Healthy Marriage and Family Formation Grant 7/3/2007 Substance Abuse and Intimate Relationships www.forest.edu

Healthy Marriage and Family Formation Grant The Training for the Healthy Marriage and Family Formation curriculum was created through the cooperative efforts of: Healthy Marriage and Family Formation Grant 7/3/2007 Jennifer L. Baker, Psy.D. Anne B. Summers, Ph.D. Debbi Steinmann, M.A. Training Instructor / Mentors Melissa A. Gibson, M.S. Kim Rozell, M.A. Graduate Assistants Brent Anderson, M.S. Matthew Biller, M.A. Cate Brandon, M.A Dawn Clinard, M.A. Jessie Clinton, M.S. Tabitha Carlson, M.S. Anup Jonathan Tony Larson, B.A. Nicole Mannis, M.A. Robert Mindrup, M.S.S.W. Colleen Quinn, Ph.D. Amber Schafer, M.A. Amanda Schroeder, B.S. www.forest.edu

Recent Statistics on Substance Abuse Healthy Marriage and Family Formation Grant Recent Statistics on Substance Abuse 7/3/2007 Substance abusers dramatically impact the lives of the people around them. One out of ten individuals currently struggle with substance abuse or dependence. Two out of ten have been alcohol dependent at some time during their lives. Statistics indicate that substance abuse is not a problem that only affects “other” people. Most of us know families that have been directly or indirectly impacted by substance abuse. Substance abusers dramatically impact the lives of the people around them.1 A 2002 nationwide survey conducted by the Department of Health and Human Services (DHHS) estimated that one out of ten individuals currently struggle with substance abuse or dependence. Two out of ten have been alcohol dependent at some time during their lives. An overview of the DHHS survey results stated, “21.6 million Americans were classified with substance dependence or abuse (9.1% of the total population aged 12 or older).” The number of substance abusers needing, but not receiving treatment is estimated at 20.5 million people.2 www.forest.edu

Healthy Marriage and Family Formation Grant How many are affected? Healthy Marriage and Family Formation Grant 7/3/2007 Substance abuse negatively impacts not only the drinker, but also his/her partner and other family members. Approximately one child in every four (28.6%), in the U.S., is exposed to alcohol abuse or dependence in the family. A third of Americans report family problems due to alcohol abuse. Substance abuse negatively impacts not only the drinker, but also his/her partner and other family members. For this reason, substance abuse is often referred to as a “family disease.”3 If 21.6 million Americans are reported to have been involved with substance dependence and/or abuse, imagine the number of children, marriages, and families that are affected. Considering only the impact of alcohol, approximately one child in every four (28.6%), in the U.S., is exposed to alcohol abuse or dependence in his/her family.2 A third of Americans report family problems due to alcohol abuse.1 www.forest.edu

Healthy Marriage and Family Formation Grant 7/3/2007 The Family Often the family system has unintentionally evolved to support the addiction. Each family member plays a role that serves a specific purpose. Each family member must perform his or her role to keep the family functioning. In all families, the behaviors of each family member influences the others. Non-abusing members of these families learn to compensate by changing their behavior to maintain balance and function within the family. Eventually, the entire family system unintentionally adjusts to support the addiction. Within these families, each member plays a role that serves a specific purpose. Each family member must perform his or her role to keep the family functioning. The role enables individual family members to cope with the dysfunctions of the family and maintain balance.4,5 Roles include: Dependent or addicted individual Enabler Hero Scapegoat Lost Child Mascot HANDOUT: Family Illness in Children www.forest.edu

Healthy Marriage and Family Formation Grant 7/3/2007 Family Roles The dependent is the substance abuser. The enabler is the one closest to the dependent. The enabler’s behavior, allows the dependent person to continue drinking. Rescuing and caretaking behaviors Taking care of household chores, etc. Inner feelings – powerlessness, self-pity, fear. In an alcoholic home, the dependent is the substance abuser. These roles are also apparent in homes without a substance abuser, but with an individual who learned unhealthy patterns in their family of origin or a previous relationship. Dysfunctional families may be equally damaging to the development and health of family members in homes with substance abuse. In a dysfunctional home, (one without a substance abuser) it may be the angry one, the stern disciplinarian, the unloving one, or the rigidly religious member of the family whose behavior demands that others play unhealthy, rigid roles to maintain balance.5 The enabler, or the family manager, is the one closest to the dependent and is usually the substance abuser’s partner. The abuser relies heavily upon the enabler. The enabler’s behavior allows the dependent to continue drinking or using through rescuing and care taking behaviors, as well as taking care of household chores. The enabler’s primary purpose is to protect the substance abuser from the consequences of his or her actions and denying the dysfunction in the family system. The enabler will act out of love, loyalty, shame, and fear to support and maintain his or her relationship with the dependent. Often the enabler reports inner feelings of powerlessness because they feel there is nothing they can do to fix the problem. Self-pity results from the enabler’s unsuccessful attempts to solve the problem, and fear that the problem will never be resolved.4,5 www.forest.edu

Healthy Marriage and Family Formation Grant Family Roles Healthy Marriage and Family Formation Grant 7/3/2007 Family Hero: often the oldest child, “high achiever” Scapegoat: often the second born child, “troublemaker” Lost Child: Usually a middle child, “loner” Mascot: often the youngest child, “class clown” The Family Hero is often the oldest child and usually a high achiever. The Hero is very responsible and works hard to get approval. Their need to achieve is usually not intrinsic, but rather an attempt to maintain the family’s façade of being normal or functional. The Scapegoat is often the second born child and may be known as the “troublemaker.” The scapegoat often associates with peers who are also from negative environments. They are often blamed for the family’s dysfunction and tend to be labeled as the “identified patient” when the family seeks help. The middle child generally takes on the role of the Lost Child and may be a “loner.” Loners are likely to handle chaos by withdrawing. They identify with the painful feelings of other family members. Since they often internalize not only their own pain, but also the pain of others, they may be a high risk for self-injurious behaviors and suicide. Finally, the Mascot is often the youngest child and is usually known as the “class clown.” He or she is usually the most fragile member of the family, and likes to be the center of attention. The role of the Mascot is to redirect attention away from the family’s dysfunction and pain through the use of humor and charm.5 ASK: Can you identify these roles within the families with whom you work or maybe within your family of origin? www.forest.edu

Summary of Family Roles Healthy Marriage and Family Formation Grant Summary of Family Roles 7/3/2007 Most people can identify with parts or combinations of these roles. However, in an alcoholic or dysfunctional family, these roles are usually fixed and inflexible. Other types of family dysfunction, addictions, or mental illness may produce similar roles in the family. To summarize, it is common for members of a substance abuser’s family to take on a particular “role” within the family system, as a way to maintain the status quo. Most people can identify with parts or combinations of these roles. However, in an alcoholic or dysfunctional family, these roles are usually fixed and inflexible. In families with other types of dysfunction, addictions, or mental illness similar roles may exist.4,5 These roles are generalizations, and are not mutually exclusive. Family members may trade roles or take on extra roles. When the mascot goes to summer camp, the oldest child may play that role in addition to continuing as hero. ASK: Are there other roles that you can identify among your clients or from your own experiences? www.forest.edu

Healthy Marriage and Family Formation Grant Impact on the Family Healthy Marriage and Family Formation Grant 7/3/2007 Increased level of stress. Higher incidence of domestic violence. Lack of trust, often due to broken promises to cut back or quit using the substance. Anger and resentment may begin to build. Substance abuse overburdens the family with increased levels of stress which may lead to verbal, physical, and sexual abuse. Higher incidences of domestic violence occur in substance abusing families compared to non-abusing families.6,7,8 The results of a study reported in the Journal of Consulting and Clinical Psychology (2001) focused on the behaviors of male alcoholic patients. The research revealed that 60% of the participants reported being violent toward their partner; 22% had engaged in violence that was likely to cause injury.7 The use of alcohol and other drugs by either parent certainly increases the risk for domestic violence. However, it is important that we do not interpret these statistics in a way that suggests a cause and effect relationship.7,8,9 Families of substance abusers usually experience a lack of trust, often due to broken promises to cut back or quit using the substance. As the sequence of broken promises grows longer, anger and resentment may begin to build. The resentment is frequently expressed as violence toward other family members.6,7,8 www.forest.edu

Healthy Marriage and Family Formation Grant Impact on the Family Healthy Marriage and Family Formation Grant 7/3/2007 When parents become preoccupied with drugs, or any other activity which dominates and monopolizes their time and energy, children suffer. Children often lack the love, support, and care that they so desperately need. Approximately 28 million children 17 years of age and younger are exposed to substance abuse and dependence in the family. Parental substance abusers/enablers fail to parent effectively or serve as positive role models. Children who witness substance abuse have increased risk of substance abuse as adults.2 When parents become preoccupied with drugs, or any other activity which dominates and monopolizes their time and energy, children suffer. The children often lack the love, support, and care that they so desperately need. Also, children of substance abusing families are more likely to exhibit symptoms of depression and anxiety than children of non-abusing families.4 www.forest.edu

Healthy Marriage and Family Formation Grant 7/3/2007 Impact on the Family Chaotic and inconsistent home environment. Lack of routines. Kids never know what to expect. Inadequate supervision and monitoring. May be exposed to violence. Increased risk of teenage substance use. Substance abuse disrupts the family environment. Children usually hold less power in the family and subsequently their feelings are frequently ignored and unexplored. Both short-term and long-term psychological, academic, and social effects are associated with substance abuse.5,10 Children are fearful because the home environment is chaotic and inconsistent. The home-life lacks routine, and kids never know what to expect (“Will it be a good day or a bad day?”). Parents may provide inadequate supervision and monitoring of their children and children may be exposed to violence.5 An increased risk of teenage substance use often leads to truant behavior, poor grades, and dropping out of school. Actually, children of alcoholics (COAs) are four times more likely to adopt substance abuse behaviors than non-COAs.5,10 VIDEO: When a Man Loves a Woman - Alice is at an AA meeting telling her “story” after 90 days of sobriety. She speaks about how her drinking has affected her husband and her children. Time: Approximately 4 minutes, start at the very beginning of her speech (1:58:19) and end when she walks off stage (2:02:29). www.forest.edu

Healthy Marriage and Family Formation Grant 7/3/2007 Impact on Couples Substance abuse often leads to unhappiness in the couple relationship. William Fals-Stewart, a noted expert in the area of substance abuse treatment stated, “It has long been known that marriage and substance abuse don’t mix . . . As drinking or drug use gets worse, it starts to take more and more time away from the couple, taking its toll by creating an emotional distance between partners that is difficult to overcome.”11 (page 1) The following is a quote from the article Alcohol problems in intimate relationships: Identification and intervention: “Drinking problems may negatively alter marital and family functioning, but there also is evidence that they can increase as a consequence of marital and family problems. Thus, drinking and family functioning are strongly and reciprocally linked. Not surprisingly, alcohol problems are common in couples that present for marital therapy, and marital problems are common in drinkers who present for alcohol treatment. Therefore, interventions that do not consider the important dynamics of the couple relationship are likely to fail. And for those who seek treatment, relationship conflict is reported as the most common precipitator of relapse by those in recovery” (page 5). Often leads to unhappiness within the relationship. www.forest.edu

Healthy Marriage and Family Formation Grant 7/3/2007 Impact on Couples Arguing and Fighting Substance abuse contributes to a cycle in which arguing and fighting results in increased conflict. The resulting anger and tension facilitates an environment that promotes more substance abuse in an effort to manage negative emotions. This pattern or cycle can dominant the life of the couple for a very long time.12 More substance abuse Increased conflict www.forest.edu

Assessment of Relational Factors Healthy Marriage and Family Formation Grant Assessment of Relational Factors 7/3/2007 Examine the extent or seriousness of substance use by each partner. Tell-tale signs Strengths and weaknesses of the couple relationship. Empowering the couple Since drinking and family functioning are strongly and reciprocally connected it is essential to examine the extent or seriousness of substance use by each partner. Tell-tale signs that substance abuse is harming the relationship include the following: Arguments about staying out late. Money problems. Not taking care of responsibilities in the home.13 With some couples, drinking or drug use is the only activity they like to do together. The couple may have isolated themselves from their families and friends. An evaluation of strengths and weaknesses of the couple relationship may reveal that they are so focused on the substance abuse they forget about the relationship strengths. Examining strengths, serves to empower the couple, helping them recognize there is hope.12 www.forest.edu

Couple Relationship Assessment: The 7 C’s Healthy Marriage and Family Formation Grant Couple Relationship Assessment: The 7 C’s 7/3/2007 Character Features Cultural Factors Contract Commitment Caring Communication Conflict Resolution When assessing a couple’s relationship, capitalize on the strength of the relationship to support recovery. William Fals-Stewart (1999) developed a conceptual framework, called the “7 C’s.” This concept describes seven critical elements of a long-term, intimate relationship to be used as part of a couple assessment. Character features (personality traits). Cultural factors (racial, ethnic, religious, family of origin, and SES variables). Contract (explicit and implicit expectations about partner’s roles and what they expect to derive from the relationship). Commitment (to be involved, remain loyal, and to maintain the stability and quality of the relationship over time). Caring (partners’ abilities to express relational behaviors which promote intimacy). Communication (open sharing of information between partners). Conflict Resolution (problem solving, anger management, violence).13 www.forest.edu

How Do I Know If My Partner or I Have a Problem? Healthy Marriage and Family Formation Grant 7/3/2007 How Do I Know If My Partner or I Have a Problem? HANDOUT: How Do I Know if My Partner or I Have a Problem? (16A) www.forest.edu

Assessment of Substance Abuse Healthy Marriage and Family Formation Grant Assessment of Substance Abuse 7/3/2007 Informal assessment Types of substances Quantities Frequencies of use Formal assessment CAGE UNCOPE An informal assessment of substance abuse includes taking a history of the types of substances being used, the type and amount of each substance, and the frequency of use. If children are in the home, they may be exposed to the physical danger of substance abuse (i.e., being exposed to methamphetamines).13 With clients, it may be helpful to contrast the positive and negative consequences of abusing substances, when compared to the positive and negative consequences of quitting. This offers the partner or couple the opportunity to conceptualize the impact that the substance abuse has on their own health as well as their relationships.13 More formal assessments, include the CAGE and the UNCOPE. Although more structured, these tools are easy to administer and score.12 HANDOUT: Symptoms of Substance Abuse for Teenagers (17A) HANDOUT: CAGE/UNCOPE (17B) www.forest.edu

Healthy Marriage and Family Formation Grant 7/3/2007 CAGE HAVE YOU EVER… Thought you should Cut down on drinking? Become Annoyed when people criticize your drinking? Felt scared, bad, or Guilty about your drinking? Taken an Eye-opener drink to feel better in the morning? A well known screening tool available to social workers and child welfare workers is the four question CAGE assessment. Have you ever thought you should Cut down on your drinking? Do you become Annoyed when people criticize your drinking? Have you felt scared, bad, or Guilty about your drinking? Have you taken an Eye-opener drink to feel better in the morning?12 This screening device can also be used as an interview with a family member or couple report. In this context the questions might be changed to: Has your partner ever attempted to Cut down on his/her drinking? Has your partner ever become Angry or upset when others comment on his/her drinking? Has your partner ever felt bad or Guilty about his/her drinking? Does your partner ever have a drink, a.k.a. Eye opener, first thing in the morning? If one or both partners answers “yes” to at least one of the above questions, then it is recommended that he or she be referred to a qualified substance abuse counselor for further evaluation. www.forest.edu

Healthy Marriage and Family Formation Grant UNCOPE Healthy Marriage and Family Formation Grant 7/3/2007 Consists of six questions. Most appropriate for identifying risk for abuse or dependence when neither is identified as the presenting problem. Easy to administer and score. The UNCOPE is a another screening tool, which consists of six questions and is most appropriate for identifying the risk for abuse or dependence when neither is identified as the presenting problem. It’s also relatively easy to administer and score.14 HANDOUT: Booklet, Understanding Substance Abuse and Facilitating Recovery: A Guide for Child Welfare Workers (Copies can be accessed through the Internet at http://www.ncsacw.samhsa.gov or call the National Clearinghouse for Alcohol and Drug Information at 1-800-729-6686) www.forest.edu

Healthy Marriage and Family Formation Grant UNCOPE 7/3/2007 U- “Have you continued to use alcohol or drugs longer than you intended or have you spent more time drinking or using than you intended?” N- “Have you ever neglected some of your usual responsibilities because of alcohol or drug use?” C- “Have you ever wanted to cut down on using alcohol or drugs but couldn’t?” O- “Has your family, a friend, or anyone else ever told you they objected to your alcohol or drug use?” P- “Have you ever found yourself preoccupied with wanting to use alcohol or drugs? E- “Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger, or boredom?” U- “Have you continued to use alcohol or drugs longer than you intended? Or have you spent more time drinking or using than you intended?” N- “Have you ever neglected some of your usual responsibilities because of alcohol or drug use?” C- “Have you ever wanted to cut down on using alcohol or drugs but couldn’t?” O- “Has your family, a friend, or anyone else ever told you they objected to your alcohol or drug use?” P- “Have you ever found yourself preoccupied with wanting to use alcohol or drugs? E- “Have you ever used alcohol or drugs to relieve emotional discomfort, such as sadness, anger, or boredom?”14 www.forest.edu

Goals for Effective Treatment Healthy Marriage and Family Formation Grant Goals for Effective Treatment 7/3/2007 Eliminate abusive drinking and drug use, and gain partner support to reinforce sobriety. Alter partner interactions to promote a family environment supporting abstinence. When working with families, substance abuse treatment must be considered as management for a life-long illness (i.e., diabetes), instead of a crisis. Standard treatments of substance abuse/dependence have traditionally focused solely on the substance abuser. More recently, some researchers have concluded that an interrelationship between substance use and intimate relationships exists. New treatments have been developed to address this issue.13 Relationship-based treatments typically have two goals: Involving the family or an intimate partner increases the probability of successful treatment and recovery. Conflict in the family or with an intimate partner does not necessarily remit after successful treatment for substance abuse. When substance abuse ends, the family members will also need to adjust to changes in the family system. According to the National Center on Substance Abuse and Child Welfare, if relational issues in the family are not treated, conflict may ensue and lead to relapse. Eliminate abusive drinking and drug use, and gain partner support to reinforce sobriety. Alter partner interactions to promote a family environment supporting abstinence.13 HANDOUT: Six Stages of Change www.forest.edu

Healthy Marriage and Family Formation Grant There is hope . . . Healthy Marriage and Family Formation Grant 7/3/2007 Chemical dependency is treatable. Families can change patterns of interaction. The process is difficult, but help is available. Treatment for the substance abuser and the family is critical. Possibly the greatest need of couples or families is hope. Substance abuse recovery is a long and difficult journey that requires commitment from everyone involved. Chemical dependency is treatable, and families can change their patterns of interaction. The process is difficult, but help is available through treatment programs and community resources like self-help groups. A few of these include Alcoholics Anonymous, Recovering Couples Anonymous, Families Anonymous, Al-Anon, Alateen, and others. For long term success, treatment for both the substance abuser and his/her family is critical. Again, substance abuse by a partner or family member affects the entire family system and treatment must include everyone in the family.13 www.forest.edu

Healthy Marriage and Family Formation Grant Websites 7/3/2007 Partnership for a Drug-Free America: http://www.drugfree.org/ American Council for Drug Education: http://www.acde.org/ National Institute on Drug Abuse: http://www.nida.nih.gov/ Phoenix House: http://www.phoenixhouse.org Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov Here is a listing of a few available resources for substance abuse. These websites have information, articles, and valuable ideas. They might be helpful for you personally, or some of the families with whom you work. www.forest.edu

Healthy Marriage and Family Formation Grant Questions 7/3/2007 Questions www.forest.edu