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).