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Section 21
Helping the Female Partners of Substance Abusers

Question 21 | Test | Table of Contents

The female partners of men who drink heavily suffer from elevated rates of depression, anxiety and somatic complaints, report low levels of relationship satisfaction (Halford et al., 1999), and often are subjected to verbal and physical abuse (Leonard & Jacob, 1988; Van-Hasselt, Morrison & Bellack, 1985; Leonard & Senchak, 1993). They often present to treatment agencies reporting that the man refuses to seek treatment, and that there are frequent marital disagreements about the man’s drinking (Halford & Osgarby, 1993). These women often seek assistance to cope with the impact of the man’s drinking (Liepman, 1993; Thomas & Ager, 1993).

There is a strong association between men’s alcohol abuse and relationship problems. Men diagnosed with alcoholism are as likely as the rest of the population to marry, but are much more likely to be divorced (Nace, 1982; Reich & Thompson, 1985). The marriages of men with diagnosed alcoholism are similar to those of other distressed couples, with low relationship satisfaction (Jacob, Dunn & Leonard, 1983; O’Farrell & Birchler, 1987), high levels of desired change by both spouses (Jacob et al., 1983; O’Farrell & Birchler, 1987) and marked deficits in communication (Frankenstein, Hay & Nathan, 1985; Hersen, Miller & Eisler, 1973; O’Farrell & Birchler, 1987).

The aim of the present study was to evaluate a program to assist the female partners of male problem drinkers. Given the previously described high risk of violence in alcohol-affected relationships, one goal of the program was to reduce the risk of assault. A second goal was to assist the woman to make an informed choice about whether to remain in the relationship. For women who decided to leave the relationship, we provided support in enacting that decision. For women who chose to stay in the marriage we sought to enhance the women’s coping, and to empower them to influence the male partner’s drinking. We also aimed to help the women to improve their relationship with their partner.

When the woman wished to remain in the relationship, we focused on how to influence the man to present for alcohol treatment. Several authors have described programs for helping women to encourage their male partner to present for alcohol treatment (Dittrich, 1993; Liepman, 1993; Thomas & Ager, 1993), although there is no empirical evidence of the efficacy of most of these programs. Sisson & Azrin (1986, 1993) evaluated a program for concerned family members of problem drinkers that included strategies for encouraging the drinker to reduce drinking and present for alcohol treatment. The program was successful in encouraging most drinkers (six out of seven in this condition) to present for treatment and reduce problem drinking. However, the effects of treatment on the marriage, the women’s sense of burden and psychological distress and the men’s aggression were not reported.

If men can be encouraged to present for alcohol treatment, as Sisson & Azrin (1986) achieved, then involving their female partners in treatment could enhance outcome. Involving female partners in alcohol-focused interventions has produced mixed outcomes. Some studies show that spouse involvement significantly improves attainment of initial reductions in drinking (Keane et al., 1984; O’Farrell, Cutter & Floyd, 1985), but other studies did not find this effect (McCrady et al., 1986). If intervention combines an alcohol focus with behavioral couples therapy, this produces improvements in relationship communication and satisfaction (O’Farrell et al., 1985), and better maintenance of abstinence (Mc Crady et al., 1986; O’Farrell et al., 1993). Furthermore, the occurrence of abuse is significantly reduced by these interventions (O’Farrell & Murphy, 1995). In the current study we recruited women and then through these women attempted to recruit the men into a conjoint alcohol-focused couple therapy (AFCT).

About half of married men in individual alcohol treatment decline offers of couple therapy (O’Farrell, Kleinke & Cutter, 1986). Given that we were attempting to enlist men who were not in any treatment, it was likely that many men would decline treatment. In order to assist women whose male partners declined involvement we developed an alternative stress management program. Stress management had two goals: to assist the woman to influence her partner to reduce drinking, and to decrease the negative impact of the man’s drinking on the woman.

The current study was a controlled trial of interventions to assist the female partners of male problem drinkers. Women whose male partners were drinking heavily were assigned randomly to one of three treatment conditions: (a) supportive counseling, (b) stress management, or (c) alcohol-focused couple therapy (AFCT). The supportive counseling condition was intended as a plausible contact control to establish if there were specific treatment effects from the other conditions. It was predicted that stress management and AFCT would each result in significantly greater reductions in spouse stress (hypothesis 1) and male drinking (hypothesis 2), and significantly greater improvements in relationship functioning (hypothesis 3) than supportive counseling. We were unsure if AFCT or stress management would be more effective, and so tested the hypothesis that there would be a differential treatment effect across these two conditions on female stress, male drinking and relationship functioning (hypothesis 4).

Treatment
Women were assigned randomly via random number tables to one of the three treatment conditions: (a) supportive counseling, (b) stress management, or (c) alcohol-focused couple therapy. In all conditions women completed the assessment battery and an extensive clinical intake interview over the first two sessions.

Supportive counseling began with education about the effects of alcohol. This included the definition of a standard drink, information about safe drinking levels based on the guidelines of the National Health and Medical Research Council of Australia (1992) and discussion of the behavioral and medical effects of drinking at unsafe levels. The major component of this treatment condition consisted of Rogerian style non-directive counseling in which participants had the opportunity to discuss their difficulties in a supportive, non-judgmental setting. No specific advice, cognitive restructuring or skills training was provided in this condition.

Stress management was an extension of the treatment described by Sisson & Azrin (1986). Like the Sisson & Azrin (1986) program, the current treatment had a number of specific components relating to influencing the man’s drinking, including: (a) assessment of the antecedents and consequences of alcohol consumption in the problem drinker; (b) review of the impact of the drinking upon the spouse and other family members; (c) providing positive consequences for not drinking; (d) scheduling competing activities, which were unlikely to be associated with heavy drinking; (e) promoting behavior that might reduce drinking; and (f) allowing negative consequences of intoxication, to occur (e.g. the client would not ring up and make excuses to his employer or relatives for missed commitments). For each such scenario the procedures were discussed and role-played with clients. Specific homework assignments were provided, and the results of the application of the procedures reviewed in subsequent sessions.

Stress management also included specific components to reduce the negative impact of the male’s drinking on the woman. Based on pilot work, we identified two core components of this aspect of the treatment: cognitive restructuring and enhancing pleasant activities. Women were assisted to identify their cognitions about the drinking, and irrational cognitions were challenged. The most common irrational cognitions included self-blame (e.g. "If I were a better wife,
he would not drink") and taking responsibility, (e.g. "I should be able to make him stop"). Women also were encouraged to increase the range of pleasurable activities they engaged in outside the home, as many women attempted to compensate for the dysfunction of their partner, which reduced the women’s pleasurable activities.

Alcohol-focused couple therapy (AFCT) was based on the approach of O’Farrell & Rotunda (1997). We included the components that formed stress management, and the woman was taught to prompt the man to present for therapy. If the drinker agreed, at presentation the man’s alcohol consumption and the couple’s relationship were assessed. The treatment program focused initially on alcohol education, motivational interviewing and goal-setting targeted at reducing drinking. Once the man was engaged in therapy we followed the procedures of O’Farrell & Rotunda (1997). The woman was helped to encourage and reinforce positively the man’s efforts to control drinking. The problem drinker received training in identification of high-risk settings for drinking, coping with urges to drink, drink refusal skills and relapse prevention. In addition, couples received training in communication and problem solving, behavior exchange and the enhancement of enjoyable couple activities. If the man refused to participate in therapy, the woman received the stress management treatment.

Discussion
The first hypothesis, that relative to supportive counseling, the behavioral treatments would result in significantly greater reductions in spouse stress, received some support. There were trends in the predicted direction, although all three conditions reduced spouse stress. Hypothesis 2, that the behavioral treatments would result in significantly greater reductions in men’s drinking, was not supported. The effects of all three treatments on male drinking was limited, with no evidence of differential treatment effects across conditions. Hypothesis 3, that the behavioral treatments would reduce relationship distress more than supportive counseling, was not supported. None of the treatments was associated with sustained, clinically significant increases in relationship satisfaction.

The women in the supportive counseling condition reported significant deterioration in their relationship satisfaction across time, while the women receiving the behavioral treatments showed some small increases in relationship satisfaction. At best, this suggests the behavioral treatments prevented further deterioration in severely distressed relationships. Hypothesis 4, that there would be differential efficacy between the behavioral treatments, was not supported.

Despite the lack of support for the predicted superiority of the behavioral treatments on most indices of outcome, it is premature to conclude the behavioral treatments have no specific treatment effects. The initial sample size of 20 participants per treatment condition provided low power to detect small differential treatment effects. The combination of attrition from treatment and some additional missing data reduced the power of the design to detect moderate effects.

The effects of the treatments on the women’s stress were variable, but there was evidence of important gains for participants. If we consider only those 27 women who completed one of the two behavioral treatments, 20 of these women (74%) showed statistically reliable reductions in reported burden, and13 (48%) showed a large treatment effect at 6-month follow-up. Replication with a larger sample size would clarify whether the observed trends for greater reductions in spouse burden in the behavioral treatment conditions is statistically reliable, and whether any differential treatment effects on relationship or alcohol outcomes might be evident.

In the current study stress management focused on changing the antecedents and consequences of drinking, but this did not impact significantly on male drinking. This seems inconsistent with the earlier work of Sisson & Azrin (1986, 1993). However, in the Sisson & Azrin study, six of the seven male drinkers were engaged in individual alcohol treatment and were required to make a behavioral contract to take Antabuse. The effects of their treatment could be attributable to the individual psychological treatments or the Antabuse, rather than behavior changes the women made. In the development of this project we considered the use of Antabuse in our treatments. Antabuse is not widely used or accepted by people abusing alcohol in Australia. Given our target group was men who were not in treatment, we anticipated resistance to the use of medication. Including Antabuse contracting might be worthwhile, though the acceptability of such contracting remains to be established.

A second possible explanation for the lack of effects of the behavioral treatments on alcohol consumption is low adherence by the women to our suggestions to change the antecedents and consequences of drinking. We did not assess adherence to those suggestions formally. Anecdotally, many women seemed resistant to these suggestions. The cognitive component of the stress management emphasized that the man is responsible for his drinking, and that the woman
should not blame herself. As our clients came to internalize these beliefs, they often saw changing their own behavior to promote drinking control in their partner as inconsistent with these beliefs.

AFCT improves relationship satisfaction in male drinkers who engage in treatment, at least when used in combination with Antabuse contracting (O’Farrell et al., 1985, 1993). The gains in relationship satisfaction in AFCT in the current study were modest from pre- to post-treatment, and had disappeared by follow-up. The potential effects of AFCT were limited by the low rate of engagement of males in couple therapy (6/21 participants assigned to this condition), although this low rate of engagement is consistent with other studies reporting low rates (less than 50%) of engagement of male problem drinkers in couple therapy (Zweben, Pearlman & Li, 1983; O’Farrell et al., 1986). Given the absence of changes  precondition to achieving sustained enhanced relationship satisfaction.

Consistent with this interpretation, in a recent study of alcohol treatment outcome changes in relationship satisfaction were predicted by reductions in women’s problem drinking (Kelly, Halford & Young, 2000). The needs of female partners of men abusing alcohol have been largely neglected. Given the level of distress in our sample, it is clear many of these women need help. However, the difficulty of engaging the problem-drinking men in treatment limited the potential effectiveness of the approach we offered the women. All our participants were married a long time (mean 15 years), the men had long-established drinking problems and there was severe relationship distress. Earlier intervention seems to be more effective. Recently we evaluated a Controlling Alcohol and Relationship Education (CARE) program offered to engaged couples in which the male was drinking heavily. CARE was associated with reductions in problem drinking, enhanced relationship communication and greater relationship stability. For those women living with men where both
alcohol and relationship problems are long established, the stress management approach evaluated in the current study reduces the sense of burden and psychological distress.

Personal Reflection Exercise #7
The preceding section contained information about helping the female partners of substance abusers.  Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Prevalence of HIV, risk behaviours and vulnerabilities of female
sex partners of the HIV positive people who inject drugs
(PWID) in Dhaka city, Bangladesh

- Reza, M. M., Rana, A. K. M. M., Morshed Khan, M. N., Safiullah Sarker, M., Chowdhury, S., Uddin, M. Z., Rahman, L., Chowdhury, M. E. I., Taher, M. A., & Khan, S. I. (2023). Prevalence of HIV, risk behaviours and vulnerabilities of female sex partners of the HIV positive people who inject drugs (PWID) in Dhaka city, Bangladesh. PloS one, 18(6), e0286673. https://doi.org/10.1371/journal.pone.0286673

Peer-Reviewed Journal Article References:
Acheson, A., Vincent, A. S., Cohoon, A., & Lovallo, W. R. (2019). Early life adversity and increased delay discounting: Findings from the Family Health Patterns project. Experimental and Clinical Psychopharmacology, 27(2), 153–159.

Joyner, K. J., Acuff, S. F., Meshesha, L. Z., Patrick, C. J., & Murphy, J. G. (2018). Alcohol family history moderates the association between evening substance-free reinforcement and alcohol problems. Experimental and Clinical Psychopharmacology, 26(6), 560–569.

Roy, A. L., Isaia, A., & Li-Grining, C. P. (2019). Making meaning from money: Subjective social status and young children’s behavior problems. Journal of Family Psychology, 33(2), 240–245.

QUESTION 21
According to Halford, why were women in the study resistant to suggestions to change the antecedents and consequences of drinking? To select and enter your answer go to Test.