Abstinence may be as hard or even harder than drinking for the alcoholic because it reveals so many problems that were obscured by the family's focus on alcohol. Denial remains as strong as ever as the family has to face the harsh realities of delusion, illusion and collusion that have dominated its reality during drinking and that are now revealed during the period of abstinence. In many families, the entire family system has been organized by alcoholism. Not every couple will or, for their own personal health should survive recovery. (Brown,1999). This could be a time of tremendous personal growth for all individuals involved or it could turn out to be a period of decline. It is this author's contention that the approach for the female partner is as important in examination as that of the alcoholic himself. As Carl Jung stated: 

Seldom or never does marriage develop into an individual relationship smoothly and without crisis. There is no birth of consciousness without pain(Cambell 1971, pg.167). 

Three focuses of therapy will be reviewed in this paper. The best known is the disease approach. Alcoholism is viewed as a disease and family members also have the disease of "codependence" (Cermak, 1986). In the disease approach, the family members are treated with therapy separate from the alcoholic. This therapy encourages the alcoholic, the spouse and the family to reach outside the family for help. The use of Al-Anon, Al-Ateen or Adult children of alcoholics groups is highly recommended as well as individual and group therapy to address various psychological issues. With this approach, family members should not actively intervene to attempt to change the alcoholic's drinking. They are encouraged to detach and focus on themselves to help with their emotional distress and to increase their skills needed to cope (The Al-Anon Family Groups, 1981, Laundergan and Williams, 1993). 

The general focus of Al-Anon is getting free of the unnecessary pain and suffering that results from living with an alcoholic or drug dependent person. Group therapy is the necessary hub around which a person can heal their codependence (Lowinsin, Ruiz, Millman and Langrud, 1992). A focus on reducing the alcoholic's drinking and working on the relationships is the primary goal of the family disease approach(O'farrell and Feehan,1999). The focus of treatment for the recovering alcoholic is Alcoholics Anonymous, a long standing mutual-help organization whose purpose is to help the alcoholic sustain abstinence and in the process of working the 12 Steps, which are the core of the program, to experience personal and spiritual growth. It is a fellowship, that is, a "mutual association of persons on equal and friendly terms; a mutual sharing, as of experience, activity or interest"(Lowinsin et al, 1992). 

Within the context of discussing codependency and its relation to the female partner of the recovering male alcoholic, there will be an exploration into the area of feminism as it relates to the therapy of the spouse. Marriage has been found to have a protective effect for men but a detrimental effect for women in terms of both mental and physical health (Sobel,1981). Women in marriage have been described as de- selfing themselves so as not to threaten men, although individual males complain that they do not feel powerful. According to Guilligan(1982), women's concern with relationships can be understood as the need to please others when one lacks power. From a systems approach, by viewing family members as equal interacting parts in recursive complementarities, differences in power, resources, needs and interests among family members is ignored. By ignoring gender differences, the therapist supports them(Hare and Marcode,1990). 

The second treatment approach involves the use of the Bowen family systems approach. Family interaction behavior is attended to as it becomes organized around alcohol(O'Farrell and Feehan,1999). Family systems theory carries with it certain basic assumptions, the most basic of which is interdependence within the system. Family members are seen to interact in predictable patterns. A change in one person's behavior of necessity affects the entire system - and also how the family members relate to each other. The identified patient is usually the least powerful family member and the individual who is demonstrating the effects of anxiety for the family(Burgess, 1998). 

The third approach is the behavioral approach, which assumes that family members can reward abstinence and that improved communication can in turn improve relationships and that this lowers the risk of alcoholic relapse(O'Farrell,1993). A review of research suggests that this form of treatment produces significant reductions in alcohol consumption and improves marital functioning(McKay, Longabaugh, Beattie, Maisto and Noel, 1993; McGrady,Noel,Abrams, Stout, Nelson, and Hay,1986; O'Farrell, Choquette, Cutter, Brown and McCourt,1993). This approach is geared directly to increase relationship factors conducive to sobriety. In this form of treatment, the alcoholic patient and family members are seen together to build support for sobriety, to increase relationship cohesion and to improve communication skills(O'Farrell and Feehan, 1999). 

The Disease Models of Alcoholism and Codependence 

According to researchers O'Farrell and Feehan(1999), the family disease approach is the best known and most widely used form of treatment. Looking at the disease model not only in terms of physiological addiction but also from the standpoint of genetics of the disease of alcoholism has become important in treatment. The definition of the disease of alcoholism given by members of the American Society of Addiction Medicine(ASAM) is as follows: Alcoholism is a primary disease.....characterized by....impaired control over drinking, preoccupation with alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial(Bean-Bayog and Blume, 1990). Research supports the belief that alcoholism is a complex genetic disorder of both multiple and environmental influences. Research also suggests that genetic markers may be associated with the varying types of the disorder and the severity of the disorder. The markers that have had repeated studies implicating them are the A1 allele of the DRD2 gene and specific allele of the ALFH2 gene(Ketlenios,1998). 

In looking into the dynamics and treatment involving the female partner of the recovering alcoholic, it is essential to examine the psychological concepts of the "illness" of codependence. According to Ceramic(1986) the proposed definition of codependence is: Codependence is a recognizable pattern of personality traits, predictably found within most members of chemically dependent families, which are capable of creating sufficient dysfunction to warrant the diagnosis of Mixed Personality Disorder as outlined in the DSM-IV.

In 1990, the National Council on Codependency developed the following definition: "Codependency is a learned behavior, expressed by dependencies on people and things outside the self: these dependencies include neglecting and diminishing of one's own identity. The false self that emerges is often expressed through compulsive habits, addictions and other disorders that further increase alienation from the person's true identity, fostering a sense of shame" (Whitfield 1991,pg.10). Wegscgeider-Cruse(1989) suggests one core concept, "other focus/ self-neglect" and four codependent subconcepts, "family of origin issues", "low self worth", "hiding self" and "medical problems".

 According to Cermak(1991), the defining criteria for codependency include: 1. Control of both self and others 2. Taking responsibility for meeting others' needs to the point of self neglect. 3. Distortion of boundaries related to separation and intimacy with others. 4. Enmeshed relationships.

O'Brian and Gaborit(1992), advocated codependency as having to do with the appropriateness of interpersonal relationships and self autonomy. These researchers have enumerated five factors related to codependency which include: caretaking; other referring; surrendering the self; faulty communication skills, and lack of autonomy.

Current unhappiness from growing up in a family that was troubled, chemically dependent or overwrought with problems in which thoughts and feelings were not expressed and discussed and in which affection was not openly displayed, is considered under the broad heading of family of origin issues. Individuals who grow up in such families learn roles that include codependent relating(Wegscheider- Cruse,1989). 

Thoughts of self-hatred and self criticism and feelings of shame, self-blame and humiliation are included in codependency(Hughes-Hammer,Martsoff and Zeller, 1998). Researchers Fossum and Mason(1986) indicate that shame evolves in individuals as a result of being raised in shame bound families.

According to Whitfield(1989), codependency includes the use of a positive front to cover and control negative emotions with repression of feelings. Thus a false self emerges. 

The aspect of medical problems in the codependent has merit. A codependent individual has a sense of current ill health when compared with families and friends. This is accompanied by worry and preoccupation with real or imagined health difficulties and impending body failure(Hughtes-Hammer et al, 1998). Researchers Gotham and Sher(1996), showed that physiological complaints or symptoms were significantly correlated with total codependency scores(r=.24 N=467 P<.0001). Hinkin and Kahn(1995), in their study found that wives of dental patients had signifi- cantly fewer symptoms when compared with wives of alcoholics.

Of importance here in the furthering of the discussion of codependency is an exploration of feministic thought as it relates to power in relationships and, more specifically, to codependent behavior.

According to Hare-Musin and Marcode(1986) feminism is futuristic in calling for social change and for changes in both men and women. Feminists have been con- cerned about the family because the family is the primary beneficiary and focus of women's labor as well as the source of women's most fundamental identity, that of mother. Feminists view the socially constructed role differences between the sexes as the basis of female oppression(Eisenstein,1983). Guilligin(1982) sees women's concern with relationships as the need to please others when one lack of power. 

Feminist researcher Collins(1998) has found that gender role behaviors and the problems associated with them result from the impact of one's position in the social hierarchy. Miller(1986) describes in detail how the personality characteristics ascribed to subordinated-dominated groups develop as a result of prolonged exposure to a limiting role. She proposes that the masculine gender role behavior results from exposure to the privileges and benefits of the dominant position and serves to maintain men's dominant status and justify the exploitation of others. Feminine gender role behaviors may be adaptive efforts to cope with or survive the realities of life in a sub- ordinate position. 

Hare and Marcode(1990) have described in their works how those in power support the use of rules, discipline, control and rationality whereas those without power value relatedness and compassion. They point out that in marital conflict men call for rules and logic whereas women request caring and compassion. 

According to Guilligan(1982), independent assertion in judgement and action is considered to be the hallmark of adulthood - but it is rather in their care and concern for others that women have both judged themselves and are judged. The conflict between self and other thus constitutes the central moral problem for women which poses a Dilemna whose resolution requires a reconciliation between femininity and adulthood. The "good woman" masks assertion in evasion, denying responsibility by claiming only to meet the needs of others; while the "bad woman" forgets or renounces the commitments that bind her to self deception and betrayal. It is precisely this Dilemna -the conflict between compassion and autonomy, between virtue and power- which the feminist voice struggles to resolve in its effort to reclaim the self and to solve the moral problem in such a way that no one is hurt.

Authors Beattie(1981) and Schaef(1986) in their work appear to see the one disturbing consequence of the recognition that women have difficulty living at the center of their own lives to be the recent phenomena of giving women the diagnosis of codependency. This is considered because they put others' needs ahead of their own and do not feel entitled to pursue their own goals. This "illness" labels women as sick for demonstrating the very traits that are culturally presented as proper female behavior. Bepko and Krestin(1990) and Lerner(1985) acknowledge that women are trained to be self-efficacious and conflict-avoidant, and then move into to discuss how women can change their lives in the direction of being more independent and authoritarian without renouncing their skills and interests in re- latedness as a key element in their lives.

Although the state of codependent behavior can be ascribed to most women, it is felt by this author as well as others(Cermak1986, Whitfield 1991and Cruse 1989) that the disease of codependency is most clearly related and most often seen in those dealing with a family member with addiction.

According to Cermak(1986), treatment of codependency involves helping clients to understand that when they say they are codependent, they are accepting that they are powerless over areas of their lives they have tried to control. Education is an important cornerstone of therapy. Teaching assertiveness training and communication skills is seen as vital. A tremendous amount of internalization will occur as the client stops blaming low self esteem on outside causes and starts recognizing that it comes from having done violence to her own feelings , having lived life controlled by compulsions, and having sacrificed integrity for the sake of security. Many clients experience profound depression as part of the grieving process. The relief that comes from no longer feeling responsible for the chemical dependence within the family will invariably be accompanied by a sense of loss. The client must relinquish her illusion of being powerful enough to force the chemical dependent to become and remain sober. 

According to Cermak(1986), treatment during the recovery period has two primary goals: helping clients to become aware of how their codependence has pervaded all aspects of daily life, and helping them see how their efforts to control the chemical dependent have intensified this problem. 

Incorporating feminism into therapy with the codependent in a relationship with a family member who is addicted has not fully been explored in the area of research. It would seem that challenging women's beliefs, expectations of them- selves and others and their socialized behaviors would enable them to expand their range of choices and take greater conscious control of the aspects of their lives over which they do have some power(Avis,1991). 

Bowen's Family System Theory 

Bowen's FST is especially useful in dealing with addicted patients. This is because the family, its history and its support (or lack of) is addressed as a key issue in treatment. Bowen's work evolved a complex theory of eight interlocking concepts that describe human interactions in terms of differentiation and emotional reactivity. These concepts include differentiation of self, family emotional system, family projection process, sibling position, triangles, cut-offs, multigenerational transmission and societal regression(Bowen,1978).

The cornerstone of the theory is differentiation of self, which refers to the individual's ability to separate intellectual and emotional systems. Differentiation is marked by the perception of personal boundaries. The well differentiated person is able to separate thinking and feeling and is able to act rather than react on an emotional level. The family emotional system refers to the climate in which the child is raised. A poorly differentiated family will be unable to escape the "stuck together" emotional fusion of the family.

According to Bowen(1978), the fusion of feelings of family members raises anxiety and makes individual rational functioning difficult, if not impossible. Family projection process is the transmission of undifferentiation and anxiety from the parents onto a specific child or children. Sibling position is the position in the family by sex and birth order. In FST, the genders are considered mutually interdependent, with certain clusters of behaviors learned as a result of sex and birth order. Triangles are the most stable emotional systems. A two person system is inherently unstable and as emotional intensity and anxiety rise, a third person is sought to diffuse the anxiety so that the couple can remain stable. The creation of the triangle with diffusion of anxiety is considered normal unless the triangles become fixed and rigid. A cut-off is the process of achieving distance from the family of origin when emotional intensity becomes unbearable. Multigenerational transmission is the transference of levels of differentiation down generations within the family. The final concept is societal regression. Stressors to the society, such as overpopulation and pollution are viewed as increasing the anxiety level of the society. The basic assumption of FST is interdependence within the system(Bowen,1978). 

According to Bowen(1978), anxiety is the subjective feeling of distress provoked by a perceived threat. Anxiety is present at all times. Behavior is motivated by a desire to reduce anxiety. Substance abuse is seen by Bowen as a maladaptive response to increased anxiety within the family. In FST one is encouraged to explore self and others in the family and to move beyond eliminating symptoms. Many psychiatric and physical symptoms are viewed as the behavioral expression of increased anxiety within the family. Addiction to any substance is viewed by Bowen(1978) as a response to anxiety. 

The use of the genogram is employed by the FST therapists(Guerin and Pendegast1976, McGoldrick, Gerson, and Shellenberg 1999).The genogram is seen as extremely helpful in creating a family pictorial of the three generational systems that mark marriages. According to McGoldrick et al(1999), the systems approach involves understanding of both current and historical context of the family. 

The primary limitation of Bowen's assumption that addiction to any chemical substance is a response to anxiety within the family seems to fall behind more recent discoveries of the biological an genetic components of addiction(Lowinsin et al 1992 and Kutlenios 1998). It also appears limited in its scope of adequately dealing with the needs and issues of the female partner and codependency. The use of the genogram as a therapeutic tool is, however, very useful in providing education for the family.

Behavioral Couples Therapy for Addiction 

O'Farrell and Feehan(1999) in their research note that although family systems and family disease approaches are popular and influential in the treatment of families with alcoholism, there is limited data as to whether or not they are effective. In comparison, behavioral approaches have relatively strong research support but are not yet widely used. Studies of behavioral family methods in alcoholism have focused on mainly behavioral couples therapy. Alcoholic Behavioral Couples Therapy(ABCT) is a collection of approaches and incorporates an intimate significant other into treatment of an alcohol problem. ABCT draws from rich empirical literature on interactional behaviors such as communication and problem solving skills, the connections between individual psychopathology and interactional behavior, and the broader literature on social support. It includes elements of behavioral self control and skills training to facilitate abstinence and better spouse coping with alcohol related situations and contingency management procedures, communication and problem solving techniques(Epstein and McCrady,1998). Alcoholic families often have skill deficits. Couples may have difficulty expressing affect, disagreeing, making requests for change, listening to and under- standing the partners communication, providing positive support or solving problems productively as a couple. Spouses many times lack coping skills to respond effectively to the alcoholic and may have difficulty balancing attention to their own needs with the responsibilities that they have to take care of in order to maintain the integrity and functioning of their families. This includes coping with the stress which is inherent in the alcoholic family(Epstein and McCrary,1998). A large part of behavioral therapy involves teaching individual coping skills to deal with alcohol related situations. Skills include self management planning, stimulus control, drink refusal and self monitoring of drinking and drinking impulses. Also included are assertiveness, cognitive restructuring, relaxation training, lifestyle balance and recreational activities. The non-alcoholic spouse is also taught a variety of coping skills to deal with drinking and abstinence. These coping skills might include learning new ways to discuss drinking and drinking situations, learning new responses to the partner's drinking and alcohol related behaviors or individual skills to enhance his/her own individual functioning. Also the area of focusing on the interactions between two partners around both alcohol and abstinence and other issues is important. Alcohol focused couple intervention use alcohol related topics as vehicles to introduce communication and problem solving skills. Considering such questions as how the couple could manage a situation in which alcohol is present, whether they will keep alcohol in the house, how the partner will assist the drinker in dealing with impulses to drink or what the couple will tell the family or friends about the alcoholic's treatment. By using such topics as vehicles for discussion, the couple is taught basic communi- cation skillls. Some clients are encouraged to become involved in Alcoholics Anonymous. Spouses are encouraged to attend Al-Anon meetings. Homework assignments are given because they teach clients how to anticipate high risk situations and planned follow-up treatment sessions are designed to contribute to maintaining change(McCrady and Epstein,1995).

Case Example: 

Tom, age 38, and Sharon age 32, have been married 15 years. This is both couples' second marriage. There are two teenaged children ages 13 and 15 from this marriage. Tom is an investment banker with a large firm and Sharon is a school teacher. Tom has had a long standing problem with alcohol and has been abstinent for 4 months. He has tried AA but it has not entirely worked for him. Sharon has welcomed the opportunity to attend Al-Anon meetings and ` has found the support very helpful. Sharon's first husband left her for another woman and the divorce was bitter. Tom's first marriage ended in divorce because of his drinking. 

Through the period of active drinking, the therapist was able top ascertain patterns of drinking and triggers. Spouse-related triggers were reviewed. ` Sharon did not condone his drinking and she did not openly get angry, even though she usually knew when he had been drinking. She said she had learned in Al-Anon to detach and she had adopted a coping strategy of pretending that he had not had a drink. It was hard to ignore her rising resentment and concern about his drinking even though neither talked about his behavior. The therapist suggested that Sharon's pattern ignoring the drinking was a subtle form of spouse-related trigger because her husband knew he could drink under certain situations. In other words, Sharon was protecting him from some of the negative consequences of drinking, which was not good for either of them. Early in treatment both filled out daily self-recording cards. Each day he monitored the frequency and intensity of his urges to drink, the number of drinks consumed and his daily marital satisfaction. Sharon kept records of her daily estimate of Tom's alcohol consumption and intensity of his urges along with her estimate of her level of marital satisfaction. This enabled Sharon to be a supportive coach to help him fight his urges. 

The next three sessions were used to develop self management plan that would help him respond to his triggers without drinking. Also the negative and positive consequences of his drinking were examined. Tom would carry a 3x5" card with him that listed the negative consequences of his drinking and he would take time to look at the card if he was in a trigger area. He would practice relaxation techniques taught in therapy. One of the things he could do was to call Sharon for a urge discussion. Sharon learned to respond in a supportive way in these conversations not to confuse his wish to drink with the act of drinking. Sharon was taught through role playing to be appropriately supportive while relinquishing his responsibility to have to inform her of his drinking.

The next 4 sessions were focused on communication training. Both were taught more effective ways to listen to each other and to express their feelings in non confrontational ways. The next 3 sessions were spent on identifying signs of possible relapse, ways to handle relapse, and developing a relapse contract. They made a decision to meet and discuss outside the therapy room to clear the air of any conflict or negative feelings, to discuss family issues that needed to be taken care of , to anticipate high risk situations that might be forth- coming and to problem solve about how he can handle them. Also they would discuss frequency and intensity of Tom's urges to drink. The relapse contract(Marlatt and Gordon 1985) includes: 1. He needs to be as honest as possible and inform her of any drinking strong urges to drink. 2. They would discuss the necessity of returning to treatment if :.he had a drink once a week for 3 weeks in a role, stress or no stress or .if he seems to be responding to previous triggers like becoming quiet or much less communicative for more than a week. 3. He will start to consider return to treatment often even with one drink 4. If he or Sharon notices a steady pattern of drinking even once every 3 weeks or every month for 3 months or if urges get stronger, return to therapy will be discussed. 5. If any of items 2,3 or 4 occur, he should contact the therapist and discuss the need to schedule an impromptu booster session. 

A follow-up session was scheduled for every three months. By the end of these sessions, he was able to maintain abstinence. He found that one of his persistent triggers was related to his completing his work at the end of the day and feeling a need to go out with fellow employees and have a drink. Dealing with this in an effective way was a challenge. He found he eventually could go out with his friends and not drink at all and in fact, after a while, he found he did not find as much pleasure in this activity as he did coming home and working out. Both felt that their relationship in the area of communication improved, although Sharon ended up feeling a need to continue therapy to assist with her feelings of depression which were not addressed in this form of therapy. Tom was introduced to an AA meeting group in which he felt more comfortable and Sharon continued to attend Al-Anon. The limitation in this form of therapy continues to be the lack of in-depth attention to the female spouse and her needs for growth and inner security. 

Treatment Recommendations:

It is apparent that the problem of alcoholism can be approached from a variety of therapeutic approaches all of which have their specific merit. The premise of this paper, however, poses the question of could there be a better way for the female partner of the male recovering alcoholic to experience the potential for growth and inner healing from her unique vantage point. I believe this is indeed possible. By incorporating the approaches for healing codependence and understanding the importance of caretaking from the feminist viewpoint, the possibility of inner change is very possible.I also believe borrowing from the family of origin concept of Bowen that the female partner can develop the needed insight to bring about such change. 

Robert Coles(1964) observed that crisis can lead to growth when it presents an opportunity to confront impediments to further development. This is exactly what the female partner is confronted with when in a relationship with a male alcoholic. This is a time of great personal assessment. Since in the period of Recovery, all attention for the alcoholic needs to be on maintaining abstinence with time devoted at a much later period to work in depth on the relationship issues, this is a prime time to explore in an in-depth way the core issues of the female spouse(Brown,1999). 

There should be a focus on core issues with the goal of resolving them when possible. According to Whitaker(1991) a core issue is one that comes up repeatedly, such as issues around control; trust: being real; identifying and owning feelings; low self esteem; depression; grieving ungrieved losses, and fear of abandonment. Also included are all or nothing thinking; high tolerance for inappropriate behavior; over responsibility for others; neglecting one's own needs, and having difficulty resolving conflict and difficulty giving and receiving love. 

Encouraging the reading of material on codependence is always helpful especially when the client is so inclined. Two books that would be included initially are "Codependent No More," by Melody Beattie and "Boundaries and Relationships," by Charles Whitfield. 

Encouraging empowerment in the client as a woman is very important. It would be most helpful to have her listen to her own inner guide, who knows and understands all that has happened in her life, and who is wise, compassionate and loving towards her. Many times the use of guided imagery to help her connect with this part of herself is extremely helpful. She can learn to trust those instincts and gut feelings about herself and situations in which she finds herself. It may also be helpful to encourage her to listen to her physical symptoms and to examine what they are saying to her. Her symptoms may be suggesting to her that they are healthy reactions of her self system to situations of inequality, powerlessness, coercion, fear and anger. Such symptoms as headaches, overeating, fatigue and depression can be listened to as powerful and helpful messages from the inner self. It is also very important to teach the client how to say No and understand the reasons why this has always been difficult for her. Teaching the client to be a self observer in a variety of situations that have proved to be very uncomfortable for her and to work on more effective ways to manage such situations. It is helpful to observe how many times there is an automatic need to explain one's behavior no matter what the situation and to take this and develop increased understanding about this behavior so that change can be made. It is important to focus on taking care of oneself mentally, physically and spiritually. The teaching of relaxation techniques, the use of relaxation tapes, the teaching of self-hypnosis and the use of biofeedback all work well in this area. Developing a clear understanding of the toll prolonged stress takes on the mind and the body is also vital. With this understanding, helping the client develop a self management program including regular time out for relaxation, the use of mindfulnesss, focus on good nutrition and exercise is very important as is following through with regular physical exams.

Journaling about one's feelings and experience is also very helpful in recognizing feelings and understanding them. This is especially helpful for the codependent female. 

It is important to challenge the client's belief system by asking her exactly where she learned that she is responsible for making other people happy. Or: who told her that she could not ask directly for something that she wanted? It is good to explore within her own family where the expectations for women arose. It is also very helpful to explore underlying beliefs of which the client may be unaware. For example, "you act as though your needs are completely unimportant" or "it sounds as if expressing your anger is bad". It is also helpful to assist her in seeing the power imbalance between men and women and to understand the impact this has on her behavior. Lastly, it is helpful for many clients to explore their spirituality and to come to their own balanced decision about what is best for them at this pivotal period of growth. In conclusion, the female partner of the male recovering alcoholic is in a place not only of much stress and discomfort, but is also where, if she is given the best direction in therapy, she can travel with her recovering partner along the path of mutual growth and genuine healing.

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