000 a year. During the interview they shared that Stacy had a stroke earlier that year. When talking about the support they received during the last year, it was directly related to their recoveries. Both were positive in their interactions with one another, taking turns in answering the questions. At times, she seemed to struggle to find some words (the stroke had impacted her in this way) and he would help fill in the spaces. Both seemed comfortable and eager to share their recovery story. 67
Recovering Couple Two Laura (age 67) and Virgil (age 70) had been married 44 years. Both had been in recovery for 29 years. Virgil attended AA and Laura attended Al Anon. Virgil had a doctorate degree and Laura had a bachelor’s degree. Both were retired with combined annual retirement income of $50,000 or more. Both biological children were grown and out of the home. The two were also foster parents to male adolescents. The couple was cordial, inviting the researcher to dinner before the interview. The researcher thankfully declined because of potential conflicts of interest. Both enjoyed sharing their stories about recovery and the influence it had on their relationship. Family of origin was discussed openly by both, which seemed to be an important part of their recovery. The two seemed to enjoy some sarcastic banter as they interacted during the interview, which seemed light and friendly, something difficult to see in their faces when reading the later transcribed interviews. Recovering Couple Three Lawrence (age 47) and Josie (age 49) both abused drugs and alcohol prior to their meeting. Becoming aware of each other’s history of drug abuse provided them a common interest. Josie described herself several times as codependent. When Lawrence started active use of drugs, she soon followed. Both attended Narcotics Anonymous (NA) meetings together and, at times, apart. The two had been together for 15 years, married five years. Lawrence had been in recovery for four years and Josie four and a half years. They had a daughter, age nine, living at home. Lawrence had a high school education and Josie has had some college 68
classes. He was working fulltime plus overtime and she was attending college as a full time student. Their combined income was $50,000 or more. Both partners were enthusiastic and interested in sharing their story, exhibiting positive energy. Incarceration and Children’s Services had a role in each partner’s decision in seeking recovery. Recovering Couple Four Sandra (age 71) and Tom (age 68) had been married for 41 years. Tom had participated in Alcoholics Anonymous and had been in recovery for 23 years. Sandra had attended Al Anon and did not complete the question on the demographic concerning her recovery. Both had higher education professional degrees—Master’s and professional Doctorate. She was retired and he was working fulltime with her yearly income as marked $50,000 or more and he left his blank on the questionnaire. Two children were grown and living on their own. The atmosphere of the interview was calm and soothing, perhaps this was a sense of where their relationship has evolved. They took turns in answering questions each elaborating more on some questions. He commented that had he not gone into recovery, he believed he would have ended the marriage out of guilt. She described his guilt as one of the characteristics that had been a positive in his recovery. Recovering Couple Five Lou (age 43) and Jada (age 45) met when they attended a divorce care class at their church. She was in recovery from alcoholism at the time and unaware that he was an actively drinking alcoholic, as it turned out, he too was 69
unaware of his alcoholism. They had been together for three years, married two months. Jada had six years in recovery while Lou had three years and both attended Alcoholics Anonymous together and apart. Both had children from prior relationships with Jada’s being 11 and 12 years of age. Lou’s are 19 and older. There were two children (Jada’s) living at home with them. Educationally, Jada had some college and Lou had a Master’s degree. Lou was fulltime employed outside the home and Jada was fulltime employed from home. Their combined income is $50,000 or more. Both were enthusiastic throughout the interview, taking turns answering the questions. They shared how he had no idea that he too was an alcoholic when first attending a meeting with her. When he came to this understanding himself, he did not first share it with her, he announced it at the meeting. They were positive and open in sharing their story of recovery together. Table 1 Participant Couple Demographics _____________________________________________________________ Partner Name Age Years Together Years in Recovery _____________________________________________________________ Bob Stacy *
66 49
9
25 10
Virgil * Laura **
70 67
44
29 29
Lawrence * Josie
47 49
15 m=5
4 4.5
Tom * Sandra **
68 71
41
23 ***
Lou * Jada
43 45
3 m = 2 months
3 6
____________________________________________________________ *** Left blank ** Codependent non-substance users * The partner that was initial active alcohol/substance user.
m = # years married
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Data Management The data collection, organization tools, and management were described in this section. The methods of data analysis and measures of soundness also provided the map applied to this research study. The first segment discussed collecting and organizing the data. Data Collection and Organization Data collection in this qualitative phenomenon investigation involved long (60 to 90 minutes), informal, and interactive process interviews (Moustakas, 1994). The researcher made use of open-ended questions, engaging the participants more deeply in the discussion. Moustakas (1994) suggested the interview should begin with a brief social conversation in order to relax the participants and create trust in the researcher. During the interview, it was important for the interviewer to create a comfortable atmosphere for the participants, which encouraged honest, in-depth responses (Moustakas, 1994). Interviews were audio taped (Creswell, 2007). The researcher utilized interview guides to evoke comprehensive responses by the participants (Appendix A, Moustakas, 1994). Once the data was collected through interviews and transcribed, the following procedures were then utilized in coding and organizing the data (Moustakas, 1994, p.119): • • •
•
horizonalizing the data—every statement relevant to the topic and question was regarded and given equal value, which lead to meaning units meaning units—these were listed from the horizonalization process clustered themes—meaning units were put into common categories or themes as well as the process of removing overlapping and repetitive statements textural descriptions of experience—the clustered meanings and themes were used to develop textural descriptions 71
•
phenomenon constructed—from the textural descriptions come structural descriptions and an integration of meanings and phenomenon
The organization and analysis work in more of a fluid rather than a linear process as the next section explains. Data Analysis Creswell (2007) stated that the process of data collection, data analysis, and report writing are not separate in the steps, but are simultaneous throughout the writing process. The craft of analyzing the data is often learning by doing and following the researcher instincts. He compared it to a spiral process where the researcher enters data, describes the data, classifies the data, interprets the data, reads the data, and manages it from beginning to end. All the while, this researcher considered context, categories, comparisons, reflection, filing, and organization of the data. In the process of transcribing, the researcher focused on developing the textural and experienced descriptions of the couple narratives around recovery. Data were described through the participant descriptions, coded, and further detailed (Creswell, 2007). Similar phrases words and stories were categorized or grouped, which developed into the core research themes discussed in the results section. Measures of Soundness In this qualitative inquiry, measures were utilized to establish the study as more sound and trustworthy (Lincoln & Guba, 1985). Trustworthiness, according to Lincoln and Guba (1985), has several components. The components include credibility, transferability, dependability, and confirmability (Lincoln & Guba, 1985). These terms are utilized as more “naturalistic” terms instead of the terms internal validity, external
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validity, reliability, and objectivity (Creswell, 2007). The procedures used in the study to produce soundness included rich, thick descriptions, triangulation, and member checks. Rich, thick descriptions (Lincoln & Guba, 1985) were utilized in this study. Participants, sites, interviews, and demographics were detailed in various sections. By the rich descriptions, transferability may be applied, which basically means that the reader may transfer the information to other settings (Creswell, 2007). Providing some demographic information also allows the reader to apply the information to one’s own context along with the textural experiences of the participants, enriching the strength and credibility of the study. Triangulation of the data was a method used to process the information to improve or support validity. By triangulation of the data the work is more credible for the data being reported. Credibility is an important component to the data (Lincoln & Guba, 1985; Creswell, 2007). This triangulation is not to be confused with the Bowen concept of triangulation (a dysfunction in which the family participates to relieve anxiety, see Chapter II). Three forms of triangulation were represented in this research. The first, form perused outside sources of supporting research in comparison of the data, which was developed in Chapter V. Next, the research data advisor was consulted in the process of triangulation in regards to the themes that emerged from the data. The results were reviewed with the advisor for clarity, understanding, and overall consumer friendly qualities for researchers, clinicians, other professionals, and laypersons. Finally, member checks provided confirmation to a credible and sound research project. Lincoln and Guba (1985) believe this to be the most critical aspect of qualitative research. Doing a member check supported a credible summation of the data since it is 73
direct feedback from the study participants. The researcher completed the member checks in two ways. Simultaneously, throughout the interviews the researcher restated participant comments in which to clarify meanings, such as “If I am understanding correctly, this is what I heard you say….” If there were questions or curiosities, the participants were given the opportunity to voice it at that time. Member checks were also completed after the analysis of the data that emerged in themes. Member couples were given one copy of the results chapter to read for clarity, confirm anonymity, understand themes, and consistency of themes comparatively within recovery. Lastly, this researcher approached this work with potential need to do peer review or debriefing (Lincoln & Guba, 1985). Some debriefing was done via brief phone conversations. The committee research advisor reviewed themes, providing peer feedback allowing for complete development of the research themes. Themes were further discussed in Chapter IV. Risks, Benefits, and Ethics The risks, benefits, and ethical practices were outlined in this section. Measures described provided the tools for risk management and protection for participants should any level of discomfort arise. The first section discussed risks. Risks to Participants The participant audio digital taping and confidentiality was discussed with each couple member. Explanations were provided about pseudonyms and changing specific details that could identify them as participants. It was also described how the digital tapes would be locked in a safe with all necessary precautions to protect their anonymity. Once transcribed, the tapes were erased. 74
With addiction recovery there is the possibility of relapse. In this study, the researcher focused on the overall impact of recovery as consideration in writing the research questions for the interviews. The questions were designed specifically to focus on how outside influences had impacted their relationships and their growth together. This was done to minimize any possibility of a negative focus from their past that may be uncomfortable to share. However, as each partner shared their experiences, there may have been past experiences or traumas that brought conflict and stress. Any stressor, conflict, or individual potential to relapse was managed by providing lists of facilities they could contact for counseling that included individual, couple, or addiction treatment (Appendix G). This researcher reserved the right to stop the interview had any current or past stressor or event experienced by either participant created critical emotional reactions during the interview. Proper procedures were set in place had there been reported any present symptoms of suicidal or homicidal ideation, as a counselor has a required obligation to act in such cases. The researcher reserved the right to stop the interview to follow appropriate procedures for getting assistance for any participant in need. Benefits to Participants Literature from the various fields of addiction, self-help support groups, and family therapy have indicated there has been little done on the relational aspects of recovery from addiction. Varieties of quantitative research have been done on the couple and behavioral therapy as treatment for addiction. Since few have asked the partners directly, this research allowed them to have a voice; to tell their story; to potentially influence the direction of future research; to provide professionals and laypersons with 75
knowledge of the significance addiction recovery has had on couples. Each couple was given a copy of the transcribed interview. Most self-help support groups focus on the individual telling his/her own recovery story at various types of meetings (Garrett, 2009). In contrast, this research allowed these couples to tell their stories together--a relational story of recovery. This may have allowed them to feel good about their accomplishments in recovery as a couple. Ethical Principles Patton (1990, p. 356), discussed the affect an interview may have on a participant in regards to qualitative methods by stating, “…because naturalist inquiry takes the researcher into the real world where people live and work, and because in-depth interviewing opens up what is inside people—qualitative inquiry may be more intrusive and involve greater reactivity than surveys, tests, and other quantitative approaches.” Because of the in-depth nature of the qualitative method measures were taken should any risks be surfaced during the interview. As already discussed in the risks section, there was potential to stir up past events and pains in early addiction and addiction recovery. Boss et al., (1996) suggested the following guidelines specific to phenomenological research to protect human subjects. These abbreviated guidelines were utilized in this current study as well. 1. 2. 3. 4.
Seeking understanding of the participant’s reality Revisiting informed consent regularly Informing everyone who participates and obtain consent Avoiding covert studies [pretending to study one thing, but really studying something else] 5. Maintaining confidentiality
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This researcher sought with every effort to be aware of the above guidelines throughout the research process from initial contact, through interviewing, and member checks. Participants were made aware that they could at any point stop the research process for themselves. Each participant was provided a list of referrals for continued counseling, should they encounter any sensitive areas not expected during or after the process of the interview or data review. Chapter Summary This section discussed the methods and procedures utilized in this study. The purpose of the research and research questions were restated. Participants and participant selection, limitations, and demographics were described. The description of data management including the collection, organization, and data analysis were highlighted. The various measures of soundness in making the research more valid were stated. Finally, the participant risks, benefits and ethical principles were discussed in this section.
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CHAPTER IV RESULTS This chapter describes the results of the interviews with couples in recovery. Moustakas (1994) viewed phenomenology as a “first method of knowledge”: “Phenomenology is the first method of knowledge because it begins with ‘things themselves’; it is also the final court of appeal. Phenomenology, step by step, attempts to eliminate everything that represents a prejudgment, setting aside presuppositions, and reaching a transcendental state of freshness and openness, a readiness to see in an unfettered way, not threatened by the customs, beliefs, and prejudices of normal science, by the habits of the natural world or by knowledge based on unreflected everyday experience” (p. 41). This study examined, through the lens of Transgenerational Theory (Bowen, 1978), what those partners experienced together in terms of how they connected, how they distanced, and how they triangulated within their relationships while in recovery. According to Bowen’s (1966; 1978) theory of differentiation of self, a person has the ability to think, reflect, and respond in a process autonomously, rather than just react to emotional pressures of a family member/partner. A differentiated person is capable of making an informed or wise decision. This person has the ability to take a stand on issues he/she believes to take action. She/he can balance a connection of family of origin and nuclear family (Bowen, 1978; Kerr & Bowen, 1988). Conversely, the undifferentiated self lacks control in one’s emotions, reacting to those around him/her. A sense of either submissive or defiant behavior surrounds him/her. Evidence of emotional distancing or fusion with family of origin is also characteristic. Bowen (1974) clearly described 78
undifferentiated self in the family where addiction/alcoholism is running rampant (see examples in Chapter II). When considering this theory some studies have viewed Differentiation of Self (Prest, 1991; Hobby, 2004) and couples in recovery (McGuinness, 1999), while the combined theory and couples have been less explored. This researcher analyzed the data and noticed similarities in those shared experiences with meanings and themes of couples in recovery through the Bowen Theory (1974; 1976; 1978) lens. The researcher highlighted similar story segments, grouped them into themes, and provided a glimpse of connectedness, distancing, or triangulating within couple interview transcriptions. The qualitative methods used here were explained in Chapter III. Core themes emerged from the interview data for these couples: Emotional Change, Interdependent Interactions, Cultivated Communication, and Treatment Dilemmas. In the next section the themes were supported first by describing them in a brief review, then detailing them with examples and quotes from the interviews. In defining terms, Emotional Change encompassed the transformation partners experienced in recovery from addiction from the beginning negative emotions to improvement in managing those emotions. Interdependent Interactions portrayed the improvement in the couple from the extremes of codependency and independency to balancing friendships, activities, time spent with sponsors, and social networks or support groups interdependently. Cultivated Communication represented the shift that the couples experienced in becoming more open, honest, trustworthy, and available in communication with each other from earlier times when openness, honesty, and trustworthiness did not exist. Lastly, Treatment Dilemmas described the experiences the
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couples illustrated about making the decision to participate in treatment, defining treatment, and unavailable treatment as it was sought. Overview Themes of Couple Recovery As Transgenerational Theory (Bowen, 1966) has its roots in emotional reactivity, it seems fitting to begin with the theme that touches on those emotional changes and successes experienced by recovering couples. Each couple may have exhibited a different way of describing the emotional change, but the tone was similar—overall freedom and peace. Partners of the alcoholic/addict expressed feelings of relief, less worry, and more freedom. The alcoholic/addict articulated feelings of self-worth, purpose, trustworthiness, and less resentment. The atmosphere around these couples in recovery exuded freedom, energy, happiness, connectedness, and support of one another. Some spoke of improved connectedness within the family of origin as well as the nuclear family. Bowen (1966; 1978) determined that triangulation employs another person or object between the partners as a tool to relieve anxiety, which could imply relational interaction problems beyond relieving anxiety such as codependency or distancing. The antithesis of triangulation seemed to come out with these couples when describing present recovery. Interdependent Interaction seemed to be a positive result of couples in recovery advocating for the use of meetings, sponsors, and other AA friends. The couples described a positive influence of AA, NA, or Al Anon sponsors, meetings, or friends. The addicts/alcoholics described the necessity of utilizing outside influences in order to create a healthier relationship with their partners. There were several instances of the recovering alcoholics describing negative feelings creeping in if it had been too long since they had been to a meeting, indirectly relating to the leverage the meetings had on their 80
relationships. Some recovering partners did not seem to share the same sentiment about the meetings, but reported maintaining connections with friends from the meetings was important for their own connection to support. Considering Bowen’s tenet of triangulation in the purest sense, individuals in the relationship might have attempted to triangle sponsors or friends to relieve anxiety or solve conflict, establishing the third person’s over-involvement. Couples described a balance of interacting with others such as sponsors that seemed a necessary daily form of treatment, more crucial for the recovering addict than for the recovering partner in some instances. There was no indication of the negative triangulations utilized, but more interdependent interactions. Several of the recovering alcoholic respondents shared that meetings have not been the place where individuals or couples bring up relational problems. If done at all, which appears rare, it is done in private with an AA sponsor. Those participating in Al Anon described occasional “bitch sessions,” not delving too deeply into relational issues. However, these partners stated that outside influences and openness to learning about better relationships were helpful in better dealing with relational problems at home. Communication and emotion are closely related in the theoretical concept of differentiation of self. It is considered as a person’s ability to achieve a sense of self that includes an ability to make a decision without the dependence on another in an emotionally charged situation autonomously (Bowen, 1974). An undifferentiated person, in an emotionally charged situation, would simply agree with the other person or distance completely as evident with the overly dependent or independent. This next core theme addresses a process of change in these areas through Cultivated Communication that the 81
couples experienced. Relationally, both recovering alcoholics and recovering partners narrate examples of the influence that recovery has had on their communication. Cultivated Communication encompasses relationship improvement in communication and trust reported by couples. The final core theme extracted from the data evoked Treatment Dilemmas in two ways. First, treatment seemed difficult to define for couples/individuals in this sample. It seemed as though self-help support groups were equated with formal treatment. Some did not count the treatment if it was done with an individual or pastoral counseling, outpatient therapy, or therapy during incarceration. It seemed as though their definition of treatment meant being placed in a short or long term residential facility. Although there was a lack of clarity about treatment options, participants freely shared experiences of decision-making about going to treatment or not going to treatment. All participants described some form of treatment or at least sought it at some point in his/her recovery, even if seemingly unrelated to substance abuse or residential treatment. The couples in this study openly shared their stories of hope and freedom from the throes of addiction. I was honored to have the opportunity to meet them and to hear their personal stories of pain and healing. I have detailed here, the themes with in-depth examples from the interviews that relate directly to connectedness, triangulation, and distancing and the process of change to differentiation of self. Theme One: Emotional Change Participants experienced Emotional Change in recovery that influenced their individual lives and their relationships. Participants shared feelings of being frightened, uneasy, resentful, or a strong dislike of self just prior to recovery or in early recovery. 82
Virgil stated, “I was terribly frightened and scared. I was terrorized, I was really in bad emotional shape” (RC2, p.1). Tom spoke of his early dislike, then presently his ability to be comfortable with himself. Tom stated, When I was drinking I, got to the point where I did not like myself, and I didn’t like the person that I had become and I would suggest that today, I like me. And I’m comfortable in my skin. I don’t spend a lot of time trying to be somebody other than who I really am or who I think I am to the extent that my recovery has progressed. I get more and more comfortable with that. So, being comfortable, with who I am, has been a huge benefit in my recovery. (RC 4, p.1) Both Tom and Sandra spoke about resentment. He described an ability to be more tolerant, recognizing resentment, and taking action. Sandra spoke of the changes from her early resentment to not carrying the resentment any longer. Tom: I’m much more tolerant as a recovering person. I accept things much more. I accept what I find offensive or off-putting, much more readily than I used to. I don’t have resentments about them to the extent that I once did. I still have resentments, but, I recognize when I have a resentment and usually I’m capable of getting rid of it in a rather short time span and I was not capable of doing that when I drank. I didn’t fully understand the aspect of the resentment that I was having and, what was causing it, and why I continued to feel the way I did. I can identify that now and I can actually do something about it. I often go to a meeting and that gets rid of it. Or talk to somebody about it. Sandra: Well, in recovery, Tom’s become the man I thought I married and who he was largely in the early years of our marriage, but probably even better than that. So he’s a whole lot easier to live with as he’s worked in recovery, and I’m happy being his wife. I don’t carry a resentment around that I did near the end of his drinking where I knew a side of him that nobody else did. And that I didn’t like, so it was a very difficult time for me because I didn’t have someone, I didn’t feel like I could easily talk to people and when he knew I did share that, that was very upsetting to him, so it’s just much, much better now. (RC4, p. 1) Tom shared his improvement in becoming more emotionally present to his partner in this next segment. Sandra described an example of how he is often more available for her. Tom: Well, when I drank, I was home more than when I was in recovery, but I was physically present, but I wasn’t emotionally present. And so, after I got into 83
recovery I became more emotionally available. At least I felt like I was really there for Sandra and I worked at that to some extent. I probably could have worked harder at it, but I worked at that. Recognizing that that was a failure on my part of not being present to some extent I worked on being present for my kids. But I was always pretty much present for my kids. I’ve never really figured out why I made that separation, but even when I drank, I was emotionally present for my kids to the extent that I was capable. I worked really hard at that even when I drank, so the emphasis was on being emotionally present for Sandra, and I think I accomplished that to some extent early on. As time progresses, I think that’s improved dramatically, and I think that for the most part that I’m there for her when she needs me. Sandra: One of the best things he says to me, and I know he’s using AA stuff, but when I’m stewing about something, and I’m sad or down and he’ll say, “well, can you change it?” No. And then I can let it go. I don’t know if he feels my using Al Anon on him, but I feel him using good things about AA with me. The Researcher: So, I think I hear you saying, the tools of the program have helped that connection. Helped you emotionally. Tom: I think that’s an accurate statement. I’m not sure I could identify with specificity which tools, but if you’re actively involved in Alcoholics Anonymous, by osmosis you become less self-centered and more sensitive to the needs of the people around you. Since Sandra’s around me more than anybody else, she ends up being the beneficiary of that. (RC4, p.3) Bob and Stacy described an interaction they had when he was working outside, how they handled it, and the significance recovery has had for them in this next segment. She shared that emotional drama was limited in recovery. He described a way of getting back to love without fear or impatience. Stacy: I was thinking, no drama. Some individuals, in their lives, it's just so much drama, and all this stuff always going on and there's [sic] times when people try to put drama in your face. I was thinking about this earlier. I think we work well together. I was thinking about when we were working with something on the car and Bob was upset, something wasn't going right, and I was real calm about it. It was like, he was real wound up about it, and I was real calm and was able to fix it. And I am not a car fixer person and I don't remember what it was, but—[was interrupted by Bob]. Bob: It was that little thing that I couldn't reach, and I asked for your help where you could get your little hands up under the engine. I was freaking out. Stacy: It just worked, you know? Bob: I was freaking out and she was just fine with it. That's typically, what happens is when one of us is losing it, for lack of a better term, the other helps the 84
other get back to, ultimately, as I say, get back to love, but—[trailed off.] The Researcher: Recovery's done that? Recovery's done that for you. Bob: Yeah because we know what to get back to. Outside of recovery, hell, I never knew what was healthy, much less what to get back to…. I had no idea! What I got back to was feeling good through drinking and drugging. That's where I went, and to have that made me feel good for a time, but it damn near killed me too. So, that wasn't a good strategy. Practicing recovery gets us back to feeling good. Really feeling good about ourselves [sic]. Gets us back to being ourselves without the upset or without the drama or without the fear or without the impatience and all that other stuff that really is so human, but really is so destructive to a relationship. (RC1, p.7) These stories shed light on a sense of autonomy that Bowen’s theory describes. These examples illustrate transitions from emotions indicative of a crisis state to those of coping. Recovery, it seems, has helped them to learn better how to respond and interact with their partners rather than just react to them. Theme Two: Interdependent Interactions Bowen (1978) formulated the tenets of triangulation, distancing, and cutoff, which described the couple creating a triangle with another person in order to relieve an anxiety. Alcohol or other drugs may serve as a form of distancing. One participant described his experience as he shared how he and his partner worked through problems or issues. He shared that he had more of a relationship with alcohol, almost as if that could be a version of triangulation. He explained that early on in the relationship with her, it felt “like cheating on alcohol.” Lou: …it was enjoy the relationship, build the closeness … and that was another thing … when you’ve had a relationship with alcohol … it’s almost like cheating on alcohol to have a relationship with a human being. At least that’s how I felt, you know, so we had to force ourselves to be intimate with and close … look in each other’s eyes and just enjoy the person and build that closeness. Really, I think that was a key to force ourselves [sic] to not say well, here’s this other thing, to just enjoy. (RC5, p.5) 85
Sandra described the context of alcohol, meetings, and sporting events as an area of contention between them early on in Tom’s recovery. She candidly shared that she was resentful of the meetings and that her own ability to cope was connected with her work outside of the home, as a distraction. Her story emanates the process of change she experienced as she moved from feelings of resentment to more positive ones in the recovery process described here: Sandra: … Early recovery, still I remember having a lot of resentments. He got all kinds of attention. When he was in treatment, he got an embarrassing number of cards supporting him, because he told people that he went into recovery. And I, not that I didn’t get support, but when he got out he went to meetings 6 out of 7 nights a week and when he wasn’t there, he was at a sporting event. So, he was gone, a lot. Although, I think, early on I was more resentful about it. I think as time went on, I became less so. But, gone because he was down in the basement drinking, or in the garage drinking or gone because he was at a meeting, was in some ways still gone. And our kids are growing up at that time too… our daughter was 13 and our son was 16, so in a year and a half our son was going to college and actually, I started working. I had just started working right when he went into recovery, so I had that experience for me that I had other things going on in my life, but over time, his going to meetings, has not been a problem and now that he recognizes his feeling a resentment. And I’m not necessarily knowing that he has a resentment and it may not be towards me, that he goes to meetings, he comes home, he’s in a better mood, and there’ve been some times when there have been ten-step meetings. So he comes home and he apologizes to me … the first time that happened it just kind of blew me away. I knew what he was doing because I knew about what it was from Al Anon, but the first 3 years, I think were kind of, were kind of rough, rougher on me, more so than it is now [sic]. (RC4, p.2) Couples responded to the following questions, which provided the means to delve into specific ways they may distance: What or who has been involved in your relationship as an aspect of your recovery? How do you distance from each other? Participants described sponsors, meetings, higher power/spirituality, actively serving, programs, and friends. It was striking to hear the stories about others and how the meetings directly or indirectly created relief for their relationship. Laura and Virgil talked about early 86
recovery describing how he used meetings at times to avoid working through things at home, but also to get some sort of feedback, while she escaped into reading books to avoid him. Toward the end of this next segment, he described how they have more of a “healthy separating” today. The transition of early recovery to long-term recovery of triangulation and distancing was noted here. Virgil: A lot of it was going to meetings, then a lot of times. Early on, one of the reasons I go to meetings, because I wanted to avoid working through something at home. I needed to check my motives on a lot of stuff too. I still go to meetings if I’m in kind of a rough space and I don’t feel comfortable here, I’ll go to meetings. She watches TV or reads a book. Laura: Or I go play [cards] with the ladies, go shopping. Virgil: She would read to escape. Laura: I did as a child. Virgil: The kids have talked to me about it too. Laura: Yeah, and early on that was the way I escaped, you know, his antics and his anger. I went and played [cards] with the ladies and I read books. Virgil – Now, I don’t read books and I got some magazines coming that I enjoy… Laura: I still read books… The Researcher: But you don’t use them the same way to distance? Laura – No. No. Virgil: So, actually, it’s kind of, it’s separating in a lot of ways. You know, I like Bradshaw’s, the Mobile, there’s a lot of ways now when she moves I don’t have to move too. I think a lot of that’s a lot of getting happy together has been healthy separating if that makes sense, maybe that’s the question you’re asking, I don’t know, but we both have the information to go do something else and we never, we’ve never had to run away from each other for a long time. Yeah, we’re pretty happy really. I feel useful. She feels useful. (RC2, p.20, 21) The above examples provide a snapshot of intimacy issues and distancing in early recovery, but members commonly reported improvement or healthier ways of getting space or working through issues. Virgil alluded to the fact that neither of them must react to the other when he described The Mobile (Bradshaw, 1988). He stated they now have healthier ways of creating space for themselves more responsive than reactive.
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Recovering couples commonly reported how going to a meeting provided a sense of relief for their relationship. Several respondents spoke of the sheer necessity those meetings or sponsors had on the relationship—without digging up specific advice for their relationship while at the meeting. Bob and Stacy commented on the use of the meetings and influence on their relationship, how working on identity helped them to establish intimacy. Stacy: Well, sometimes when I go to a meeting, I'm able to share something that might help someone else or someone might say something that helps me. And anything that I'm able to do to improve myself, my thinking is good for us. The Researcher: So, you work that into your relationship it sounds like? Stacy: Yeah Something that's good for me, it helps me. That affects my life here with him. (RC1, p.8) Bob: I would say for me, you have to put that into context, I would put it into context of my recovery career. I've been in recovery for 25 years. And during that time, much of what I learned about relationships, I've learned in meetings, so that has certainly impacted our relationship. I've learned much, but, but not everything. I've also learned how NOT to do relationships…. (RC1, p. 8) The next respondent, Tom, described a similar experience to Bob’s—how the meeting helps him to better understand relationships through observing others and reading literature. Seeing others that have struggled allowed him the knowledge and tools to work at having a better relationship. Tom: The only self-help group that I’ve participated in is Alcoholics Anonymous…you go to an AA meeting and you get out of self. You’re able to observe other people and see how their behavior has impacted other people and if you work at relating as opposed to comparing, you can identify with that. I can identify with that and I can then take steps to modify my behavior. I was a typical alcoholic in the sense that if I drank too much, I thought I was only hurting myself and I had no realization whatsoever, the impact that alcoholism could have on a family. AA helped me understand how my consumption of alcohol not only affects me, but it affects the people that I’m around, my boys, my peers, and work, but most of all my family. So, once a person knows that their behavior is 88
not appropriate, in terms of the kind of relationship they want, they can take steps to change that behavior and therefore, make the relationship better. If you don’t know that your behavior is interrupting with the relationship well then it’s pretty difficult to say, “well I ought to change that,” but AA did that for me. The Researcher: …what I think I heard you say is …hearing their stories about some of their own difficulties…helped shed a lot of light for you, so that you could adapt and make some changes in your own relationship. Tom: Early on I read a lot of literature about alcoholism, not so much the scientific or the technical of it, but how it affects people emotionally and spiritually. And from a relationship standpoint I read a lot, so it was a combination of what I read and what I saw. And what I heard at AA meetings. (RC4, p.5) Here, Bob points out that meetings provide a network of support and friends, which seems to have provided positives for his relationship with his wife. Bob: And it's just a place to let loose. And also, it'll recharge my battery with positive healthy energy as opposed to negative energy. So, I look at a meeting as a battery charger. So, that's been it for me. The other thing is, I am absolutely totally grateful that there are meetings, not only for me, but for Stacy! Stacy gets into her stuff too, and when she goes to a meeting she always comes home more of who Stacy is. They center her. She always comes back more centered, more of who she is, and better for it. And selfishly speaking, so am I, because I'd much rather her be her than be whatever it is that's coming up, some crazy person or whatever. The Researcher: (chuckles) Bob: That's the disease, so that's another aspect. I see them [sic] very helpful for her. But there's another aspect that affects both me and her [sic]. And I see benefits galore. Meetings are a place where you can meet people and develop really long-term, meaningful relationships, which form into a network of support. It is really, really unhealthy for a couple to just be with each other--just with each other. A really healthy relationship is one that's open and interacting with the outer world and I have many, many, many, many, many, friends, good friends that are in recovery, that are my friends that I interact with--same with Stacy. She's got hers, a ton of women friends that are really, really, her friends. And for me when I am interacting and looking at Stacy, and she's happy and secure, and motivated, and supported by her friends, that makes me happy. That's good for me. That's good for me because it's good for her. So, meetings do that for her and they do that for me. It gives an opportunity and a place to meet people who have a similar value system and we can interact and have friendships outside of the meeting, which I think is really, really, important. I think that people, friendships, people that love and support us outside of the relationship is an integral part of a relationship being successful. Without that, a relationship can turn in on itself.
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People start eating at each other and there is nothing there. You can't generate something by just going at each other. You can generate by going up and being available to other energy being put in [sic]. (RC1, p.9) The next participant and his partner shared the various tools utilized early on in their relationship including a divorce care group at church and pre-marital therapy. The marital counseling he spoke of here was actually pre-marital counseling, which Lou labeled as marriage counseling. In maintaining a healthy relationship the couple utilized outside entities to serve as support for each other individually in recovery. Jada stated (RC5, p. 3), “But I really stuck to my guns by saying ‘I cannot be your sole support person to begin with.’ First of all, I felt I was too new to sobriety and I didn’t know what I was doing. I thought people were telling [me] men with men women with women.” Her partner, Lou, in another segment shared his experiences about outside support for recovery: Lou: I would say while alcohol was a big thing, I would say bitterness over divorce was a big thing for me … The divorce care group that we both attended and are still involved with today, because we want to keep that ministry and those doors open for other people, but that was a key… Additionally, we went to marriage counseling and keeping us from spinning off and try helping us get centered on our higher power [sic]. I think that was important too. I think utilizing that resource, even though that was a little expensive, but having that counselor – (trailed off). And so we took divorce care, we took AA, we took marriage counseling and then, going to church and hearing what the pastor has to say [sic]. And becoming convicted and trying to get a relationship with our higher power – (trailed off). All of that the divorce care tools, marriage counselor tools, going to church and AA – (trailed off). There was a theme in all of them, even though they were specialized. It was get a relationship with Christ…. Jada: …And we would go back to counseling if needed. I mean, if we got to a point where we were stuck. (RC5, p.16, 17)
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People at the meetings served as relief for the next couple as they shared their own separate recoveries and the significance on the relationship. Their story here provided an example of the couple ability to balance recovery interdependently. Lawrence: Well we try to have it…we rely on each other to stay clean … we have a separate … we do keep it separate, because … her problems or her issues with her people that gets her pissed off and upset don’t really bother me. And I have to remember that too, just because something is important to her, is not important to me. I can’t downplay that. You know, we have separate programs and different ways of staying clean, but we do rely on each other, so it’s kind of a contradiction. Josie: Well, it’s just an ongoing process. When I first came home, because … going to prison was where I got clean. But when I first came home, he was still in jail, so I was having [sic] to live alone and try to keep things together. And started doing recovery and I was deathly afraid that he was going to get out of jail and not want to stop drinking … It came to a point where I had to, I took it to my support that I had in NA … I was scared to death that he was going to get out of jail, and I told him we could not be together if he couldn’t try this way of life. So, that was the scary part. I met nice people in [city name left out]. That’s where a lot of our main support is in NA. Several were couples and no more [sic], but they’re still amicable with each other and they said, “Well just remember what you had then, won’t keep you together now, so if you make it, you’ll be lucky.” And that was back 4 ½ years ago. (RC3, p. 1) Theme Three: Cultivated Communication The couples in the study conveyed narratives about relationships and communication with their partners. Bowen’s concept, family of origin, merits mention as one couple shared the predominance of distancing and estrangement in communication from some family members and the healing process. Each of the couples commonly shared communication improvements and increased trust in communication. One couple shared their story about recovery’s significance as it relates to their communication interactions. Lawrence: Yeah. The trust and like I said not having to worry about where the money is at, although I don’t think that money matters a lot but…pay the bills, 91
and car payment and then it’s gone … but I know it’s going to places it needs to go. So, you know, just the honesty … we could be open now without having to worry about a fight. Josie: We communicate. Lawrence: Yeah, communication. Josie: Like I said in the past, we … really were shortchanging ourselves in addiction … we were so limited on what our lives were like, what we did … it was a very small box that we lived in. You know, it was get up, get high, find some way to get high, find some way to get more drugs so we could get high again. Oh, yeah, play with the kid for a minute … our existence was so small for so long. It is to me a blessing … I keep hearing these other people talking about how their marriages ended when they got clean. And they’re so grateful they’re clean today but they can’t live together because they have nothing in common. And it’s like I keep remembering that. And that’s something to be so grateful for. I have so much gratitude today because I do have the people that mean most to me in my life and I’m not alone. But I know, on the other hand…I can also stand on my own two feet today and I don’t have to have a person in my life to define me. Although, he’s the other half of my whole and I couldn’t have told you that in addiction. It was just hmm, hmm. I love him, but nah, nah, nah, he’s always doing this and that, and it was always bitching about each other all the time. It wasn’t – (trailed off). God, I don’t know if we ever had, I don’t know maybe we had some meaningful conversations here and there, but…. (trailed off) Lawrence: Probably Josie: Probably while we were high! Lawrence: Yeah! Yeah, we were meaningful, but we were stoned. Josie: Today, we do just so much, our lives are full, you know. Even, getting into recovery has brought spirituality back into our lives … we both started going to church. (RC3, p. 8-9) Sandra felt unrestricted to speak freely, which seems to translate into less isolation for her. It also sounds as though recovery has allowed her to better adapt to his quiet moments. Recovery apparently has allowed some sense of a clearer understanding for interpreting the quiet times, indicating an improved awareness in communication in the relationship. Both support within the relationship and outside influences provided support for improved communication. Sandra: But there were two brother-in-laws that he had seen be alcoholics and go into recovery. That was part of your experience. So, I did talk to my … one sister about how when I was feeling like I couldn’t talk to people. I never talked to your 92
parents about it. I didn’t talk much to your sister about it. It was sort of like I had to keep it to myself, so, it was a feeling of being freer in talking about what’s going on. And when Tom was angry there was not a question of his being violent or really emotionally abusive in a usual sense. He just went quiet. And that was really difficult, but that hasn’t been a pattern, since he’s been in recovery. The Researcher: So, recovery for you, it sounds like also brought him more involved in communicating with you instead of isolating, is that what you said? Sandra: Oh yeah, he’s a very – (trailed off). He’s not a chatty person, so it’s hard to get him sometimes to talk or to listen, but it’s, but [he] doesn’t have lots of layers of other stuff going on. Tom: That’s fair. (RC4, p. 4) The next segment intertwines the willingness to communicate and accept each other in the couple relationship. Virgil also talked about the relationship with his mother, in reference to family of origin, and the impact it had on overall communication and relationship with his wife. The Researcher- It sounds like you keep two individual recoveries. You do your thing, and you do yours, so how does that impact you as a couple in recovery? Virgil: It gives me a really easy way to piss her off (laughter). Laura: He goes to Al Anon also. Virgil: She’s come a long way. It has not seemed as hard for her to slide out of her ruts as it has been for me, for some of the ruts. For some of them, she’s pretty deeply ingrained and I don’t know if she’ll ever be able to – (trailed off). I think we’ve both decided that there’s things that we can agree to disagree on [sic]. Parts of her I can disagree with and there’s parts of me that she can accept [sic]. She doesn’t have to like it all the time and she’ll ding me every once and awhile. Then I will ding her every once in awhile. We try to get along now. (RC2, p. 6-7) In this above segment, Virgil spoke of how they “ding” each other on occasion, which was a reference to the sarcasm that characterized so much of their communication with each other. The two referred several times to Virgil’s sarcasm. It appeared to be a fun, humorous aspect of their relationship. At times, it did seem to be intense, but the couple would laugh and seem comfortable with it, even repairing a harsh comment later in the conversation. “I think we’ve both decided that there’s [sic] things that we can agree to 93
disagree on” (Virgil, p. 7). These statements seem to affirm how the two have learned to accept each other and to adapt in ways as to be not so sensitive in communication. As the conversation continues below, Virgil spoke of how his own pain in his relationship with his mother infiltrated his relationship with his wife. He also shared how he processed healing, which translated to improvement in relationship and communication with his wife. The Researcher: Do you think recovery is the vehicle that helps you do that? Virgil: I don’t know how to separate my recovery from getting spiritual. My recovery until the last 9 or 10 years, my self-esteem was so low. I’d rather be by myself than with anybody else. It’s surprising to think back how long that low self-esteem persisted. She’s helped me a lot with it just in working her own program … so I’ve done a lot of inner-child work. There were times that I had a very challenging job. I just had to quit. I couldn’t call this person out, this supervisor out. There were times during lunch hour, I’d come home, and she would hold me. I had another friend that would hold me. I was a mess. When I quit drinking, I was done. I was done drinking. I knew I was done. Initially, I tried to blame a lot of the dysfunctional stuff too, I picked up because I couldn’t find a better way to do business. I blamed that on alcohol, but it wasn’t, it was me, and so, I guess it was about 7 or 8 years into recovery, Laura started talking divorce and I went to a retreat. Retreat’s been good to me. I still go to them. She does too. The Researcher: Are they AA retreats? Virgil: Yeah Laura: AA/Al Anon Virgil: And I came back and went into therapy. And started dealing with maternal issues. So, I’ve kind of gone full circle with that. In therapy, he told me, I need to go confront my mother…[sic] Virgil: You know how those therapy sessions go. The Researcher: (laughs) I know Laura: (laughs) Virgil: Anyway, he told me that, “you need to know she loves you” because our family never said that. Who was supposed to know, and…So, she was living in a retirement home in the [undisclosed city] area, and I had my sister that was a little older than me, they lived close by, so since it was [undisclosed city], I spent the weekend at my sister’s and she got mom out of the home. Finally, I was going to do this, thinking she just kind of a poor old woman, you know. Then when I went to go to bed that night, my guts just went (ripping sound). So anyway, the next day, I told Mom I couldn’t remember a time when I wasn’t angry at her [sic], just my earliest memories, I was angry at her. And I said, “I got it from you, and I know that Grandpa was alcoholic, was he mean to you?” She says, “No, it was 94
Mom!” I could see her, she kind of opened up and her eyes teared up and then it was gone. And then I said, “I need to know that you love me,” and she said “I did, but you were different ” And my sister that’s just older than me who’s in the fellowship [AA] too, says, “How is he different?” And eventually, it came out that I reminded her of herself in her family of origin. And when our younger son got married here a few months ago, his fiancé wanted to do a collage of him growing up, so I was down in the basement looking at all the pictures and stuff. My mom, when she retired, she went to [southern state] in the winters and stuff. And she got to write a personalized history and with some of the pictures, I found her introduction. And like right there in the first or second paragraph, it said that where she thought her mother was especially mean to her… Well, it’s just there full circle, you know. She gave what she got, but I have really worked actively at forgiving her. Laura’s happy to be angry. It still hurt my relationship with her still a lot from ours. I still had such an empty – (trailed off). Laura: I occasionally, would say, Virgil, my name is Laura, I’m not your mother. Virgil: I would have way more anger. Of course, it would be from my mom, but she [Laura] was the one that triggered it. And you would know that, so we’ve done a lot. I’ve done an awful lot of work on that. And we’ll do things to let each other … it’s important to let each other know when we, we’ve got one that was just below the water line. We’ll flip each other off, or something like that. (Says with a smile). Laura: Or say ouch. (Smiling back). (RC2, p. 7-8) The narrative above reveals the transformation that can occur in communication from utilizing recovery tools and treatment. The interaction demonstrates, not only the partner’s responses throughout the recovery process, but the communication that was cultivated throughout, such as when Laura stated (RC2, p.8), “Virgil, my name is Laura, I’m not your mother.” Virgil admitted that the difficulties he had with his mother translated into the relationship with his wife (RC2, p.8), “Of course, it would be from my mom, but she [Laura] was the one that triggered it.” In the same segment, Virgil shared that they have better communication even though it may seem harsh to the outsider. He spoke of the willingness to confront his mother and to release her control over him in the present relationship with his wife.
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This next couple discussed the influence of their recovery on each of them individually. This resulted in an environment in which communication was cultivated. In response to how the two have changed together, Jada stated (RC5, p. 15), “I think hearing people’s stories and discussing them. It’s so nice to have an intellectual conversation with somebody, you know, if we go hear a lead or even if we see something on the news like that lady that said she lost her baby, then it came out she was drunk. Just being able to have a conversation with somebody that can relate.” She also shared more in-depth about the influence their communication has had on change in values, perspectives, and compromises. Jada: I want to say that that’s probably the answer. My answer to that question would be that he’s teaching me to not be so black and white. So that’s what helps me too … he’s able to give me a different perspective and say people make mistakes. Even my kids … if they make a mistake or they forgot or (pause). And I’m helping him with responsibility and accountability, so where I might be like a Sergeant and he is like [too laid back], you know, Shangri-La, I call it. We help each other, we’re helping each other change, [interviewer name], in that where we can find a happy medium. Where it’s not so much, okay you’re good, all right good. Okay, you’re grounded for 2 weeks because you didn’t bring your dishes in. That is a big one. The Researcher: So, you found compromise where you were so opposite in some places. Lou: Yeah Jada: Yeah, he’s helping me change in being more grace-filled and I’m helping him change in being, in allowing responsibility be the teacher and teach … consequences I guess. (RC5, p. 15-16) Similarly, Bob shared how interaction with his partner helps them both at being in relationship when meetings are involved--“being in relationship with Stacy, and Stacy being in relationship with me. That has changed me” (RC1, p. 14). Although he is not directly speaking of communication, he describes the structure in which communication is cultivated as part of their agreement in partnership and compromise. He also talks 96
about how that agreement includes being a “mirror” for one another. This mirror is an indication of how well or not so well they are being in the relationship. Bob: I would answer that question this way. The process of being in relationship with Stacy, and Stacy being in relationship with me—that has changed me. It has allowed me to be more of me. More open to life, and the experience of life. And there is some things in life that you can't experience by one's self [sic]. You just can't. I don't want to be cute here, but it's real tough experiencing riding a double bicycle when there is only one person on it. The Researcher: (chuckles) Bob: … there are some things in life that one cannot experience without being in a relationship. And being in a relationship offers some unique sources to grow. And what they are is learning how to compromise when you need to, get on your knees and pray with somebody when you don't want to, and experience the real wonder, joy, and experience of being loved by somebody [sic]. The Researcher: Uh huh Bob: And loving somebody! You can't experience that by yourself! You can't. It takes a partner. And the other thing is that in a relationship, one of the things I value, you know, in a relationship, she is my mirror. I am living my experience with her, by agreement so let me know what I am looking like at the moment. (RC1, p. 14-15) Cultivated Communication is a common theme among the couples in this group. Each spoke of ways that they have been able to open up to each other, family members, and differences in their abilities to shape and influence each other. The narratives indicated abilities that they seem to share from utilizing recovery principles in their daily lives. Communication through a responsive interaction is evidence of differentiation of self as portrayed in Transgenerational Theory (Bowen, 1978). Theme Four: Treatment Dilemmas The narratives of treatment portrayed three dilemmas. The first was the decision of whether to go to treatment or not. The second was when treatment was sought, some were denied. The last dilemma was an apparent discounting of treatment received, which participants were unaware. Tom shared the process he experienced in the decision of
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whether to go to treatment or not. He talked of how he reacted when his children saw him like they had never seen him just prior to deciding to go to treatment. AA was an option, but not without the potential of negative pressure on his profession and business. He shared an experience he had at church, when he prayed, asking God to help him control the drinking, just wanting to cut back. Others plead for him to go to treatment, but it was in the dark of the night that the decision became clear—go to treatment. Tom: Being an example for my children was very important to me, and so most of, a lot of my drinking was done when they weren’t present. And, I worked pretty hard at that. It used to irritate me that they hadn’t gone to bed yet, so I could drink. And it wasn’t… there were times that I drank when they were around, but I never drank a lot when they were around. And it was a Saturday and Sandra and the kids were at an event in another town and I was home alone, and somebody had given me a bottle of alcohol and I started drinking it. For whatever reason, I drank a lot of it. I was not the type of alcoholic that could consume a lot of alcohol at one time. I’ve talked to people who could drink a whole 5th of whiskey at one setting. I wasn’t capable of doing that, but I probably had, I probably drank half of this bottle. So, I was pretty drunk when they got home and my kids saw me for the first time, they saw their father really drunk. And I had tremendous remorse over that. I was at the point where I knew I had to do something, but I was feeling pretty hopeless. I didn’t feel like there was really any alternative. I was aware of Alcoholics Anonymous. I knew that that was an option, but it didn’t seem like an option for me, because if I went to Alcoholics Anonymous, I would lose my profession. Not that it would be taken from me, but nobody would come to see me, use my services, and I didn’t feel like I could do that to the family. So, I was trying to convince myself to be much more stronger willed and get a control over it. And still, the thought was, drink less, it was never quit drinking. It was drink less, because I hadn’t accepted the fact that I was alcoholic. And it was the fact that I was weak-willed. I didn’t have enough self-discipline to control the amount I drank. During that period of time I told Sandra that I wanted to quit, but I couldn’t. Sandra: I think he said something like, “I need help.” You might have said those words. In this segment Tom spoke of the struggle, the dilemma of the ultimate decision of whether treatment was the best option for him. His thoughts centered on those options during a period of days. Professionally, the perceived impact seemed high if he began attending AA. He certainly believed the attendance at meetings would harm his business, 98
people would not want to use his service, and ultimately the financial loss ensued. He believed that becoming stronger in his will, drinking less, controlling it, and working at self-discipline was the better answer. He shared with Sandra that he wanted to quit, but could not. The decision did not seem to involve her thoughts about it, however. The narrative about Tom’s decision continues here as he described vividly his experiences. Sandra did become involved in the process by calling his best friends that advocated for his going to treatment. Tom: The following day was Sunday. We went to church as we always did. Once again, I asked God to help me control my drinking. I certainly didn’t ask God to help me stop drinking. I was miserable all that day. Probably hung over, but I didn’t have terrible hangovers. It was more the guilt and remorse. And late in the day, Sandra called two of my best friends, who happened to be my pastor and my doctor and they came and spent an hour and a half or two hours with me, telling me that I needed to go to a treatment facility and I assured them both that, while I appreciated their concern, that wasn’t the solution. I couldn’t, I just couldn’t disappear for 28 days. Sandra: In the middle of [sport] season. Tom: I don’t think that was paramount at that time. Sandra: Oh, it was during [an important time of year for work]. Tom: Yeah. That I was going to do something, well, at some point they decided they talked all they could, so they left. I went to bed that night having no idea what I was going to do. I just knew I had to do something and I was starting to become teachable…not very, but a little bit. And I got awakened in the middle of the night. I couldn’t sleep, so I sat in my living room. I smoked at the time. I smoked a cigarette. I said, “God, I can’t handle this anymore, you got to take it, you got to take over for me.” I’m going to say, immediately, it was clear to me that what I needed to do was to go to a treatment facility (chuckles). I went back to the bedroom, woke up Sandra and say, “I’m going to a treatment facility as soon as I can get in.” That’s pretty much the end of that. The next day I went to a treatment facility. Sandra: I knew places to call and find out about it, so our pastor and I drove him up there. And he was there the 28 days and he did before he left, he did tell people that he worked with, so it was not a secret where he was. And I didn’t have to be telling any stories or anything like that. I was glad that he was there and getting help. I don’t know what point you had a phone conversation when you might have said something about whether you were going to stay there the whole time or not, but he came to believe he needed to stay there the whole time. And we did some family… some couples weekends. I think I went up a couple times and the kids 99
went one weekend. That was really … good that we did that. My son … he was playing a sport and he had to give up some of that in order to go up there … his coach said, “You need to do this for your dad.” And I’m sure he’s never regretted it. (RC4, p.7-8) The above experiences seem similar to the struggle others experience with addiction and decision for treatment. An interesting aspect to note was that Sandra seemed to be outside of that decision process. Her role seemed to be supportive, no matter what the decision. Similarly, Virgil explained his own dilemma concerning the decision of whether or not he should attend treatment. His experience: Virgil: But anyway, I went to our minister for some counseling because the suicidal feelings and the stress I was under. And he gave me some things to do for depression. I think when I saw him the first time he helped me make the connection between hangovers and suicidal feelings, then taking a [depressant/alcohol] for depression. He didn’t word it that way, but I did make that connection. He asked me how much I drank and I kind of lied by omission, like we do … I went on about my business for a while (pause). I was terribly frightened and scared. I was terrorized, [on a fishing trip]… It was a nice balmy, summer night, and I couldn’t find any peace at all. So, I went back, and I think I was in my sleeping bag, and I prayed. I think I said something like “God help me.” And I can’t describe how I felt warm all over … it didn’t last long and when it was over, I knew everything was going to be all right. The big edge was lifted off of all the fear I had been living with. For a while, I thought I was special on account of that happening, but it happened because I needed it. Anyway, I did get drunk the last time and the next morning the bad feelings were back, so I called the minister again and he asked if I wanted to go to treatment and I said I wasn’t that bad (laughed). Then he thought AA might be the place for me and I didn’t know it at the time, but his father was alcoholic, so I was very fortunate to hear a lot of stories about ministers in the AA fellowship. The Researcher: He had some understanding. Virgil: He said he would take me to an AA meeting or find me a temporary sponsor, or I could just go, so here, I just went. I was afraid of the people there, but I was more afraid of where I’d been. The Researcher: (to Laura) During that time, what was happening with you in this recovery and what he was going through? Laura: I think I recognized that his drinking was a real problem, but he didn’t pay attention to me and what I would tell him [sic]. I was a little miffed when he … followed the minister’s advice and went to AA. How dare him! I’d been telling him that forever! 100
The Researcher: Had you also gone to Al Anon? Laura: Oh, No. No, it was a – (interrupted by Virgil). Virgil: You didn’t tell me to go to AA. You just thought I should quit drinking. Laura: Yes, right. And, it was a few months later that I found Al Anon. I had gone with him to a couple of meetings. He was telling me about how great these meetings were. I went to a couple of them, and they were drunk-a-logs. And, I thought, “Holy cow, I’ve lived with this, I don’t need to hear somebody else’s.” (RC2, p. 1-2) When approached, both Tom and Virgil initially rejected the idea of treatment. Tom went to residential treatment while Virgil utilized AA meetings and individual and pastoral therapy, and experienced positive results. Their partners shared their sides of the story in the interaction as well. Sandra talked of her relief. Laura mentioned her irritation with the fact that he had not listened to her, to which he responded—“you never told me to go to AA, just that I should quit drinking,” which she affirmed. Another dilemma concerning treatment was when one of the participants shared a story of his attempt to receive treatment. Bob shared his experience attempting to get treatment years prior to meeting Stacy. Bob: Oh, treatment for me, it was 25 years ago that I got myself into a lot of trouble both legally, at least I define as trouble, DUIs and continually drinking and health problems and the like. And to make a long story short, I knew I needed some help. I knew from my growing up that there was this thing called AA and that they helped alcoholics. I didn't know there was treatment. No idea there was treatment. And there wasn't much of it, quite frankly, 25 years ago. There was some. So, I went to AA and got the 12 Step program and that helped me have that awakening that I told you about. And then everything changed and I no longer needed to drink and drug. But there is another aspect that I would like to share it is sort of indirect from that. After 2 or 3 years in recovery, working the steps, working the program, and working and healing, as part of getting better, I got in touch with, and began experiencing my feelings. I had no idea how to deal with them and I crashed and burned emotionally. I used to be a sales person. And I was a real good one as long as I didn't have any feelings. But when I started having feelings, it was – (trailed off) The Researcher: (chuckles) Bob: It, it, just threw me for a loop. So I really became darn near unemployed, I didn't know what was going on, I was going crazy, and by then I knew about 101
treatment, so by golly, I need treatment. So, I made a few calls, so on and so forth and I was told that by a counselor "have you been drinking and drugging?" "Well no, I have been sober about 3 or 4 years "Well, you can' t get treatment, you have to be using." "You mean to tell me I have to go out and get drunk again to get treatment?" And that was the answer. Also, the expense of treatment, it was very expensive. It still is. And so I never did get treatment for those reasons. One, I didn't know about it, Two, when I did know about it I was sober and I didn't qualify for treatment, now isn't that strange… The Researcher: Isn't that strange? Bob: Yeah, in my view, not drinking and drugging is one thing, but it's just the beginning of recovery and my additional problems were every bit as serious as my addiction problems. Every bit, if not more serious, if there was one thing I needed treatment for, I believe still, that would have helped a lot then, but I wasn't eligible for it. So, That's the reason why I didn't do treatment. (RC1, p. 11) The experiences Bob shared is not atypical, in fact, this is the way our treatment systems still work. Also, the way the entire AOD (alcohol and other drug) treatment system set up, does not allow for mental health diagnoses. So, it seems that Bob’s dilemma would still occur if he continued to remain sober and sought treatment for emotional issues. Having dealt with addiction recovery for many years, it would seem that he should have the opportunity to ask a trained professional with expertise in addiction and mental health services to provide him the services he needs. It seemed with some of the study participants that a clearer definition of treatment needed to be stated. In conversations before the recorder was turned on, while reviewing for the study criteria, some stated that they had not received treatment, but each of the couples shared some form of treatment scenario within their story even before the question about treatment was asked. Perhaps clarifying that treatment could come in many forms, which include meeting with a pastor, individually with a counselor, or some outpatient treatment. In reading the interaction below, understand that I believe the response was because of a divide in my meaning versus their meaning of treatment. 102
The Researcher: Well, how has either the decision to participate in treatment or the decision not to—how has that impacted your recovery as a couple [sic]? Josie: Oh, we have choices today. You know, we can choose not to go to that meeting, we can choose to not share. We can choose not to go down to a retreat in southern Ohio where he always works. And I usually do a workshop. I did a workshop this year on steps 10, 11, and 12 and he did [unclear word “gating”] people around. But, I mean we have choices. We don’t have to go. The Researcher: So, you see your self-help support meetings and retreats and things like that as treatment. Lawrence: Sure Josie: Yeah The researcher’s next question, specifically meant to address meeting with a counselor or any form of treatment, whether it was group, individual, or residential, but the interpretation of the question seemed residentially focused. The two go on to describe specific details of meeting individually for counseling. The Researcher: What about any specific residential or outpatient or any kind of other treatment that you may have had during your relationship? Josie: I never had any (laughs). Lawrence: Neither of us went through any treatment or detox. Josie: I did counseling. Lawrence: Besides [name of agency] and the [name of jail program] in jail, and I was in outpatient with [James]. Josie: I did counseling with [Jenna]. And … when I came home [from prison] … I had to apologize to her [Jenna] because I’d lied so much that first year I was seeing her. Then I went to prison. When I came [back] … I started seeing her again, ‘cause that was part of my provisions with Children’s Services, but it was good for me. I like [Jenna], I like her a lot [sic]. So, going and talking to her … she finally had to say, “You know we need to discuss how much longer you will be coming, because there’s not much more I think I can do for you at this point.” So it was nice having her to talk to, because when I started going back and seeing her, he was still locked up, so I was still on my own. I had a choice then … I didn’t have to go to meetings. I wasn’t required to do anything. I was on postrelease control and all I was required to do is to show up every month and to keep my nose clean, but I was also trying to do something for me. And I also wanted [daughter] back, you know, and he was still locked up [sic]. And I started going to meetings and yeah, I started going to get a paper signed, my stubborn ass said I don’t need to do this, but along the road, it was the very thing that kept me from making bad choices. Because when I came home, I didn’t know anybody that didn’t get high except for the people that were going to meetings. I mean, everybody I knew drank or smoked crack or did coke or heroin or something. I 103
didn’t know a damn person that was clean, so that was a big motivation to go to meetings because I knew if I sat long enough in that house—got a trailer and I was working on it. And it was a nice diversion and it kept me busy and I was working—but you know, at night ultimately, I was there alone before he got out. I would lay there and I would cry myself to sleep at night and my choices to go to meetings was [sic] probably the best choice I could make because otherwise I might have went the other way [sic], even though I wanted everything to be different. The Researcher: So, it sounds like for both of you, the decision—(to Lawrence) go ahead. Lawrence: I think, I think I had to go down to [name of agency], because I got a DUI when all this was going on too, so I think I was required to go to [name of agency]. But, when I got out of jail … I had to go in front of Judge [Barnum] … I’d already made a decision you know that I wanted a new way of life and I’m just tired of this … to me, I’d already made a decision. I wanted a new way of life and I didn’t want to use anymore, so, I went to [James] for like another year probably. And the last, we went down to once a month and the last couple of months is I was talking about what albums we have and stuff [sic]. Josie – [James] told him he was boring because he never had any problems. Lawrence: Yeah, I was boring. He thinks you know that when you decide to get clean and in recovery your life is supposed to be this total chaotic mess, so… Oh, my God, you want to kill yourself, so and nothing’s right, you know…Well, it’s not how it was for me. It was, finally, oh (sigh). Josie: It was exactly the opposite for us. Lawrence: I don’t have to live this way any more…what a relief…and I got this job, Josie, it’s like everything, everything fell into place. (RC3, p.16-18) The various individual therapies discussed above had me pondering how many people that I had spoken with had defined treatment in a different way, that even though they had received treatment, they believed otherwise. They stated, “neither of us had treatment,” then they provided an in-depth account of each of their experiences with individual counseling. Also, before the recording, Lawrence indicated having attended a jail program. When asked the same question, Lou also mentioned he had not had treatment. He made this statement later in the interview: Lou: I was a good liar, especially to myself, though. You know, it’s funny, I think I did do some sort of treatment and evaluations way back, but it’s all blurry. But I
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think that didn’t help me for crap. I know I did a lot of stuff back then to appease people, but (trailed off). (RC5 p.15) Gagne and colleagues (Gagne et al., 2007) researched the definition of recovery in comparing the fields of mental health and addiction. The definition of recovery has been unclear, which appears that similarly the definition of treatment is also elusive. The participants in the study provided accounts of various dilemmas to treatment from the decision-making process to understanding treatment options. The narratives brought to light themes that related to Transgenerational Theory (Bowen, 1976; 1978), the research questions, and couples in recovery. Couple’s responses although not representative of couples coping with addiction and recovery, leant support for the concept that recovery both challenges and potentially assists in improving a couple’s relationship skills. Specifically participants grasped differentiation of self, connectedness, interdependent interactions, and attempts at repairing distance/cutoff. The couples’ accounts share a common thread—the couples improved in their relationships with one another in ways that were adaptive or in ways that could simply point toward recovery’s influence on them as individuals and partners in Emotional Change, Interdependent Interactions, and Cultivated Communication. Treatment Dilemmas, though not directly connected to the concepts of Transgenerational Theory, is an important theme of this study, further processed in the discussion and limitations of this study.
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CHAPTER V SUMMARY, IMPLICATONS, AND DISCUSSION Summary of the Study This phenomenological study was conducted because of my interest in addiction recovery and the couple relationship. The intent of this study was to have a better understanding of couples in recovery to address an issue that had not been covered in the literature. Transgenerational Theory provided the lens to examine those experiences in this phenomenological study. Characteristics described in the couples’ narratives were demonstrative of the concept of differentiation, of self as described in Transgenerational Theory. Several characteristics that the couples shared included connectedness in emotion, communication improvement, and the ability to become more balanced in separateness and togetherness. The characteristics were grouped into the following themes: Emotional Change, Interdependent Interactions, Cultivated Communication, and Treatment Dilemmas. In reviewing of literature for this study, the definition of recovery was limited (Gagne, White, & Anthony, 2007). Gagne and colleagues challenged the fields of addiction recovery and mental health recovery to develop a definition. Recently, Substance Abuse and Mental Health Services Administration (SAMHSA) posted the research results in the pursuit of that definition (del Vecchio, 2012). Over 1,000 participants were involved in developing the working definition. The definition addressed 106
both recovery from substance use disorders and mental health disorders and the process of change. This definition described an individual as improved in health and wellness striving to thrive in life with a component of self-direction. They also discussed an initiative called the Recovery Support Strategic Initiative, which determined four major dimensions: Health, Home, Purpose, and Community. The Health dimension defines the individual who manages the disease healthily in both physical and emotional wellbeing. Home addresses s2and safe living, while Community focuses on the social network for support instilling love, friendship, and hope. Lastly, Purpose encompasses meaningful activities with independence through resources and income to be involved whether in employment, volunteering, family, creative endeavors, or education. There are ten principles highlighted to provide a guide or direction for the recovering individual. Within the principles, recovery is person-driven, holistic, culturally based or influenced. The guiding principles also determine that recovery has many pathways. Peers, allies, relationship, and social networks are supportive of recovery. Lastly, recovery involves the individual interacting in community, family, and personal responsibility with respect. When considering the themes from the couples that engaged in this study, the narratives seem to hold threads of commonality weaving through the concept of differentiation of self in Transgenerational Theory and the above definitions. The following segment intertwines those commonalities in the four core themes discovered (Emotional Change, Interdependent Interactions, Cultivated Communication, and Treatment Dilemmas).
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The Four Themes and Transgenerational Theory Essentially, Transgenerational Theory has an element that describes emotional anxiety. As the person has more anxiety with little or no means of properly channeling it, triangulation, distancing, cut-off, fusion, and generally lack of differentiation in behavior occurs. In early recovery of the participants, there were descriptions of emotion that involved intense resentments by both the addict in recovery and the recovering partner. Sandra described resentments early on in recovery when Tom was gone as much at meetings as when he had been drinking. Her way of coping, as she described it, was to distance and pour herself into the distraction of work. She also became involved with Al Anon, which may have better helped in dealing with that anxiety. Tom spoke of how he worked at becoming more emotionally present for his partner as a result of his own recovery. Utilizing recovery tools learned from self-help support groups provided a process for Sandra, Tom, and others, to promote emotional change in their lives. Interdependent Interactions was the next theme that emerged. The couple narratives described an interaction with others within the meeting settings, with sponsors, friends, and even attempts toward interacting with family of origin in some instances. These occasions were preluded by some challenges in early recovery, however. For instance, Lou talked about how he distanced himself from all relationships to have a relationship with alcohol and when he found his wife, he stated that it was like cheating on alcohol. Virgil spoke of how in early recovery he would go to meetings to avoid issues at home. Laura distanced early on through reading books; Sandra described the first three years of recovery as being more challenging. These experiences seem to parallel some aspects of early recovery in distancing and difficulty with intimacy with their partners. 108
The couples then described a transformation. The narratives indicated a shift from acting out ways of distancing, to interacting in more healthy ways. Reading the AA literature, utilizing the support, and in many cases seeking further treatment translated to healthier relationships at home. The correlation of shifting from distancing to improved interactions seems rooted in recovery tools. Josie described the meetings as a place she received her main support, as she faced losing her partner to using drugs upon release from jail. The interactions there relieved her fears and anxieties. Lawrence related a balance of maintaining their separate recoveries, yet also maintaining a balance in the support they provided each other. The recovery process supported the improvement to interdependent behaviors within their relationship. “It was a very small box that we lived in…” Josie used these words to describe her past level of communication with Lawrence. He discussed the foundations of communication grounded in recovery, that better cultivated trust and honesty. As for Sandra, she spoke of changes in Tom through his recovery that had been a factor in how she communicated with him, specifically the non-verbal form of communication. Early in his recovery she reacted to when he “went quiet,” but she did not feel safe talking about that then. She recounted her ability to speak more freely about his recovery today than in earlier stages of his recovery. Virgil verbalized other facets of communication that he experienced. Because of the many years of struggle with addiction, he sought treatment and part of that treatment was a recommendation to confront his mother about his formative years. Laura would have to say to him, “I’m not your mother.” He knew that working out the issues he had with his mother would also help in other ways, namely in communication and intimacy with his wife. This has helped communication improve. 109
Sarcasm may be considered a remnant of what some would say is underlying anger, but the two seemed to have made it a loving banter that went on during conversation. They also talked about how they would be more open to each other in sharing hurt, if they were hitting a little too close to a painful spot. Jada and Lou spoke of how they worked out the way their values were being challenged and the necessity of focusing on communication. This couple was together the shortest number of years, three years and only married two months. Lastly, Bob spoke of the agreement to act as each other’s “mirror,” as they have agreed to tell each when they each needed to get some support, potentially from attending an AA meeting. Bowen (1974) observed the alcoholic family in the clinical setting by viewing the alcoholic and the level of differentiation. From an observational lens and the couple narratives, those themes connect to the concepts of his theory in several ways. The similarities support the possibility that couples may be struggling in becoming differentiated in early recovery. The descriptions of high anxiety, fear, resentments, and initial reactions frame aspects of lacking differentiation. Details of triangulation, cut-off, and fusion were not evident in the present lives of these couples. Earlier years had more evidence of the lack of differentiation. Couples stories focused more on the positive changes they experienced, so delving further into the early recovery will be valuable in future research. The theory, fully viewed, illustrates that lack of differentiation occurs in the family where addiction is active, but the stages in early recovery have not yet been explored (see Recommendations for Future Research). Bowen spoke of the individual that was willing to step out of the overly anxious role brings influence to change in the family system, which is supported in the stories as 110
each of the individuals tell of their participation in meetings or treatment. He also acknowledged that when both partners were active, willing, and focused outcomes were much better (Bowen, 1974). Throughout the narratives, support for both partners willingness, focus, and activity in recovery is plentiful. One of the studies reviewed in the literature supported the idea that as recovery progresses, the experience for all involved becomes more similar (Petroni et al., 2003). Treatment Dilemmas, the final theme, seems a less likely fit in viewing it through the Transgenerational Theory, however, those dilemmas in making the decision to attend treatment when initially approached with it may indicate a lack in differentiation. It is notable that the two couples in long term recovery when telling the story of treatment decisions, none of them talked about the partner’s perspective about whether or not he should go to treatment in both the narratives with Laura and Virgil and Tom and Sandra. Perhaps there were more conversations with their partners, but if there had been, it was not discussed by the couples during the interview. Alternatively, these same couples may have seen the decision for treatment as their husband’s individual decision and willing to support whatever was decided. The principles of recovery are parallel to the couples’ narrative experiences in a number of ways. The degrees of differentiation of self and the changes of the breadth of the interactions in the couples related to the principles of recovery that were defined by SAMHSA. In applying recovery principles to the themes in this study, a hint of diversity may be seen within this participant sample; participant pathways to recovery may differ in cultural views, value systems, ages, generational differences, and lengths of recovery.
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Words of hope emanated throughout their stories. Recovery networks were utilized extensively by all of the participants. Most of the participants in the study sought counseling services or treatment, at some time either before or during recovery potentially addressing trauma. Virgil shared that in counseling he worked at facing the trauma of the experiences with his mother, which directly impacted his relationship with Laura. Lou and Jada spoke of the trauma from their prior relationships and their desire to overcome that in their recovery by utilizing premarital counseling. Tom and Sandra shared a story of seeking marital therapy during a time they were struggling with a decision. Stacy received counseling services. Bob searched for treatment after being sober for three years. Lastly, Josie and Lawrence had experiences of treatment discussed surrounding the individual counseling they each received. Finally, the couples in the study communicated a sturdy case of responsibility and the involvement of other individuals, peers, and allies. They also spoke of community involvement stemming out of their healthier lives. The whole of their conversations leaned toward a holistic approach in how they became healthier in their lives overall that potentially translated to healthier parent-child relationships. Although children were mentioned, the couples did not talk extensively as to how their addiction impacted the lives of their children. Some participants alluded to the health and success of their children, but not directly in relationship to recovery. This section discussed recovery in the couple relationship. The themes in this study signify recovery changes and success with the couples as the concept of differentiation of self, prior research, and recovery principles highlighted above as evidence that tools of recovery improve the health of couple relationships. It lays the 112
foundation for Emotional Change, Interdependent Interactions, and Cultivated Communication. The major dimensions (del Vecchio, 2011) of health, home, purpose, and community also radiate from the narratives. Existing Research and the Four Themes Few studies have been done about couples in recovery. The themes arising from the data indicate that the utilization of self-help support groups, recovery tools, and treatment provided support change within the relationship. This study observed the ideas that cohesiveness and recovery in the couple relationship reveals improvement in differentiation of self over time with such recovery practices. Other research may have similar implications. A qualitative study completed by Martin (1999) discovered language couples in recovery utilized in their relationships together. The language she found from her study indicated some similarities with this phenomenological inquiry. The commonly used words and phrases included speaking of fear, love, work, honesty, gratitude (and synonyms), loss of control, and detachment. The researcher also described use of twelvestep program and spirituality language. Many of these same words were used in this study as couples spoke of fear, hope, love, honesty, spirituality, and twelve-step language as well. There also seemed to be a considerable focus on the influence the meetings and spirituality in the language in this research compared to the findings of Martin (1999). The language seems fitting to the themes of Emotional Change, Interdependent Interactions, Cultivated Communication, and Treatment Dilemmas. Researchers have studied Behavioral Couple Therapy among substance abusing partners in relationship together. O’Farrell, Hooley, Fals-Stewart, and Cutter (1998) 113
examined expressed emotion (EE) in alcoholic patients and their partners. Their hypothesis was Behavioral Marital Therapy along with a medication would decrease EE and relapse. One of the findings indicated that Alcoholic patients that had a high EE spouse were more likely to relapse. Also, lower EE partners, seemed to have longer time and a decrease in the percentage of relapse within a 12 month period. Although the qualitative inquiry here does not imply causal relationships, the data from O’Farrell and colleagues does relate to the Interdependent Interaction Theme discussed and differentiation of self. Bowen Theory and emotional reactions seemed to be supported by both study measures from O’Farrell et al. (1998) as well as those themes in this research. McGuinness (1999) examined couples adult children of alcoholic and adult children of non-alcoholic parents. She anticipated that the marital partner that had an alcoholic parent would have higher levels of unfulfilled needs, lower levels of differentiation of self, and would score higher on factors one and two of the dominanceaccommodation scale than their partners, adult children of non-alcoholic parents (ACNAs). When there were no significant differences indicated between groups, her explanation of how the positives from the results seemed to maintain better levels of differentiation of self than was expected were related to unanticipated factors of individual growth, potentially from individual treatment. This same concept was found in the recovery definition research and principles (del Vecchio, 2011) that recovery is supported through relationships and social networks. The social networks as determined through the SAMHSA’s new recovery principles state the following (p.2): “An important factor in the recovery process is the presence and involvement of people who believe in the person’s ability to recover; who offer hope, support, and encouragement; and who 114
also suggest strategies and resources for change.” Translating the qualitative results in this phenomenological study has similar underpinnings to those just mentioned within the social networks—hope, support, and encouragement. Another study investigated self-help support groups and treatment in couple relationships by McCrady, Epstein, and Hirsch (1996). The aspect of the research most supportive of this study was that utilizing couple treatment with both AA and Al Anon involvement was effective in determining an increased participation in the meetings. The researchers also discussed that the overall Al Anon therapy groups had little difference among them. The participants in this qualitative study reported a positive experience from utilizing self-help support group meetings, which coincided with the findings of McCrady et al. (1996). Since it is difficult to determine whether treatment or self-help support groups influenced the overall change in differentiation in this study, it is important to consider the potential factors of treatment in the recovery process. As Byrne et al. (2005) analyzed the aspects of the group therapy on those in a group therapy setting as helpful: the structure and content were significant; characteristics of group process (imitative learning, universality); and specific skill building curriculum (family of origin and patterns of relating). These researchers have found that treatment shaped the change process specifically from the group interactions. Perhaps the same characteristics happen in the self-help support group arena. The characteristics described in this phenomenological study sample utilized treatment, therapies, and self-help support
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groups. A determination of what in those factors was most effective is not feasibly separated. This delineation allows for future directions in research, which will be discussed further in that section. MEMBER CHECKS Member checks were utilized in this research as a credibility or validity measure. Triangulating the data, as described by Creswell (2007), in the form of member checks assisted in confirming and strengthening the theme concepts. The participants in the study were asked if they would be willing to participate within that process. The participant couples read through the results chapter. They were asked to observe the themes as a fit for their own experiences in recovery and their relationship together. They were also asked to confirm the transcription as accurate to their own meanings, experiences, and appropriateness of anonymity within the transcription. All of the couples responded back with feedback and comments see TABLE 2. Anonymity is not only an important aspect of this research project, but also necessary in the recovering community. Participants verified that specific changes to the original dialogue were appropriate in maintaining anonymity. No changes needed to be made. Extraneous words or phrases removals were requested, which was completed. When naming one of the meaning units, the term positive triangulation seemed to fit the data that was surfacing, which instinctively did not seem appropriate to name it as such. One participant couple questioned that theme, confirming the need for change. For better clarity and decreasing confusion of the theme with the theory, it was changed to Interdependent Interactions, which better captured the meaning of the meaning in positive
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relationship terms. Triangulation in Bowenian terms had a negative tone, which was not the intent of that analysis segment. No other respondents questioned the theme names or descriptions. TABLE 2 Member Check Responses ___________________________________________________________________ Accuracy of Transcription
Accuracy of Anonymity
Agreement with Themes and comments ___________________________________________________________________ RC1 * ** Concerned about the name and definition of a theme, which was changed to better describe the data (the theme is now titled Interdependent Interactions) RC2 ** Asked to correct one Liked the way the themes transcription quote were grouped from using alcohol as an antidepressant for treating depression. (p. 97) RC3 Accurate
** Enjoyed the themes. Found the treatment definition dilemma “insightful.”
RC4 ** Accurate Wanted extraneous Language—removed ums…
Themes accurate “nice record to have. important for recovery community”
RC5 ** Accurate Agreed with the themes “no areas of concern” __________________________________________________________________ ** No Changes Requested * No response
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LIMITATIONS This research was a qualitative exploration of couples in recovery. The participants were gathered using purposeful sampling. Flyers were placed in recovery clubs, recovery rallies, and meetings at one mid-western city. Five couples volunteered, which is a small number. All the participants represented the white, heterosexual population with combined incomes greater than $50,000 per year. Participants reported having a high school and higher education. Half of them were Masters level or higher education level. The small sample size allowed for the rich stories and experiences the participants shared, but the sample may not be indicative of the general population. Although some level of treatment was a criterion for participation in this study, it was difficult to find volunteers that met the criteria. Participants were accepted into the study even if they stated they had not been involved in treatment. An interview question was then adapted to ask why they did not participate in formal treatment. Before this question was asked however, most participants had already recounted that they had, in fact, participated in some form of treatment or counseling. There seemed to be a divide in the understanding of the meaning of treatment for the participants. Residential treatment seemed to emanate that meaning for them, discounting other forms. It also became clear that exploring the definition of addiction treatment was important, but time constraints disallowed it. Participants were asked to briefly comment on the results chapter for member checks. Perhaps more specific questions could have been formulated on a questionnaire,
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which could have given a more in-depth approach to the member checks. It may also have provided detailed descriptions they formulated to improve the overall validity of the study. One limitation of this study was the lack of exploration of spirituality. All of the participants selected a religious or spiritual orientation on their demographic form. Each of the couples also shared various aspects about a Higher Power or some spiritual practice or awakening experience. Couples experiences provided glimpses of spirituality, but the questions of the study did not delve into the concepts of spirituality or that influence within the relationship. Attachment was another area, which could have been explored in this population. There were snapshots of some couple descriptions that seemed to indicate a need for extended examination of attachment struggles. Issues of separation, intimacy, and possible insecurity in early recovery stages were not examined. This study did not explore those areas of attachment injury that may have occurred in the family of origin, and which could have transmitted further to the couple relationship. Finally, a factor limiting this study was the exclusion of children in the interview. Children were excluded per the assumptions of structural therapy—a family is healthier when the parents are healthier, which also supported the concept of differentiation of self in Transgenerational Theory. Had children been included there could have been more limitations placed on who could participate, long-term married couples, age limit on children, and blending families. Participants did mention their children in various aspects of the interviews. The participants in this study varied in all aspects that included
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blending families with adult children, adult children, children still living at home, and foster children. Time constraints were a factor in not further exploring their relationship in regards to their children. IMPLICATIONS FOR CLINICAL PRACTICE There are some observations for professionals to consider when treating the addicted population. From this study it may be inferred that treatment and other recovery practices may have some influence on the improvement in the couple relationship. Agencies may not be addressing this need. Fals-Stewart and Birchler (2001) found similar conditions when they conducted a national survey of agency use of Behavioral Couple Therapy (BCT). Less than five percent of the agencies were even aware that BCT existed. They posited that the divide between research and implementation of therapy was a potential barrier. Becoming in tune with the research and practice, needs to be assertively pursued. Defining basic treatment concepts may be warranted. Residential treatment is not the only form of substance abuse treatment available for the individual. The various forms may range from residential treatment (long term as well as short term), individual counseling, group therapy, educational groups, intensive outpatient groups, family therapy groups, pastoral counseling, and couple therapy. Treatment may be approached with different forms, styles, and theoretical foundations, but that does not negate the potential outcome of that treatment. Understanding how to work within the culture of recovery has implications to better serving this population. Many clinicians that work in the field of substance abuse treatment understand the importance self-help support groups, but other clinical 120
professionals may not have a full understanding of that significance. The meetings that the couples reported attending, seemed to have a great deal of to them. Self-help support groups seemed to be a factor in promoting change in the relational interactions in the couples and created healthier ways of emotionally responding, communicating, and connecting. Clinicians who may not understand the worth of self-help meetings should be cautioned against discouraging attendance, based on the experiences these couples shared. Self-help support group meetings are not clinical in nature, but provide an important link to healthy individuals and couples. Participants in this study, spoke of the lack of couple support and also the absence of discussion of relationships within the meetings. Further, in developing the review of literature, Recovering Couples Anonymous was uncovered. Little is known about this group, but increased awareness within the profession about all possibilities for assistance for couples and families would be advantageous. The systems approach to working with the addicted population has strengths and support in theory (Bowen & Kerr, 1988) and practice (McCrady, 1986; O’Farrell & FalsStewart 2001). Continued clinical and outcome research should carry on with couples in recovery to refine clinical practice. Improving the depth of understanding of couple needs during the recovery process has many facets to explore. FUTURE RESEARCH IMPLICATIONS Future research has several areas of potential focus according to the study limitations. This research may be duplicated with a more diverse population including socioeconomic differences, race, sexual orientation, and differing family forms. A 121
longitudinal qualitative study comparing couple recovery over a period of years could also be a potential focus. Existing or newly designed questionnaires may be utilized to further explore these themes in relationship to recovering couples. The quantitative nature of such studies may extend to the more generalized population. This study focused on couples in recovery where partners met while one was still actively engaged in using and no time constraints were applied. A priority in this study was to delve into the strengths and resiliencies of couples that remained together through recovery. Comparing short versus long term relationships and short versus long-term recovery will likely provide a sharper picture of the differences among recovering couples. Interviewing divorced individuals that did not make it beyond early recovery may also provide a better understanding of the needs couples may have in recovery. A balance of the two could help to inform clinicians working with couples at different stages in the process of recovery. Future researchers may perhaps apply a duplicate of this study while viewing it through a different theoretical lens such as attachment theory, clinical therapy techniques, or recovery principles. Conceivably, questions could be applied using no theoretical view to delve into the phenomenon of couples in recovery. Theory development in this area could serve to assist in explaining the connections in resilient recovering couples. Further research in understanding treatment options and education may be warranted. A larger systems study of treatment availability and access would serve in providing information of the process, toll, and issues involved in finding, affording, and receiving treatment. Studies of treatment could also view the family participation in attempting to find treatment for loved ones. 122
Can an inanimate object be triangulated into a relationship as that third party to relieve anxiety? Can a relationship with an inanimate object occur? Not in the truest sense, but experiences in clinical work seem to lean in that direction. Research is quite thin concerning this possibility. Researchers need to consider further examination of this perception. Spirituality and couples in recovery may also be worth exploring more extensively. Spirituality surfaced at multiple times during the interviews, as a common value the partners seemed to share. Researchers may consider exploring whether the value of a Higher Power or spiritual practices was present in their lives before active alcoholism/addiction and recovery. Other research may measure the occurrence of the Higher Power practices that arise from recovery processes RESEARCHER TRANSFORMATION The first thought that comes to mind at this juncture is: “I have so many more questions that need answering!” I will not spew a barrage of questions now, but I will share those experiences I had through the research process. In designing the flyers, my idea was to stop by some local meetings to ask if I could leave the flyers. The self-help support group meeting arena encompasses a tradition that no person push his/her own agenda within the meetings. I was invited in to a local Al Anon meeting—actually it is one that I used to attend many years ago. I knew the tradition, questioned it, and stated that I would just like to leave flyers. In spite of that, the chair of the meeting welcomed me to introduce my study to the group before the meeting began. I introduced my study, and two people immediately left the room. It was not my intention to offend, but I may have done just that. This reaction could have been an indication of the comfort level of 123
the Al Anon members. Maybe they were new to the meetings or they just did not understand what was happening. After that experience, I decided to take a different approach—making someone uncomfortable in a place they were seeking solace was not an option. I attended a recovery rally where I was allowed to set up a booth where several potential couples showed interest. Additionally, I did not want to give up on the meetings altogether, so I went to some AA meetings about a half an hour before they started and talked with people then. Finally, some participants volunteered through word of mouth. One of the participants of this study questioned some of the data in the results section during the member check. The question was concerning whether or not alcohol or an inanimate object could be a part of a triangle in the relationship. In the literature, I could not find anything that addressed this specifically, so I decided to contact by email an expert, Dr. Michael Kerr, who authored directly with Dr. Bowen (see Kerr & Bowen, 1988). The correspondence detailed (personal communication, April 13, 2012): The Researcher: I was wondering if Bowen's Theoretical concept of triangulation would also explain or include as part of the theory that alcohol, drugs, or other inanimate objects could also be triangulated in the couple relationship? Dr. Kerr: Strictly speaking, the concept of the triangle involves three living people. The "insiders" play an active part in maintaining the triangle and the "outsider" plays an active part in maintaining it as well. It is true that alcohol, inanimate objects, dead people, and such can serve the same function as an alive third person and, in that way it is similar to a triangle, but it does not meet all the criteria for a triangle. For example, the outsider's reaction to being in the outside position is part of what creates and sustains a triangle. In contrast, Jack Daniels never pleads, "We have to stop doing this!" I prefer to describe substance abuse as one member of a chronically anxious fused twosome distancing into drug abuse. I would just leave it at that and not invoke the triangle for the reasons that I mentioned above.
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Having this clarification provided a distinct explanation for the concept of triangulation. It also helped to confirm the idea that substance abuse may become a form of distancing within the couple relationship. The process in this research was invigorating for me professionally and personally, but the couples I met with fueled that experience. It was a privilege to meet and speak with each of the recovering couples. They were open, enthusiastic, and passionate during the interview process. After every interview I felt an energy and excitement. I knew the stories they were willing to share had so many common threads. The themes that surfaced confirmed some of my own early experiences and provided understandings of how couples in recovery succeed.
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O’Farrell, T. J., & Fals-Stewart, W. (1999). Treatment models and methods: Family models, In B. McCrady (Ed.), Addictions: A Comprehensive Guidebook, 287-305. New York: Oxford University Press. O’Farrell, T. J., & Fals-Stewart, W. (2001). Family-involved alcoholism treatment: An update. In M. Galanter (Ed.), Recent developments in alcoholism, volume 15: Services research in the era of managed care (329-356). New York, NY: Plenum. O’Farrell, T. J., Hooley J., Fals-Stewart, W., & Cutter, H. S. G. (1998). Expressed emotion and relapse in alcoholic patients. Journal of Consulting and Clinical Psychology, 66(5), 744-752. Office of Applied Studies. (2003). The alcohol dependence or abuse among parents with children living in the home. Results from the 2002 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 03-3836, NHSDA Series H-22). Rockville, MD: Substance Abuse and Mental Health Services Administration. Available online: http://www.oas.samhsa.gov//.adss.htm Office of Applied Studies. (2008). Results from the 2007 National Survey on Drug Use and Health: National findings (DHHS Publication No. SMA 08-4343, NSDUH Series H-34). Rockville, MD: Substance Abuse and Mental Health Services Administration. Also available online: http://oas.samhsa.gov Parker, G., & Hadzi-Pavlovic D. (1990). Expressed emotions as a predictor of schizophrenic relapse: An analysis of aggregated data. Psychological Medicine, 20, 961-965. Patton, M. Q. (1990). Qualitative evaluation and research methods (2nd ed.). Newbury Park, CA: Sage Publications. Petroni, D., Allyn-Byrd, L., and Lewis, V. (2003). Indicators of the alcohol process: Critical items from the Koss-Butcher and Lachar-Wrobel analysis of the MMPI-2. Alcoholism Treatment Quarterly, 21(2), 41-56. Prest, L. A. (1991). Family of origin, dyadic relationship and the level codependence: A comparison of alcoholic and non-alcoholic couples. Unpublished doctoral dissertation. Virginia Polytechnic Institute and State University. Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice, 20, 161-173.
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APPENDICES
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APPENDIX A INTERVIEW QUESTION GUIDE 1. Tell me about your experience during the process of recovery. 2. How you have been able to stay connected? Explain your time alone, independent of each other? 3. How have you as partners been impacted by recovery from addiction? 4. How have self-help support groups impacted your relationship (i.e. AA on couple relationship from each partner’s perspective)? 5. How has specific treatment (i.e. residential or intensive outpatient treatment) of the addict impacted you as a couple? 6. What has helped you change together? 7. During the process of recovery who or what else seems to have been involved in your relationship? 8. What mechanisms do you use to distance yourself from your spouse or others?
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APPENDIX B DSM-IV-TR DIAGNOSES The DSM-IV-TR (2000), describes substance dependence in which three or more of the following symptoms must be present in the same 12-month period (APA, 2000, p. 197): 1) tolerance, as defined by either of the following: a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect b) markedly diminished effect with continued use of the same amount of the substance 2) withdrawal, as manifested by either of the following: a) the characteristic withdrawal syndrome for the substance b) the same (or closely related) substance is taken to relieve or avoid withdrawal symptoms 3) the substance is often taken in larger amounts or over a longer period than was intended 4) there is persistent desire or unsuccessful efforts to cut down or control substance use 5) a great deal of time is spent in activities necessary to obtain the substance(e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain smoking), or recover from its effects 6) important social, occupational, or recreational activities are given up or reduced because of substance use 7) the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption) The DSM-IV-TR manual also defines substance abuse as follows (APA, 2000, p. 199): A. A maladaptive pattern of substance use leading to clinically significant impairment or distress , as manifested by one (or more) of the following, occurring within a 12-month period: 134
1) recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) 2) recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use) 3) recurrent substance-related legal problems (e.g., arrests for substancerelated disorderly conduct) 4) continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights) B. The symptoms have never met the criteria for Substance Dependence for this class of substance.
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APPENDIX C DEMOGRAPHIC SURVEY Participant Pseudonym: ____________________________ 1. What is your age? ________ Partner’s age? ________ 2. What is your sex? (Please Circle) Male Female 3. What is your race/ethnicity? _____Caucasian ______Native American _____African-American ______Asian or Pacific Islander _____Hispanic ______Other (__________________) 4. How long have you been married/together? ______ 5. Were you ever separated? ___ yes ___no If so, about how long ago? _________ For how long? _________ 6. What is the highest grade in school that you have completed? _____Less than high school _____ High School _____ Technical School _____Master’s degree _____Some college _____Doctoral degree _____Bachelor’s degree _____Other (please specify)____________________ 7. What is your current work status? _____Full time paid employment _____ Disability _____Part time paid employment _____ Retirement _____Full time employment from home _____Unemployed _____Homemaker
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8. Counting all sources of income, what is your family’s total yearly income before taxes? (optional) _____Under $10,000 _____$30,000 to $34,999 _____$10,000 to $14,999 _____$35,000 to $39,999 _____$15,000 to $19,999 _____$40,000 to $44,999 _____$20,000 to $24,999 _____$45,000 to $49,999 _____$25,000 to $29,999 _____$50,000 or more 9. If you are a parent, please list each of your children by age and gender. _____Not applicable _____Gender, Age_____ _____Gender, Age_____ _____Gender, Age_____ _____Gender, Age_____ _____Gender, Age_____ 10. Religion _____No affiliation _____Protestant _____Catholic
_____Jewish _____Christian _____Other (___________________)
11. How long ago was addiction/alcoholism active in your relationship? _______ 12. How long have you been in recovery? _______
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APPENDIX D FLYER TO RECRUIT PARTICIPANTS
Understanding Recovery from Alcoholism or Substance Addiction with Their Partners My name is Cheryl L. Thomas and I am a licensed professional clinical counselor, marriage and family therapist, and a doctoral student in marriage and family therapy at The University of Akron. I would like to meet and talk with recovering alcoholics or addicts and their partners about their experience with recovery. The purpose of this study is to gain a better understanding of the impact of the recovery process to the couple relationship. Information from this study will be used to inform professionals in providing possible services for the couple, not just the individual. The purpose also fulfills an area not explored—the couple’s voice in recovery. Participants will not be asked to explore their active past experiences of the negative behaviors and events that may have occurred. Interested couples will be asked to participate in one private interview. The interview will focus on gathering your story. You will also be asked to review the data to put forth your input to the interpretation of it.
Department of Counseling College of Education Akron, OH 44325-5007 330-972-7777 • 330-972-5292 The University of Akron is an Equal Education and Employment Institution
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For purposes of this study, one partner must have considered him/her self as have a problem with either a substance abuse or substance dependency. He or she must have at any time in their recovery attended treatment, counseling/therapy, and a self-help support group. Neither partner should be actively using a substance or be participating in a formal treatment setting. The participants may be attending a self-help support group, but is not mandatory. The couple should not be separated or divorced over the length of the relationship for this study. The consent form is enclosed. This form provides further information about the study and any potential risks. If you have additional questions about the study please call and leave a confidential voice mail at 330-351-0862. When I receive the copy of the consent form I will contact you by phone to answer any questions and discuss arrangements for an interview. This study has been approved by the Institutional Review Board # 2011038 at The University of Akron, Office of Research Services 330-972-7666. Thank you for your time! Cheryl L. Thomas
Department of Counseling College of Education Akron, OH 44325-5007 330-972-7777 • 330-972-5292 The University of Akron is an Equal Education and Employment Institution
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APPENDIX E INFORMED CONSENT TO ACT AS RESEARCH PARTICIPANT
TITLE: The Impact of the Recovery Process on Couple Relationships: A Qualitative Examination INVESTIGATOR:
Cheryl L. Thomas, M.A., M.A.Ed., LPCC-S, LMFT Doctoral Student The University of Akron Department of Counseling and Special Education Akron, OH 44325 (330) 351-0862
DISSERTATION ADVISOR: Dr. Patricia Parr The University of Akron Department of Counseling and Special Education Akron, OH 44325 (330) 972-8151
Department of Counseling College of Education Akron, OH 44325-5007 330-972-7777 • 330-972-5292 The University of Akron is an Equal Education and Employment Institution
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RESEARCH STUDY DESCRIPTION: You are invited to participate in a study being conducted by Cheryl L. Thomas, a Doctoral level student from the Department of Counseling, College of Education, The University of Akron, Akron, OH. This study focuses on the life stories (a phenomenology) of adult couples who have experienced recovery from addiction/alcoholism. Specifically, the study will examine information about the experience of living through recovery as a couple. If you decide to participate, you will be asked to take part in an interview at a convenient time and place for you. The interview should take approximately two hours of your time. You will also be asked to review and write down any feedback of the data that comes out of your interview for accuracy, which will take about an hour. Participation in the project is completely voluntary. There are specific criteria that need to be met to participate in this study. For purposes of this study, one partner must have considered him/her self as have a problem with either a substance abuse or substance dependency. He or she must have at any time in their recovery attended treatment, counseling/therapy, and a self-help support group. Neither partner should be actively using a substance or be participating in a formal treatment setting. The participants may be attending a self-help support group, but is not mandatory. The couple should not be separated or divorced over the length of the relationship for this study. RIGHT TO REFUSE OR END PARTICIPATION: You may refuse to answer any questions and may withdraw from the study at any time without penalty.
Department of Counseling College of Education Akron, OH 44325-5007 330-972-7777 • 330-972-5292 The University of Akron is an Equal Education and Employment Institution
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CONFIDENTIALITY: Your confidentiality will be protected throughout the study. Any data obtained from you through audiotapes of interviews will be kept confidential and will not be heard by anyone but the researcher. The identities of individual participants will not be revealed during presentation or write-up of findings. Pseudonyms (different names) will be used in conjunction with direct quotes. There will be no identifying information about the individuals used in the research. Data will be stored for 3 years from the date of publication and then destroyed. The results may be disseminated in research publication, teaching or training, or professional presentations. RISKS AND BENEFITS: There are no obvious medical or emotional risks involved in this study. However, there is always the possibility that sensitive feelings may be evoked through discussing one’s life story. Attached is a list of referrals should therapy or treatment need to be utilized. If this researcher foresees any emotional risks, the participant(s) will be removed from the study and proper clinical referrals and practices will be followed. Once the dissertation is complete, a benefit is that you will receive a transcript copy of your recovery story interview (with pseudonyms in place of your names) to keep. Another benefit is that other couples may have a better concept of their own recovery because of your willingness to share. Lastly, you may learn more about the positives changes of your partner and yourself in the process recovery through telling your story. If you have any questions about this dissertation research, you can call me at 330351-0862 or my advisor Dr. Parr at 330-972-8151.
Department of Counseling College of Education Akron, OH 44325-5007 330-972-7777 • 330-972-5292 The University of Akron is an Equal Education and Employment Institution
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LIMITATIONS OF RESEARCHER RESPONSIBILITY: The researcher is not responsible for any counseling or treatment services to the participants either directly or indirectly as a result of this study. If the participants do not have a therapist or treatment center, appropriate referrals will be given along with contact information. This research dissertation has been reviewed and approved by The University of Akron Institutional Review Board (IRB) for the Protection of Human Subjects. Questions about your rights as a research participant can be directed to Ms. Sharon McWhorter, Associate Director, Research Services, at 330-972-7666. Please have this information with you, when contacting the IRB. If you should need to call concerning this research, you will need to have this form with the title of the research and name of the researcher. Thank you for your participation! VOLUNTARY CONSENT: All of the information concerning this study has been explained and any questions answered by Cheryl Thomas. I understand that there will be a brief phone interview, a completion of a demographic questions survey, an interview with follow-up. By signing this form, I agree to participate in the study. I also agree to brief voicemail messages being left at phone contact information.
Department of Counseling College of Education Akron, OH 44325-5007 330-972-7777 • 330-972-5292 The University of Akron is an Equal Education and Employment Institution
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I CONSENT to participation in this project: ___________________________________ Name of Participant (Please PRINT) ___________________________________ Signature of Participant
________________ Date
I GIVE MY CONSENT for the interview to be audiotaped: ___________________________________ Name of Participant (Please PRINT) ___________________________________ Signature of Participant CONTACT INFORMATION: Please provide your contact information. NAME(S)_____________________________________________ PHONE NUMBERS _____________________ _____________________ _____________________
Department of Counseling College of Education Akron, OH 44325-5007 330-972-7777 • 330-972-5292 The University of Akron is an Equal Education and Employment Institution
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APPENDIX F PHONE INTERVIEW GUIDE Hello. Thank you for contacting me. I appreciate your interest in my study. I would like to tell you a little about my research and myself. Do you have some time right now? My name is Cheryl Thomas. I am a Doctoral student in the Marriage and Family Therapy Program at The University of Akron. In order to complete my program, I am working on a research project in which I am interested in finding out how couples have worked through recovery from addiction to gain a better understanding of their experiences in the process. My research advisor and supervisor is Dr. Patricia Parr. She is in The Department of Counseling and holds independent licensure in Marriage and Family Therapy and Professional Clinical Counseling. You may contact her at 330-972-7779 should you have any questions. I would like to meet and talk with you and your partner together about your recovery experience in an interview session. The interview should take about an hour and a half. If you agree, the interview can take place in your home or a public place where you feel comfortable. You will not be asked to explore your past active substance abuse experiences or negative behaviors and events that may have occurred then. Do you have any questions at this time? Do you mind answering some questions for me right now? 1. Have you ever been in formal treatment? (needs to answer yes) 2. Are either you or your partner currently in formal treatment? (needs to answer no) 3. What self-help support groups have you attended? (needs to answer yes by the alcoholic) 4. Has your partner remained with you throughout your substance abuse and recovery? (needs to answer yes) 5. Have you abused any alcohol or other drugs (street or prescribed) in the past year? Or currently? (needs to answer no to both) 6. Has your partner abused any alcohol or other drugs in the past year? Or currently? (needs to answer no to both) 7. Are you currently separated or divorced living apart from your partner?
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If the responses to the questions are met, the interview will continue as follows: I want to just remind you that this is a research interview about experiences. It is not counseling or treatment. Do you have any questions about the consent form you received? This form provides further information about the study and any potential risks and benefits. If you have additional questions about the study please call and leave a confidential voicemail at 330-351-0862. May we go ahead and schedule time for the interview? Time and place set. Thank you for your time. I look forward to meeting with you! If the responses are such that the criteria are not met, the following will be stated: Thank you so much for your interest in my study; however, I am looking for specific criterion and I need to have participants _____________________________ (I will choose the one that fits the situation, the number are in the respective order of questions 1-8 above): 1. in which one partner has been in formal substance abuse treatment. 2. in which neither of you are in current treatment. 3. in which the alcoholic/addict must have at some point been involved in selfhelp support groups. 4. that remained together throughout the active substance abuse and the recovery. 5. that have not used or abused any alcohol, street, or prescription drugs currently or in the past year. 6. whose partner has not used or abused alcohol, street, or prescription drugs currently or in the past year. 7. that is not currently living apart from each other. Your time is appreciated!
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APPENDIX G COUNSELING AGENCY REFERRAL LIST
If any participant should need the treatment services of a therapist or agency due to associated distress with this study or other distress, this list of local agencies is provided to all participants to select treatment of their choice. The below agencies are not endorsed nor services paid for by researcher, Cheryl L. Thomas, nor The University of Akron. 1. Clinic for Individual and Family Counseling located at The University of Akron 330-‐972-‐ 6822. http://www.uakron.edu/clinics/ifc/. The Clinic offers reduced fees on a sliding scale basis for persons seeking individual and family counseling. The Clinic does not turn anyone away based on income levels. 2. The Counseling Center located at 2285 Benden Dr., Wooster, Ohio 330-‐264-‐9029. http://www.ccwhc.org/. The Center provides a comprehensive array of treatment services and also offers a number of specialized programs designed to prevent mental and emotional problems. 3. Alcohol, Drug Addiction, and Mental Health Board (ADM) located at 100 W. Cedar St. #300, Akron, Ohio 330-‐762-‐3500. http://www.admboard.org/. The ADM Board is linked with a variety of drug and alcohol treatment centers and an assessment there provides those various choices. 4. STEPS at Liberty Center located at 104 Spink St. Wooster, Ohio 330-‐264-‐8498. http://www.stepsatlibertycenter.org/. STEPS has various treatment options for alcohol and drug abuse and dependence, which includes residential, intensive outpatient, non-‐intensive outpatient, individual and group therapies.
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APPENDIX H
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