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Chapter 10 Family Systems and Chemical Dependency

Catherine A. Hawkins

Texas State University-San Marcos

Raymond C. Hawkins, II

Fielding Graduate University

Previous chapters indicate that alcoholism and other drug addictions frequently impair an individual’s physical, psychological, and social functioning. There is also recognition that alcoholism and other drug addictions adversely affect the individual’s marital and family relationships. In a Gallup poll, more than a third of respondents reported that drinking had caused problems in their family (Newport, 1999). Another Gallup poll based on interviews with 902 U.S. adults with an immediate family member with a drug or alcohol addiction reported that the family member’s addiction had a negative effect on their own mental health (70 percent of respondents) and their relationship with other family members (51 percent) (Saad, 2006). These negative effects are far-reaching, given the prevalence of parental alcoholism. “It can conservatively be estimated that approximately 1 in every 4(28.6 percent) children in the United States is exposed to alcohol abuse or dependence in the family” (Grant, 2000, p. 114).

Defining alcoholism at the family level lacks specificity, despite its intuitive appeal. Many terms in the literature attempt to capture this phenomenon, such as family disease, alcoholic family, addicted or chemically dependent family, alcohol impaired family, or family with an alcoholic member. An understanding of the family dynamics associated with alcoholism or other drug addiction must entail descriptions of interactive processes that occur throughout the life cycle of the family. In addition, family is a term that is no longer clearly defined in society. The material presented here applies to all forms of families, including nuclear, extended, single-parent, communal, kinship, and gay/lesbian.

This chapter examines some of the more noteworthy efforts to specify the etiology and treatment of the family processes associated with chemical dependency. The term alcoholism will be used, although theoretically, much of the scholarly literature can be reasonably generalized to other drug addiction. The literature on a family perspective of chemical dependency, including the theory, research, and treatment of alcoholism and other drug addiction in families, is discussed. Three dominant theoretical approaches—behavioral, stress coping, and family systems—are presented. The constructs of codependency, children of alcoholics, and adult children of alcoholics are explored as they relate to family dynamics. The ways in which theory shapes practice with chemically dependent family systems are addressed along with more specific treatment information. Finally, a case example is presented that illustrates some of the main concepts discussed in this chapter.

A Family Perspective in Theory, Research, and Treatment

During the early decades of the twentieth century, a scientific tradition emerged in the social sciences. The study of alcoholism, however, was restrained by the moral overtones attached to the problem, which led to the belief that alcoholism was not amenable to scientific inquiry. The growing Temperance Movement culminated in the Prohibition amendment in 1919. Attempts at treatment of alcoholism (which were almost exclusively directed at men) consisted largely of removing the individual to a residential program for detoxification and some therapy, known euphemistically as “the cure.” In Alcoholics Anonymous, Bill W., a founder of Alcoholics Anonymous (AA), describes his “rehabilitation” as belladonna treatment, hydrotherapy, and mild exercise (AA, 1939).

In the 1930s, the disease or biological model of alcoholism began to gain acceptance. AA, founded in 1935, embraced this model. Although AA was originally oriented toward men, wives would hold meetings modeled after AA to discuss the effects of alcoholism on their lives. (Lois W., Bill W.’s wife, is credited with organizing the first meeting.) At this same time, psychoanalysis was growing in popularity, and it explained alcoholism in terms of psychopathology. Both these models were limited to an examination of the etiology of alcoholism in the individual. Psychoanalysts acknowledged the impact of family dynamics on psychopathology, and they had some interest in the family aspects of alcoholism, but they looked at psychopathology in terms of each individual partner rather than their interaction (Lewis, 1937). Psychoanalytic practice wisdom prohibited the involvement of family members in therapy with the alcoholic, as this was believed to contaminate the therapeutic transference. Another development of the 1930s was the emergence of the fields of marital therapy and child guidance, with their focus on interpersonal relationships. However, early practitioners used a collaborative approach in which separate therapists would meet with family members, and then the therapists would consult with each other on their treatment session (Goldenberg & Goldenberg, 2008).

Theory and research on alcoholism grew through the 1940s and 1950s but continued to be limited to a study of its physiological and emotional effects on the individual (predominantly middle-aged Anglo males), such as the seminal work by Jellinek (1960). Even the conceptualizations of alcoholism in the marital dyad maintained an individual focus (Billings, Kessler, Gomberg, & Weiner, 1979; Finney, Moos, Cronkite, & Gamble, 1983). For example, the distressed personality model, rooted in psychoanalysis, held that underlying psychopathology in the wife led to the development and maintenance of a drinking problem in the husband (Futterman, 1953; Kalashian, 1959; Price, 1945). Alternatively, the stress personality model, which applied to both genders, viewed personality disturbance in the spouse as resulting from the chronic stress in the home generated by the alcoholic (Jackson, 1954).

In the 1940s, the concurrent approach to marital and family therapy began to emerge. In this model, one counselor would work with a couple but would meet with them separately (Goldenberg & Goldenberg, 2008). One of the first attempts to include families in treatment involved concurrent group therapy for alcoholics and their wives (Ewing, Long, & Wenzel, 1961; Gliedman, Rosenthal, Frank, & Nash, 1956). These early programs demonstrated that involving spouses increased the completion rate of treatment and expanded the criteria of successful outcome to include both partners’ psychosocial functioning as well as abstinence by the alcoholic (Steinglass, Bennett, Wolin, & Reiss, 1987). By 1948, the support groups organized by the wives of AA members had become a formal network called Al-Anon Family Groups, targeting spouses of both genders. (For a description of the Al-Anon program, see Albon [1974], Kurtz [1994], and Keinz, Schwartz, Trench, & Houlihan [1995].) In 1957, Alateen was formed for teenage children of alcoholics, and later, Alatot groups were developed for younger children. By the late 1950s, the conjoint approach to marital and family therapy was introduced, in which one counselor would meet with couples and families as a unit (Goldenberg & Goldenberg, 2008).

In the 1960s, as social science moved away from a strictly individual perspective and began to consider the influences of the environment, a third model for conceptualizing alcoholism in the marital dyad emerged. The psychosocial model integrated the distressed personality and stress personality models (Bailey, 1961). It focused on the consequences of the alcoholic’s drinking behavior and the spouse’s coping style on both the marital partners. Through the 1960s, the rise of systems theory and behavioral theory led to a broader perspective that focused on the interactive, reciprocal nature of family processes. Although conjoint family therapy developed during this time, family treatment for alcoholism continued to consist of a concurrent program for nonalcoholic spouses (i.e., wives). This was attributed to the general ignorance of alcoholism by family therapists, who often failed to identify this problem or considered it secondary to other problems. When alcoholism was recognized as a problem, family therapists frequently referred these families to alcoholism treatment programs, where alcoholism was viewed as an individual disease (Steinglass, 1987). Alcoholism counselors reportedly avoided a family perspective due to lack of training or a belief that it was incompatible with the disease model.

This situation gradually changed during the 1970s and 1980s. Today, some type of family involvement is often included in most alcoholism treatment programs. There is considerable variation across programs, however, ranging from “family night” to full-fledged family therapy. At the same time, both the self-help and clinical movements recognize that family members have problems in their own right due to the dynamics of alcoholism. This led to such concepts as codependency, children of alcoholics, and adult children of alcoholics. According to Seilhamer and Jacob (1990), Western cultures have long recognized the detrimental impact of parental alcoholism on children. However, there was little interest in these children until the first publications identifying the clinical implications of being raised by an alcoholic parent began to appear (Ackerman, 1986; Bosma, 1972; Cork, 1969; Slobada, 1974). This was soon followed by an awareness of the impact of parental alcoholism on the adult functioning of offspring (the Adult Children of Alcoholics or ACOA movement). Being the child of an ACOA (i.e., grandchild of an alcoholic), whether the parent is alcoholic or not, also has a potentially negative impact, since alcoholism can affect families for several generations (Smith, 1988; Stein, Newcomb, & Bentler, 1993). As a result, self-help and advocacy groups (such as the National Association for Children of Alcoholics) have emerged. ACOA support groups originally began in the 1970s under the auspices of Al-Anon. Over the next few years, independent ACOA groups developed, and Co-dependents Anonymous (CODA) groups were also established.

Since the 1990s, with the advent of behavioral managed care, cost containment has affected substance abuse treatment. For example, Platt, Widman, Lidz, Rubenstein, and Thompson (1998) conducted a review of the research literature on support services, including family therapy, as an adjunct to substance abuse treatment. The authors found that despite clear evidence of the need for support services to increase treatment effectiveness, clients often do not receive these services through their health care provider or get adequate referrals to other agencies. Steinglass (2006) and Corless, Mirza, and Steinglass (2009) critique the impact of managed behavioral health care on systemic medicine and call for the family therapy field to more directly address substance misuse.

The scholarly literature on family treatment includes studies in which the alcoholic is typically a parent, spouse, or child. As described elsewhere in this book, there is a long-standing tradition of using a family perspective with adolescents, although empirical studies in which the chemically dependent person is a woman or a member of a racial or ethnic minority group are limited. There is an emerging literature on family treatment in which the alcoholic family member is elderly, mentally ill, or gay/lesbian.

Theories on Alcoholism and the Family

Chapter 2 covered many theories regarding the etiology and treatment of alcoholism. At one extreme is a strict medical model, also known as the disease model, focused on individual biological factors with virtually no consideration of familial, social, or psychological variables. At the other extreme is a strict family systems model, focused on the family as a unit, with little consideration of the individual as distinct from the family. In the middle are theories that address, to varying degrees, both the individual and the familial aspects of dysfunction, such as behavioral and stress coping models. The difference between these various theories can be quite confusing, even to a person familiar with the chemical dependency field. This section will discuss the three predominant models that address alcoholism at the family level: behavioral, stress coping, and family systems.

Family systems theory evolved in the 1950s as an outgrowth of general systems theory, which emerged in biology in the 1940s. This theory represented an epistemological shift from a reductionist, linear (cause and effect) way of thinking to one of circular causality, process orientation, and the interrelatedness of parts. The crux of systems theory, as applied to people, holds that addiction, like any other human behavior, exists in a larger context. However, the family is viewed not merely as the context for an individual’s behavior but also as an entity unto itself. Rather than expressing individual pathology, the presence of problematic behavior (such as alcoholism) in a family member is considered a symptom of underlying dysfunction in the system. The alcoholic is referred to as the identified patient to indicate that it is the system itself that is dysfunctional. Rather than identifying the effects of alcoholism on the individual members of the family, a family systems approach focuses on the individuals and the interactions among them. The structure and dynamics of the family are assessed, and intervention is planned, through applying systems concepts such as homeostasis, boundaries, triangles, and feedback. (See any basic family therapy text, such as Nichols [2009], for a discussion of these concepts.)

The behavioral and stress-coping models first developed as theories of individual behavior but now incorporate a systems perspective. They recognize that relationships among the family members are interrelated and reciprocal and that the individual both influences and is influenced by other family members. In turn, the family exists as part of the larger social system that affects both individual and family functioning. However, these models differ from family systems theory in that the family is generally seen more as a context for individual behavior than as an entity unto itself. Although all three theories share a social systems orientation, the term family systems is used here specifically in reference to that particular theoretical orientation, even though the term is often used more broadly in the literature. Further, it should be noted that most family systems intervention models actually treat the family as a closed system, rather than focusing on the family’s interactions with the larger environment.

Family Systems Theory of Alcoholism and the Family

This section focuses on family systems theory, especially three significant areas of family systems literature on alcoholism: rituals and routines, shame, and rules and roles. A discussion of the behavioral and stress-coping models is presented later in the section on assessment and treatment.

Two criticisms of family systems theory should be noted. First, some critics claim that it is largely descriptive, non-scientific, imprecise, and virtually untestable. However, its defenders consider such criticisms to be irrelevant, since the main value of systems theory is not as a traditional scientific model but as a fundamentally different approach to the conceptualization of clinical problems and therapeutic interventions. Second, feminist theory contends that there is a gender bias in family systems theory. Goldner (1985) argues that the central tenet of context—defined as a boundary that can be drawn around a family, thereby making it a distinct entity—disregards the social forces that influence the family. Another central tenet, circularity, assumes an equal distribution of power when, in fact, women are often regarded as subordinate to men within families just as they are within the larger society. Goldner warns that ignoring the impact of the social context can lead to theorists and practitioners “blaming the victim” and “rationalizing the status quo” rather than challenging oppressive sex-role arrangements in family life.

Rituals and Routines

Steinglass and colleagues (1987) distinguish between an alcoholic family, which is tantamount to an alcoholic system, and a “family with an alcoholic member.” This distinction is made by applying three core concepts of family systems theory: (1) organization, (2) morphostasis or internal regulation, and (3) morphogenesis or controlled growth. The authors cite numerous studies that demonstrate the significance of ritual invasion in the development and maintenance of alcoholism in a family.

In the alcoholic family, chronic alcoholism has become its central, organizing theme. According to Steinglass et al., in these families alcoholism is no longer just operating at the individual level, it has become incorporated into virtually every aspect of the family. The erratic and unpredictable behavior of the alcoholic, over time, often elicits a characteristic response from other family members. Their behavior becomes impaired and contributes to the perpetuation of the drinking behavior, thus establishing a circular, reciprocal pattern within the family. The functioning of a family organized around alcoholism can be further understood by applying the principles of family systems theory, such as wholeness, boundaries, and hierarchies.

This organization occurs through a process in which the family’s regulatory behaviors (morphostasis) are altered to make them more compatible with avoiding the stress and conflict associated with alcoholism. The family accommodates to alcohol-related behaviors in an effort to achieve short-term stability (the process of morphostasis is also called homeostasis). However, this increases the likelihood that the drinking will continue, because the system has (inadvertently) been organized to maintain it. Family rituals offer the clearest opportunity to investigate this developmental process since they are considered to be the most meaningful shared activity.

Rituals, encompassing cultural traditions, family celebrations, and daily routines are symbolic events repeated in a systematic fashion over time that convey a sense of belonging among family members. Cultural traditions include religious and secular events that are generally observed by the larger society, such as Christmas, Thanksgiving, or Independence Day. Family celebrations, such as birthdays, graduations, weddings, vacations, and reunions, are special events that, although perhaps shared with the larger society, are practiced in unique ways by each family. Daily routines are the most distinctive form of activity and vary widely across families. Routines reveal how the family relates in terms of time and space, such as dinnertime, bedtime, and leisure time. “The one construct that more clearly encapsulates the notion of the Alcoholic Family (a family organized around alcoholism) (is the) invasion of family regulatory behaviors by alcoholism” (p. 72). For example, the family may stop having meals together if the mother drinks in the evening and does not prepare them.

The family’s long-term growth and development (morphogenesis) entails three major tasks that determine the family’s identity: defining boundaries, establishing a family theme, and choosing shared values. Although greatly simplified in the present discussion, families accomplish these tasks as they move through a common developmental pathway encompassing early, middle, and late phases. During each developmental phase, the alcoholic family makes crucial, usually unconscious, decisions to either challenge or accommodate the drinking behavior of a family member and thus shapes family identity. In the early phase, the family initiates its identity. A key variable is how closely a couple links with their respective families of origin (which may also be alcoholic), since this will influence how the family responds to emerging drinking behavior. If the drinking behavior is not resolved, the middle phase for alcoholic families is characterized by maintaining this established identity. For alcoholic families, this means organizing around alcohol-related behaviors (i.e., invasion of rituals by alcoholism). In the later phase, the family consolidates and defends its alcoholic identity and, if the drinking is not successfully confronted, transmits this identity to future generations. Thus, according to this model, the etiology of an alcoholic family is rooted in the sacrifice of morphogenesis (long-term growth) for morphostasis (short-term stability).

Shame

Another construct associated with alcoholic systems (which is clinically derived but lacks adequate empirical validation) is shame. Although normative shame is necessary for an individual to be socially functional, shame-bound families are thought to engage in pathological patterns of communication and interaction that instill a sense of toxic shame in their offspring. There is considerable theoretical literature on the relationship between shame and chemical dependency at both the individual and family level (Fossom & Mason, 1986; Hawkins, 1996c; Kaufman, 1985a, 1985b; Potter-Efron, 1989; Potter-Efron & Potter-Efron, 1988).

Fossom and Mason define shame as “an inner sense of being completely diminished or insufficient as a person . . . the ongoing premise that one is fundamentally bad, inadequate, defective, unworthy, or not fully valid as a human being” (p. 5). Shame differs from guilt in that the latter comprises a painful feeling of regret for one’s actions while the former is an acutely painful feeling about one’s self as a person. Guilt offers the opportunity to reaffirm personal values, repair damage, and grow from the experience. Shame, however, is more likely to foreclose the possibility of growth, since it reasserts one’s self-identity as unworthy. Although shame is experienced as an intra-psychic process, its development occurs primarily through the interactions of the family. A shame-bound family operates according to

a set of rules and injunctions demanding control, perfectionism, blame, and denial. The pattern inhibits or defeats the development of authentic intimate relationships, promotes secrets and vague personal boundaries, unconsciously instills shame in the family members, as well as chaos in their lives, and binds them to perpetuate the shame in themselves and their kin. It does so regardless of the good intentions, wishes, and love which may also be a part of the system (p. 8).

Shame-bound systems can be addictive, compulsive, abusive, phobic, or exhibit some combination of these behaviors. Alcoholic families are susceptible to shame in at least two ways. First, members often construct elaborate networks for hiding the alcoholism from each other and from the community. Second, alcoholism is frequently associated with emotional, physical, or sexual abuse. Such abuse, as well as neglect, is usually cloaked in secrecy. Secrets maintain the equilibrium of the system by inhibiting family members from changing their behaviors. Thus, secrets serve to perpetuate the addiction as well as the shame of the people involved.

Kaufman (1985b) provides an explanation of how shame is transmitted from the family level to the individual. He theorizes that a single developmental process is involved that takes different pathways, either to a healthy self or to a shame-bound self. The outcome depends on the prevailing affect encountered by the child over time in his or her interactions with adults, primarily the parents. If the child’s basic needs (physical and emotional) are understood and acknowledged on a consistent and predictable basis over time, the child acquires an inner sense of trust and competence in his or her ability to get needs met. Ultimately, the child develops healthy self-esteem. However, if the parent fails to meet the child’s needs, the child attributes this as personal failure and feels deficient. If this pattern is repeated consistently over time, the normative experience of shame (which occurs when one’s needs are not met) evolves into the person’s inner experience or identity. A shame-bound self is governed by feelings of being diminished, lonely, worthless, and alienated. Given the complexity of any family system, a child is likely to experience a combination of enhancing and diminishing responses. Parents can replace a shame-inducing reaction in a child with an affirming one by accepting and explaining the parent’s own responsibility for the interaction. Thus, they free the child from the sense that he or she failed to elicit the needed response from the parent. Unfortunately, many alcoholic and codependent parents fail to take this corrective step.

Rules and Roles

Wegscheider (1981) proposes a now classic model of family interactive processes. Both the alcoholic and other family members suffer from very low self-worth and reinforce it in each other. Thus, in a reciprocal process the family system does not encourage the health and wholeness of its members, nor do members encourage the health and wholeness of the family. All families, over time, establish rules and roles that determine values and goals, regulate power and authority, specify responses to change, and establish patterns of communication. These rules are seldom recognized consciously. “Alcoholic families are governed by rules that are inhuman, rigid, and designed to keep the system closed—unhealthy rules. They grow out of the alcoholic’s personal goals, which are to maintain his [sic] access to alcohol, avoid pain, protect his [sic] defenses, and finally deny that any of these goals exist” (p. 81). Wegscheider uses the analogy of a mobile, with family members suspended and held together by strings, which represent rules. Any action by the alcoholic reverberates throughout the system. The family’s reactions are intended to bring stability, but they actually produce a long-term maladaptive response.

Families also adjust to alcoholism through the process of establishing roles (i.e., outward behavior patterns). All families function through roles (such as parent, child, etc.), but roles in alcoholic families take on an added dimension. Although there is little empirical study on the subject, the model suggests that these roles are a way of maintaining stability, since families fail to confront the problem of alcoholism, which threatens the system. Thus, the family may preserve its identity, but at a high price of which it is seldom aware. Wegscheider describes six typical family roles: dependent (the alcoholic), enabler (the powerless spouse or partner), hero (the overachieving child), scapegoat (the delinquent child), lost child (the isolated child), and mascot (the immature child). This is only a schema; in small families, one person may assume more than one role and, in large families, one role may be played by several people. Further, roles may shift over time. Although these roles may appear in all families at some time, in alcoholic families, they are “more rigidly fixed and are played with greater intensity, compulsion, and delusion” (p. 85).

Codependency and Related Constructs

As discussed, alcoholism can be viewed at both the individual and familial level: An alcoholic suffers from personal impairment and contributes to the impairment of his or her family. Likewise, other family members can develop individual impairment and contribute to familial impairment. In turn, family dysfunction can exacerbate each individual family member’s problems. The impairment of family members (alcoholic or non-alcoholic) can encompass the three related constructs of codependency, children of alcoholics, and adult children of alcoholics.

Codependency

Several definitional issues need to be considered in a discussion of codependency. It is a ubiquitous concept in the fields of chemical dependency and mental health, yet there is no general agreement as to its meaning. The concept is clinically derived and has received limited empirical attention (e.g., Carruth & Mendenhall, 1989; Cullen & Carr, 1999; Wright & Wright, 1999). Despite its intuitive appeal, this ambiguity has led to much confusion and controversy in the appropriate use of this concept in assessment and treatment. In addition, although the term is used irrespective of gender, it is typically applied more to women (Roth & Klein, 1990). This bias raises concerns about ignoring the oppression of women, discounting gender socialization, or pathologizing what may actually be highly desirable human traits (Bepko, 1989; Frank & Golden, 1992; Jordan et al., 1991). (See Chapter 15.)

The concept originated when chemical dependency counselors first turned their attention to the spouse (i.e., wife) of the alcoholic. They used the term enabler since it was observed that the behavior of the spouse often served to support the alcoholic’s drinking. Another early term was co-alcoholic, which implied that the spouse also suffered from the disease through her relationship with the alcoholic. By the late 1970s, this term was replaced by codependent as the term chemically dependent became the more popular way to describe alcoholics and addicts.

Codependency is a useful framework for explaining some of the dysfunctional behaviors observed in the spouses of alcoholics. In their efforts to cope with the stressors brought on by their spouse’s drinking, they eventually become a part of the problem by enabling it to continue through their own dependence on the relationship with the alcoholic. This concept is also useful in treatment, since it provides a framework for spouses or other family members regarding their own recovery from the effects of alcoholism. The concept is often applied more broadly to describe individuals who engage in ongoing dysfunctional relationships, whether chemical dependency is present or not. Although these definitions imply that the individual is codependent in relationship to an alcoholic or other person, the individual is actually engaged in a disease process of dependency in his or her own right (Schaef, 1986). Codependent characteristics are thought to emerge from childhood abuse experienced in one’s own family of origin. Hence, there is a clinically derived, theoretical relationship between the constructs of shame and codependency (Hawkins, 1996b, 1996c, 1997).

The concept of codependency defies precision (Morgan, 1991), and various authors have defined it with their own constellation of attitudes and behaviors. Two representative definitions that capture the gist of this concept are offered here. Black (1990) states that codependency is “characterized by the numbing of feelings, denial, low self-worth, and compulsive behavior. It manifests itself in relationships when you give another person power over your self-esteem” (p. 6). Whitfield (1997) defines it as “any suffering and/or dysfunction that is associated with or results from focusing on the needs and behavior of others . . . (so) that they neglect their true self—who they really are” (p. 19).

The prevailing developmental explanation is that codependency first occurs when children grow up in shaming family systems. They lose the ability to distinguish between their needs and the needs of others, and they do not develop a firm sense of self (Kaufman, 1985b). In adulthood, such individuals have difficulty managing stress, have problems engaging in mature relationships, are at increased risk for alcoholism, and are particularly vulnerable to becoming involved with an alcoholic or pre-alcoholic partner. Further, in the absence of some sort of treatment, these individuals will likely perpetuate this cycle with their own children. A term often used in the clinical literature to convey this concept is adult child, which implies that “within each of these adult-age individuals there is a child who has difficulty experiencing a healthy life until . . . recognition and healing of the past occur” (Black, 1990, p. 3). Interestingly, however, the literature on codependency and shame does not necessarily overlap. This is perhaps because codependency originated as a self-help movement, whereas conceptualizations of shame are more theoretically derived; however, knowledgeable practitioners link the two concepts.

Children of Alcoholics

A related issue to codependency is the concept of children of alcoholics (COAs). As stated previously, estimates indicate that at least one in four children under the age of 18 in the United States is exposed to alcoholism and/or alcohol abuse (NIH, 1999). There is substantial clinical and empirical literature that indicates the detrimental effects of alcoholism on all family members, especially children, regardless of developmental stage (e.g., Copello et al., 2005; Gruber & Taylor, 2006; Peleg-Oren & Teichman, 2006). This more recent data confirms patterns identified over several decades. Being the child of an alcoholic puts an individual at greater risk for alcoholism than the child of a non-alcoholic (Cadoret, 1990; Russell, 1990; Sher, Walitzer, Wood, & Brent, 1991). While there may be a genetic component to this risk (Cadoret, 1990), studies indicate that family environment is also a critical contributing factor (Cook & Goethe, 1990; Heath & Stanton, 1998; McGue, 1997; Seilhamer & Jacob, 1990; Copello et al., 2005). In addition to being at an elevated risk for alcoholism, children raised by alcoholic parents may be more vulnerable to psychosocial impairment than other children. COAs are “over-represented in the caseloads of medical, psychiatric, and child guidance clinics; in the juvenile justice system; and in cases of child abuse” (Seilhamer & Jacob, 1990, p. 169). Sher and colleagues (1991) found that in addition to being at higher risk for substance abuse problems, COAs showed more behavioral under control, neuroticism, and psychiatric distress as well as lower academic achievement and verbal ability than non-COAs.

Ongoing research is beginning to distinguish specific risk factors in families with a history of alcoholism that are associated with COA outcomes. Windle (1997) provides a dynamic diathesis-stress model of developmental psychopathology for COAs that shows how parental alcoholism may or may not lead to adult disorders. In this model, a family history of alcoholism influences other numerable variables—including biopsychosocial risk factors, situational stressors, and mental/physical health problems—that are reciprocally interactive within a broader sociocultural and historical context. Hill and colleagues (1997) point out the need to consider the interaction of parental alcoholism with other familial factors that can impair adult functioning, such as childhood socioeconomic stress. In a retrospective study using an adult sample, Dube et al. (2001) explored the relationship between parental alcohol abuse and child maltreatment. They found that COAs were 2 to 13 times more likely to experience adverse childhood events than non-COAs, and for those raised by both mothers and fathers who were alcoholic, the odds were even higher. Estimates of the relationship between parental substance use problems and child abuse and neglect differ based on the different ways these problems are measured (Testa & Smith, 2009), but parents with substance use disorders involved in the child welfare system often have co-occurring problems such as mental illness, domestic violence, housing, etc., that must also be addressed if the home is to become suitable for the child (Marsh, Ryan, Choi, & Testa, 2006).

Hussong et al. (2008) recently reviewed three longitudinal studies of type and severity of negative life stressors. Their research involved 1,752 participants, 56 percent of whom were COAs, spanning the first 30 years of life. COAs were differentially more vulnerable to family-related negative stressors than non-COAs. Hussong et al. interpreted this result as indicating that COAs had experienced a disruption of the normal stable family routines that might predispose them to increased risk for psychopathology. This greater exposure to negative life stressors may be particularly detrimental to certain COAs who have temperaments characterized by impulsivity or sensation seeking (Sher et al., 2010; Dick et al., 2010). Caspi et al., 2010 recently summarized the literature on this genetic sensitivity to certain environments. Possessing a specific gene variant alone (e.g., short 5-HTTLPR allele) does not simply determine increased likelihood for negative outcomes. Protective environments may ameliorate these vulnerabilities while the invasion of the protective family rituals/routines may exacerbate them.

Family-based preventative efforts are critical in reducing the incidence of child and adolescent substance abuse. Lochman and van den Steenhoven (2002) reviewed 30 years of research and conclude that behaviorally-oriented parenting programs directed at particular risk factors can have a significant impact on improving parental disciplinary efforts and children’s behavior. The literature suggests that development of alcohol and other substance misuse by COAs and adolescents in general may be prevented by a particular form of extended protective environment: parental monitoring or supervision. Several recent empirical studies (Fromme, 2006; Fromme, Corbin, & Kruse, 2008; Wetherill & Fromme, 2007; Wetherill, Neal, & Fromme, 2010) and reviews (Lockman & van den Steenhoven, 2002; Vellerman et al., 2005) have substantiated the importance of close monitoring of adolescents’ exposure to risky environments where substance misuse is likely, particularly in high school and the transition to college. Close parental monitoring may be particularly important for adolescent COAs who are genetically sensitive to risky environments (e.g., teens with impulsivity and/or sensation-seeking temperaments).

The precise nature of risk or specific familial influences remains unclear. Johnson and Leff (1999) support earlier findings on negative outcome for COAs but caution that more rigorous longitudinal studies are required to provide definitive evidence for true deficits or developmental delays. Menees and Segrin (2000) found that adults who had a positive family history for alcoholism but did not have other significant family stressors reported no higher levels of family distress than adults who had a negative family history. An emerging literature has shown empirical support for the relationship between exposure in childhood to distressing parental problem drinking and the development of anxiety disorders and substance abuse in adult offspring. There is not a direct link, however, since this model identifies the mediating effect of anxiety sensitivity in this relationship (MacPherson, Stewart, & McWilliams, 2001).

The child or children of an alcoholic, like the substance abuser or other family members, may need to be the target of intervention. The National Association of Children of Alcoholics developed care competencies that outline the knowledge, attitudes, and skills that a professional must have to meet the needs of children and adolescents affected by family substance abuse (see Adger, 1998). There are three inclusive levels pertaining to the primary role of the professional: Level I: clinical care; Level II: prevention, assessment, intervention, and coordination of care; and Level III: long-term treatment. In short, all health care professionals should be aware of COAs’ complex and comprehensive needs.

Children of alcoholics often show remarkable resiliency in the face of potentially detrimental effects of parental alcoholism and grow into well-functioning adults. Family units in which a parent has an alcohol use disorder may also be described as resilient (Coyle, Nochajski, Maguin, Safyer, DeWit, & McDonald, 2009). In fact, many COAs do not display alcoholism or other psychopathology in adulthood, while many non-COAs do exhibit these problems. Nevertheless, COAs often employ coping strategies (such as suppressing feelings), which may even appear adaptive in adulthood, but are not necessarily conducive to mature functioning.

Adult Children of Alcoholics

The psychosocial difficulties experienced by children and adolescents living with an alcoholic parent do not necessarily end as the individual matures. There is strong evidence that the vulnerability of many COAs extends into adulthood (Sher, 1997). According to the Center for Substance Abuse Prevention (2010), of the estimated 27.8 million children of alcoholics in the United States, about 16.8 million are adults over the age of 18.

As indicated above, in alcoholic families, there is not a free flow of emotional expression and open communication. Black (1981) coineda phrase that captures the powerful injunctions regarding behavioral and emotional expression in these families: “Don’t talk, don’t trust, don’t feel.” Further, these family environments are often characterized by other seriously dysfunctional behaviors that contribute to individual impairment, such as conflict, stress, violence, and child maltreatment. Parental alcoholism may or may not be related to adult impairment—in particular, the so-called adult children of alcoholic (ACOA) syndrome proposed by chemical dependency counselors. This syndrome refers to a behavioral and emotional pattern displayed by some individuals from families with a history of parental alcoholism and codependency characterized by a restricted range of affect and extreme distrust of intimacy (Black, 1981, 1990; Woititz, 1990). Although widely accepted in the chemical dependency field, the ACOA syndrome has not been validated through empirical research. Only a few studies have attempted to specify the individual or family characteristics associated with the ACOA syndrome (Hawkins, 1996a; Hawkins & Hawkins, 1995, 1997).

The literature on the etiology of the ACOA syndrome lacks specificity. An internalized sense of shame is linked to the dysfunctional behaviors of many adults, including those who display the ACOA syndrome (and who may or may not be alcoholic). Individuals who grew up in “shame-bound” families, whether characterized by alcoholism or other pathology, are thought to often experience impairment in adulthood. However, coming from a family with parental alcoholism or other pathology is not sufficient for the development of characteristics of the ACOA syndrome. According to Kaufman (1985b), theory on the development of shame does not predict a particular pathogenic family process (i.e., alcoholism, incest, mental illness, etc.). He surmised that the model of a “shame-based” identity can be applied only to adults since it is presumed that children (less than age 18) have not fully developed a stable identity, healthy or otherwise.

Pathogenic processes in the family of origin are hypothesized to increase the risk of adult offspring establishing pathogenic family processes in their family of procreation. Studies suggest that the way in which rituals and routines are practiced in the family of origin may have either a detrimental or a protective influence on the development of alcoholism in offspring (Bennett, Wolin, & Reiss, 1988; Bennett, Wolin, Reiss, & Teitelbaum, 1987; Wolin & Bennett, 1984; Wolin, Bennett, & Jacobs, 1984; Wolin & Wolin, 1993). In essence, these authors found evidence that families that had a breakdown of rituals were associated with lower levels of functioning in young offspring, higher levels of alcoholism in adult offspring, and lower levels of ritual practices by adult offspring in their family of procreation. Thus, a cross-generational pattern is established that perpetuates alcoholism and its related problems.

To conclude, definitional issues complicate an understanding of the emotional and behavioral patterns of alcoholism, codependency, COA, ACOA, and shame. These terms (and the constructs that they represent) are interrelated but are poorly defined; therefore, it is difficult to distinguish them from each other. Not all ACOAs meet the profile of codependency, nor are all codependent individuals from alcoholic or addicted families. Hawkins and Hawkins (1995) developed a measurement instrument, the Adult Children of Alcoholics Tool, to clarify these concepts (see Box 10.1).

BOX 10.1 The Adult Children of Alcoholics Tool (ACAT)

There is evidence of the ACAT’s validity and reliability as a standardized self-report measure of current mental health functioning. It is hypothesized to reflect the internalization of shame and the negative attributes (inhibited emotional expression, difficulties with intimacy, and interpersonal distrust) characteristic of growing up in an alcoholic family (Hawkins & Hawkins, 1995). None of the items in the ACAT mentions a drinking problem or alcoholism in the family of origin. This is because the ACAT was developed explicitly to measure the respondent’s endorsement or internalization of the core psychological attributes of the ACOA syndrome, not merely his or her identification with being the offspring of an alcoholic parent. The ACAT may be a useful tool for practitioners and researchers in assessing potential vulnerabilities in individuals with a family history of alcoholism. It has been shown to be a valid and reliable measure of the ACOA syndrome. This initial identification can then be further explored as part of an interview process. Individuals scoring 30 or above on the ACAT, when informally interviewed, most often reported that they had a sense of pathogenic shame or current mental health problems.

Directions

The following questions refer to your family of origin, the family with which you spent the most time when you were growing up. Indicate how strongly you agree or disagree with each statement by choosing the appropriate letter. Fill in the blank preceding each statement with the letter A, B, C, D, or E, depending on your choice: A = Strongly Agree; B = Somewhat Agree; C = Neutral; D = Somewhat Disagree; E = Strongly Disagree. Item scoring weights are as follows, corrected for reverse scored items: A = 3, B = 2, C = 1, D = 0, E = 0. ACAT total score = Sum of items 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 18, 19, 20, 21, 22, 24, 25, 26, 27, 28, 29, and 30.

Part I ACAT Items

I tend to not talk about the real problems in relationships with people I care about.*

*These items can be deleted to form a 25-item scale.

I try to take a lot of responsibility for people and things.*

When there is a problem in my family we can talk about it. (reverse scored)

The idea of loss of control is intolerable to me.

It is hard to share problems with people I love.

It is easy to trust members of my family. (reverse scored)

It is difficult for me to set aside responsibilities for awhile and enjoy play.

When I have a problem with someone I care about I am reluctant to discuss it, for fear of “rocking the boat.”

I find it easier to avoid situations where I have to take control in my family or personal relationships.

Consistency and predictability are usually the rule in my family.

I usually look out for others’ needs before my own.

People who know me might call me a compulsive giver.*

There is very little predictability in my family.

I have always felt comfortable bringing my friends home to meet my family. (reverse scored)

Ever since I was young I have learned to be tough and not to cry.

If I can just ignore a problem it will not hurt so bad and I can handle it easier later.

There is something about me that seems to attract needy individuals, or people with any kind of problem.*

I want to trust others, but it is so much easier just to rely on myself.

I have trouble following a project from beginning to end.

I tend to overreact to changes over which I have no control.

It doesn’t matter much to me whether others approve of my actions or not. (reverse scored)

When I start a new a project I usually have no difficulty finishing it. (reverse scored)

Deep down I have usually felt that I am quite different from other people.*

I have difficulty forming intimate relationships with others.

I have a strong need for others’ approval and affirmation of my actions.

It’s hard for me to decide when to get close to people and when to back off from them.

Telling the truth about problems is encouraged in my family. (reverse scored)

Sometimes I find it hard to draw a line between my feelings and the feelings of people who are close to me.

I have a tough time being honest about my feelings toward others.

There are times when I think that anyone who could love me is stupid or worthless.

I tend to keep a cool head during a crisis, while others are getting upset.*

My judgments of others are not nearly so harsh as my judgments of myself.*

Part II ACAT Items**

**Optional measures of problem drinking

My father drinks (or did drink) about alcoholic drinks a week. (Note: One 12 oz. can of beer equals one 5 oz. glass of wine or 1.5 oz. of hard liquor.)

0–1

2–3

4–5

6–9

10 or more

My mother drinks (or did drink) about alcoholic drinks a week.

0–1

2–3

4–5

6–9

10 or more

I drink (or did drink) about alcoholic drinks a week.

0–1

2–3

4–5

6–9

10 or more

Currently, or at any time in the past, which of the following biological relatives have been a “problem drinker”?

father

mother

father and mother

none

Currently, or at any time in the past, which of the following biological relatives have been a “problem drinker”?

paternal grandparents

maternal grandparents

paternal and maternal grandparents

none

Currently, or at any time in the past, I regard (ed) myself as a “problem drinker.”

yes

no

Note: Reverse-scored items are included to minimize response-set bias, since all items are answered either “agree” or “disagree.”

Source: R. Hawkins & C. Hawkins, Research for Social Work Practice (Vol. 5. Issue 3), pp. 317–339, copyright © 1995 by Sage Publications.

Assessment and Treatment of Alcoholic Families

There are many reasons for including the family in treating what has traditionally been viewed as an individual problem. Wegscheider (1981) identifies several ways that involving the family can benefit the alcoholic in his or her individual treatment: They can provide useful information about the patient, may be alcoholic or emotionally disturbed themselves (and negatively affect the patient if they are not treated), are likely to continue to enable the patient’s dependency if they do not receive assistance, and may help break the cycle of drug misuse in their offspring.

There are also reasons for focusing treatment on the family itself. It is unproductive to treat an individual separate from the system if he or she will be returning to live with the family. Family members are also under stress and probably in need of help, and only through participating together in treatment can the family truly understand its dynamics and develop new behaviors. There is some evidence that alcoholics show a better response to treatment when it includes family members, especially the spouse (Collins, 1990). Edwards and Steinglass (1995), in a meta-analysis of 21 studies, conclude that family-involved treatment is particularly effective in motivating alcoholics to enter treatment. Such an approach allows the family to share a common goal and, even if problems continue, to perhaps experience some success in non-drinking areas of communication and interaction.

In family treatment, the goal of therapy is not only sobriety for the identified alcoholic but also improvement in family functioning. Elkin (1984) identifies five goals for treatment: (1) stop the drinking and/or isolate the drinking member, (2) stop life-threatening or destructive behavior of family members, (3) disengage children from parental roles and alter inappropriate parent/child alliances, (4) help re-form the parental alliance and authority, and (5) support members in obtaining necessary resources outside of the family. Kitchens (1991) recommends targeting inflexibility, boundary confusion, parent/child coalitions, scapegoating, inadequate communication, discounting feelings, and unhealthy rules. Copello et al. (2005) examined the literature on family interventions in the treatment of alcohol and drug problems and identified three broad categories: “1) working with family members to promote the entry and engagement of misusers into treatment; 2) the joint involvement of family members and misusing relatives in the treatment of the misuse; and 3) responding to the needs of the family members in their own right” (p. 371). In a review article, Rotunda, Scherer, and Imm (1995) state that successful family treatment of alcoholism requires addressing relapse prevention and the tendency toward conflict (including violence).

A family may enter treatment through several routes. Lawson and Lawson (1998) describe four ways that a therapist may come in contact with alcoholic families. First, a family may seek therapy with the undesirable behavior of a child or adolescent as the presenting problem, which may be substance abuse or a reaction to family dysfunction caused by hidden addiction in one or both of the parents. Second, a family may acknowledge a parental alcohol problem in which drinking does not lead to significant behavior changes, is not a source of major conflict, seems incidental to other problems in the family, and may diminish as other problems are addressed. Third, a family may present with alcoholism as the major problem such that the system is organized around the drinking, which is a source of severe conflict and intensifies other problems, and is typically of lengthy duration. Behavior changes in the alcoholic while drinking are extreme and frequent. Fourth, the family may seek help after the alcoholic has completed treatment, even years into recovery, due to new problems that have emerged or developmental changes.

Thus, families may enter treatment with or without the goal of directly addressing alcoholism in a spouse, parent, or child. Depending on the nature of the treatment they receive, the alcoholism may or may not be addressed. Since alcoholic families are quite adept at keeping their “secret” hidden, alcoholism may not surface unless the therapist looks for it. If the family acknowledges the problem but the alcoholic or addict does not, a process called intervention, developed by Vernon Johnson (1998), has been used to engage patients in treatment. There is limited empirical support for the effectiveness of this approach (Loneck, Garrett, & Banks, 1996). A description of the Johnson Institute (JI) intervention technique is presented in Box 10.2. Ethical concerns have been raised about the JI intervention, primarily around the issues of coercion and confidentiality (Conner, Donovan, & DiClemente, 2001). They contend that this technique requires further evaluation and offer a detailed description of several alternative approaches for engaging the substance abuser in treatment. The ARISE program (which stands for A Relational Intervention Sequence for Engagement) is a less confrontational but progressively more intense three-stage approach (Garrett et al., 1997, 1998; Landau et al., 2000). Conner et al. acknowledge that there is limited research on the effectiveness of this approach as well. They extrapolate from evaluation studies of interventions similar to ARISE, however, and suggest that this approach may be more effective than JI in terms of the rates of treatment entrance, completion, and relapse prevention. Fernandez, Begley, and Marlatt (2006) argue that JI and AA (the predominate help-seeking approaches in the United States) are more limited than ARISE and similar family-based interventions, and cite some empirical studies to support their position.

BOX 10.2 Intervention

Intervention is based on the premise that alcoholics who are in denial will resist any attempt to be engaged in treatment. Therefore, presenting them with the need for help must be done in a way that they can accept. Usually, conducted in conjunction with a specially trained professional, an intervention is a carefully planned and rehearsed procedure. In a nonjudgmental tone, significant persons in the alcoholic’s life (such as family members, friends, employer, doctor, etc.) confront him or her with firsthand, specific, behavioral feedback regarding how the alcoholic’s drinking has affected them. Once the alcoholic’s denial has been weakened by the reality of his or her behavior, the interveners present acceptable treatment options to the alcoholic, permitting him or her some input in the decision making. The alcoholic’s excuses for avoiding treatment have been anticipated, so they are less likely to be successful.

Loneck, Garrett, and Banks (1996) provide a review of the literature on the effectiveness of the Johnson intervention as a therapeutic technique. They note that although the Johnson intervention (JI) is highly effective for engaging and retaining clients in inpatient treatment, the effectiveness for outpatient treatment and the differential impact of variations of the JI have not been evaluated. This review found that patients receiving JI were more likely to enter treatment than those receiving other methods of referral (coerced, noncoerced, unrehearsed intervention, and unsupervised intervention). Of patients entering treatment, those in the JI and coerced referral were equally likely to complete treatment and were more likely to complete treatment than the other groups.

Unilateral family therapy is another approach that targets the family to engage the substance abuser in treatment (Thomas & Ager, 1993). Conner et al. (2001) identify that the primary goal of this three-stage approach is to improve the functional level of the family, which may in turn modify the substance abuser’s behavior, including his or her willingness to enter treatment. They note that while promising, this approach lacks sufficient empirical support of its efficacy. Finally, the authors describe the Community Reinforcement and Family Training (CRAFT) program, developed by Meyers, Smith, and Miller (1998). The primary goals of this approach are helping family members to encourage the substance abuser to stop drinking, to enter treatment, and to engage in better self-care. The training program occurs over several sessions, and if it is effective in getting the substance abuser to enter treatment, significant others continue active involvement through the family program. The authors note that the effectiveness of the CRAFT approach has been demonstrated through clinical evaluations.

Once the substance abuser has entered treatment, involving the family in the treatment and aftercare process appears to enhance effectiveness, regardless of the specific treatment approach used. Conner et al. describe two therapeutic approaches that include the family in treatment: behavioral marital therapy (BMT) and the community reinforcement approach (CRA). Both approaches are effective in that “contingency management and behavioral contracting, components of both BMT and CRA, have demonstrated empirical support” (p. 170). After treatment is completed, involvement of the family in the aftercare and maintenance stage leads to improved outcomes. They identify two primary family approaches for this stage: couple relapse prevention (a component of BMT) and self-help groups, such as Al-Anon.

Regardless of the specific approach utilized, to be effective the therapist must assess the stage of the family’s development in the addiction/recovery process, since the focus of intervention and prognosis varies accordingly. Brown and Lewis (1999) identify four stages (drinking, transition, early recovery, and ongoing recovery) and three domains of experience (the environment, the family system, and the individual) that must be considered. Similarly, Buelow and Buelow (1998) present a developmental model based on three stages: early abusive, middle dependent, and late deteriorative. In both models, key tasks of the therapist are noted for each stage. Conner et al. synthesize theory and research on addictive behavior change, using the Prochaska, DiClemente, and Norcross (1992) five-stage process model of precontemplation, contemplation, preparation, action, and maintenance. Although this model is based on the individual, the authors observe that “the family, in its response to the substance abuser’s behavior, is likely to go through stages of readiness to change that parallel those of the substance abuser” (p. 150).

In counseling families, as opposed to counseling individuals, specific ethical concerns need to be considered. Whittinghill (2002) points out that ethical guidelines have not kept pace with the rapid expansion of family therapy as an approach to substance abuse treatment. Benshoff and Janikowski (2000) discuss several concerns, some of which are common to family therapy, such as handling secrets, using diagnostic labels, and addressing conflict. In addition, special concerns may emerge in counseling chemically dependent families, especially around informed consent and confidentiality. There may be an expectation of family involvement by treatment agencies and the criminal justice system, but family members may not want to participate. Finally, the authors note the need for therapists to engage in ongoing self-awareness and values clarification, since chemically dependent families often present with complex and challenging problems.

A family-oriented perspective in the treatment of alcoholism does not imply that the family caused the problem. In fact, as noted throughout this book, there is likely no single cause of chemical abuse or dependency. These problems may arise from and be maintained by a combination of biopsychosocial factors in the individual, family, and community. A family-oriented approach conceptualizes the problem in terms of family functioning and directs treatment at that level. Although differing theoretically, each of the models presented here recognizes that interactive patterns maintain the drinking and contribute to family dysfunction. Therefore, each advocates family involvement in some aspect of treatment and contends that any changes will affect the system, not just individuals.

Behavioral Perspective

A behavioral approach to working with couples or families is based on principles of behavioral theory. Such principles can be used either as behavioral therapy of families or as a model of family therapy that utilizes behavioral principles (see the next section). Briefly stated, behavioral theory argues that virtually all behavior is learned (as opposed to inborn) and maintained (or conditioned) through environmental or social consequences, such as reinforcement. Social learning theory and cognitive-behavioral theory add to the conditioning theories by recognizing that cognitive processes, such as modeling, mediate between the individual and the environment.

How does behavioral therapy apply to chemically dependent families? These families often attempt intuitively to use positive reinforcement (reward drinking behavior through attention or caregiving), negative reinforcement (protect the chemically dependent individual from the negative consequences of alcohol or drug use), or punishment (inflict a penalty on the person for drinking or drugging) (McCrady, 1986). Unfortunately, each of these responses is considered to increase the likelihood of drinking. Behavioral therapy, on the other hand, attempts to apply the principles of reinforcement to achieve desirable results. “The guiding principle of the application of behavioral techniques in family treatment of alcohol abuse is to increase and reinforce positive behaviors/interactions among family members and to decrease negative behaviors/interactions related to drinking” (Collins, 1990, p. 288). Another application of behavioral theory to family treatment is modeling. For example, the therapist can model more functional interaction with the alcoholic for family members, and the non-abusing spouse can model more appropriate drinking behavior for a non-abstinent individual (O’Farrell & Cowles, 1989).

Behaviorally oriented family treatment differs from systems-oriented family therapy in several important ways. Treatment begins with a behavioral assessment of family difficulties, which identifies specific areas to target for intervention, as well as a careful analysis of antecedent and consequent events. Assessment is an ongoing process, and intervention is modified in response to changing behaviors. Treatment is directed at observable behavior, and there is no effort to address intrapsychic processes or interpersonal patterns (other than those specifically related to the target behavior). The causes and effects of the problem are seen as linear rather than circular. Further, the behavioral approach tends to focus on dyadic interactions rather than triads. Families are often educated in the principles of behavior therapy so that they can monitor and modify their own behavior and interactions.

Behavioral couples therapy (BCT) is the most common application of the behavioral perspective with families in the substance abuse field. It is demonstrably cost effective, since it reduces alcohol-related time spent in the hospital or jail, which is far more expensive than providing therapy. O’Farrell and Fals-Stewart (1999) state that in contrast to other family approaches, which are widely used but not well researched, the behavioral approaches have strong empirical support but are not widely used. There is a rapidly expanding empirical literature verifying the effectiveness of BCT (e.g., Schumm, O’Farrell, Murphy, & Fals-Stewart, 2009; Winters, Fals-Stewart, O’Farrell, Birchler, & Kelley, 2002). Fals-Steward et al. (2009) state that multiple studies over the last30 years have consistently found the following benefits of BCT compared to individual therapy or partner-involved control groups: 1) reduced substance use, 2) improved relationship satisfaction, and 3) greater adaptive functioning (less partner violence and better custodial child adjustment).

Stress-Coping Perspective

The stress-coping and behavioral models are similar in many respects. Both were first used to address addiction in the individual, and both have been expanded to include marital and family relationships. Like the behavioral and systems perspectives, the stress-coping perspective recognizes the reciprocal nature of family interaction. However, it differs from the family system perspective since it does not view the family as a unit unto itself. Rather, the family is viewed within a larger comprehensive approach encompassing the stress, resources, and coping of individual members. For the alcoholic, this theory contends that “substance use represents an habitual maladaptive coping response to temporarily decrease life stress and strain” (Hawkins, 1992, p. 161).

Stressors may or may not precipitate drinking; this depends on a number of factors. For example, Cronkite, Finney, Nekich, and Moos (1990) identify factors that interact to influence the recovery process for the alcoholic, such as demographic characteristics, personal resources, prior functioning, treatment program and experiences, life context, and coping responses. This model can also help to understand the functioning of other family members, although treatment variables would be less directly relevant. According to Cronkite and colleagues, “An alcoholic’s life context can provide a supportive milieu for continued improvement, cushion the impact of stressors, or trigger a relapse” (p. 309). For the spouse and children of an alcoholic, other factors in their lives besides the alcoholic’s behavior must be considered in order to help them to adapt better, such as environmental factors, life stressors, and the functioning of the individual or other family members. For children, this particularly refers to the non-alcoholic parent.

Family involvement using the stress-coping approach can vary widely (Wills, 1990). Al-Anon can be viewed as using this model in that it emphasizes the development of skills for coping with the stress of dealing with an alcoholic loved one. Al-Anon members are encouraged to find satisfaction through their own pursuits. Edwards and Steinglass (1995) note that, while Al-Anon is the most commonly implemented aftercare program for families, there are no systematic data on its long-term effectiveness. In addition to Al-Anon, family members can learn more adaptive coping through individual therapy. These individual efforts, in turn, can have the added effect of facilitating changes in the alcoholic, since change in one member affects the whole system. Marital or family-oriented treatment assists members in identifying personal and familial stressors that impede the recovery process and shows them how to develop more adaptive cognitive and behavioral coping mechanisms, communication patterns, and problem-solving skills. Wallace (1985) identifies five coping mechanisms often employed by the spouses of alcoholics that may actually encourage continued drinking: (1) withdrawal, (2) protection of the alcoholic, (3) attack, (4) safeguarding family interests, and (5) acting out. Encouraging the spouse to identify more effective strategies can be a complex process, since “the effectiveness of a particular coping skill will vary, in all likelihood, with (1) the situation itself, (2) the individual alcoholic, (3) the characteristics of the spouse, and (4) the strength and cohesiveness of the marital bond” (Rychtarik, 1990, p. 357).

Family Therapy Perspective

Family therapy can be contrasted to individual therapy, which views problems as internal. Family therapists “believe that the dominate forces in our lives are located externally, in the family. . . . When family organization is transformed, the life of every family member is altered accordingly. [Over time, this process] continues to exert synchronous change on each other” (Nichols, 2009, p. 5). Family therapy (including marital therapy) represents a shift from viewing people as individuals to viewing them through their relationships to others. Models of family therapy have been classified using several different theoretical frameworks, such as Bowenian, strategic, structural, experiential, psychoanalytic, cognitive-behavioral, solution-focused, and narrative. Although the models share a family systems theoretical orientation, they differ in terms of conceptualization of the problem, specific goals of treatment, strategies and techniques, and role of the therapist. (For a discussion of these models, see any basic family therapy text, such as Nichols [2009].)

Until recently there has been no model of family therapy designed specifically to address addiction (Steinglass, 1987, 2009). Rather, the philosophy, goals, and strategies of each model are applied to alcoholism as the presenting problem indicative of underlying dysfunction in the family system. The behavioral or stress-coping perspectives focus directly on the alcohol-related behaviors of family members, whereas the family therapy perspective focuses more on the nature of the relationships among family members, which may not be unique to alcoholism. Collins (1990) states that, “the specific nature of the individual’s impairment may be a less potent contributor to family dysfunction than is the fact that the family contains an impaired member” (p. 304). Several authors provide clinical guidelines using a family systems perspective (e.g., Lawson & Lawson, 1998; Lawson, Lawson, & Rivers, 2001; McCollum & Trepper, 2001; Perkinson, 2002). For example, Lawson and Lawson address the commonly related problems of family violence, sexual dysfunction, and divorce. McCollum and Trepper examine four areas in which family therapy has been misunderstood by the general public and many mental health professionals: parental blame, biologically-based disorders, the disease model of addiction, and differences in terminology.

Steinglass and colleagues (1987) emphasize that alcoholic families are highly heterogeneous (as are families with an alcoholic member). They believe that “it is no more credible to propose that a single treatment approach will make sense for each and every alcoholic family than it is to assume that all alcoholic families follow comparable developmental courses or manifest the same personality features” (p. 364). Therapists are also heterogeneous and should match their family therapy approach to their personality, individual style, and family background (Kaufman & Kaufman, 1992).

Steinglass et al. (1987) provide a four-stage model, briefly highlighted here, for working with alcoholic families. The first stage is a careful assessment in which overall family functioning is evaluated (including the role of alcoholism) and the primary problem is identified and defined at the family level. The assessment, to determine if the system represents an alcoholic family or a family with an alcoholic member, can be accomplished through an interview focused on family rituals to ascertain the extent to which they have been invaded by alcoholism. If the family has become organized around alcoholism,

a treatment program that leads to a cessation of drinking on the part of the family’s alcoholic member will, in such families, have profound implications at almost every level of family life. Thus, in such situations, overall treatment success is likely to depend not only on efforts aimed at alcoholism per se, but also on a comprehensive approach to dealing with the family-level implications of the cessation of drinking (p. 333).

The developmental phase of the family also needs to be ascertained since this has implications in terms of treatment goals and outcome criteria. Alcoholism may or may not be the presenting problem for a family. Families often seek help when they are in the midst of a developmental crisis. It is possible for a family to resolve their developmental crisis without eliminating the drinking. For example, they describe a family making the transition to the later stage of its development. At this stage, one of the family’s developmental tasks is to launch adult children into age-appropriate roles. The family successfully achieved this goal even though the parents’ drinking pattern remained unchanged.

The outcome of the assessment determines the course of treatment. For an alcoholic family, therapy must target the alcoholism first and then the presenting problem (if it remains after the alcoholism is addressed). For a family with an alcoholic member (i.e., not organized around alcohol), the problem as presented by the family becomes the focus of treatment. The alcoholism may be addressed within this context, using traditional family therapy techniques.

On the other hand, if alcoholism is identified as the problem, the second stage is referred to as family detoxification, which consists of eliminating alcohol from the family system. The authors recommend that the therapist use a problem-solving approach, which entails contracting with the alcoholic to stop drinking (including completing a medical detoxification regimen, if necessary) and identifying responsibilities for each family member. The alcoholic may refuse to acknowledge a problem and to detoxify, yet the family may still decide to continue treatment. If so, the alcoholic is excluded from the therapy. Examples of tasks in the contract are removing alcohol from the home and reinstating family routines. The therapist should anticipate difficulties in negotiating and implementing the contract, since the family is attempting to change instilled patterns.

Following successful completion of the assessment and detoxification stages, drinking is no longer considered the major issue. The next two stages address family interactional patterns, using any one of the models of family therapy. The third stage addresses the family’s emotional instability that follows when drinking no longer occurs in a family that has been organized around alcohol. The task of this stage is to assist the family in tolerating this shift and in establishing new patterns that are not tied to alcohol. A psychoeducational approach explaining the difficulty of making these changes can be very helpful.

The fourth stage, in which the family consolidates changes, can result in two possible outcomes. In the first, called family stabilization, the interactional patterns remain essentially unchanged, but the family no longer relies on drinking to regulate them. Alternatively, family reorganization occurs when the family fundamentally alters its interactional patterns.

The foregoing framework is a general guide, since it is possible that a family will drop out of treatment at any stage. Further, a family may slip back into alcohol use at some point. In the latter instance, the therapist can renegotiate a detox contract and support the family in continuing to make changes. A family systems approach is not always the treatment of choice, since family members are not always available. In addition, family therapy does not eliminate the need to include individually oriented interventions in the treatment, such as AA or Al-Anon.

Steinglass (2009) has refined his family systems treatment model for substance abuse to include motivational interviewing, calling this newly integrated approach systemic-motivational interviewing (SMI). Motivational interviewing was developed in the 1980s as an alternative to confrontational techniques that were widely used in the United States but deemed ineffective. It is regarded as more humanistic and consistent with harm reduction and relapse prevention approaches. Preliminary data indicate it is effective with individuals, but there is no research on couples or families. Since SMI is based on prior empirical evidence of both family therapy and substance abuse treatment, Steinglass contends that it has strong face validity. SMI specifically targets the underlying belief system, particularly regarding ambivalence about change, felt by all members of the family. In this model, there are three stages: assessment and consultation, family-level treatment, and aftercare and relapse prevention. Steinglass postulates that one promise of this model is that it “potentially bridges the divide currently separating the worlds of family therapy and substance abuse treatment” (p. 171).

Effectiveness of Family Treatment

As discussed in Chapter 6, data on the effectiveness of treatment for alcoholism are often equivocal, as relapses rates remain high. This same pattern applies to studies that examine the effectiveness of family-level intervention, although there is general support for the positive outcomes of family therapy for alcoholism and substance misuse (e.g., Edwards & Steinglass, 1995; Steinglass, 1987, 2009; Steinglass et al., 1987). Although acknowledging limitations of the data, these authors point out that no other treatment has been shown to be any more effective in producing desirable changes in behavior. O’Farrell, Murphy, Alter, and Fals-Stewart (2008) observe that “meta analytic reviews indicate that involving the family in the patient’s treatment generally is an effective means to promote recovery from alcoholism and drug abuse” (p. 464). In another recent review, Copello, Velleman, and Templeton (2005) also conclude that family involvement in substance misuse treatment can be very effective. Austin, Macgowan, and Wagner (2005) summarize family-based intervention approaches that have shown promise in early controlled studies, but add that these findings require replication by independent investigators. They also note (as do Crespi & Rueckert, 2006), that family therapy can only be effective if it is implemented properly; both articles call for clinicians to be properly trained.

There are several earlier noteworthy studies of family-oriented approaches that indicate effectiveness. Edwards and Steinglass (1995) “reviewed findings from twenty-one studies investigating the efficacy of family therapy as a treatment for alcoholism and found evidence to support the potential usefulness of including family members in all three phases of alcoholism treatment—initiation of treatment, primary treatment rehabilitation, and aftercare” (p. 500). No single family therapy approach was shown to be more effective, and some family variables influenced the findings (i.e., gender of the identified alcoholic, commitment to and/or satisfaction with the marriage, and spousal support for abstinence). Liddle and Dakof (1995) examined controlled treatment outcome research of family therapy for drug abuse in both adolescents and adults. They found “family therapy . . . to be more effective than other treatments in engaging and retaining adolescents in treatment and reducing their drug abuse” (p. 521), although only one study provided support in the adult area. Stanton and Shadish (1997) conducted a meta-analysis of 15 experimental studies of couples and family therapy in treating substance abuse. They found that family therapy was more effective than individual therapy, peer-group therapy, or family psychoeducation. Family therapy also proved to be effective for both adolescents and adults. Involvement of family members was significantly effective in reducing drug use and treatment dropout rates as well as in increasing the length of participation in treatment. The authors attributed this finding to the more supportive stance of family therapy as opposed to the more confrontational approach of traditional chemical dependency interventions. Lipps (1999) reviewed the literature for family therapy with alcoholism, comparing the efficacy of the behavioral versus the family systems approach, and found that neither proved superior. On the other hand, O’Farrell and Feehan (1999) reviewed the literature on behavioral couples therapy and found that it was associated with improved family functioning, which in turn was linked to better mental health and psychosocial functioning in the offspring.

Additional studies continue to support this overall trend toward effectiveness. Carise (2000) found that family involvement in treatment significantly increased the likelihood that cocaine and alcohol abusers would complete the full course of treatment, although the author did not evaluate the impact of family involvement on continued recovery. Thomas and Corcoran (2001) conducted a meta-analysis of empirical studies with adult subjects comparing two spouse/family intervention approaches, either with the abuser’s involvement (primarily behavioral couples therapy) or without the abuser’s involvement. Findings indicated that “family members can successfully affect the substance user’s behavior in terms of inducing them into treatment and reducing chemical use” (p. 570). Stanton (2004) reviewed 19 outcome studies on engagement into treatment that compared substance abusers alone to substance abusers and a concerned person (since the vast majority of substance abusers either live with their parents or maintain close contact). The findings indicated the clear value of including family members in the engagement process, especially since only 5–10 percent of alcoholics or addicts in any given year engage in treatment or self-help groups.

Despite the clinical appeal of support groups as a resource for families with an alcoholic member, there is limited research on the efficacy of this approach (Keinz et al., 1995). Richter, Chatterji, and Pierce (2000) examined the literature on the relationship between Al-Anon membership and certain components of adaptive life functioning. They reviewed three correlational studies—McBride (1991), Humphreys (1996), and Keinz et al. (1995)—in addition to their own qualitative study. The findings suggest the effectiveness of Al-Anon in helping family members. One unique component of a day treatment program for substance abusing adolescents, called Pathway Family Center, placed early stage abstinent teens in cross-fostering “host homes” to extend the protective 12-step sponsorship to 24 hours per day (Deskovitz, Key, Hill, & Franklin, 2004). The apparent effectiveness of this innovative component remains to be validated in a controlled study.

Finally, a critical aspect of effectiveness in family-level treatment of substance abuse pertains to special populations. While there is a growing literature on family therapy with diverse populations, there is limited empirical research specific to substance abuse issues. Delva (2000) explores culturally-specific family-oriented substance abuse treatment interventions, considering group affiliation based on race/ethnicity, gender, age, class, and sexual orientation. Cuadrado and Lieberman (2002) address traditional Hispanic family values and substance abuse prevention and intervention. The Treatment Improvement Protocol 39 on substance abuse treatment and family therapy addresses special populations, including rural populations (Center for Substance Abuse Treatment, 2004). Further, clinicians must be skillful in assessing and treating clients with co-occurring psychological disorders and addictive behaviors (Barrowclough et al., 2001; Clark, 2001; Mueser et al., 2009; Rotunda and O’Farrell, 1997; see also chapter 13).

Case Example

The following case example illustrates some main points emphasized in this chapter, particularly regarding the family therapy perspective (e.g., Steinglass, 1987; 2009). The names and significant data for the family have been altered. There is considerable variation among families, therapists, and modalities; this case represents only one possible approach. Since it does not describe specific intervention techniques employed, such as family sculpting (originally developed by Duhl, Kantor, & Duhl, 1973), an illustration of applying this technique with the family is provided in Box 10.3 .(While this case pertains to an Anglo family, Wycoff and Cameron (2000) provide a case study of a Hispanic family.)

Presenting Problem

Emily is a white, 18-year-old high school senior. She was admitted to City Psychiatric Hospital in December following a suicide attempt. She had no history of prior psychiatric treatment or difficulties. She presents as an attractive, intelligent, and cooperative adolescent. Behavioral and emotional problems emerged one year ago and escalated rapidly: conflict with her parents over money, studying, household duties, and curfew; school failure and truancy; depression; and social isolation. If these problems persist, she will not graduate in May.

While in the hospital, Emily revealed extensive substance abuse, primarily alcohol, but occasional use of marijuana, cocaine, and “pills.” She would use “whatever was available.” She began drinking two years ago and reported that she “loved” alcohol, both the taste and the way it made her feel. Typical use consisted of daily drinking and weekend binging to the point of intoxication. She successfully hid her drinking from her parents. She described them as “preoccupied with their own problems.” Emily feels that her father abuses alcohol. She claims that her suicide attempt, mixing alcohol with barbiturates, was an accident. It occurred after her boyfriend broke up with her and she felt “sad and lonely.”

After being evaluated in the hospital, Emily was transferred to a residential treatment program for adolescent substance abusers. She seems to have benefited from this treatment in that she now describes herself as “in recovery.” She realizes that she must remain abstinent, and she attends several AA meetings a week. She meets regularly with the high school social worker and participates in a weekly peer support group. Although she feels that she is “turning her life around,” conflict has continued with her parents. She and her family were referred to Mental Health Clinic for one hour a week of outpatient family therapy following her discharge from the treatment program.

BOX 10.3 Family Sculpting

Family sculpting is an experiential technique used by family therapists to visibly display the dynamics of a family. It allows the family to experience themselves in an active way, rather than passively discussing their relationships. Using spatial distance and physical position, one member of the family arranges the other members in relation to how he or she perceives the family’s dynamics at a particular point in time. Family members are usually instructed not to speak as they complete the exercise. This nonverbal technique can be especially useful if family members seem reluctant to express their feelings or if they are unable to describe their perceptions. It can be a creative way to pull out a silent member, take full advantage of a particularly perceptive member, or bypass familiar verbal patterns. Prior to beginning, the therapist should briefly explain the process and engage the willingness of members to participate.

Consider the family described in the case example that began on page 277. Assume that Emily is the sculptor and that this exercise is being used early in therapy, before any significant changes have occurred. Emily might be asked by the therapist to arrange the members of the family in a scene depicting a typical evening at home in the present. Imagine that Emily motions to her mother to stand in one corner of the room facing the wall. She indicates that her father should stand in another corner facing the wall. She positions her brother in the third corner facing the wall. Finally, Emily places herself in the fourth corner of the room, also facing the wall. This sculpture graphically shows Emily’s perception of the family as distant and disengaged. When they discuss the sculpture, the family might acknowledge the effect of not eating dinner together and isolating themselves in separate rooms. Thus, the sculpture conveys the powerful sense of loneliness and lack of support that Emily feels.

Through sculpting, a family might gain awareness and sensitivity in a way that would not be possible through a verbal exchange. As a result, they might be better able to modify interactional patterns. Applying the family principles discussed in this chapter, it appears that this family is an alcoholic family in the sense that alcoholism has been allowed to invade family rituals, such as eating and spending time together. The family has assumed rigid rules and roles that perpetuate the alcoholism and do not support the health and growth of individual members or the family as a whole.

Sculpting can be implemented in many variations. For example, Emily might be asked to sculpt the family again, this time depicting how she would like them to relate. Imagine in this case that she brings them together in circle at the center of the room, close together but not touching and facing each other. This could lead to further discussion about how they can change roles, rules, and so on. Alternatively, sculpting could be used at the end of the family therapy to show progress made. In another variation, a different family member could sculpt the family to show his or her perceptions. Someone could sculpt the family at a time before the alcoholism invaded the family’s rituals and they interacted together. The therapist could even sculpt the family, if needed. Sculptures can become quite complex with large nuclear and extended families, especially if there have been major disruptions over time. Members often become quite enthusiastic and creative in sculpting.

Family History

Other family members are the father, Jim, an accountant (age 42); Susan, a homemaker (age 42); and Jason, a high school freshman (age 15). They are a white, middle-class family. Both Jim and Susan described their family of origin as traditionally suburban middle class, with a breadwinner father and homemaker mother. They met in college, married immediately after graduation, and had their first child two years later. Jim described his father as a steady drinker, who was frequently verbally abusive. In retrospect, Jim believes that his father drank heavily throughout Jim’s childhood and adolescence, although he believes that his mother protected him and his older brother from much of their father’s alcoholic behavior. Susan reported that there was considerable conflict between her parents, who divorced when she was 16 years old. She rarely saw her father after the divorce. She reports no substance use by her parents.

The couple described their marriage as “average,” although closer inspection reveals that they seldom interact. Jim, who is self-employed, has been focused on his business over the last few years. The struggling local economy had severely cut his income. Susan is actively involved in several charity and social organizations. They acknowledged having “drifted apart.” In fact, there is little indication that the family as a whole has much interaction, since they do not eat meals together and spend most of their time in separate rooms. Jim acknowledges that he has three to four drinks a night but does not see this as a problem. Susan confirms this intake and feels that Jim’s drinking is a way for him to relax, given his work stress. Susan drinks socially on occasion. Jason denies any drinking or drug use, and his parents believe that this is an accurate report.

Assessment

According to a family systems perspective, Emily is the “identified patient” in this family. Although she clearly has an alcohol abuse problem in her own right, underlying factors in the family appear to be contributing to her difficulty as well as to that of other family members. One pattern observed in this family is triangulation. This concept can refer to the tendency of a marital dyad to maintain stability in their relationship by focusing their attention on a third person, usually a child. When a child experiences difficulties, the parents’ attention is diverted away from addressing the underlying problems in their relationship. From a systems perspective, all family members are participating in this pattern with the goal of reducing stress and conflict. Emily’s problems could be seen as a way to keep her parents engaged with each other through their mutual concern for her. Thus, they are spared from having to confront the lack of emotional support in their marriage. Developmentally, Emily is at an age when she should be starting to emancipate. This pattern may also serve to keep her in a non-adult role with her parents.

This family presents with at least three generations of active substance abuse. Jim is likely the adult child of an alcoholic father and a codependent mother and appears to be in denial regarding his own alcohol abuse problem. One could hypothesize that he learned the “don’t talk, don’t trust, don’t feel” rules that are often encountered in these families. It is not surprising that he is having difficulties with intimacy in his marriage and with his children. Susan suffered a severe blow to her sense of security when her parents divorced and her father became distant. She may not recognize the potential for a similar outcome in her own marriage. They have evolved into a classic male alcoholic, female codependent pattern in which both minimize the extent of problems that alcohol is causing in their family. They are locked in behavioral patterns that are self-defeating and are actively training their children into these roles as well. It appears that alcoholism accounts for the lack of shared rituals and routines in their daily life. Thus, according to the Steinglass model, they can be described as an “alcoholic family.”

Treatment

From a systems perspective, the focus of therapy will be on improving family functioning for the benefit of all family members. Since there is apparent active alcohol abuse in two family members (Emily and Jim), this will be the initial focus of treatment. Although Emily is engaged in a recovery program, numerous factors combine to jeopardize her sobriety as well as the well-being of other family members, including Jim. These include the continued presence of alcohol in the home (despite her clear request that it be removed), her father’s unwillingness to admit to his own alcohol abuse, ongoing conflict with her parents, and the general lack of emotional support in the family. Therefore, the therapy begins with the immediate goal of cessation of Jim’s drinking and removal of alcohol from the home. Once this is addressed, the goal will become to assist the family in developing patterns of interaction and communication that foster the growth of all family members. The therapy will be conducted following the four-stage model of Steinglass et al. (1987) discussed earlier in this chapter.

Stage one is diagnosing alcoholism and labeling it as a family problem. In the initial session, the therapist assesses the family functioning by questioning each family member in order to gain information as well as establish a therapeutic relationship with them. Jim and Susan adamantly insist that Emily’s oppositional behavior is the source of their family’s current problems. They feel that otherwise they would be “fine” and cite their previous successful functioning prior to Emily’s difficulties as evidence of their position. Emily remains noticeably sullen throughout the session. Jason seems to make every effort to appear invisible and grudgingly agrees with his parents when asked for his perspective.

In the next session, Emily becomes more vocal. She had met with her school social worker who urged her to share her concerns about her father’s drinking and her mother’s acquiescence in family therapy. She defiantly reports that her father is an alcoholic and that “I should know.” She and Jim immediately become entangled in a conflict. He denies that he has a problem and accuses her of trying to shift the blame for her behavior. Susan and Jason watch in silence, with evident discomfort. When questioned by the therapist, Susan expresses concerns for Jim’s health, revealing her fear that he will have a heart attack due to the stress of their financial situation. She apparently attempts to deflect the focus back to Emily by adding that their daughter’s difficulties have exacerbated his stress. When questioned again about Jim’s drinking, she seems to minimize it by stating that he just drinks to relax.

The family is in a standoff, and it is crucial for the therapist to address this impasse openly. She presses Jason for his opinion, since the silent member of a family is often the most valuable source of information. He reluctantly agrees with both Emily’s and Susan’s concerns: He thinks his father drinks too much and also worries about his health. With Jason’s revelation, Susan’s resolve to protect Jim in his denial appears to weaken. Although she continues to waver, she and the children gradually align in their concern about Jim’s drinking. They identify the following problems: embarrassment when he is drunk in public, anxiety when he wants to drive while intoxicated, fear of his angry outbursts, sadness over his emotional unavailability, concern regarding his poor health, and worry over financial instability.

Jim becomes increasingly defensive and the therapist moves to keep him engaged in the therapy. She reframes this feedback in terms of his family’s honesty: Although painful, it is an indication of their love for him. She commends him for having developed such a sense of trust with his family that they were willing to be so honest. It should be noted that the therapist is not labeling Jim as alcoholic at this point. Rather, she is keeping the focus on the family members’ current topic and facilitating their efforts to state directly how his drinking is causing problems in their family. This strategy reduces the possibility that the father will attack the therapist, be supported by family members, and manage to avoid this issue. The session concludes with the therapist clearly stating that Jim’s drinking seems to be a major problem for the family.

On the third session, the family comes in with a crisis: Jason had gotten into a fight at school and was suspended. Some crisis was almost to be expected, since the family homeostasis had been disrupted last week. One could hypothesize that Jason (perhaps unconsciously) was assisting Emily in maintaining the family’s familiar patterns, particularly in terms of keeping the focus off Jim’s drinking. The therapist quickly moves to counteract this attempt to regain stability by using a psychoeducational approach with the family. She explains the idea of “family system” and how the behavior of each member affects the family as a whole. She observes that the last session disrupted their usual patterns and notes how distressing this can be. This shows that she is empathic with their situation, places this crisis in a larger context, neutralizes the diversion, and enables her to return the focus to Jim’s drinking.

A long silence is broken by Jim’s query as to whether the therapist thinks that he has a drinking problem. Aware of the importance of this juncture, she responds that this certainly seems to be the case, based on behavioral indicators, but primarily because she has heard the concerns of his family and cannot disregard them. Since his attendance at this session indicates how strongly he is committed to his family, she is sure that he has heard their concerns as well. (This response puts Jim in a bind, since to disagree with the therapist would suggest that he is disregarding the concerns of his family and would call into question his commitment to them.)

Jim does not respond and is obviously distressed by his predicament. Susan tries to “rescue” him by stating her concern about the problems involving Emily and Jason. The therapist explains that she has not forgotten this, but that Jim’s drinking must be addressed first if the family is to resolve other problems successfully, especially since Emily is already engaged in treatment. They are reluctant to confront him further so, rather than engage in a power struggle with the family, she wonders aloud at the “power” that alcohol seemed to have over them. Jim breaks the silence, defiantly saying that alcohol has no power over him. She asks why he thinks that his family is so threatened by the topic (in this way, she highlights the process of alcoholism in the family, not Jim’s alcoholism, per se). This provides a less threatening avenue for Susan, Emily, and Jason to once again talk to Jim about his alcohol abuse and the effect it has on them.

In the next session, Jim indicates the effect that his family’s disclosure had on him. He was quite withdrawn during the ensuing week. He attempted to prove them wrong by showing that he could quit drinking whenever he wanted. However, in the face of his family’s feedback and the unexpected struggle he had in avoiding alcohol, Jim reluctantly agrees that he might have a problem. At this point, several significant events have transpired in the therapy: Jim’s denial regarding his alcohol abuse has been broken and his problem has been placed within the larger context of the family. The therapy enters stage two: removal of alcohol from the family system.

The family and therapist agree to work together to help Jim stop drinking. The next step is to develop a detoxification contract with the entire family, since this is now regarded as a family problem. Since hospitalization is not indicated, the therapist recommends an eight-week outpatient program (only a therapist adequately trained in assessment should make treatment recommendations). Jim agrees to make an appointment with this agency for an evaluation prior to the next session. He will also remove all alcohol from the home. Jim asks that the family spend more time together and feels that this will assist him in not drinking. He becomes tearful as he talks about how he feels uninvolved in his children’s lives (the therapist notes that he did not include Susan in this sentiment). The family agrees to have dinner together in the evenings. The therapist praises the family for their courage in confronting this problem together, acknowledges the difficulty of their task, but reassures them that they can succeed in making desired changes.

The therapist begins the fifth session by reviewing the family’s implementation of the detox contract. Jim has removed all the alcohol from the house, enrolled in an outpatient treatment program, and abstained for the full week. Family members confirm that he has not appeared to drink. However, they did not share any meals together. Susan, although expressing her relief over Jim’s adherence to the contract, feels that he has become more “moody.” Jim admits to feeling unsupported by the family, particularly since Susan has not organized any meals. Susan says that there were too many different schedules among them to plan a specific time for dinner (i.e., disruption of routines). The therapist anticipated problems with the contract, since the family is attempting to change entrenched patterns. She empathizes regarding the challenges they face, commends them for their successes, and assists them to negotiate a better plan. After considerable discussion, all members agree to adjust their schedule to have dinner together three times a week and to participate in the family component of Jim’s outpatient program. (It is important to recognize that the process of assisting them to develop new skills for problem solving, such as negotiation, is as important to the therapy as the product, the new contract. The therapist also notes the weak unity and authority in the parental dyad. Thus, she is continually engaged in assessment, gathering information that will be useful when they begin to address non-alcohol-specific family patterns.)

The next week, Jim enters treatment, and for six weeks, his behavior indicates that he is clearly engaged in his treatment program. He expresses a sense of camaraderie with other males that he has not enjoyed since being in the military. Nevertheless, he is finding it difficult not to drink and relies heavily on AA meetings and his sponsor for guidance. The family is actively involved in the family program. Emily is particularly enthusiastic, given her previous positive experience with treatment. She and her father have fewer conflicts as they support each other in their recovery efforts. Jim becomes more involved in Jason’s sports activities. The children have developed a habit of “checking in” with Jim at least once a day. Jim frequently expresses regret that he was not more available to them due to his drinking. The family is managing to have three dinners together a week and is trying to share one activity on the weekend.

As Jim maintains sobriety, the therapy shifts into stage three: the emotional desert. Jim is six weeks into his treatment and has been sober for two months. The focus of therapy is to support the family as they adjust to the absence of alcohol in the family system and to tolerate these changes. For years, they have slowly altered their behavior to accommodate Jim’s drinking. In turn, family members have developed maladaptive behavior, such as Emily’s drinking, Susan’s codependence, and Jason’s withdrawal. They must learn new patterns of interaction and communication. Since Jim drank excessively for a number of years, the shift from a “wet” to a “dry” state is extremely stressful. The therapist expects this transition to be difficult and again uses a psychoeducational framework to help them understand the nature of these changes.

Susan’s adjustment appears to be the most difficult. She expresses a sense of unfamiliarity with Jim and discomfort with his new behavior. Toward the end of his treatment program, she begins to express anger toward him for now being the “perfect father,” despite years of being emotionally absent. Although pleased that the family is growing closer, she feels that an unfair burden has been placed on her to prepare meals and provide emotional support while Jim “has fun” with the children or is self-absorbed in his recovery. Susan reveals that she has not been attending Al-Anon meetings or reading about codependency. The therapist indicates that, although Susan and Jason do not have a drinking problem, they must also work on their recovery.

The therapist now concentrates on non-alcohol-specific areas of family functioning. Susan’s concerns have touched on core problems of intimacy in the couple’s relationship. To reinforce an appropriate boundary between the parental and child subsystems, the therapist requests a meeting with Susan and Jim alone. (Although marital therapy seems indicated in this case, this change in format is not always necessary.) The goal of this marital therapy is to assist them in sharing their feelings and to solving problems through the use of traditional marital therapy techniques. An early task is to set guidelines for fair fighting as they express mutual feelings of bitterness and regret. The disorganization in the relationship is punctuated by joint statements regarding the possibility of divorce; yet, both partners indicate their commitment to each other and their desire to improve the marriage. After several conflictual sessions, the therapist is effective in helping each partner take responsibility for his or her contribution to the breakdown of their marriage and to work toward conflict resolution.

The prospect of divorce is unsettling to both of them. This crisis unveils deep fears in Susan stemming from her parents’ divorce, and she gains insight into the origins of her codependency. She realizes that she assumed a child-like position in the marriage, such as giving Jim full authority over financial matters and not monitoring her children’s activities. This appears to be the source of many of her complaints about changes in the family (i.e., being forced into a more mature role). She held the irrational belief that being more assertive and independent would cause him to leave her. For his part, Jim acknowledges that he encouraged her dependence, since this was the model he observed in his family of origin. However, this same upbringing left him with strong unmet emotional needs and weak coping skills. Therefore, he was equally dependent on Susan and fearful of abandonment by her. He was overwhelmed by his perceived sole responsibility for the financial well-being of the family. Rather than turn to his wife for assistance, alcohol became a way of coping with his fears. Once they identified these feelings, they were able to view each other’s behavior in a more positive light and to build trust in their relationship.

The therapist met with Jim and Susan for six weeks. Jim completed his eight-week treatment, participates in the weekly follow-up program, and has been sober for over three months. Emily continues to attend follow-up sessions at her treatment program and has been sober for almost six months. As Jim and Susan address their marital problems directly and change their relational patterns, the family enters stage four: family reorganization. The goal of this stage is to help the family in their reorganization through traditional family therapy, since their basic patterns of functioning have significantly changed. (If Jim had maintained sobriety but their interactional patterns had gone unchanged, the goal would have been family stabilization.)

A new stability in the marriage leads to overall improved functioning in the family. They remain in family therapy for two more months. As Susan and Jim continue to work on achieving mutuality in their relationship, their parenting improves. They make joint decisions regarding the children and feel more comfortable in asserting their authority. Thus, rules and expectations become clearer, and as a result, Emily and Jason show more age-appropriate behavior. Jason begins to explore an unexpressed artistic ability. In the past, Jim had tried to push him into athletic pursuits, for which he was not temperamentally suited. Although problems still arise, they offer opportunities for the family to build and practice new skills for problem solving and conflict resolution. The family interacts more and eats together on a regular basis, with Jim sharing parental responsibility with Susan. They show more effective communication, particularly pertaining to emotional expression. All family members attend support groups to address their individual needs. Jim and Susan jointly sought advice for addressing their financial problems and are implementing a plan.

Breaking old patterns and consolidating new ones is a trial and error process that transpires over the course of therapy. Yet this process will continue even after therapy is completed. One of the last issues discussed is Emily’s impending graduation and her plans to attend college in the fall. She wants to begin working this summer so she can save her money and offset some of the expenses, since the family’s financial situation remains uncertain. Jim’s business has shown slow improvement since he quit drinking, and Susan is considering part-time employment.

At the final session, while reviewing treatment gains and looking forward to the future, the family seems to realize that the end of therapy is really a beginning. Jim voices their commitment to break the cycle of alcoholism and codependence in their family. From Emily’s attempt at death, the family has begun a new life.

Chapter 15 Gender, Substance Use, and Substance Use Disorders

An-Pyng Sun

University of Nevada Las Vegas

Gender has a powerful influence on an individual’s life both in normal development and the domains of dysfunction, diseases, and disabilities. The relationship between gender and substance abuse is complex. Biological predispositions, tradition, and culturally prescribed norms provide much of the foundation for these relationships. Social and economic realities and the constantly changing environment add further complexity. This chapter aims to facilitate gender-competent practice by presenting substance-abuse prevalence rates, identifying gender-relevant consequences and etiological or risk factors of substance abuse, and highlighting gender-based issues with respect to substance abuse treatment.

Prevalence of Substance Use and Substance Use Disorders among Men and Women

Although men continue to outnumber women in rates of substance use and substance use disorders, these gender differences have narrowed in the past several decades. In the 1980s, the alcohol abuse and dependence rate for men was five times the rate for women; since 2002, it has narrowed to two times the difference (Greenfield, Pettinati, O’Malley, Randall, & Randall, 2010). The Substance Abuse and Mental Health Services Administration’s (SAMHSA, 2010) National Survey on Drug Use and Health (NSDUH) also shows that for each year from 2002 to 2009, the male to female ratio for substance use disorders (abuse or dependence on alcohol or illicit drugs) was about 2:1. Rates are converging largely due to women’s increased substance use and substance use disorder rates rather than any substantial decline in men’s rates. Studies show that men from different birth cohorts in the United States do not vary much in their lifetime drinking rates, whereas women who were born between 1954 and 1963 have a significantly higher lifetime drinking rate than women born between 1944 and 1953. The female drinkers from the latter birth cohort were also more likely to develop alcohol dependence than female drinkers from the earlier birth cohort (Grucza, Bucholz, Rice, & Bierut, 2008). Gender convergence trends have also been noted internationally (Greenfield et al., 2010; Österling & Berglund, 1994).

Data from the 2009 NSDUH show that among individuals aged 12 or older, 58 percent of men were current drinkers versus 47 percent of women; 11 percent of men and 7 percent of women were current illicit drug users; and 34 percent of men and 22 percent of women reported current tobacco use (SAMHSA, 2010). Nearly 12 percent of males and just over 6 percent of females had a substance use disorder (abuse or dependence). Men clearly exceeded women in substance use and substance use disorder (SUD) rates for all age groups except the group aged 12–17, in which the SUD rates were similar for girls and boys (7.4 percent and 6.7 percent, respectively).

Given that twice as many men as women have substance use disorders and that women tend to encounter more barriers in entering alcohol and other drug (AOD) treatment, it is not surprising that men account for a much higher proportion of admissions to treatment for alcohol problems and most drug problems (SAMHSA, n.d.a). Men far outnumber women in admissions for alcohol problems only, alcohol with secondary drug problems, and marijuana, followed by heroin, cocaine (routes other than smoked), and PCP. Men are also more likely than women to be admitted for primary drug problems in the following categories: cocaine (smoked), other opiates (e.g., nonprescription use of methadone, codeine, morphine, oxycodone, opium, and other drugs with morphine-like effects), amphetamines, and other stimulants, though the gender gaps for these categories are not as wide as those for the first-mentioned categories. Women, on the other hand, outnumbered men in admissions related to tranquilizers by 0.6 percent, and they outnumbered men by 17 percent in admissions related to sedatives. The total numbers of admissions for problems related to tranquilizers and sedatives, however, are much lower than those for problems related to alcohol, marijuana, heroin, cocaine, and other opiates. Geography also affects gender ratios with respect to primary substance of abuse at admission. For example, in the past few years in the category of amphetamines, men outnumbered women slightly nationwide, but women outnumbered or were equivalent to men in the states of Florida, Texas, Nevada, Arizona, and New Mexico. In general, in 2008, the top three primary substances of abuse at admission are alcohol, marijuana, and opiates for men and alcohol, opiates, and cocaine for women (SAMHSA, n.d.a).

Consequences of Substance Use and Substance Use Disorders among Men and Women

Substance abuse and dependence clearly create negative health and social consequences (World Health Organization, 2007). Researchers estimate that drug abuse and dependence may shorten an individual’s life expectancy by about 22.5 years and that excessive drinking may reduce a person’s life by about 30 years. Men and women who drink alcohol or use drugs experience similar consequences in certain domains but different consequences in other domains because different biological, psychological, social, and cultural factors impinge on the two sexes. Both substance-abusing men and women are subject to a high likelihood of negative consequences. The research also suggests the following differences:

Substance-abusing men are more likely to report, more obvious/externally directed, and antisocial consequences than their women counterparts;

Substance-abusing women often experience more internalized distress and long-term physical and health problems than their male counterparts;

Substance-abusing women may progress from alcohol and other drug initiation to abuse or dependence more rapidly than substance-abusing men;

Substance-abusing women’s lack of resources, having a history of childhood abuse, and gender role expectations may put them at a higher risk for certain negative consequences than substance-abusing men;

Substance-abusing women of child-bearing age are at risk for miscarriage or delivering a child affected by in utero exposure to alcohol or drugs, whereas it is uncertain whether men’s substance abuse affects the fetus;

Both substance-abusing men and women may perpetrate violence toward intimate partners/significant others, but substance-abusing women may be at higher risk to be victimized.

Some of these consequences could also be the causes of substance abuse or the relationships may be reciprocal. For example, alcohol abuse may result in reduced inhibitions that precede domestic violence, while being a domestic violence victim may prompt alcohol use to dull emotions and pain. More studies are needed to confirm and clarify these relationships in order to aid practitioners in incorporating the information into substance-abuse prevention, education, screening, assessment, and treatment.

Personal, and Social Consequences

Men overall report more negative consequences from alcohol abuse than women do; this may be because men usually drink a greater amount and more frequently than women. However, after controlling for the level of drinking, men show an equal or a higher level of alcohol-related problems than women. For example, some studies find that men are either equally or more likely to report acute negative consequences (e.g., Kuendig et al., 2008; Plant, Miller, Thornton, Plant & Bloomfield, 2000). Kuendig and colleagues measured six consequences by adopting questions from the Alcohol Use Disorders Identification Test (AUDIT; see Chapter 5 for a description of this instrument). Men and women clearly and consistently differed on “blackouts” and “role failures,” with men more likely to experience both. The two sexes did not differ on “injury,” “loss of control over drinking,” “guilt,” and “pressure to cut down drinking.” Graham et al. (2011) found somewhat different results. Men in their study were more than twice as likely as women to report blackouts (being “unable to remember [the] night before),” to fail “to do what was expected” of them, and to have experienced harm to family relationships. Men were nearly three times more likely to have injured themselves or someone else, and to have experienced harm to their marriage or work, nearly four times more likely to engage in a “fight or physical fight,” and more than four times more likely to drink in the morning to “get over bad effects.” Although women’s substance-abusing behaviors are more likely to be subjected to harsh sanctions from society than men’s are, women are less likely to report alcohol-related social consequences than men (even after controlling for drinking level) (Bongers, van de Goor, van Oers, & Garretsen, 1998). Various reasons may explain this. Women may be more cautious in monitoring and controlling their behavior when drinking than men because of social norms, ascribed gender roles, and the stigma attached to drinking (Caudill et al., cited in Bongers et al.). It is also possible that women underreport their alcohol-related social consequences because of the stigma attached to their behavior (Bongers et al.).

Binge Drinking and Drunk Driving

Alcohol-impaired driving fatalities have decreased from close to half of all driving fatalities in 1982 to about one third in 2009 (U.S. Department of Transportation [DOT], n.d.a, n.d.b). Men are more likely to be the drivers in alcohol-related fatalities. In 2008, among male drivers in fatal crashes,25 percent had a blood alcohol concentration of 0.08 percent (0.08 grams per deciliter) or above; among female drivers in fatal crashes, the figure was 13 percent (U.S. DOT, 2010). Men are more likely to engage in binge drinking than women, and male binge drinkers are also more likely to drive after binge drinking than female binge drinkers. For example, Naimi, Nelson, and Brewer (2009) analyzed data from 14,085 binge drinkers in the United States. Of all recent driving-after-binge-drinking episodes, 83 percent of the drivers were men. Thirteen percent of the men and 8 percent of the women reported driving either within two hours of or during their latest binge drinking incident. SAMHSA (2010) also found that about 16 percent of men and 9 percent of women drove under the influence (DUI) of alcohol during the past year.

Although men continue to have a far higher rate of DUI episodes than women, the gender gap in official DUI arrest rates narrowed in the past two decades. Nearly 11 percent of DUI arrests in 1982 and more than 18 percent in 2004 were of women, while men’s rates declined and then stabilized. Schwartz and Rookey (2008) find evidence that the converging gender gap in DUI arrest rates may have more to do with changing laws and legal ramifications than the possibility that liberalized gender roles are prompting women to drink more heavily. Since the 1990s, many states lowered the criterion for DUI arrests from a blood alcohol level of 0.10 percent to 0.08 percent. They suggest that this may have resulted in more arrests of women, because women tend to drive under the influence of a lower level of alcohol than men do. According to Schwartz and Rookey:

The organization of gender may not have changed all that much over time. . . . it is women who are still the primary caretakers of children and nurturing remains key to fulfilling female role obligations; standards of beauty and women’s virtue have not changed all that much; and behavioral expectations for women, compared with men, remain more restrictive . . . It may also be . . . that women’s lives have changed a great deal, but that these changes do not manifest themselves in drunk-driving behavior . . . Because drunk driving has the potential to affect the lives of others profoundly, it may not be as subjectively acceptable to women, even given changes in women’s opportunities to commit this crime. (p. 664).

Physical Health Problems

Compared to men, women may progress faster from their initial substance use to the development of substance use disorders. Many studies have shown that, with an equivalent amount of alcohol consumption, women are more likely than men to experience the adverse effects of alcohol, and given a “drinking career” of equal length, women tend to develop alcoholism problems faster than men. This phenomenon in women has been labeled the “telescoping effect” (Piazza, Vrbka, & Yeager, 1989). Several factors may result in the telescoping effect. When an equivalent amount of alcohol is consumed, women tend to experience a higher blood alcohol concentration (BAC) than men do (Ely, Hardy, Longford, & Wadsworth, 1999). Women’s higher BAC may be related to their smaller body size and proportionately less body water and more body fat than men, as alcohol is diffused in body water (Mumenthaler, Taylor, O’Hara, & Yesavage, 1999). Some research also suggests that women’s lower level of the enzyme gastric alcohol dehydrogenase in the gastrointestinal system may also contribute to a higher BAC, although this idea awaits further proof (Graham, Wilsnack, Dawson, & Vogeltanz, 1998; Walter et al., 2003).

Consistent with the concept of the telescoping effect, extensive studies show that both sexes suffer alcohol-induced liver, heart, and brain problems despite the fact that women consume less alcohol than men. The female liver is more prone to the toxic effect of alcohol than the male liver, and women develop liver injuries and diseases more rapidly than do men. A large population-based study (Becker et al., 1996) indicated that compared to men consuming 1 to 6 drinks weekly, men consuming 14 to 27 drinks weekly had a higher risk of developing alcoholic cirrhosis/liver diseases. For women, an intake of 7 to 13 drinks weekly would increase such a risk. Women additionally may suffer obesity, osteoporosis, breast cancer, and reproductive system dysfunction, and pregnant women may give birth to infants with fetal alcohol syndrome or fetal alcohol spectrum disorders. Female heavy drinkers have a significantly higher mortality rate than male heavy drinkers (see reviews by Kay, Taylor, Barthwell, Wichelecki, & Leopold, 2010; Nolen-Hoeksema, 2004; Sun, 2009). Some drugs, such as cocaine and opioids, also show evidence of telescoping effects in women, although more studies are needed. Women may progress from cocaine initiation to cocaine abuse or opioid initiation to opioid addiction very quickly and experience more health-related problems than men do (Kay et al. 2010).

Fetal Alcohol Syndrome/Fetal Alcohol Spectrum Disorder

Drinking during pregnancy increases a woman’s risks of prenatal death of the fetus or delivering a baby with fetal alcohol syndrome (FAS) or fetal alcohol spectrum disorder (FASD) (Gemma, Vichi, & Testai, 2007; Mattson, Crocker, & Nguyen, 2011). An FAS diagnosis requires all of the following three criteria: (a) all of the three facial abnormalities that involve the upper lip and eyelids (“smooth philtrum,” “thin vermillion border,” and “small palpebral fissures”), (b) growth deficits, and (c) central nervous system/neurodevelopmental abnormality (Centers for Disease Control and Prevention [CDC], 2004, p. viii; Sokol, Delaney-Black, & Nordstrom, 2003). The diagnosis for individuals who do not meet the criteria of the classic FAS may be considered under the term FASD (Sokol et al.). FAS is a medical diagnostic term, while FASD is an umbrella term, not a medical diagnosis (CDC). FASD encompasses FAS, partial FAS, alcohol-related neurodevelopmental disorder (ARND), and individuals who are affected by alcohol-exposure prenatally but without any diagnosis (Mattson et al. 2011). The prevalence of FAS in the United States is estimated to be 0.5—2.0 per 1,000 live births, and the prevalence of FAS or other FASD is about 10 per 1,000 live births (National Association of State Alcohol and Drug Abuse Directors, 2005). Box 15.1 describes tools available for screening women who plan to become pregnant or are pregnant for risk drinking.

Although changes in somatic growth and minor facial malformations may be the most common characteristics of a prenatally alcohol-exposed child, “the effects of alcohol on brain development are most significant in that they lead to substantial problems with neurobehavioral development” (Jones, 2011, p. 3). Prenatal AOD exposure may cause short- and long-term damage to an infant with respect to cognitive, physical, and behavioral development (Little & Yonkers 2001; Mattson et al., 2011; Streissguth, 1997). For prenatally exposed preschool children, the negative effects may include hyperactivity and inattention problems if moderate maternal drinking during pregnancy is involved. For prenatally exposed school-aged children, the negative effects may include memory deficit, learning problems, impulsivity problems, and psychiatric conditions such as mood disorders if moderate maternal drinking during pregnancy is involved (see the review by Sokol et al., 2003). The same review also showed that maternal binge drinking during pregnancy may result in an even more adverse effects on the fetus, causing future developmental delays. These prenatally exposed children may also show a lack of persistence in pursuing goals during their preadolescent period as well as manifest multiple neurobehavioral problems during their adolescent years. The negative effects of prenatal exposure to maternal drinking may be carried into adulthood. The problems may be related to executive-functioning insufficiency and may include difficulties with problem solving and daily life-functioning tasks as well as antisocial behavior and increased substance abuse.

No threshold has been identified indicating the level of drinking during pregnancy that will cause FAS or FASD. Generally speaking, binge and heavier drinking seem more risky than non-binge and light/moderate drinking. The professional community recommends abstinence for women who are pregnant or preconceptional, given the lack of a clear threshold for risky drinking during pregnancy (Sokol et al., 2003). Not all alcohol-exposed infants, however, will show medical complications or developmental problems. Some research shows that less than 10 percent of women who drink heavily during pregnancy give birth to babies with FAS (Gemma et al., 2007). Various factors—the type and combination of drugs/alcohol used, the amount and frequency of use, during which trimester the use occurs, the mother’s reactions to the use, and the fetus’s genetic vulnerabilities to alcohol and other drugs—may determine whether a baby will show severe, mild, or no symptoms (Gemma et al., 2007; Little & Gilstrap, 1998; Streissguth, 1997). Researchers have also proposed some additional maternal risk factors that may increase FASD liability: maternal age older than 30 years, genetic background, ethnic group, poor socioeconomic status, prior child with FASD, and maternal undernutrition (see Jones’s review, 2011, pp. 5–6).

BOX 15.1 Screening Pregnant Women for Alcohol Problems

The telescoping effect, in which women tend to develop alcohol and other drug problems more quickly than men, makes it critical that women’s chemical abuse problems be recognized early(Piazza, Vrbka, & Yeager, 1989). Duckert (1987) recommends routine screening for substance abuse during a woman’s regular gynecological and prenatal care, and Turnbull (1989) suggests further training of medical, mental health, and social service professionals so they can recognize the signs of substance use disorders in women.

Screening Instruments

Most of the commonly used screening instruments for alcohol use disorders were developed using primarily male samples, but some screening instruments that are more sensitive to detecting alcohol problems in women have been developed. For example, the TWEAK test was developed from items on the MAST and CAGE tests and from the T-ACE (another gender-sensitive instrument) in order to better screen for risk drinking during pregnancy (NIAAA, 1993; Russell, 1994). It takes less than one minute to administer the TWEAK in an obstetrical/gynecological medical setting (Chang, 2001). To avoid causing a confrontation and triggering a denial, the TWEAK addresses tolerance to the effects of alcohol, instead of directly asking women about how much alcohol they have consumed (see the test items below).

Russell (1994) found that making these adaptations helped the TWEAK outperform the widely used MAST and CAGE with a group of pregnant African American women in the Detroit area. Simple wording changes seemed to make a substantial difference in detecting alcohol problems in this group of women (Chan et al., 1993). Testing has involved the addition of items (Dawson et al., 2001) and use with women who have different socioeconomic characteristics (Chang et al., 1999). Bradley and colleagues (1998) found the CAGE, AUDIT, and TWEAK more sensitive with black than with white women and that the TWEAK may be a better choice than the CAGE or AUDIT with white women. These authors note the need for lower cutoff scores on the CAGE and AUDIT for women compared to men and suggest that interviewer rather than self-administered instruments may be more useful. Schafer and Cherpitel (1998) also found gender and ethnic biases on some of the items that comprise the more commonly used alcohol screening instruments (such as the CAGE, AUDIT, BMAST, and TWEAK; see Chapter 5 of this text). For example, men were more likely to endorse items on the scales regardless of diagnosis. Instruments that do a better job of screening women for drug problems in addition to alcohol problems are also needed.

The TWEAK Test

T  Tolerance: How many drinks can you hold?

W  Have close friends or relatives Worried or complained about your drinking in the last year?

E  Eye opener: Do you sometimes take a drink in the morning when you get up?

A  Amnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?

K (C)  Do you sometimes feel the need to Cut down on your drinking?

A 7-point scale is used to score the test. The Tolerance question scores 2 points if a women reports she can hold more than five drinks without falling asleep or passing out. A positive response to the Worry question scores 2 points, and positive responses to the last three questions score 1 point each. A total score of 2 or more points indicates the woman is likely to be a risk drinker.

Source: The TWEAK test is reprinted by permission of Marcia Russell, Ph.D., Prevention Research Center, Pacific Institute on Research & Evaluation.

Sexually Transmitted Diseases and HIV/AIDS

Drug-abusing men and women are both at high risk for contracting HIV/AIDS. Injecting drugs with infected equipment makes both men and women highly vulnerable. Engaging in unsafe sex with men who are injection drug users IDUs heightens women’s risk, while fewer men become infected from a female partner. Socially impoverished and marginalized women, such as homeless women and street prostitutes are at much higher risk for contracting HIV/AIDS and other sexually transmitted diseases (STD) than other women due to their lack of resources, sex trading, and high degree of exposure to violence from male partners (Elifson, Sterk, & Theall, 2007; Wenzel, Tucker, Elliott, & Hambarsoomians, 2007).

Some studies find that men have a higher rate of IDU than women (e.g., CDC, 2010; Wright et al., 2007); some find that women are more likely than men to be IDUs (Shillington & Clapp, 2003); other studies report no significant difference between the two sexes (Pugatch et al., 2000). In reconciling the inconsistency, Sun (2009)explained that in the general population, adolescent or adult women may have equivalent or lower rates of IDU than adolescent or adult men (e.g., those in the CDC’s year 2009 sample and those in Wright et al.’s sample), while among clinical (treatment) samples or samples of people with severe drug problems, adolescent or adult women may be more likely to be IDUs than their male counterparts (e.g., those in the treatment programs in Shillington and Clapp’s study).

Regardless of whether men or women are more likely to be IDUs, living with an IDU family member, particularly sex partners, increases the odds of sharing injecting equipment (Fitzgerald, Lundgren, & Chassler, 2007). Women are more likely to share or borrow injecting equipment because they are more likely than men to have an IDU sexual partner (Booth, Lehman, Brewster, Sinitsyna, & Dvoryak, 2007; Evans et al., 2003). Studies confirm that having a primary sex partner who is an IDU is a better predictor of syringe sharing or HIV risk behavior among women (Lum, Sears, & Guydish, 2005) than among men (Choi, Cheung, & Chen, 2006). A woman is likely to obtain used injecting equipment from her sex partner, whereas a man is likely to get it from close friends (Davies, Dominy, Peters, & Richardson, 1996). Furthermore, social norms and gender role expectations may put women at increased risk of using used needles/drug because the man usually uses the equipment first and passes it on to his female partner to use (Bennett, Velleman, Barter, & Bradbury, 2000; Lum et al., 2005). More studies illuminating gender effects on equipment use would give further insights into these behaviors that may be useful in HIV/AIDS prevention.

Even when women engage in sex with someone who is not an IDU, they are at increased risk for HIV/AIDS. Women, particularly substance-abusing women, may be in a less powerful position to practice safe sex. Women are less likely than men to report they use condoms or use them consistently during sex (Booth et al., 2007; Evans et al., 2003). Women may feel powerless to negotiate condom use because of expectations of a negative reaction or interpersonal violence by their male partner on whom they rely for financial support (Surratt & Inciardi, 2005; Witte, Batsukh, & Chang, 2010). This is especially true for substance-abusing, impoverished women including street-walking sex workers and homeless women. The women may engage in risky sex in exchange for money to meet survival needs or get a fix for their drug habit. Furthermore, substance-abusing women are more likely than substance-abusing men to trade sex for money or drugs, and sex trading may increase STD/HIV/AIDS risks because multiple sex partners are involved (Otto-Salaj, Gore-Felton, McGarvey, & Canterbury, 2002; Pugatch et al., 2000).

Even among more advantaged women, gender inequities in sexual relationships may weaken women’s ability to practice safe sex. Roberts and Kennedy (2006) found that although the college women they studied were confident of their ability to ask their male partners to use a condom, half of the women did not refuse sex after their partners decline to use one. Any alcohol or other psychoactive drug use before or during sex may decrease inhibitions or prevent women from warding off unwanted sexual advances from men who can easily overpower them, further increasing women’s vulnerability to unsafe sex (for a more detailed review, see Sun, 2009). Women also experience higher rates of sexual abuse during childhood and/or adulthood than men, and sexual or physical trauma may attenuate their decision-making ability to practice safe sex (Wyatt, Myers, & Loeb, 2004).

Intimate Partner Violence

Different research methods and measurements may contribute to the inconsistent findings about intimate partner violence (IPV) prevalence rates among men and women in the general population. For example, the National Violence Against Women Survey reports that the lifetime rates of IPV victimization are approximately 25 percent among women and nearly 8 percent among men (Tjaden & Thoennes, 2000); however, the National Family Violence Survey reports that men and women generally share a similar rate of IPV victimization (i.e., 11–12 percent) (see National Institute of Justice, n.d.). Archer’s meta-analysis (2000) revealed that women are slightly more likely than men to perpetrate IPV if the IPV was measured based on “specific acts,” whereas men are more likely than women to perpetrate IPV if the IPV was measured based on “physical consequences of aggression (visible injuries or injuries requiring medical treatment)” (p. 664). Summarizing various studies, Stuart, O’Farrell, and Temple (2009) found that victimized women have a higher likelihood of experiencing depressive symptomatology, physical injuries, and medical attention resulting from the physical injuries, missing work, and using mental health services than victimized men.

Substance-abusing men and women are more likely to perpetrate IPV than men and women in the general population. Empirical studies have established a link between substance abuse and IPV perpetration and victimization: substance abuse problems are overrepresented among people who seek IPV treatment, and IPV problems are overrepresented among people who seek substance abuse treatment (see reviews by Kay et al., 2010; Stuart et al., 2009). Stuart et al.’s review of studies showed that the prevalence rate of male-to-female IPV in the past year was between 58 percent and 85 percent across samples of men receiving inpatient treatment for alcohol use disorders, and it was between 54 percent and 66 percent in men receiving outpatient treatment for alcohol use disorders. O’Farrell and Murphy (1995) found that the IPV perpetration rate of their sample of alcoholic men in treatment was four to six times higher compared to a demographically matched and nationally representative sample of men.

Researchers have focused on substance-abusing men when studying IPV perpetration and on substance-abusing women when studying IPV victimization (Chermack, Walton, Fuller, & Blow, 2001). Chermack et al. believe that the lack of information on substance abusing men with respect to IPV victimization and on substance abusing women with respect to IPV perpetration prevents a better understanding of gender issues in the field. Stuart et al.’s (2009) review showed that 50 percent to 68 percent of women in substance-abuse treatment perpetrated IPV in the past year, including 25 to 50 percent who were involved in severe violence perpetration. Chase, O’Farrell, Murphy, Fals-Stewart, and Murphy (2003) studied 103 female alcoholic patients seeking couples-based outpatient alcoholism treatment. Sixty-four percent of the women had been victimized by their male partner during the year prior to treatment (22 percent of the cases involved severe violence). Sixty-eight percent of the women perpetrated violence on their male partner (50 percent involving severe violence).

Research findings tend to suggest that substance abuse precedes violence. For example, Stuart et al.’s (2009) review showed that the likelihood of IPV occurrence could be 8 to 19 times higher on a day a man drinks than on a day he does not drink. Fals-Stewart, Golden, and Schumacher’s study (2003) indicated that after controlling for factors of relationship dissonance and antisocial personality, the likelihood of male-to-female IPV occurrence was three times higher on a day when the man used cocaine than on a day he did not. Research shows that substance abuse can also be a result of violence, in that victims suffering emotional and physical consequences associated with IPV may self-medicate with substance use (Collins et al., cited in Stuart et al., 2009; Martino, Collins, & Ellickson, 2005). In addition, substance abuse may precipitate not only IPV perpetration among men and women but also IPV victimization among them, particularly among women. For example, Schneider, Burnette, Ilgen, and Timko (2009) found that about 47 percent of the substance-abusing women in their study (versus 23 percent of women in the general population) and nearly 10 percent of the substance-abusing men (versus eight percent of men in the general population) experienced IPV victimization. Various studies have shown that substance abuse may make women more vulnerable to sexual or nonsexual IPV or other violence (in some cases, regardless of the degree or status of the perpetrator’s drinking; see National Institute on Alcohol Abuse and Alcoholism [NIAAA], 1999). Parks and Fals-Stewart (2004) studied 94 college women and found that the odds of the women encountering sexual aggression were seven times greater and the odds of the women encountering nonsexual aggression were about four times greater on days when they consumed any alcohol than on days when they did not consume alcohol. As mentioned earlier, 64 percent of the female patients with alcohol use disorders in Chase et al.’s study (2003) had been victimized by their male partner during the year prior to treatment, and 68 percent perpetrated violence on their male partner.

To provide more effective assessment, treatment, and prevention, it is important to understand risk factors for IPV among substance-abusing clients. Research on the topic is in its infancy. Risk factors for IPV may include the type and level of substances abused, the quality of the couple’s relationship, history of childhood abuse, and their social and economic resources (e.g., education and income). For example, Schneider et al. (2009) found that IPV victimization tends to happen to men and women who abuse alcohol or alcohol and other drugs more often than to those who abuse drugs only. Chase et al. (2003) found that the male partners’ alcohol problem, especially an alcohol abuse/dependence diagnosis, may contribute to substance-abusing women’s IPV victimization. Some studies show that cocaine use may precipitate woman-to-man IPV (Chase et al.) and man-to-woman IPV (Fals-Stewart et al., 2003). In addition, Schneider et al. found that both male and female injection drug users (IDUs) are more likely to become IPV victims than their non-IDU counterparts, possibly because of the severity of the IDUs’ drug problems and their precipitation of IPV. Chase et al. report that predictors for substance-abusing female IPV victimization by male perpetrators may include “men’s belief that the female alcoholic patient’s drinking causes the couple’s relationship problems,” and men’s “less positive feeling about the female alcoholic”1 (p. 144). Chase et al. also noted that women’s belief that the relationship problems caused their drinking problems and women’s “poorer relationship adjustment” (e.g., desire to end the relationship with their partner) may predict their IPV perpetration toward the male partner. Among both substance-abusing women and men, a history of child physical or sexual abuse may increase IPV victimization risk (Schneider et al). Furthermore, substance-abusing women without a high school diploma/GED may be more likely to experience lifetime IPV victimization (Schneider et al.); likewise, lower education may predict substance-abusing women’s IPV perpetration toward the male partner (Chase et al., 2003).

Etiology and Risk Factors

Empirical studies find that men and women share etiological and risk factors for substance abuse, though women’s substance abuse may be more related to environmental factors (e.g., substance-abusing families of origin and substance-abusing male sexual partners), while men’s substance abuse may be more related to genetics, impulsive behavior, pleasure-seeking, and social occasions.

Family History and Adverse Childhood Experiences

Studies consistently find that substance-abusing women are more likely than substance-abusing men to come from a dysfunctional family of origin or a family with a history of alcohol or drug problems, and/or to have had adverse childhood experiences (ACE) (Boyd, 1993; Chatham, Hiller, Rowan-Szal, Joe, & Simpson, 1999; Chermack, Stoltenberg, Fuller, & Blow, 2000; Deng, Vaughn, & Lee, 2003; Howell & Chasnoff, 1999; Langan & Pelissier 2001; Messina, Marinelli-Casey, Hillhouse, Rawson et al., 2008; Schneider, Kviz, Isola, & Filstead, 1995; Toray, Coughlin, Vuchinich, & Patricelli, 1991; Westermeyer & Boedicker, 2000; Zilberman, Hochgraf, & Andrade, 2003; Zimmer-Höfler & Dobler-Mikola, 1992). For example, in comparing 277 substance-abusing women and 365 substance-abusing men, Westermeyer and Boedicker (2000) found statistically significant differences indicating that the women were more likely to have a mother who abused substances (30 percent versus 22 percent), one or more siblings who abused substances (56 percent versus 41 percent), and one or more grandparents who abused substances (39 percent versus 29 percent). Another study found that 42 percent of 63 methamphetamine-dependent female probationers versus 32 percent of 147 male counterparts came from a family with drug abuse problems (Rao, Czuchry, & Dansereau, 2009).

Studies have reported a proportionate relationship between the number of categories of adverse childhood experience (ACE) an individual experiences and the risk of developing substance-abuse problems later in life (Dube et al., 2002; Felitti & Anda, 2010). This relationship holds true regardless of whether the individual has an alcoholic parent or not (Dube et al.). The 10 categories included in ACE studies are childhood emotional abuse, physical abuse, sexual abuse, emotional neglect, physical neglect, domestic violence, substance abuse in the family, mental illness in the family, incarcerated family members, and parental divorce or separation (Felitti & Anda, 2010; Hillis et al., 2004). Dong et al.’s (2004) study indicates that ACE does not occur alone or independently and that 81 percent to 98 percent of their study respondents who had been exposed to one ACE reported at least a second ACE. Felitti and Anda studied a cohort of more than 17,000 Kaiser health plan patients, half of whom were women, and found that women were more likely than men to report having encountered at least five (of the 10) ACE categories. Felitti and colleagues (1998; Felitti & Anda, 2010) suggested that ACEs may first interrupt a person’s neurodevelopment, which in turn may impair the person’s emotional, cognitive, social, and other functioning. That impairment further precipitates engagement in health-risk behaviors and subsequently results in disability and disease, and finally, an early death.

Marital Status and Substance-Abusing Sexual Partners

Findings on the effect of marital status on an individual’s alcohol and drug use and abuse are not completely consistent. Research and theory suggest that married men and women tend to report a lower rate of various problem behaviors—violence, crime, mental illness, and substance use disorders—than their non-married counterparts (see Fleming, White, & Catalano’s literature review, 2010) because marriage acts as a protection or mechanism of social control and social support (Maume et al., Sampson & Laub, Umberson, cited in Fleming et al.). Married women (pregnant or nonpregnant) are less likely than non-married women to use alcohol, binge drink, use illicit drugs, or smoke (Burd, Martsolf, Klug, O’Connor & Peterson, 2003; CDC, 2009; Huang & Reid 2006; Tsai, Floyed, & Bertrand, 2007). Family responsibilities and an intimate partner’s support and companionship may contribute to married women’s lower substance use or abuse rate. Non-married women have more freedom to engage in various functional or dysfunctional behaviors, or feelings of boredom and emptiness may precipitate their substance use or abuse. For men and women with substance use disorders, studies also suggest that marriage helps prevent substance abuse relapses while not being married has the opposite effect. For example, Walter et al. (2006) found that at one-year follow up, “living alone” and being “separated/divorced” predicted relapse for both alcoholic men and women who received detoxification services. Walton et al. (2003) found that at two-year follow up, being single predicted relapse to alcohol or drug use among men and women who received substance abuse treatment.

Social development theory, however, further suggests that “the influence of social bonds depends on the behavior of the socializing unit to which an individual is bonded” (Catalano & Hawkins, cited in Fleming et al., 2010, p. 164). The relationship is not simply one of marital status. Fleming et al.’s study of 909 young adults revealed that “more supportive, enjoyable, and satisfying relationships were related to less use only in situations in which the intimate partner was not substantially involved in substance abuse” (p. 164). Other studies support this finding. For example, Hser, Huang, Teruya, and Anglin (2003) found “no spousal drug use during follow-up” was one factor related to abstinence for both men and women.

Many studies document that substance-abusing women are more likely to be introduced to drug use by their male sexual partner than the other way around (Hser et al., 1987; Brady & Randall, 1999; Eldred & Washington, 1976; Riehman, Hser, & Zeller, 2000; Wilsnack & Wilsnack, 1991). They are also more likely to keep using when their partner continues to use. Based on Haavio-Mannila’s work, Wilsnack and Wilsnack stated “Women are more likely to imitate the drinking behavior of higher status males, whether in the family or in the work place than men are to imitate female drinking behavior”(p. 150). A recent qualitative study suggests that substance-abusing women’s low self-worth with respect to their intimate relationships with men is one of four major factors contributing to relapse to substance use. The study found that many of the women based their self-worth and sense of well-being on their relationships with men, which is not atypical of women in the general population. Fear of losing “her man” may prompt a woman to engage in substance use to please her drug-using partner or to “keep him home.” A woman may stop using substance because her male partner decides to stop using, and she may go back to using because he wants to use again. As one woman in that study said, “My whole world revolved around him” (Sun, 2007).

The effects of marital status on substance abuse relapse are more consistent for men than women. Being married tends to be protective with regard to treatment outcomes and usually predicts less relapse among men, whereas this is not always the case for women. For example, Schneider et al. (1995) found that at three months following treatment, being married protected against relapse for men but it was a risk factor for relapse among women. This finding perhaps can be explained from two perspectives. First, previous research has indicated that substance-abusing women may be more likely to be married to substance-abusing men than vice versa. Thus, substance-abusing spouses may adversely affect women’s recovery and post-treatment outcomes. Second, regardless of their spouse’s AOD-using status, substance-abusing women, compared to substance-abusing men, are more sensitive and vulnerable to negative interpersonal relationships, including their relationships with their spouses (McKay, Rutherford, Cacciola, Kabasakalian-McKay & Alterman, 1996; Sun, 2007). Weaver et al. (2000) found that women perceived “family” and “marital/intimate relationships” to be two major psychosocial stresses during both pre-recovery and recovery. Practitioners report that in working with alcoholic men who have non-using female partner, the focus seems to be on issues related to substance abuse or abstinence contract compliance, whereas when working with substance-abusing women who have non-using male partners, the emphasis more often is on communication skills, relationship issues, and enhancing positive interactions (Winters, Fals-Stewart, O’Farrell, Birchler, & Kelley, 2002). Compared to a woman who has a substance-abusing male partner and/or a (marital) relationship loaded with tension, a woman who is single or divorced may be better able to focus on her recovery, prompting better treatment outcomes (Wilsnack & Wilsnack, 1991).

Reducing Negative Emotions versus Enhancing Positive Emotions as a Substance Use Trigger

Among clinical samples, research findings suggest that women may be more likely to relapse to AOD when attempting to reduce their negative emotions, whereas men may be more likely to relapse to AOD while trying to seek pleasure or enhance their positive emotions. This seems to be consistent with at least two theories that accentuate the different traits of the two sexes. Theories suggest that women are more prone to depression and the negative implications of interpersonal conflicts and life stressors than men. Women’s hormonal fluctuations and their socialization to suppress their desires to assert and express themselves and to internalize their negative feelings may contribute to this phenomenon (see Sun’s review, 2009). Noble (2005) calls depression “the leading cause of disease-related disability in women” (p. 49). Zilberman, Tavares, Blume, and El-Guebaly’s (2003) review showed that women with depression have a higher likelihood of developing an alcohol use disorder later in life than their female counterparts without depression and their male counterparts with depression. The depression-drinking sequence seems consistent with the self-medication hypothesis among women.

Theories also suggest that men have a lower level of self-regulation and are more likely to engage in sensation seeking than women (Quinn & Fromme, 2010). Self-regulation is “the effortful control of thoughts, emotions, and behaviors in the service of a goal; it includes such capacities as planning and the ability to delay gratification” (Quinn & Fromme, p. 377). Sensation seeking is “a tendency to seek and enjoy novelty and excitement,” which often predicts behavioral risks such as drinking and unsafe sexual practice (see Quinn and Fromme’s review, p. 376).

Negative emotions or unpleasant moods may be triggers for substance abuse relapse for both men and women. Most research finds that women in clinical samples are more likely to relapse due to negative emotions than their men counterparts are, while a handful of studies find no difference between the two sexes in this regard (e.g., Annis et al., 1998, cited in Walitzer & Dearing, 2006), or that men are more vulnerable to the trigger of negative emotions than women (e.g., Hodgins et al., 1995, cited in Walitzer & Dearing, 2006). Numerous clinical studies find that women are more likely than men to use substances or relapse in order to self-medicate negative emotions, including those related to interpersonal conflicts and life stressors (e.g., Annis & Graham, 1995; Back, Brady, Jackson, Salstrom, & Zinzow, 2005; Chong & Lopez, 2008; Haseltine, 2000; Hser, Anglin, & Booth, 1987; Langan & Pelissier, 2001; McKay et al., 1996; Pisinger & Jorgensen, 2007; Thom, 1986; Zimmer-Höfler & Dobler-Mikola, 1992; Zywiak, Connors, Maisto, & Westerberg, 1996; Sun, 2007).

Positive emotions or “external situations and euphoric states” may also be relapse triggers for men and women. Research suggests either that men are more likely to relapse due to positive emotions than women are or that there is no significant difference between the two sexes concerning this trigger. Although many studies (Annis & Graham, 1995; Back et al., 2005; Haseltine,2000; Hser, Anglin, & Booth, 1987; Langan & Pelissier, 2001; Thom, 1986; Zywiak et al., 1996) suggest that men are more likely than women to use AOD to seek pleasure, enhance positive feelings, or for social reasons, other studies (McKay et al., 1996; Pisinger & Jorgensen, 2007; Zimmer-Höfler & Dobler-Mikola, 1992) indicate no significant difference between the two sexes. Scourfield, Stevens, and Merikangas (1996) offer additional insight on the concepts of self-medication and thrill-seeking with respect to women. They divided participants of each gender (132 women and 130 men) into four groups—substance abuse only, substance abuse and comorbid anxiety, anxiety only, and a control group without any of these disorders. Among women, the “substance abuse only” group had a significantly higher thrill-seeking score than the “substance abuse and comorbid anxiety” group, whereas there was no significant difference in the thrill-seeking scores of the “substance abuse and comorbid anxiety” group, the “anxiety only” group, and the control group. Among men, there was no significant difference in the sensation-seeking score between the “substance abuse only” group and the “substance abuse and comorbid anxiety” group. Scourfield et al. stated that their findings provide some support for the self-medication theory for women and that thrill-seeking may be a stronger factor impacting women’s substance abuse when self-medication of negative mental states is not an issue.

Genetics

Genetic influences may contribute to alcohol and drug disorders in a similar fashion as they do to other chronic illnesses, such as type 2 diabetes mellitus, asthma, and hypertension (McLellan, Lewis, O’Brien, & Kleber, 2000). Various factors including gender, ethnicity, types of substances used, and psychiatric comorbidity add complexity to the relationship between genetics and substance use disorders (McGue, Pickens, & Svikis, 1992). Whether genetics affect men and women equally and similarly is a controversial topic in the research on gender and substance abuse (Heath, Slutske, & Madden, 1997). Today, scholars are particularly interested in gene-environment interactions and their effects on mental disorders or psychopathology, including substance use disorders (e.g., Agrawal et al., 2010; Cadoret, Riggins-Caspers, Yates, Troughton, & Stewart, 2000; Enoch, 2011; Guo, Elder, Cai, & Hamilton, 2009; Tsuang, Stone, & Johnston, 2008; van Os, Rutten, & Poulton, 2009). While the research needed to clarify these relationships has a long way to go, available data show evidence of gene-environment interactions, with some indicating that the gene-environment interactions may be stronger for women than men.

Many twin and adoption studies indicate that genetic influences (heredity) explain about 40 to 60 percent of the variance in developing alcohol abuse or dependence (Goldman, Oroszi, & Ducci, 2005; Heath et al., 1997; McGue, 1999; McGue et al., 1992; Tyndale, 2003). Some studies find that genetic influences may be stronger for men than women (Han, McGue, & Iacono, 1999; King, Burt, Malone, McGue, & Iacono, 2005; Prescott et al., 2005). For example, Han et al. found that the proportion of variance heredity explained for liability to alcohol, tobacco, and drug use are 60, 59, and 33 percent, respectively, for men versus 10, 11, and 11 percent, respectively, for women.2 Another line of research, however, demonstrates that genetics affect both sexes to equal degrees (Kendler et al., 1992; Heath et al., 1997; Prescott, Aggen, & Kendler, 1999; Prescott & Kendler, 1999; Kendler et al., 2003). The inconsistent research results pertaining to women may be due to methodological issues. For example, some studies contain very small samples of women (Prescott et al., 2005), and female twin studies with participants recruited from treatment programs may be less likely to discern the genetic influence than when comparisons are made with counterparts recruited from the general population (Prescott et al., 2005; Prescott & Kendler, 2000).

Although gene-environment (G × E) interaction is not a new concept, geneticists are giving more attention to the social environment in understanding human behaviors and human disorders, such as mental disorders and pathology, including substance use disorders. G & E interaction refers to “the dependence of a phenotypic trait’s expression on a particular environment” (Cadoret et al., 2000, p. 253). Tsuang et al. (2008) explain that “gene-environment interactions occur when environmental influences on a trait differ according to a person’s genetic predisposition, or when a person’s genetic predisposition is expressed differently in different environments” (p. 27). The G & E interaction approach posits “a causal role not for either genes or environment in isolation, but for their synergistic co-participation in the cause . . . where the effect of one is conditional on the other” (van Os et al., 2009, p. 19). True genetic effects and true environmental effects can be identified only if G × E interactions are considered.

Various studies provide evidence of a gene-environment interaction in understanding the effect of nature and nurture on human behavior and disorders. For example, studies have shown that children with a birth parent who has antisocial personality or sociopathy are more likely to exhibit delinquent behavior if they are adopted by parents who have had adverse experiences (psychiatric problems, divorce, or separation) than if they are adopted into more functional families (see Cadoret et al.’s review, 2000). Guo et al. (2009) studied 600 monozygotic twin pairs, dizygotic twin pairs, and full sibling pairs and found that among adolescents, a greater level of drinking by best friends (an environmental factor) is likely to lead to an increase in the level of genetic contribution to the drinking behavior, whereas a lower level of drinking by best friends is likely to restrain the genetic influence on alcohol use. Agrawal et al.’s (2010) study of 2,176 young twin women also showed that an increase in peer substance involvement is associated with a stronger expression of genetic influences.

Several researchers further pointed out that the G & E factor may influence adolescent girls or young women more than their male counterparts with respect to deviant behavior, drinking, or substance abuse. For example, Cadoret et al.’s adoption study (2000) showed that having an adoptive parent who had adverse experiences (an environment factor) does not predict much of the variance in the adopted child’ aggressivity (about 2 percent for females and slightly less than 2 percent for males). When having an antisocial birth parent (a genetic factor) is added to the statistical models, the equation significantly predicts aggressivity for both sexes (about 6 percent for females and 7 percent for males). However, when the G × E interaction was added to the equation, the amount of explained variance rose to about 15 percent for females, though it remained the same for males (7 percent).

Substance Abuse Treatment for Men and Women

Chapter 11 of this text discussed the need for culturally relevant or culturally specific treatment when assisting people who identify with particular ethnic or cultural groups; Chapter 12 did the same for those who are gay, lesbian, bisexual or transgender. As Chapters 9 and 14 indicate, treatment must also be age relevant. Various evidence-based treatment methods and approaches discussed in these chapters and in Chapter 6—such as motivational interviewing/motivational enhancement therapy, brief intervention, cognitive behavioral therapy, twelve-step facilitation, contingency management, community reinforcement approach, pharmacological treatments, and so on—have been developed and validated to help substance-abusing men and women. Many issues and challenges in treatment, some old, some new, deserve further exploration and attention as we consider gender-relevant approaches.

Life Issues versus Drug Issues

One perspective with regard to gender and substance use disorders is that women’s substance abuse problems are more likely to be a manifestation or consequence of dysfunction in various psychosocial domains, whereas men’s substance abuse problems are more likely to be the source or cause of the dysfunction in various psychosocial domains. Numerous treatment outcome studies show that although substance-abusing women (especially drug-abusing women) present more severe and negative pretreatment psychosocial characteristics and substance use disorder symptoms than their male counterparts (e.g., Fiorentine, Anglin, Gil-Rivas, & Taylor, 1997; Messina, Marinelli-Casey, Hillhouse, Rawson et al., 2008; Pelissier, Camp, Gaes, Saylor, & Rhodes, 2003; Weiss et al., 1998), women’s treatment outcomes are equivalent to or better than men’s (Dawson et al., 2005; Porowski, Burgdorf, & Herrell, 2004; Pelissier et al., 2003; Pelissier & Jones, 2005; Rao et al., 2009; Walitzer & Dearing’s review, 2006). More research is needed to understand the factors that affect treatment outcome success for each of the sexes. Improvement in various psychosocial domains (e.g., mental and physical health, parenting skills, vocational skills, spousal and other interpersonal relationships, and housing), which usually occurs via provision of comprehensive case management, may contribute to improving substance use problems, and improvement in substance use problems may contribute to better functioning in the various psychosocial domains among women. A bi-directional path may also be applicable to men, but it may not be as distinct.

Data collected by the SAMHSA-funded Residential Women and Children and Pregnant and Postpartum Women programs on 1,200 female clients from 32 treatment sites provide a clear picture of the harsh reality these women face. At admission, 40 percent of the women used crack cocaine, followed by alcohol (14 percent), methamphetamine (13 percent), and heroin (8 percent);54 percent of them had 3 or more children;52 percent had less than a high school/GED education; 49 percent had mental health problems; only 8 percent were employed; 77 percent were victims of abuse; 47 percent had children removed by the child protective services; 50 percent were involved with the criminal justice system; 60 percent had health problems (Porowski et al., 2004). In another example, Messina, Marinelli-Casey, Hillhouse, Rawson et al. (2008) obtained pretreatment data on 236 male and 351 female methamphetamine-dependent prisoners and found that compared to men, women were significantly more likely to lack a high school education (22 vs. 15 percent), to be unemployed (30 vs. 11 percent), to have a young child (73 vs. 60 percent), to have a more severe drug problem, to report being abused before age 18 (emotional abuse, 55 vs. 37 percent; physical abuse, 42 vs. 27 percent; sexual abuse, 42 vs.11 percent), to report familial arguments (40 vs.26 percent), to experience “familial substance abuse while growing up” (63 vs. 50 percent), to witness “familial violence to other family members” (55 vs. 39 percent), and 9 percent of women versus 3 percent reported experiencing six types of childhood adverse events.

Despite women’s adverse background characteristics at treatment admission, they tend to improve after receiving appropriate services, especially comprehensive case management and residential treatment. For example, SAMHSA’s Residential Women and Children and Pregnant and Postpartum Women programs offered pregnant and parenting women three essential service components: (a) long-term (6 or 12 months) residential treatment, (b) on-site residential services for their infants and young children, and (c) a comprehensive package of services (e.g., substance abuse treatment, prenatal and pediatric care, nursery and preschool services, parenting skills, mental health care, vocational training, legal services, and transportation). Porowski et al. (2004) found that six months after discharge, 61 percent of the women reported no relapse and a significant pre-post decrease in alcohol and drug use categories. Though there was no control group for comparison purposes, Porowski et al. report that these women’s treatment programs consistently produced larger reductions for each type of substance use than found in large-scale studies that included mostly men receiving residential treatment services (see Gerstein & Johnson, 1999). Not only did the women reduce their substance use during the follow up period, they also improved in the psychosocial domains. For example, among the abstainers (women who did not relapse to drug use during follow up), 44 percent lived with a substance-using partner at treatment admission compared to 5 percent post-treatment; among those who relapsed (used substances during follow up), the rate decreased from 46 percent to 24 percent. For the abstainers, the treatment admission employment rate was 7 percent compared to 44 percent at follow up; for relapsers, the employment rate increased from 6 percent to 26 percent.

Case management and comprehensive services may be more effective for substance-abusing women than substance-abusing men. For instance, Morgenstern, Hogue, Dauber, Dasaro, and McKay (2009) found that Coordinated Case Management, “a continuity-of-care intervention focused on engaging clients in drug treatment, linking them directly to needed ancillary services, and fostering transition to employment,” improved employment for female substance-using welfare recipients but not for their male counterparts(p. 956). This may be due to men and women’s different pre-treatment characteristics. Women may have faced significantly more employment barriers than men, and men may have been much more ready to work than women prior to treatment. Findings such as those on employment offer support for the theory that substance-abusing women, compared to their male counterparts, need “habilitation” rather than “rehabilitation.”

Treatment Entry, Completion, and Success

Although substance abuse treatment benefits women and substance-abusing women tend to fare better than substance-abusing men after treatment, women are less likely than men to enter or complete treatment. Although women’s treatment entry rate has improved over the last two decades—women accounted for 28 percent of the total substance-abuse treatment admissions in 1992, 30 percent in 2001, and 32 percent in 2007 (Office of Applied Studies, n.d.), women still have a lower treatment entry rate relative to their substance abuse prevalence rate. Once in treatment, women’s completion rate is also lower than men’s:37 percent of women and 45 percent of the men completed treatment in 2002, 40 percent versus 46 percent in 2003, and 39 percent versus 47 percent in 2004, respectively (Office of Applied Studies, 2009). Research shows, however, that women are equally likely to participate and complete treatment when family, economic, and other barriers are addressed (Green, 2006).

Lack of child care services is a major barrier to women’s treatment participation. Substance-abusing women are more likely than their male counterparts to have a child, but most treatment facilities do not accommodate women’s childcare needs. Brown, Vartivarian, and Alderks’s (2011) review showed that many mothers experience difficulty finding child care when seeking treatment, particularly low-income or single mothers, and that some mothers avoid treatment due to worries about losing child custody if they are unable to find child care. SAMHSA’s (n.d.b) 2009 National Survey of Substance Abuse Treatment Services showed that only 8 percent of substance-abuse treatment programs offer childcare for clients’ children and less than 4 percent offered residential beds for clients’ children.

Since men are more likely to manifest acute and more pronounced symptoms and consequences of substance use disorders than women (Plant et al., 2000), men are more likely to attract attention and be identified and referred to treatment than women with substance use disorders (Guthrie & Flinchbaugh, 2001). A study found that when pediatricians were presented with fictional female adolescent girls with drug-abusing symptoms (e.g., runny nose, loss of appetite, worse relationship with parents, and loss of interest in school), they were more likely to render a diagnosis of depression than drug use disorder, whereas when fictional counterpart male adolescent boys with identical symptoms were presented, these pediatricians were more likely to render a diagnosis of drug use disorder than depression (National Center on Addiction and Substance Abuse [CASA] at Columbia University, 2000).

Stereotypes and stigma may also discourage women from entering treatment. Women may have internalized the stigma stemming from society’s harsher sanction on their substance-abusing behavior than men’s substance-abusing behavior, causing women to be more hesitant than men to acknowledge their substance-abuse problems and treatment need. For example, respondents in one study were less sympathetic to a female rape victim if she was intoxicated during the incident as they perceived that she should not have used alcohol to begin with; however, they were more merciful toward a male perpetrator who drank alcohol when victimizing a woman, since “it’s not the man, but the alcohol” that created the problem (cited in Blume, 1997). Another study showed that women respondents tend to censure women’s drinking more so than men’s (cited in Blum, Nielsen, & Riggs, 1998). Internalized stigma may discourage women from seeking substance abuse treatment because of shame and guilt.

To more effectively identify and link women to treatment, society’s overall harsh and punitive attitude toward substance-abusing women, especially women who are mothers or pregnant, must change. Strategies that are sensitive to women’s dilemmas and concerns can better achieve the goal. For example, Sokol, Martier, and Ager (1989) believe that one reason their T-ACE screener outperformed the CAGE (see Chapter 5) in screening pregnant women was the use of the “tolerance” question (i.e., “How many drinks does it take to make you feel high?”), which replaces the CAGE question “Have you ever felt bad or guilty about your drinking?” Sokol et al. surmise that women may be less likely to perceive the tolerance items as an indicator of drinking; therefore, a woman who unconsciously or intentionally attempts to minimize her drinking may be more honest in answering the tolerance items. Russell et al. (1996) further point out that the T-ACE question “How many drinks can you hold?” tends to be more sensitive in detecting pregnant women’s drinking than T-ACE question, “How many drinks does it take to make you feel high?” Since women are more likely to seek care in primary care or mental health facilities than specialty substance abuse treatment programs, and since they are also more likely to be referred by child protective services and income maintenance/welfare offices than men, practitioners in these settings need to be acquainted with gender-sensitive substance abuse screening tools and procedures (also see Box 15.1).

The criminal justice system is the largest source of referrals to substance abuse treatment (37 percent in 2007) (SAMHSA, 2009). More men than women are referred to substance abuse treatment by the criminal justice system. In 2007, that ratio was 3:1 (SAMHSA). Regardless of a client’s gender and the source of a client’s referral to treatment, a brief intervention or Motivational Interviewing (MI) component may be added to the initial screening process to facilitate the positive-screened client’s following through with the referral treatment (see Chapter 6 of this text for information on MI).

Gender-Specific and Gender-Responsive Treatment Approaches

Although more research on woman-specific substance-abuse treatment is still needed, knowledge in this area has emerged in the past three decades to counteract the reality that substance-abuse treatment programs have traditionally been developed for men. On the other hand, although substance-abuse treatment is traditionally designed for men, male-specific developmental challenges have been overlooked in providing treatment and services to men (Woodford, 2012). Both men and women are “gendered beings,” and they each need special considerations in treatment. Box 15.2 is presents some considerations for working with men, and Box 15.3 provides an example of a gender-relevant approach for assisting women.

Box 15.3 presents some considerations for working with men.

BOX 15.2 How to Help Men in Substance Abuse Treatment Groups

Men can present unique challenges when they come voluntarily or involuntarily to substance abuse groups. The following twelve considerations may be helpful in guiding practice with men who seek assistance for substance abuse.

The Context of Masculinity

In groups, men often present a “macho” veneer as a way of attempting to gain control both over their treatment requirements and over other people in the group. This is particularly true with involuntary clients who have lost control by being forced into treatment. The way men present in group (how they act, how they interact with others, what they say) has to be discussed and linked to the masculine culture that pushes men into drugs.

Setting a Context for a Male Exclusive Model or a Male Inclusive Model of Masculine Development

Discussions about masculinity must involve considerations about women’s roles in helping men grow up and in the treatment of women in their lives (grandmothers, mothers, daughters, wives, sex partners, friends, and therapists). Asking men about their early and current experiences with women may be helpful in their understanding of what drove early drug-abusing behavior and what drives their behavior now in relation to significant females in their life.

Men as Clients

The socialization of men and women makes it hard for men to seek help. Men do not like to be interviewed about feelings and, arguably, are hard-wired differently so that processing emotions is more difficult. In addition, males have higher rates of oppositional defiant disorder and attention deficit disorder than females. With these characteristics, the treatment process of accepting help, sitting still, listening, and attending can make treatment a daunting task.

Men of Color Have Different Life Experiences Than White Men

Latino and African-American men believe they are treated worse by “the system” because of their race. The therapist needs to directly address race when it is raised and acknowledge that society does treat people differentially based on race, as well as gender, religion, sexual orientation, class, (dis)ability, and age. The discussion can then move on to asking the speaker to link that reality with the need to stop abusing drugs.

Female Therapists and Male Clients

Macho posturing by involuntary clients may be more evident with women therapists (though it can be argued that it is more common with some male therapists with whom they may be competing). Bringing therapist gender into the session and tying that to experiences with women outside of the group is one way to address issues the men may have about female therapists and women in their lives.

Men as Financial Providers

Whether acquired legally or illegally, money is a key conduit to drugs. When men have no money, they are devalued and feel less competent as a man. This may be the most intractable issue for men. Often undereducated and with a spotty employment history, the opportunities for change for some of these men, particularly in the current economy, are bleak. Yet job training programs have been shown to have some successes.

Men “Dissed” as Fathers

Many men in treatment may have troubled relationships with their children. Setting aside time to discuss parenting issues can be helpful for current as well as future fathers. The emphasis should include the nurturing aspects of parenting, not just the discipline and control issues with which parents often struggle. By emphasizing the nurturing aspects, a context of love can be set that can be a metaphor for how the men could treat other significant people in their lives.

Men and Their Own Fathers

Whether fathers were present or absent in men’s lives, the legacy of fatherhood has a profound impact on future generations. Usually some of the earliest messages about masculinity, treatment of women, work, and money come from fathers. Helping men draw connections between their own behavior and their father’s can be facilitated through drawing a family tree (or genogram) and seeing that some fathering patterns are intergenerational.

Men and Male Friends

Men are raised to do activities with other men (often sports-related) while women are socialized to have face-to-face interactions. Talking to men about their friendships with men can get to the core of the relationships that often lead to peer pressure and drug abuse. Men are advised to stay away from their old friendships yet may not be taught about normative friendships between men. Helping men to understand how friendships are started and maintained can lead to new, more adaptive social support systems.

Men and Violence

Without understanding the currents of violence inherent in many substance abusers’ lives and how violence appears as a metaphor in group discussions, opportunities to curtail the cycle of violence will be missed. Violence can be addressed specifically by asking the men to what extent it has been a part of their life and to what extent they wish to keep it a part of their life.

Real Men Don’t Cry

For men who have been raised to be tough and not show emotions, and who have learned to mask feelings with drugs, crying is the ultimate sign of weakness. An early reference to expressing emotions and crying will give men permission to cry in the group. Their behavior will be normalized. Asking men’s reactions to someone else (it may be a woman) crying will further help to pave the way for a range of emotions to be expressed.

Sexual Issues

Drug use can also be connected to sexual dysfunction or a gateway to sex without responsibility. Men may hint at dysfunction overtly or metaphorically. Handling discussions about sexual functioning and sexual orientation are similar to discussions about masculinity and sharing of emotions. Information can be placed before the group (or the individual) as a form of education that can help normalize men’s experiences in these realms.

Source: Adapted from “One dozen considerations when working with men in substance abuse groups” by G.rL. Geif from Journal of Psychoactive Drugs, 41(4), 387–390, 2009. Reprinted by permission of the publisher Taylor & Francis Ltd. www.informaworld.com.

Co-Occurring Mental Disorders and Service Coordination

As Chapter 13 of this text demonstrates, substance use disorders often co-occur with mental disorders and other illnesses or disabilities. Among the mental disorders that often co-occur with substance use disorders are depression, anxiety, post-traumatic stress disorders (PTSD), borderline personality disorders (BPD), and antisocial personality disorder (APD). Child maltreatment and risky sexual or drug-using practices also occur in the presence of substance use disorders. To effectively serve clients, co-occurring disorders must be addressed by collaborating with other systems and professionals (Cocozza, Jackson, Hennigan, Morrissey, Reed, Fallot et al., 2005; Farley, Golding, Young, Mulligan, Minkoff, 2004; Messina, Marinelli-Casey, Hillhouse, Ang, Hunter, & Rawson, 2008; Sacks, McKendrick, & Banks, 2008). Addressing trauma is especially critical in substance abuse treatment as it may be the root of substance use disorders and/or other co-occurring disorders such as PTSD, as well as a consequence of substance use disorders, such as intimate partner violence.

BOX 15.3 Using the Relational Model to Help Women with Substance Use Disorders

By Sue Marriott, LCSW, CGP

The relational model, a conceptual approach to treatment that validates women’s experiences, has evolved over the past few decades (Belenky et al., 1986; Gilligan, 1982; Jordan et al., 1991; Miller, 1976). The relational model provides a unique perspective on psychological growth and women’s substance abuse. Theorist and clinicians at the Stone Center have sought to understand and describe psychological development, emphasizing the centrality of relationships in the lives of women. The Stone Center Working Papers* provide a more complete description of this history and details of the model. While this is a promising theory-driven paradigm, empirical research is needed to understand its efficacy as a form of treatment for women.

* Available from Wellesley Centers for Women, Wellesley College, Wellesley, MA, http://www.wcwonline.org.

According to traditional psychological theories, human development is actualized from immature dependency to mature independence, leading to a sense of self that is self-sufficient, independent, and bounded. The relational model proposes a paradigm shift in which women are viewed in the context of their relationships and their environment. From a relational perspective, a woman seeks to engage in increasingly authentic and complex connections with herself, others, and her community. The desire for connection is recognized as life affirming, and problems manifested are understood as springing from the effects of nonmutuality, isolation, abuse, and disconnection (Miller, 1984).

The central paradox of the relational model is that women disconnect with significant parts of themselves in order to remain connected with others in relationships (Miller, 1990). Thus, one might see a woman develop a pattern of smiling when she is angry, inhibiting her sexuality, or saying she doesn’t know (when, in fact, she knows exactly), all in an attempt to stay connected interpersonally. By shutting down true parts of themselves, women often end up feeling lonely, depressed, and disconnected.

Healthy connection is marked by an increasing ability to represent one’s thoughts, feelings, and perceptions in relationships and by allowing oneself to be moved by others (Kilbourne & Surrey, 1991). In a healthy relationship, each person is compelled to grow and be enriched, and this sometimes occurs through healthy conflict. Each person impacts the other.

From a relational perspective, a woman’s abuse of chemicals is often an attempt to make or maintain a connection (Covington & Surrey,2000). Substance use is often supported by the woman’s environment and the patriarchal community that promotes independence and devalues the role of women. Substance use can also insulate one from the pain of abuse, disconnection, and isolation before it spirals into addictive disease. It is often when intoxicated that women feel more able to share hidden parts of themselves, thus fostering the feeling of belonging and the sense of being known. Women often describe their drug of choice in relational terms, such as their “lover,” their “enemy,” or their “best friend.”

The relational model’s paradox is evident when women use chemicals not so much for the effects of the drug itself but in order to stay connected to their substance-abusing partner. Women’s substance use often begins, renews, or markedly increases upon a significant loss—for example, the break-up of a relationship, the development of a health problem, or being disowned by one’s family of origin. Relationships are also apparent in influencing women’s decision to enter treatment due to entreaties of loved ones, the threatened loss of custody of their children, or when drug use begins to jeopardize a primary relationship. Take the following case example.

Case Example

Linda is the 31-year-old mother of two. She reported to outpatient psychotherapy with the complaint of marital problems. Linda began using alcohol at the age of 12 and began using dependently at age 23. She continued her alcohol dependency until age 28, when she quit drinking after discovering she was pregnant with her first child. (Her connection with the unborn child allowed her to expand and take care of herself in a way in which she was previously inhibited.) She had completed a substance abuse treatment program about five years previously but felt it was a waste of her time. Instead, she decided on her own to quit drinking alcohol and had abstained for two years.

As a child, Linda witnessed domestic abuse between her parents. Her mother believed it was her job to hold the family together and thus endured the battering by her husband “for the sake of the kids.” Linda was sexually abused by a neighbor from the age of 8 to 10 years old. When Linda tried to tell her mother about the sexual abuse, her mother responded that she “should have known better.” Her mother reminded her that she had warned her about that particular neighbor and told her not to go near him again.

Early in therapy with Jan, a relationally informed therapist, Linda mentioned several previous attempts at counseling with therapists that she felt were harmful to her. Although Linda was unaware of it, her feelings of harm from these relationships were directly related to the childhood experiences of neglect and abuse that resulted in fear and distrust of relationships, especially with anyone she perceived to be in authority. Linda also revealed to Jan that she regularly takes low doses of OxyContin, a powerful narcotic prescription pain reliever. Even so, she identified alcohol as her only problem substance and said she was proud that she hadn’t had a drink since she decided to stop. When Jan questioned her current substance use, Linda seemed hurt and defensive and indicated that she was there for marital problems.

Jan was aware of Linda’s refusal to discuss her substance use and her unsuccessful previous interventions. She knew that the narcotic use was a major factor needing attention in order for Linda to move forward, but she decided to enter the relationship through the door Linda had opened: her desire to work toward a better marriage. Jan saw herself as helping Linda to trust someone for the first time in her life.

Jan initially focused on supporting any small step Linda made at being authentic with her, and she supported the small, achievable changes Linda wanted to make in her marriage. Jan asked many questions about how Linda saw herself and how she felt about her life. She let Linda be her own expert and took her objections about her previous care seriously, without joining in or villainizing the previous therapists. Jan also noted that Linda was unable to discuss the problems she had with previous therapists directly with them, and this pattern would continue with her if left unchecked.

Over time, Linda revealed that her husband, Dylan, was being treated for a recently diagnosed neurological disorder with OxyContin. Jan wondered about the connection between Linda’s use of this drug and her husband’s disease. Linda was struck with the insight that since her husband’s diagnosis, she had become his sole caregiver. She had given up much of her own life’s pleasure to take care of him and would not even allow herself to question this arrangement, which allowed her to stay in the prescribed role of a “good wife.” Instead, she began taking the drug with him and thus had unwittingly joined him in this mildly drugged state, providing an escape from the reality they were creating.

This insight surprised Linda, and although she continued to use the drug, she began to ask Dylan to do more things for himself. Jan and Linda’s discussions about healthier connections expanded, and Linda used the safety she had created with Jan to begin to discover how she actually felt about her marriage, how to begin to say no at work and at home, and eventually how to reconnect to parts of herself she had lost years earlier. For example, Linda began to give voice to her concerns about Dylan’s OxyContin use, even though it was prescribed by a doctor to whom Linda would normally have given away her own authority because of the implicit power difference.

Jan used Linda’s concern for Dylan’s drug use as an opening to explore Linda’s own use of the narcotic. By this time, Linda had developed other safe and supportive relationships with female friends, as well as Jan, so that she could more readily explore her relationship with this drug. Although Linda did not admit to having a drug problem, she found giving up OxyContin much more difficult than her decision to stop drinking. Linda discovered that when she did not take the drug, she became irritable and depressed.

Using a relational perspective, Jan continued to assist Linda in finding parts of herself she was denying. With little prompting, Linda’s anger began to emerge. In her early “relational map,” Linda had learned to turn off her own feelings and to attend to others in order to keep herself safe. In witnessing how others handled anger, Linda had never even let herself near the experience of feeling anger herself. Her mother buried anger; her father acted it out. Both methods are dangerous, and in Linda’s case, denying her anger became life threatening. Since the feeling had to go somewhere, Linda did what many women unwittingly learn to do: protect their connection with others by turning their feelings inward—in this case, resulting in depression.

Linda began to feel her anger and slowly tested out expressing it in treatment sessions. With Jan’s support, Linda confronted Jan on several perceived instances of unfairness and insensitivity. For example, Linda told Jan she thought it was unfair when she was charged for a session after becoming sick and canceling at the last minute. This represented one of the first times in her life that Linda had felt the security of a relationship enough to directly challenge it. She and Jan were able to work out these feelings and agree on ways to resolve the issues. Eventually, Linda was able to express anger to family members. As Linda became better at addressing her feelings, she was able to completely stop her drug use. She described the experience of expressing anger as transforming.

Despite previous objections, Linda was finally willing to participate in Alcoholics Anonymous (AA) and to use the program’s Twelve Steps in her overall recovery. She had come to see herself as a competent woman with an addiction problem. She had found a way to be a part of the program without feeling like she was losing herself or being compliant to it. She objected to some parts of the traditions but sought out a few safe others who could support her voice without having to defend AA. With this support, Linda engaged more fully in the recovery process and later with the recovery community, eventually going on to serve on organizing committees for the program.

Once sober, Linda continued to increase her support network and became more intimate with her husband. This intimacy included authentic, gentle confrontation of Dylan regarding his drug use and his passivity in his medical care. With her support, Dylan changed doctors and began utilizing alternative therapies, decreasing his reliance on pain relievers for his disease. Through their more secure attachment, Linda and Dylan propelled each other to grow personally and expanded their relationships with others. Although they have some rocky times, Linda and Dylan remain committed to each other, and Linda has maintained her sobriety.

Source: “The Relational Model: A New Perspective on Women’s Substance Abuse.” Reprinted with permission of Sue Marriott, LMSW-ACP, CGP.

Men and women in the general population may have different propensities for specific mental disorders. For example, research shows that when both sexes experience sexual abuse during childhood, women are more likely to develop affective disorders, PTSD, and BPD in its aftermath, whereas men are more likely to develop APD. Cutajar et al.’s (2010) large, prospective study of 2,688 Australian subjects with a childhood sexual abuse record plus matched control subjects without a childhood sexual abuse record reported that abused females were nearly 2.5 times more likely, later on, to have an affective disorder diagnosis, more than 7 times more likely to have PTSD, and more than 7.5 times more likely to have BPD than their female controls; abused males were no more likely than their male controls to have any of these three disorders. Abused females were also more likely than abused males to have these three disorder diagnoses. On the other hand, abused males were nearly 4 times more likely to have an APD diagnosis than male controls; whereas there was no difference between the abused females and the female controls on APD diagnosis. Abused males were also more likely to have an APD diagnosis than abused females. Both the abused males and abused females were more likely to have a substance use disorder than their non-abused counterparts, and there was no significant difference between abused men and women regarding the likelihood of having a substance use disorder.

Substance-abusing men and women, in particular, may be susceptible to different types of co-occurring disorders. The more frequently found comorbid psychiatric disorders among addicted women are depression, anxiety, and eating disorders; among addicted men, they are APD, pathological gambling, and “residual attention deficit disorder” (Blume & Zilberman, 2005). Some studies, mostly of samples of incarcerated substance abusers, show that although women are more likely to have internalizing disorders (e.g., anxiety, depression) (Langan & Pelissier, 2001; Messina, Marinelli-Casey, Hillhouse, Rawson et al., 2008; Zlotnick et al., 2008), the sexes do not differ on APD (Langan & Pelissier, 2001; Messina et al.) or other externalizing disorders (e.g., hyperactivity, impulse control disorders, or aggression) (Zlotnick et al.). Messina et al. reported that methamphetamine-dependent MD men with APD tended to have more adverse childhood events (ACEs) than MD men without APD, but there was no significant difference between the number of ACEs of MD men with and without depression. In contrast, MD women with depression had significantly more ACEs than MD Women without depression. MD women with APD also tended to have more ACEs than MD women without APD.

Substance use disorders and co-occurring mental disorders may be closely related to an individual’s experience of childhood and adulthood trauma although identification of the specific causal mechanism between them awaits more research. Men and women seem to be prone to different traumatic events. Farley et al. (2004) studied 959 chemical-dependent outpatients and found that women were significantly more likely to have experienced “rape” or “other sexual assault” and to have been “beaten by family member” or to have experienced a “break-in while present” than men; whereas men were more likely to have been “mugged,” experienced “war events,” and “saw someone killed or injured” than women. The two sexes did not differ regarding the likelihood of chance meeting partner violence. Furthermore, men and women may respond to trauma differently. For example, the National Comorbidity Study reported that 51 percent of females and 61 percent of males had experienced a trauma in their lifetime, and of them, 20 percent of females and 8 percent of males manifested PTSD symptoms (Kessler et al., cited in Kubiak & Rose’s review, 2007). The level of burden or intensity of the traumatic events may also affect an individual’s reactions and adaptations. For example, Farley et al. found that approximately 30 percent of substance abuse treatment patients they studied who experienced zero to four traumatic events relapsed compared to 40 percent of those who experienced 5 to 13 traumatic events. An individual’s previous experience and his or her resilience may also contribute to how he or she reacts to trauma.

Traumatic events are prevalent among individuals with substance use disorders. Although traumatic events do not inevitably result in PTSD, many substance-abusing clients suffer partial PTSD or other sub-clinical mental disorder symptoms, which often sabotage their substance abuse treatment, precipitate relapses, and prevent long-term recovery. Routine screening, assessment, and treatment of traumas among substance abusing clients have been emphasized in the recent decades (Farley et al., 2004). A systemic procedure and a structured screening interview for traumatic experience are recommended for eliciting reliable information (Bastiaens & Kendrick, 2002). Gender issues may also be relevant in trauma screening. For example, Ketring and Feinauer (1999) found that men and women yielded similar scores on a research tool called the Trauma Symptom Checklist-33 (TSC-33 [Briere & Runtz, 1989]) when they had experienced mild or moderate abuse. However, when the severity of abuse escalated, women’s symptoms and trauma scores increased accordingly, but men’s symptoms and trauma scores did not increase. Ketring and Feinauer suggest that this may be because women tend to internalize their symptoms regardless of the severity of symptoms, whereas men tend to internalize their relative mild or moderate symptoms but will externalize very severe symptoms. The TSC-33 measures only internalized symptoms. In assessing men for trauma (e.g., sexual abuse), both internalized and externalized symptoms (e.g., antisocial behavior and sexual acting out) must be addressed (Ketring and Feinauer).

Various evidence-based, trauma-informed and trauma-specific interventions and treatments have been developed in the past two decades. Among them are the Trauma Recovery and Empowerment Model for women (TREM) and M-TREM for men (Community Connections, n.d.; SAMHSA, n.d.c; Toussaint, Van DeMark, Bornemann, & Graeber, 2007) and Seeking Safety developed to help women who have both a substance use disorder and PTSD (Najavits, 2009). Seeking Safety can also be used to help men with a co-occurring substance use disorder and PTSD or traumas (Najavits et al., 2009). Messina, Grella, Cartier, and Torres (2010) used Covington’s Helping Women Recover and Beyond Trauma model with substance-abusing female prisoners and found that compared to women in the standard prison-based therapeutic community, women who received this treatment remained in residential aftercare longer, reduced their drug use more, and had a lower rate of re-incarceration after parole (12 months). Covington’s model contains four modules (self, relationship, sexuality, and spirituality) plus a focus on “teaching women what trauma and abuse are, helping them to understand typical reactions to trauma and abuse, and developing coping skills” (Messina et al.,p. 100). Citing Judith Herman, Covington (2008) stated that trauma is “a disease of disconnection” and it may take three steps to help women to establish “reconnection.” The first step is helping women focus on safety issues, build a safe environment, and care for themselves “in the present.” The second step involves “remembrance and mourning,” with the women expressing their stories of past trauma and mourning the loss of their old selves. Self-soothing and other techniques may be added to this step to lower the possibly higher risk of relapse during this stage. The final step is to help women establish a new self and new future. Clark and Power (2005) suggest that many substance abuse treatment programs may not have staff available to provide trauma-specific services, but trauma-informed services are cost-effective and can be incorporated by enhancing providers’ abilities to screen and assess women’s substance abuse, mental health, and trauma-related issues. Trauma-informed services emphasize that providers must understand the effects violence and abuse have on women, value women’s strengths, avoid retraumatizing the women, and respect women’s participation in developing their own treatment plan. The outcomes of SAMHSA’ “Women, Co-occurring Disorders, and Violence Study” showed effectiveness of a comprehensive and integrated trauma-informed approach, and suggested that more integrated counseling generates more favorable results(Cocozza et al., 2005).

Mutual-Help Groups

Today women are about one-third of Alcoholics Anonymous (AA) members (Alcoholics Anonymous World Services, 2008). Some AA meetings are for women only, and some men are holding meetings of their own. Women are featured in many more of the recovery stories in the “Big Book” of Alcoholics Anonymous, and at some meetings, “women are starting ‘the Lord’s Prayer’ with ‘Our Father and Mother’” (Davis & DiNitto, 2005, p. 530).

The Twelve Steps of Alcoholics Anonymous have helped many men and women recover, but there is also interest in mutual-help groups developed specifically for women and for men. Kasl (1990) claims that since “the steps were formulated by a white, middleclass male in the 1930s, not surprisingly, they work to break down an overinflated ego, and put reliance on an all-powerful male God” (pp. 30–31). She believes that most women need just the opposite—to strengthen their sense of self and affirm their own inner wisdom. Earlier, Jean Kirkpatrick (1978) expressed similar sentiments about women’s identity. In 1975, she introduced a self-help program called Women for Sobriety (WFS), which she believed could successfully be used alone or as a complement to AA and other programs (Women for Sobriety, 1976).

Rather than the Twelve Steps of AA (see Chapter 6), WFS uses the Thirteen Statements of Acceptance. For example, “I am a competent woman and have much to give life” (Women for Sobriety, 1989). Groups are lead by certified moderators. At the heart of WFS is its New Life Program. Kaskutas (1989) studied WFS and identified four major themes of the program: no drinking, positive thinking, believing one is competent, and growing spiritually and emotionally. She describes the program as follows: During meetings, members focus on what happened to them during the previous week and on current topics posed for discussion. But unlike in AA, members are discouraged from telling the stories of their drinking and from introducing themselves as alcoholics or addicts because these are considered examples of negative rather than positive thinking. During meetings there is much more cross-talk (back and forth conversation) than in AA. Kaskutas calls the WFS program far less directive than AA. For example, members are not told to “keep coming back,” to “get a sponsor,” or to “work the steps.” Participants are encouraged to work the program each day.

Despite differences in the philosophies of AA and WFS, some women take what they need from each program and make good use of both. A survey of 600 WFS members revealed that approximately one-third were also current AA members, primarily for “insurance” against relapse, for the wider availability of meetings, and for sharing, fellowship, and support (Kaskutas, 1994). Kasl (1990) also offers an alternative set of steps to AA that she says emphasize empowerment—for example, “We became willing to let go of our shame, guilt, and other behavior that prevents us from taking control of our lives and loving ourselves.” WFS has been adapted for use by men in a program called Men for Sobriety.

Chapter 10 Family Systems and Chemical Dependency

Catherine A. Hawkins

Texas State University

-

San Marcos

Raymond C. Hawkins, II

Fielding Graduate University

Previous chapters indicate that alcoholism and other drug addictions frequently impair an

individual’s physical, psychological, and social functioning. There is also r

ecognition that

alcoholism and other drug addictions adversely affect the individual’s marital and family

relationships. In a Gallup poll, more than a third of respondents reported that drinking had

caused problems in their family (Newport, 1999). Another

Gallup poll based on interviews

with 902 U.S. adults with an immediate family member with a drug or alcohol addiction

reported that the family member’s addiction had a negative effect on their own mental health

(70 percent of respondents) and their relatio

nship with other family members (51 percent)

(Saad, 2006). These negative effects are far

-

reaching, given the prevalence of parental

alcoholism. “It can conservatively be estimated that approximately 1 in every 4(28.6 percent)

children in the United States

is exposed to alcohol abuse or dependence in the family”

(Grant, 2000, p. 114).

Defining alcoholism at the family level lacks specificity, despite its intuitive appeal. Many

terms in the literature attempt to capture this phenomenon, such as family disea

se, alcoholic

family, addicted or chemically dependent family, alcohol impaired family, or family with an

alcoholic member. An understanding of the family dynamics associated with alcoholism or

other drug addiction must entail descriptions of interactive p

rocesses that occur throughout

the life cycle of the family. In addition, family is a term that is no longer clearly defined in

society. The material presented here applies to all forms of families, including nuclear,

extended, single

-

parent, communal, kin

ship, and gay/lesbian.

This chapter examines some of the more noteworthy efforts to specify the etiology and

treatment of the family processes associated with chemical dependency. The term

alcoholism will be used, although theoretically, much of the schol

arly literature can be

reasonably generalized to other drug addiction. The literature on a family perspective of

chemical dependency, including the theory, research, and treatment of alcoholism and other

drug addiction in families, is discussed. Three domi

nant theoretical approaches

—

behavioral,

stress coping, and family systems

—

are presented. The constructs of codependency, children

of alcoholics, and adult children of alcoholics are explored as they relate to family dynamics.

The ways in which theory shape

s practice with chemically dependent family systems are

addressed along with more specific treatment information. Finally, a case example is

presented that illustrates some of the main concepts discussed in this chapter.

A Family Perspective in Theory, Res

earch, and Treatment

Chapter 10 Family Systems and Chemical Dependency

Catherine A. Hawkins

Texas State University-San Marcos

Raymond C. Hawkins, II

Fielding Graduate University

Previous chapters indicate that alcoholism and other drug addictions frequently impair an

individual’s physical, psychological, and social functioning. There is also recognition that

alcoholism and other drug addictions adversely affect the individual’s marital and family

relationships. In a Gallup poll, more than a third of respondents reported that drinking had

caused problems in their family (Newport, 1999). Another Gallup poll based on interviews

with 902 U.S. adults with an immediate family member with a drug or alcohol addiction

reported that the family member’s addiction had a negative effect on their own mental health

(70 percent of respondents) and their relationship with other family members (51 percent)

(Saad, 2006). These negative effects are far-reaching, given the prevalence of parental

alcoholism. “It can conservatively be estimated that approximately 1 in every 4(28.6 percent)

children in the United States is exposed to alcohol abuse or dependence in the family”

(Grant, 2000, p. 114).

Defining alcoholism at the family level lacks specificity, despite its intuitive appeal. Many

terms in the literature attempt to capture this phenomenon, such as family disease, alcoholic

family, addicted or chemically dependent family, alcohol impaired family, or family with an

alcoholic member. An understanding of the family dynamics associated with alcoholism or

other drug addiction must entail descriptions of interactive processes that occur throughout

the life cycle of the family. In addition, family is a term that is no longer clearly defined in

society. The material presented here applies to all forms of families, including nuclear,

extended, single-parent, communal, kinship, and gay/lesbian.

This chapter examines some of the more noteworthy efforts to specify the etiology and

treatment of the family processes associated with chemical dependency. The term

alcoholism will be used, although theoretically, much of the scholarly literature can be

reasonably generalized to other drug addiction. The literature on a family perspective of

chemical dependency, including the theory, research, and treatment of alcoholism and other

drug addiction in families, is discussed. Three dominant theoretical approaches—behavioral,

stress coping, and family systems—are presented. The constructs of codependency, children

of alcoholics, and adult children of alcoholics are explored as they relate to family dynamics.

The ways in which theory shapes practice with chemically dependent family systems are

addressed along with more specific treatment information. Finally, a case example is

presented that illustrates some of the main concepts discussed in this chapter.

A Family Perspective in Theory, Research, and Treatment