Differentiation and Relationship Satisfaction:
Mediating Effects of Alcohol Use
Dissertation
Presented in Partial Fulfillment of the Requirements for
The Degree Doctor of Philosophy in the Graduate
School of The Ohio State University
By
Felisha Lynn Lotspeich Younkin, MS, MFT
Graduate Program in Human Development and Family Science
The Ohio State University
2013
Dissertation Committee:
Professor Suzanne Bartle-Haring, Advisor
Professor Anastasia Snyder
Professor Keeley Pratt
i
Copyright by
Felisha Lynn Lotspeich Younkin
2013
ABSTRACT
The purpose of this study was to examine the relationship between differentiation
and alcohol use and how these factors interact to influence relationship satisfaction in
couples. Bowen’s Family System’s Theory suggests that alcohol and other substances
are used as a distance regulator in relationships, but this idea has not been tested in a
clinical sample. Using structural equation modeling with AMOS20, I tested 3
hypotheses. The first hypothesis was that couples with higher differentiation are less
likely to use alcohol because they do not need it to regulate distance. I also hypothesized
that couples who used more alcohol had lower relationship satisfaction. Finally, I
hypothesized that alcohol acts as a mediator between differentiation and relationship
satisfaction. The models produced a poor fit to the data, suggesting nonlinearlity in the
data. Therefore, repeated measures ANOVA was conducted and showed significant
results, suggesting that alcohol served as a successful distance regulator. Results support
previous findings that alcohol recovery can have a destabilizing effect on the family
system because of the important function of alcohol use in intimate relationships. This
study has important clinical implications because it provides a picture of the mechanism
that underlies alcohol use in intimate relationships, which is a good starting point for
planning and considering the effect of therapeutic interventions.
ii
Dedicated to my family
xi
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ACKNOWLEDGEMENTS
Dr. Suzanne Bartle-Haring, thank you for being brilliant and for the chance to
learn from you. Also, thank you for your leadership and patience as I learned about
differentiation through my own life experiences. Dr. Keeley Pratt, thank you for your
passion for the field, for introducing me to MedFT, and for all your help with my career
development. Dr. Kate Adkins, thank you for mentoring me from the beginning of
graduate school and for the opportunity to work alongside of you. Dr. Rashmi
Gangamma, thank you for being me with me from the early childhood all the way
through the adolescent stages of becoming a therapist. I put you through a lot so thank
you for hanging in there and for being so calm through it all. Dr. Slesnick, thank you for
teaching me what to “do” in the therapy room.
Dr. Anastasia Snyder, thank you for teaching me demography and secondary data
analysis and for leading by example of successful work-family balance. Dr. Amy
Bonomi, thank you for mentoring me even early in graduate school when I first started
teaching. Drs. Sarah Schoppe-Sullivan and Claire Kamp-Dush, thank you for the chance
to work on the new Parent’s Project. I learned so much about research through that
experience.
Graduate school friends, thank you for challenging and inspiring me and for
making school fun. Who else would understand therapy and theory jokes?—no one else
but you guys.
My clients and students, thank you for the opportunity to learn from you.
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Mr. and Mrs. Beaver, thank you for reminding me that there is life outside of
graduate school and to focus and finish.
Pat and Ed, thank you for keeping the kids safe and happy while we worked. You
made it possible for me to be a graduate student and have two kids at the same time.
Gary, thank you for also helping take care of us through this process—we could
not have afforded life with both of us in school without you.
Mom and dad, thank you for being my first teachers and my #1 fans. Remember
when I said I wanted to learn “all there is to know”? You gave me a great start, and you
taught me that the point of learning is to help someone.
Grandpa, thank you for giving me a love of learning. Grandma Janice, thank you
for being a calm and gentle spirit in my life. Grandma Joy, thank you for speaking truth
boldly. Grandma Mary, thank you for loving me so much and for supporting my
education.
Karen, Raychel, Bekah, Dylan, and Adam, thank you for being my best friends
and for making sure that I have fun.
Mike, thank you for being just the partner I need for life. Your steadfast
confidence and sense of humor have helped sustain us through the last five years in
which we have gone to school, worked, and become the parents of two little ones. I love
you.
Ella and Finnley, thank you for being my joy and my dream come true. I want
you to know so many things but mostly how much you are loved.
God, thank you for being “a light unto my path and a lamp unto my feet.” I want
to make my life count for you.
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VITA
2007........................................................................................BA, Miami University
International Studies,
Latin American Studies
2008-2009 ..............................................................................Graduate Teaching Associate
The Ohio State University
2009-2010 ..............................................................................Graduate Research Associate
New Parents Project
The Ohio State University
2010........................................................................................MS, The Ohio State
University Human
Development and Family
Science
2010-2012 ..............................................................................Graduate Research and
Teaching Associate, The
Ohio State University
2012-2013 ..............................................................................Clinical & Research Intern
and Graduate Teaching
Associate The Ohio State
University Couple and
Family Therapy Clinic
2013........................................................................................Clinical Intern
Nationwide Children’s
Hospital Eating Disorder
Program
PUBLICATIONS
Bartle-Haring, S., Lotspeich Younkin, F. & Day, R. (2012). Family to school spill-over:
School engagement in context, Family Relations, 61, 192-206.
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Mendenhall, T. Pratt, K., Phelps, K., Baird, M., & Younkin, F. (in press). Invited coauthor for Chapter 9: Advancing Medical Family Therapy through Research: A
Consideration of Qualitative, Quantitative, and Mixed-Method Designs to be
published in Medical Family Therapy: Advanced Applications.
FIELDS OF STUDY
Major Field: Human Development and Family Science
Minor Field: Couple and Family Therapy
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TABLE OF CONTENTS
Abstract ..........................................................................................................
ii
Dedication ......................................................................................................
iii
Acknowledgments..........................................................................................
iv
Vita.................................................................................................................
vi
Table of Contents ...........................................................................................
viii
Lists of Tables ................................................................................................
x
Lists of Figures ..............................................................................................
xi
1. Chapter 1: Introduction ............................................................................
1
1.1. Family Systems Theory ....................................................................
2
1.2. Bowen’s Family Systems Theory .....................................................
3
1.3. Objectives of Current Study .............................................................
8
1.4. Implications of the Study ..................................................................
9
2. Chapter 2: Review of literature ................................................................
11
2.1. Alcohol Use in Relationships ...........................................................
12
2.2. Hypotheses of the Current Study ......................................................
20
3. Chapter 3: Methods ..................................................................................
21
3.1. Selection of Sample ..........................................................................
21
3.2. Instruments of Data Collection .........................................................
23
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3.3. Data Analysis Procedures .................................................................
26
4. Chapter 4: Results ....................................................................................
29
4.1. Missing Data .....................................................................................
29
4.2. Study Variable Descriptive Statistics ...............................................
29
4.3. Correlations.......................................................................................
30
4.4. Model Test ........................................................................................
31
4.5. Nonlinearity Assessment ..................................................................
34
4.5.1. RMA for Separateness and Male Alcohol Consumption
35
4.5.2. RMA for Separateness and Female Alcohol Consumption
36
4.5.3. RMA for Connectedness and Male Alcohol Consumption
38
4.5.4. RMA for Connectedness and Female Alcohol Consumption
40
5. Chapter 5: Discussion ..............................................................................
42
5.1. Summary of Findings .......................................................................
42
5.2. Relation to previous literature ..........................................................
47
5.3. Strengths and Limitations .................................................................
49
5.4. Clinical Implications .........................................................................
50
5.5. Future Research ................................................................................
51
5.6. Conclusion ........................................................................................
53
References ......................................................................................................
75
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LIST OF TABLES
Table
Page
Table 1: Columbus Demographics.................................................................
54
Table 2: Sample Descriptive Statistics ..........................................................
55
Table 3: Descriptive Statistics of Variables ...................................................
56
Table 4: Drinking Categories .........................................................................
57
Table 5: Depression Severity Categories .......................................................
58
Table 6: Correlations of Key Variables ........................................................
59
Table 7: Results from Original Model ..........................................................
61
Table 8: Means and Standard Deviations from Repeated Measures ANOVA
63
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LIST OF FIGURES
Figure
Page
Figure 1: Proposed Model ..............................................................................
65
Figure 2: Hypothesized Theoretical Model ...................................................
66
Figure 3: Original Testable Mode ..................................................................
67
Figure 4: Alternative Hypothesized Theoretical Model ...............................
68
Figure 5: Alternative Testable Model ...........................................................
69
Figure 6: Separateness and Male Alcohol Consumption ...............................
70
Figure 7: Separateness and Female Alcohol Consumption ...........................
71
Figure 8: Female Relationship Satisfaction and Male Relationship Satisfaction
72
Figure 9: Connectedness and Male Alcohol Consumption............................
73
Figure 10: Connectedness and Female Alcohol Consumption ......................
74
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CHAPTER 1
Introduction
About 17.6 million Americans (8.46% of the adult population) abuse alcohol or
are alcohol dependent (Grant, et al., 2004). Nearly one third of people who are married
meet the criteria for an alcohol use disorder in their lifetime (Hasin, Stinson, Ogburn, &
Grant, 2007), and even unmarried users rarely live in isolation. Research shows that
alcohol abuse by one person in an intimate relationship negatively affects the physical,
emotional, and psychological health of the other person (Schaef, 1992; Homish et al.,
2006). Also, in families in which there is a member who abuses alcohol, there are higher
rates of child abuse and neglect, financial crises, and intimate partner violence than in
families without alcohol/substance abusing members (Laslett, Room, Dietze, & Ferris,
2012; Rotunda, Scherer, & Imm, 1995; Waller et al., 2012).
Despite evidence of the impact of an individual’s alcohol/substance use on
others, there is little research on the impact of alcohol/substance use on intimate
relationships and characteristics of intimate relationships. Researchers have shown that a
discrepancy between alcohol/substance use in heterosexual couples is associated with
lowered relationship satisfaction and disrupted intimacy (Homish et al., 2009) and that
alcohol/substance use is associated with disrupted communication and a higher likelihood
of dissolution (Jacob & Leonard, 1992; Leonard & Rothbard, 1999; Marshal, 2003).
Since alcohol and substance use affects relationships and relationship satisfaction affects
1
overall well-being (Andrews & Whitey, 1976; Gove, Hughes, & Briggs Style, 1983),
more study on the process behind alcohol/substance use in couple relationships is
warranted to inform effective therapeutic interventions for couples in which there is an
alcohol/substance use problem.
Family Systems Theory
Family Systems Theory (FST) provides a theoretical foundation for the impact of
alcohol/substance use on relationships. Begun (1996) reviews FST, explaining that one
core assumption of the theory is that the family is a system that is more than the sum of
its parts. Therefore, in order to understand a family, one must understand how the
membership in the family changes, how each individual changes, how the family
relationships and the family context changes.
Another core assumption is that changes in any part of the system or family affect
the entire system Also, changes in individuals in the system affect the entire system.
Therefore, there is a degree of what Minuchin (1974) calls a “circularity of influence” in
family systems.
Families develop a certain level of balance or homeostasis at which they function
comfortably. Any change in the system requires the family to adapt and adjust in an
effort to return to homeostasis or to achieve another homeostasis. Steinglass and
colleagues (1977) point to this phenomenon and its connection to alcohol abuse when
they suggest a destabilizing effect in recovery of an alcoholic on a family system.
Therefore, alcohol may also serve a function in the family system since it is included in
the family processes that contribute to the family’s ability to maintain homeostasis and
2
viability (Steinglass, Davis, & Berenson, 1977). We can conclude that a similar process
happens in couple relationships, and it is this process that is the basis for the current
study. When there are developmental or other changes in an individual family member,
changes in the interaction patterns between individuals, new family members are added,
or family members leave, the changes reverberate throughout the system.
Some researchers see an overlap between family systems theory and attachment
theory (Marvin, 2003; Akister & Reibstein, 2004). Attachment theory, with its
foundation from John Bowlby, states that a child and caregiver form an
attachment/relationship through the first year of life. The theory posits that in order for a
child’s social and emotional development to occur normally, a child needs to develop a
relationship with at least one primary caregiver (Bowlby, 1949). In Attachment Theory,
a secure attachment is the most desirable type of relationship between a child and
caregiver, and this relationship is characterized by stability in that the child is able to rely
upon the caregiver and know that he/she will be accessible and sensitive to the child and
his/her needs. Secure attachment is also facilitated by the caregiver’s ability to model an
appropriate balance of openness (ability to support exploration) and closeness (ability to
provide safety) (Becvar & Becvar, 2003). This balance of openness and closeness is
similar to the balance of autonomy and relatedness that is explained in Bowen’s Family
System’s Theory, which will be discussed in the following section.
Bowen’s Family Systems Theory
Bowen’s Family Systems Theory, with its cornerstone concept of differentiation,
is an integral part of the foundation of family therapy theory, and provides a useful way
3
of explaining family processes. This concept of differentiation from Bowen’s theory is
defined by how well an individual is able to maintain a sense of self in the midst of
pressure from relationships and how well he/she can maintain cognitive functioning in
the midst of emotional pressure (Klever, 2005; Bowen, 1976; Elieson & Rubin, 2001).
Bowen (1976) hypothesized that alcohol/substance use and addiction are symptoms of
the lack of differentiation in relationships. In effect, alcohol/substance use/addiction may
be a distance regulator for a couple since they are unable to balance separateness and
connectedness in their relationship (Bowen, 1976).
Eight concepts form the building blocks of Bowen’s Family Systems Theory.
These concepts are differentiation of self, triangles, nuclear family emotional system,
family projection process, multigenerational transmission process, emotional cutoff,
sibling position, and societal emotional process. The concepts of differentiation of self,
triangles, nuclear family emotional system, family projection process, and
multigenerational transmission process are particularly salient to the current study and are
described below.
Differentiation of self. Differentiation is defined by how well an individual is able
to maintain a sense of self in the midst of pressure from relationships and how well
he/she can maintain cognitive functioning in the midst of emotional pressure (Klever,
2005). To measure this construct, Murray Bowen, M.D. (1978), created the
differentiation of self scale with all levels of human functioning on one scale. The lowest
possible level on the scale is a “0”, and a person at this level is the most undifferentiated
that he/she could be. The highest level of differentiation is a “100”. Low levels of
differentiation are associated with no sense of self, or a state of fusion in relationships so
4
that the people become an undifferentiated ego mass, which is a state in which there are
no clear distinctions between the thoughts, emotions, and behaviors or various people in
the system. People who are lower on the scale are more vulnerable to stress, and it takes
them longer to recover from stress than people higher on the scale (Friedman, 1991). It
takes a greater amount of stress for people who have high levels of differentiation to
show symptoms, and they recover more quickly from stress than those with lower
differentiation. People with higher differentiation levels have a more defined and
autonomous sense of self. When people have higher differentiation levels, there is less
emotional fusion in their relationships. As a result, there is less energy devoted to
maintaining their sense of self in their relationships, and they have more energy available
for goal-directed activity. These people are better at differentiating between feelings and
objective reality (Bowen, 1978).
Bowen (1978) explained that differences in differentiation impact lifestyles and
thinking patterns so much that people choose spouses and close personal friends who
have their same level of differentiation. Furthermore, Bowen believed that the greatest
intensity of fusion occurs in the emotional interdependency of marriage. The level of
differentiation of self determines the level of fusion between spouses. The way that
spouses handle fusion determines how undifferentiation is absorbed and in which areas
symptoms will be expressed under stress. In systems with low differentiation, individuals
may use alcohol/substances to cope with stress, thus adding a symptom and therefore
more stress to the system. Differentiation levels will also affect how the people in the
system deal with this symptom (Bowen, 1978).
5
Research about the connection between intimacy and differentiation provides
empirical evidence for the construct of fusion and the idea that some styles of intimacy
could be damaging to intimate relationships. For example, in relationships in which there
is a high level of fusion/low level of autonomy, couples have difficulty sustaining a
satisfactory level of sexual desire (Perel, 2008; Schnarch, 1991). Bataille (1968) and
Knee and colleagues (2008) found that a certain distance is required in relationships in
order to maintain a sexual desire. This supports the logic that there is a dance of
closeness and distance in relationships that must be maintained in order for the
relationship to survive.
Triangles. Bowen (1978) saw two-person systems as the most unstable unit of family
systems so these dyads form themselves into three-person systems when they are under
stress. When a system is larger than three people, it becomes a series of interlocking
triangles. Bowen called the triangle the “molecule” of the family system because it is the
smallest stable element of a family system. Triangles can form with three people or with
a dyad and a third part such as alcohol/substance use. In this way, the alcohol/substances
can serve to stabilize a dyad in that it is used to regulate the distance between the two
people in the dyad.
Nuclear family emotional system. In order to understand this concept, it is first
important to understand what Bowen (1978) called a pseudo-self. He explained that there
is a basic self, which is not negotiable in relationships and not changed by coercion, but
the pseudo-self is made up of facts, beliefs, and principles acquired through relationships.
Individuals acquire these characteristics because they feel that they are supposed to or to
enhance their positions in relationships, but these characteristics are not aspects of the
6
person’s actual or basic self. This pseudo-self is negotiable in relationships and is the
aspect of an individual that fuses with others and is directly related to the person’s
differentiation of self. Those with lower levels of differentiation have more pseudo self
and less basic self, while those with higher levels of differentiation have more basic self
and less pseudo self. The pseudo self of the individuals in the system make up the
building blocks of the nuclear family emotional system.
The nuclear family emotional system (or emotional system as Friedman (1991)
called it so that it could be used to refer to a group of people that have become connected
and have developed emotional interdependence with each other) develops its own
principles of organization (Friedman, 1991). In the nuclear family emotional system,
symptoms can show up in one of three places: 1) in the marital relationship 2) in the
health of one of the spouses, or 3) in the children (alternatively between the parent and
child). Many people characterize relationships as successful or unsuccessful based on
whether or not the couple stays together or whether or not the couple is happy. Bowen,
in contrast, decided that a successful family unit is one in which there are little or no
symptoms in all three places (Friedman, 1991). Alcohol/substance abuse can be one
symptom that could develop in one or more members of a family.
Multigenerational transmission process. This concept is a label of the process in
which through generations, children emerge from their families with differentiation levels
that are higher, equal, or lower than those of their parents (Bowen, 1978). Klever (2005)
stated that through this process, the child in the family who is most fused with his/her
parents will develop the lowest level of differentiation. This results in slight variations of
differentiation levels between family members (Klever, 2005). Bowen (1978) explained
7
that if a child emerges with a lower differentiation level than his/her parents, marries
someone with an equal differentiation level, and then produces a child with an even lower
level of differentiation, then a process occurs in which people move toward a lower and
lower differentiation level through multiple generations. McCrady (2012) and
Merikangas (1990) explain how alcohol/substance use is often a problem through
generations in a family, which is related to the idea of to the multigenerational
transmission process in that alcohol may be a symptom that is passed through generations
through this process.
Bowen (2007) wrote about the connection between his theory and the symptom of
alcohol use. He believed that excessive alcohol use occurred in a family when anxiety
was high, and then the appearance of the symptom increased anxiety even more. In
response to the anxiety, each family member responds by doing more of what he/she was
already doing, which leads the family member who drinks to drink even more. At that
point, the symptom can lead to a “functional collapse” in the family or can become a
chronic pattern.
Objectives of Current Study
The purpose of the current study is to understand how couples use
alcohol/substances to regulate distance in their relationships. I will consider how
alcohol/substance use mediates the relationship between differentiation and relationship
satisfaction. Therefore, the purpose of the proposed study is to examine the relationship
between differentiation, emotional intimacy, alcohol/substance use, and relationship
satisfaction in a sample of couples seeking therapy at an on-campus couple and family
8
therapy training clinic. Not all of the couples present with alcohol or other drug use as a
presenting concern, or as a problem more generally. Based on anecdotal evidence
through the history of the clinic census, some report alcohol or other substance use as a
presenting concern, some do not claim it to be a problem, and others do not use alcohol
or substances at all. Therefore, I expect to have a continuum of alcohol/substance use to
compare couples’ level of differentiation between those with little to no use, with those
with abuse and addiction.
Implications of the Study
Since alcohol/substance use is such a prevalent and usually difficult problem in
families, Since alcohol/substance use continues to have a high prevalence rate (Grant, et
al., 2004; Hasin, Stinson, Ogburn, & Grant, 2007), and researchers have documented its
impact on families (Homish et al., 2009; Jacob & Leonard, 1992; Leonard & Rothbard,
1999; Marshal, 2003; Andrews & Whitey, 1976; Gove, Hughes, & Briggs Style, 1983),
gaining a better understanding of the process by which it is used as a distance regulator in
intimate relationships is an important outcome of this study. Little dyadic research has
been conducted on this topic so this study will make a significant contribution to the
literature in that regard. This study could also have important clinical implications since
knowing the process could further the development of effective therapeutic strategies.
Specifically, clinicians could be better informed in how to alleviate the distress of their
clients struggling with problems related to alcohol/substance use.
Overall, this study could contribute to literature that provides evidence for the
significance of Bowen’s Family Systems Theory in clinical practice. From research on
9
alcohol/substance use treatment, we know that family therapy is more effective than
individual therapy (Stanton, Todd et al., 1982; Kaufman & Kaufman, 1992; ZieglerDriscoll, 1977; Joanning, Thomas, Quinn, & Mullen, 1992; O’Farrell, 1995) so it is
important to increase knowledge in the area of family therapy theories in order to inform
treatment of alcohol/substance use.
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CHAPTER 2
Review of Literature
Substance use and addiction are major public health problems that contribute to
the mortality and morbidity rate in our society. For example, in 2010, 25,962 people died
of alcohol-induced causes in the United States (Murphy et al., 2013), and research has
demonstrated that, for many chronic diseases, the risk of disease increases with
increasing average daily alcohol consumption (Rehm et al., 2003). They cost society
billions of dollars each year, and they contribute significantly to crime rates and the
suffering of individuals and families ((Starling & Kumar, 2010). ).
In the DSM 5, the categories for substance abuse and substance dependence were
combined into a single disorder and measured on a continuum from mild to severe. A
Substance Abuse Disorder (SUD), based on the DSM 5, is either mild, which requires
that the patient meet 2-3 of the criteria, moderate (4-5 criteria), or severe (6+ criteria)
(Compton et al., 2013). The following are the criteria for Alcohol Use Disorder based on
the DSM 5: A problematic pattern of alcohol use leading to clinically significant
impairment or distress, as manifested by at least two of the following, occurring within a
12-month period: 1) Alcohol is often taken in large amounts or over a longer period than
was intended. 2) There is a persistent desire or unsuccessful efforts to cut down or
control alcohol use. 3) A great deal of time is spent in activities necessary to obtain
alcohol, use alcohol, or recover from its effects. 4) Craving, or a strong desire or urge to
use alcohol. 5) Recurrent alcohol use resulting in a failure to fulfill major role
11
obligations at work, school, or home. 6) Continued alcohol use despite having persistent
or recurrent social or interpersonal problems caused or exacerbated by the effects of
alcohol. 7) Important social, occupational, or recreational activities are given up or
reduced because of alcohol use. 8) Recurrent alcohol use in situations in which it is
physically hazardous. 9) Alcohol use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that is likely to have been
caused or exacerbated by alcohol. 10) Tolerance, as defined by either of the following:
a) A need for markedly increased amounts of alcohol to achieve intoxication of desired
effect. b) A markedly diminished effect with continued use of the same amount of
alcohol. 11) Withdrawal, as manifested by either of the following: a) The characteristic
withdrawal syndrome for alcohol. b) Alcohol (or a closely related substance, such as a
benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
In a study comparing the DSM-IV and DSM-5 criteria, 80.5% of individuals who
met criteria for DSM-IV alcohol dependence were in the DSM-5 moderate to severe
Alcohol Use Disorder (AUD) category (Dawson et al., 2013). In another study using the
same general population sample of U.S. adults found that the Alcohol Use Disorders
Identification Test (AUDIT C), a popular brief screener for AUD, cutoffs provided
optimized identification of DSM-IV alcohol dependence and DSM-5 moderate-to-severe
AUD (Dawson et al., 2012)
Alcohol Use in Relationships
Research shows that the health of the partners of those who abuse alcohol suffers
due to their lack of engagement in behaviors to prevent their own illnesses and stress
12
from taking care of their alcohol abusing partners (Homish et al., 2006). They also have
higher rates of chronic illnesses such as high blood pressure, ulcers, cancer, and
gastrointestinal problems (Schaef, 1992). In a study by Steinglass (1981), researchers
found that spouses of alcoholics experienced symptoms of obsessive-compulsive
disorder, interpersonal sensitivity, depression, anxiety, hostility, and phobic anxiety.
Within families, the effects of alcohol abuse extend from child abuse and neglect to
financial crises to intimate partner violence (Laslett, Room, Dietze, & Ferris, 2012;
Rotunda, Scherer, & Imm, 1995; Waller et al., 2012).
Despite evidence of the impact of an individual’s alcohol/substance use on others,
there is little research on the impact of alcohol/substance use on relationships and
relationship characteristics. Research shows that alcohol/substance use plays a role in
couples’ relationship formation and dissolution. Specifically, Martino, Collins, &
Ellickson, (2004) found that adolescents who used substances were likely to marry
younger than those who did not. Two possible explanations are that those who use
alcohol/substances are more impulsive and have a higher sensation-seeking drive than
others. Also, alcohol/substance use is responsible for cognitive deficits and impaired
judgment. Therefore, adolescents then participate in risky sexual behavior, get pregnant,
and then marry early (Martino, Collins, & Ellickson, 2004). Collins Ellickson, and Klein
(2007) found that 11% of divorced men and women claim that alcohol/substance use
played a role in their divorce and that alcohol/substance use rates are higher among
divorced individuals compared to married individuals (Collins, Ellickson, & Klein,
2007). As seen by the reviewed literature, there are few longitudinal studies in this area.
13
Therefore, longitudinal research is needed since causation cannot be determined by cross
sectional research.
There are several reported harmful effects of heavy drinking for couples including
conflict, dissatisfaction, and intimate partner violence (Testa et al., 2012; Foran &
O’Leary, 2008). Research shows that when one partner drinks significantly more than
the other partner, relationship satisfaction and intimacy are disrupted in couples’
relationships (Homish et al., 2009) and that alcohol/substance use is associated with
disrupted communication (Jacob & Leonard, 1992; Leonard & Rothbard, 1999; Marshal,
2003). Within families, alcohol/substance use interferes with the development of a sense
of connection for offspring with alcoholic/substance abusing parents (Seilhamer, Jacob,
& Dunn, 1993). From a family therapy perspective, the inability to develop intimacy in
relationships results in the lack of satisfactory relationships in general and may contribute
to the instability in relationships (Cordova, Gee & Warren, 2005).
McCrady (2012) explains that families form the environment in which people
initiate and develop alcohol or substance use disorders. Genetic vulnerabilities to
developing Alcohol Use Disorders (AUDs), family attitudes about alcohol, and family
drinking patterns have direct effects on drinking (McCrady, 2012). In family pedigree
studies, we see individuals who are first-degree relatives (brothers, sisters, parents, or
children) are four to seven times as likely to develop alcohol dependency as people in the
general population (Merikangas, 1990). Another piece of evidence for the genetic
influence on alcoholism is that in adoption studies, children who are born to an alcoholic
parent and then adopted by nonalcoholic parents are more likely to develop alcoholism as
adults than adopted children born of nonalcoholic parents (Clonginger, Bohman, &
14
Signardsson, 1981). However, at the same time, we know that genetic effects are not
deterministic but are instead a factor that relates to vulnerability and risk and interact with
other environmental factors (Slutske et al., 1998).
Many alcoholics report that before they drink, they often experience one or more
of the following distressing events: a family argument, poor communication, inadequate
family problem solving or nagging (O'Farrell & Fals-Stewart, 1999). Several authors
during the late 1980s and 1990s suggested ways in which the process of using
alcohol/substances as a distance regulator occurs. Steinglass (1981) suggested that when
the alcoholic was “wet” (i.e. actively using), the family system adapted to that alcoholic
being “absent,” (i.e. emotionally unavailable or behaving erratically and unpredictably).
That is, other family members took over the roles of that family member including
providing a sense of connection for the nonalcoholic parent, while remaining separate
from the alcoholic parent. At some point that separateness of the “romantic” partners
became too much, and according to Steinglass (1981), the alcoholic then became “dry”
(i.e. tried to limit drinking).
During this “dry” period there was some time in which the
system became destabilized but hopeful that the alcoholic had changed. However, since
the two partners could not regulate their own sense of self as separate as well as
connected within the relationship, the alcoholic reverted back to being “wet,” in order to
“balance” the system, so to speak. Few studies have tested this idea or Bowen’s theory
more generally in clinical settings (Titelman, 1998).
Despite the interference with intimacy reported in some studies, many people
report that one of the reasons they drink is to feel closer to their significant other.
Leonard and Mudar (2004) found this to be true when they asked couples about their
15
expectations for drinking. Participants reported that they expected to experience more
intimacy, have greater sexual experiences, have greater power, and have more fun once
they drank alcohol.
Recently, researchers have examined the way that alcoholics and their families
interact with each other. To assess the interaction patterns in couples with alcoholic
members, Singh, Bhattacharjee, and Kumar (2009) compared a sample of 30 spouses of
men diagnosed with alcohol dependence syndrome and 30 spouses of men with no
psychiatric diagnosis and/or alcohol dependence diagnosis. The sample consisted of
patients who came to the “De addiction Centre”, a psychiatric hospital located in India.
Participants were given the Family Interaction Pattern Scale (FIPS) and the General
Health Questionnaire-12. The FIPS is a 106-item scale with six domains including
measurements of reinforcement, social support, role, communication, cohesiveness, and
leadership. Questions are based on a four point Likert scale with a higher score
indicating dysfunction in that area. The researchers found differences between the two
groups in terms of their total score on the FIPS and specifically in its domains of
reinforcement, social support, role, communication, and leadership, which showed
differences in the quality of interactions between families with an alcoholic member and
those without an alcoholic member. Wives of alcoholics reported that their husbands
provided poor support, did not function in their roles well, communicated unclearly, and
had poor leadership styles. The wives reported that as a couple, they had poor support in
their families and poor communication within the family (Singh, Bhattacharjee, and
Kumar, 2009). One major limitation of this study is that the analysis was not dyadic
16
since the researchers only collected data from the wives instead of from both husbands
and wives.
Frankenstein et al. (1985) found that wives of alcohol-dependent husbands were
better at problem-solving when their husbands were drinking compared to when they
were not drinking and that alcohol increased the positive interactions between these
spouses. In contrast, in another study Jacob, Ritchey, Cvitkovic, and Blane (1981),
compared the interactions of eight alcoholic and eight nonalcoholic couples. They found
that alcoholic couples had more negative interaction during the drinking period than the
non-drinking period. Some of the measures they used for the interaction were hostility,
blame, and criticism levels.
Derrick et al. (2010) compared relationships between couples with concordant
and discrepant drinking patterns. Concordant couples are those in which both partners
drink, and discrepant couples are those in which one member of the couple drinks. They
hypothesized that concordant heavy drinking couples would have stronger expectations
for the effects of alcohol on their relationship than discrepant couples. Participating
couples were divided into 4 groups: concordant heavy drinkers (n=68), heaving drinking
husband (n=79), heavy drinking wife (n=35), and concordant abstainers/light drinkers
(n=69). They measured intimacy/openness in couples and expectations about how close
they will feel to their partner after drinking (e.g., “Feel closer to your partner”; “Feel
more loving and accepting of your partner”). Wives in the heavy drinking couples
reported stronger expectations for intimacy after alcohol use than wives in the other three
groups. Husbands in couples in which either or both partners were heavy drinkers
reported stronger expectations for intimacy than husbands in the comparison couples.
17
Results suggest that wives’ intimacy/openness expectancies may indeed reflect heavy
drinking when their husband is also a heavy drinker. Husbands’ intimacy expectancies,
however, do not appear to reflect their own heavy drinking. Rather, husbands’
expectancies appear to reflect the drinking of either partner.
Steinglass, Davis, & Berenson (1977) had ten couples enter treatment in a hospital
in which they were asked to drink normally for the first week of treatment. As they
observed these couples, they found that during intoxication, couples followed a specific
and clearly identifiable interaction pattern. One couple they observed “used” alcohol as a
way to be able to freely express emotion surrounding depression related to the loss of a
significant loved one. Another couple was able to discuss their sexual difficulties more
openly, and the husband (who struggled with impotence) became flirtatious and sexually
suggestive toward his wife.
These results, with some fairly small samples, suggest that alcohol and substances
have an intimacy effect. That is, in couples in which alcohol is used, there is an
expectation that it will increase their intimacy. It appears that these expectations are met
to some degree. However, with continued drinking and further addiction, the
expectations are no longer met, suggesting that continued use leads to a break down in
other relationship processes.
Family responses to treatment give us more insight into the function that
alcohol/substances play in the family. Since, according to FST, alcohol or drug use
serves a function in the family system and “helps” the system maintain homeostasis,
treating and changing alcohol/substance use can disrupt the family system. Families are
oftentimes resistant to disruptions in their homeostasis so they as a result, can be
18
unknowingly resistant to treatment for alcohol/substance use (Zwebwn & Perlman,
1983).
According to FST, problems in families and in turn in therapy will come during
times of change or when stress is put on the family system (Begun, 1996). When there
are changes surrounding the alcoholic’s effort to change his/her drinking patterns, this
will result in changes in the family such as the adjustment of roles and family dynamics.
For example, while the alcoholic member drank, he/she may have abandoned his/her
responsibilities. When the alcoholic is sober, roles and the dynamics of family decision
making and authority must change. In couples, other things that may change are the
dynamics associated with sex and intimacy. In parent-child relationships, if an
adolescent struggles with an AUD, then the parent’s responsibilities in terms of behavior
management and communication with the adolescent change (Zweben & Perlman, 1983).
Some examples of times of stress on a family system include launching children, job loss,
and death of a family member.
One of the major limitations of this study is its homogenous sample with most
participants being Vietnamese. This sample is unique in that the participants are in an
environment in which heroin users experience high rates of blood-borne virus infection,
upload overdose, criminal justice system involvement, and poor retention in substance
use treatment. Participants also had easy access to heroin.
The lack of research in the area of the effect of alcohol on relationship dynamics
and relationship characteristics such as relationship satisfaction informed the hypothesis
for the current study:
19
Hypotheses of the Current Study
The objective of this study is to examine the relationship between differentiation
and alcohol/substance use and how these factors interact to influence relationship
satisfaction in couples.
The following are the hypotheses:
H1: Couples with higher differentiation are less likely to use/abuse alcohol/substances.
According to Bowen, individuals use alcohol/substances because they are anxious
about experiencing emotions within relationships. In contrast, those with higher
differentiation levels have less of a need to use alcohol/substances because they are not
experiencing anxiety about their relationships.
H2: Alcohol/substance use decreases relationship satisfaction.
Past research shows increased relational distress and instability due to
alcohol/substance use.
H3: Alcohol/substance acts as mediators in the relationship between differentiation and
relationship satisfaction.
20
CHAPTER 3
Methods
Site of Data Collection
Data for the study was collected at the Ohio State University’s Couple and Family
Therapy Clinic. This clinic serves approximately 75 new clients a year including
families, couples, and individuals. All clients served at the clinic are English speaking.
The clinic operates on a sliding fee scale with fees ranging from $10-$65. The majority
of the clients in the clinic are Caucasian. The Ohio State University Couple and Family
Therapy Clinic is a training clinic, meaning that therapists are doctoral students
supervised by the American Association of Marriage and Family Therapy (AAMFT)approved supervisors.
Selection of Sample
Approval from the Institutional Review Board was obtained before beginning data
collection. All clients in the clinic were invited to participate in research during their first
therapy session.
The sample for this study was 45 couples who were in treatment at The Ohio
State University Couple and Family Therapy Clinic (OSU CFT Clinic). Couples
attending the clinic who consented to participate in research completed questionnaires
before their first session which included questions about demographic information to
account for control variables and the measures listed below.
21
The sample consisted of males between the ages of 18 and 76 (M=32.02,
SD=11.47) and females between the ages of 15 and 65 (M=30.43, SD=9.48). Male
Income ranged from 0 to $150, 000 (M=$37, 114.59, SD=$35,882.06), and female
income ranged from 0 to $190,000 (M=$42,824.23, SD=$43,564.82). Males reported
that their relationships were between 0 and 35 years (M=6.36, SD=7.62), and females
reported relationship length between .58 and 38 years (M=7.12, SD=8.13). Males had
between 0 and 6 children (M=.97, SD=1.26), and females had between 0 and 7 children
(M=1.03, SD=1.33). The majority of research participants were Caucasian/White (74%)
with the others being Asian (1.9%), Black (11.1%), Hispanic/Latino (3.8%), Native
American (.9%) and Mixed (.9%).
The sample was highly education with 30.6% having
some college education, and 25.9% having a Bachelor’s degree.
Since the sample was a nonprobability sample, it was important to compare my
sample to the sample from which it was pulled in order to test for generalizability. Figure
2 shows the demographics of Columbus, Ohio, which is where the data was collected.
However, since the sample was taken from a university training clinic, the results were
not generalizable to other clinical samples. Couples who attend university training
clinics are unique to the overall clinical population since not everyone is willing to come
to a training clinic. Clients present to the clinic with a variety of concerns such as
relationship conflict, effects of an affair, parenting challenges, depression, and anxiety,
etc.
22
Instruments of Data Collection
A demographic questionnaire was used to collect key socio-demographic
variables including the respondent’s age, race, gender, education, and income.
Depression. Depression was measured using the Patient Health Questionnaire
(PHQ-9) (Kroenke et al., 2001) a measure which includes 9 questions about depressive
symptoms such as whether the client has “little interest or pleasure in doing things” or is
“feeling down, depressed, or hopeless.” In order to assess the severity of the depressive
symptoms, clients marked their answers to these questions on a 4 point Likert scale: not
at all, several days, more than half the days, and nearly every day over the past two
weeks. Responses received a 0, 1, 2, or 3 score, and the overall depression score was the
sum of these individual item’s scores with higher scores indicating more depressive
symptoms. Overall scale reliability was.89. This measure is not a diagnostic assessment
of depression based on the DSM-IV, but it measured depressive symptoms.
Since there are mixed results in the literature about the relationship between
depression and alcohol/substance use, depression was a control variable in the proposed
study. In the literature, alcohol use leads to higher levels of depression and that
depression leads to more drinking (Bazargan-Hejazi, Ani, Gaines, Ahmadi, & Bazargan,
2010). Also, partners of people who suffer from alcoholism experience depression as a
result of their partner’s drinking. Steinglass, Bennett, Wolin, and Reiss (1987) assessed
the effect of depression and alcohol use on relationship satisfaction but only from the
perspective of how one person’s alcohol use affects the relationship. Bazargan et al.
(2010) also found a gender difference in the relationship between depression and alcohol
23
abuse with alcohol abusing men being 2.5 times more likely to be depressed than nonabusing men.
Differentiation. A newer instrument was used to measure differentiation. This
instrument, the Family Distance Regulation (FDR) (Anderson & Sabatelli, 1992; BartleHaring & Sabatelli, 1998; M. Bowen, 1976; Sabatelli & Bartle-Haring, 2003), designed
by Bartle-Haring, was adapted from the Social Connectedness Scale (Lee et al., 2001)
and the Healthy Separation Subscale of the Separation Individuation Test for Adolescents
(Levine et al., 1986). It has been found to be related to child outcomes in the expected
direction (Bartle-Haring, Lotspeich Younkin, & Day, 2012; Ponappa, 2012). The version
used in this study used a repeated dyadic method like circular questioning. Each partner
was asked about their perception of themselves and their perception of how their partner
would answer the same set of questions about them. This instrument includes 15
questions about emotional closeness and distance in relationships such as, “I feel
understood by my partner” and “While I like to get along with my partner, if I disagree
with something he/she is doing, I usually feel free to say so”. Answers are based on a 5
point Likert scale from strongly agree to strongly disagree.
Alcohol/Substance Use: The alcohol/substance use measure was adapted from the
AUDIT-C (Bush et al., 1998) and the Self-Evaluation of Drug Use Screen (Miller &
Appel, 2010). The questions from the AUDIT-C ask the respondent how much alcohol
the respondent consumes and also asks the respondent to report how much his/her partner
consumes. The first question is: “How many drinks did you have on a typical day when
you were drinking in the past year?” Response options are never, monthly or less, 2 to 4
times a month, 2 to 3 times a week, 4 to 5 times a week, or 6 or more times a week. The
24
second question is: “How many drinks did you have on a typical day when you were
drinking in the past year?” Response options are 0 drinks (0 points); 1 to 2 drinks (0
points); 3 to 4 drinks (1 point); 5 to 6 drinks (2 points); 7 to 9 drinks (3 points); or 10 or
more drinks (4 points). The third question is: “ How often did you have 6 or more drinks
on one occasion in the past year? Response options are never (0 points); less than
monthly (1 point); monthly (2 points); weekly (3 points); or daily or almost daily (4
points). Scores are added so that they are a possible score from 0 to 12.
Questions from the Self-Evaluation of Drug Use screen asked the respondent to
rate how much of a problem his/her or his/her partner’s alcohol/drug use is for the
respondent as an individual and for the couple’s relationship. It also assessed whether or
not the respondent has a desire to change his/her alcohol/drug use. These questions were
originally created to serve as a way for clinicians to utilize motivational interviewing
with problem drinkers because they believed that problem drinkers first had to realize
that they had a problem before they could try to change it. The questions were not asked
in this study for the same reason. Instead, the purpose was to use a measure that
combines an objective view of alcohol/substance use (with the questions about quantity
from the AUDIT-C) with a subjective view of how much the respondent thinks his/her or
his/her partner’s alcohol/substance use is a problem in their lives and their relationship.
Relationship Satisfaction: For the purposes of this project, relationship
satisfaction was measured on a 10 point scale with 1=not at all satisfied and
10=completely satisfied. This single item has been used in previous studies in the clinic
and was highly correlated with the Kansas Marital Satisfaction Scale (.86), a commonly
used measure of relationship satisfaction.
25
Data Analysis Procedures
In order to test the model in Figure 1, Dyadic Data Analysis strategies were used.
That is, methods were used that allowed me to test variables based at the individual level
but take into account the data was nonindependent. The model in Figure 1 is known as
the extended Actor Partner Interdependence Model (APIM; Kenny, Kashy & Cook,
2006). APIM is specifically designed to assess bidirectional effects within longitudinal
designs. Although, this study is not longitudinal, this method is still useful in assessing
bidirectional effects in couples. It is useful to study interdependence in relationships
because it occurs whenever a person’s emotion, cognition, or behavior affects the
emotion, cognition, or behavior of his/her partner (Cook & Kenny, 2005).
The significant contribution of the study will be to examine not just the actor
effects (i.e. how an individual’s own differentiation influences, his/her own substance
use, and his/her own relationship satisfaction) but how the partner effects are at work in
this model as well, which is not well known given the current state of the literature. That
is, it is less clear, for example in a couple in which the male partner is addicted to some
substance, how the female partner’s level of differentiation impacts her partner’s use of
substances and relationship satisfaction. It is also less clear how the partner’s selfreported use (rather than the perspective of the other) impacts the other’s emotional
intimacy, substance use and relationship satisfaction. Thus, the APIM is necessary in
order to account for nonindependence, to provide unbiased estimates and to provide
appropriate significance testing.
26
The dependent variable, relationship satisfaction, is one that is especially
important to study using APIM because we know that the relationship satisfaction scores
of husbands and wives are usually positively correlated (Cook & Kenny, 2005). Using
statistical methods such as ANOVA for analysis treat the satisfaction scores of the two
members of a couple as if they are completely independent of one another. Kenny (1995)
explains that when two variables that are supposed to be correlated are treated as
independent, then the test statistic and degrees of freedom are inaccurate and the
statistical significance is biased. APIM allows the dyad to be treated as the unit of
analysis, a very useful tool when studying couples.
Schumacker and Lomax (2010) explain that there are three ways to judge a model
for significance in SEM. All three of these were used when evaluating the model in
Figure 1. First, the chi-square and root mean square error of approximation (RMSEA)
were evaluated as indices of fit. A non-significant chi-square suggests a good fit in that
the observed covariance matrix and the estimated covariance matrix are quite similar or
exactly the same. The RMSEA, however, is a test of close fit rather than perfect fit, like
the chi-square test. Values of .80 and below are considered acceptable with values of .05
and below considered evidence of a close fit to the data. Second, the significance of the
individual paths in the model was evaluated. Finally, the magnitude and direction of the
paths were evaluated.
To understand how the individual’s scores on the AuditC were related, I did an
Intraclass Correlation (ICC). This means that I took the three items from each person’s
AUDITC and the three items from their partner’s AUDITC that were about them and
27
compared them. The ICC gave me a score comparing between scores and comparing
within scores.
28
CHAPTER 4
Results
Missing Data
There was very little missing data. Little’s MCAR test was used to determine
whether the data for the variables of interest were missing at random or not. This test
suggested that the data was missing at random and thus linear interpolation was used to
replace the missing values. With no missing data, the modification indices could be
calculated in AMOS, the structural equation modeling software used to estimate the
models.
Study Variable Descriptive Statistics
Table 3 shows the descriptive statistics of the main variables. male perception of
male alcohol consumption ranged from 0 to 9 (M=3.74, SD=2.44). Male perception of
female alcohol consumption ranged from 0 to 9 (M=3.06, SD=2.07). Female perception
of female alcohol consumption ranged from 0 to 8 (M=2.51, SD=1.94). Female
perception of male alcohol consumption ranged from 0 to 10 (M=3.73, SD=2.65). For
the AUDIT-C, a score greater than 4 for males and greater than 3 for females means that
the individual is most likely consuming alcohol at unhealthy levels (Quality enhancement
research initiative, 2010). As Table 4 shows, 25 males (59.5%) perceived that they did
not have a drinking problem, and 17 (40.5%) perceived that they had a drinking problem.
Twenty-nine females (37.4%) perceived that their partner did not have a drinking
29
problem, and 14 (32.6%) perceived that their partner had a drinking problem. Thirtythree females (76.7%) perceived that they did not have a drinking problem, and 10
(23.3%) perceived that they had a drinking problem. Twenty-two males (62.9%)
perceived that their partners did not have a drinking, and 13 (37.1%) perceived that their
partners had a drinking problem.
Male depression ranged from 2 to 21 (M=9.51, SD=5.22), and female depression
ranged from 2 to 29 (M=10.79, SD=6.87). For the PHQ-9, the maximum score is 27,
with lower scores being better than higher scores. Scores of 5, 10, 15, and 20 represent
cut-off points for “mild”, “moderate”, “moderately severe”, and “severe” depression
respectively (Kroenke, Spitzer, & Williams, 2001). As Table 5 shows, 19 males (46.3%)
and 14 females (32.6%) had mild depression. Eleven males (26.8%) and 13 females
(30.2%) had moderate depression. Eight males (19.5%) and five females (11.6%) had
moderately severe depression. Three males (7.3%) and seven females (16.3%) had
severe depression.
Correlations
Table 4 shows the correlations of key variables. These correlations suggested that
male relationship satisfaction was positively related to female relationship satisfaction.
Male relationship satisfaction was also positively correlated with male perception of male
connectedness, male perception of female separateness, and male perception of female
connectedness, female perception of male separateness, female perception of male
connectedness, and female perception of female separateness. Female relationship
satisfaction was negatively correlated with female depression and negatively correlated
with male perception of female alcohol consumption. It was positively correlated with
30
male perception of the female alcohol/substance use. It was also positively correlated
with male perception of male separateness, male perception of male connectedness, male
perception of female connectedness, female perception of male separateness, female
perception of male connectedness, and female perception of female separateness. Male
depression was negatively correlated with the female perception of the male separateness.
Female depression was negatively correlated with male perception of the male
connectedness, female perception of male connectedness, and female perception of
female connectedness.
Model Test
Figure 2 shows the model of my original hypothesis based on Bowen’s Family
Systems Theory. In this hypothesized model, differentiation and depression are
negatively related. Differentiation is negatively related to alcohol use, and depression is
positively related to alcohol use. Alcohol use is negatively related to relationship
satisfaction. There are direct positive relationships between differentiation and
relationship satisfaction, and there is a direct negative relationship between depression
and relationship satisfaction.
Figure 3 is a graphic depiction of the original model tested. To operationalize
FDR, a latent variable was created with eight indicators including the male perception of
male separateness, male perception of male connectedness, female perception of female
separateness, female perception of female connectedness, male perception of female
separateness, male perception of female connectedness, female perception of male
separateness, and female perception of male connectedness. Two ratio variables (one for
31
males and one for females) were created by dividing connectedness by separateness. The
purpose of this variable was to operationalize the idea that differentiation is a balance of
connectedness and separateness rather than a single score. In this model, FDR, the
differentiation ratio, male and female depression, and relationship length are exogenous
variables. Alcohol consumption (Question 1 from the AUDITC) and the effect of alcohol
and substance use (question 3 from the Self Evaluation of Drug Use Screen) are
mediating variables between the exogenous variables and relationship satisfaction. The
model produced a poor fit with a χ2 value of 367.1 (df= 104), CFI=.513, RFI=.081, and
NFI=.497 and an RMSEA=.240. Male perception of male separateness and female
perception of male connectedness loaded significantly on FDR. The Male
Connectedness/Separateness variable was significantly correlated with both male and
female relationship satisfaction.
Figure 4 is a graphic depiction of an alternative hypothesized model, which was
also theoretically based on Bowen’s Family Systems Theory. In this hypothesized
model, all relationships are negative. Based on the fact that the original model produced
a poor fit to the data, several revisions were made for this alternative model. The
relationship between the FDR latent variable and relationship satisfaction may not have
been linear. That is, given Bowen’s theory, it may be possible to be “too close” or “too
separate,” thus treating the FDR latent variable as a continuous linear variable with high
scores suggesting “better” differentiation may have masked any relationship with the
dependent variables. Also, since separateness and connectedness are supposed to be
“balanced” in healthy relationships, the differentiation ratio was included
(connectedness/separateness) along with an ideographic correlation of the two sets of
32
subscales for each couple to account for the balance between the two sets of variables.
When these variables were added, the fit of the model decreased and changed the
associations of the FDR latent variable with the dependent variables. These attempts to
account for the “balance” appeared to be a confound in the model rather than adding any
consistency to model results. Given the computations of “balance” between
connectedness and separateness were unsuccessful, only the separateness subscale was
used in the alternate model. This scale is designed to assess the person’s perception of
how well they can maintain a sense of self while in relationship to the partner. This may
be the best way to assess differentiation of self. The best fitting measurement model
included 2 factors for separateness: male perception of male and female separateness and
female perception of female and male separateness. Thus both latent variables provide an
assessment of the “couple’s” separateness from the male and female perspectives.
Figure 5 is a graphic depiction of the alternative model tested. In this model,
differentiation is the dependent (endogenous) variable rather than the exogenous variable.
Relationship length, male and female perceptions of their own alcohol consumption, male
and female perception of their alcohol/substance use, and their depression scores were
used as exogenous variables. Relationship satisfaction mediated the relationship between
the “control” variables and the separateness scores for both males and females. This
model also produced a poor fit with a χ2 value of 85.1 (df= 35), CFI=.587, RFI=.049,
NFI=.573, and an RMSEA=.185.
33
Nonlinearity Assessment
Since the original model produced a poor fit and revisions to the model did not
account for the balance between separateness and connectedness, an investigation of the
nonlinearity of the associations among variables was performed. The assumption behind
this decision was that since there is data at one point in time and if alcohol serves as a
successful distance regulator, we would expect to see “higher” differentiation scores for
those who appear to have a problem with drinking and are more satisfied with their
relationships.
A repeated measures ANOVA (RMA) was performed to test this assumption. A
RMA allows for the treatment of the couple (dyad) as the unit of analysis because dyad
member is the repeated measure. This method provides a depiction of the difference
between the dyad members by modeling the centralized intercept and slope for all
couples in the dataset. The intercept is the average separateness score across partners,
and the slope is the average difference between partners (Maguire, 1999).
In order to do the RMA, the relationship satisfaction variables were recoded so
that they were divided into 3 equal groups. There were 52 couples for this analysis with
continued data collection in the clinic. For male relationship satisfaction, there were 20
males in group 1 (low relationship satisfaction), 16 in group 2 (mid relationship
satisfaction), and 16 in group 3 (high relationship satisfaction). For female relationship
satisfaction, there were 19 females in group 1, 17 in group 2, and 16 in group 3.
Dummy variables were created for the drinking variable in which males and
females were categorized according to whether or not they had a “drinking problem”
(0=no drinking problem, 1=drinking problem). These categories were based on the cut-
34
off scores for the AUDIT-C (a score greater than 4 for males and greater than 3 for
females means that the individual is most likely drinking at unhealthy levels) (Quality
enhancement research initiative, 2010).
Four 3 (male relationship satisfaction) x 3(female relationship satisfaction) x
2(male alcohol consumption) x 2 (female alcohol consumption) RMAs were conducted
with spouse as the repeated measure. In two of the RMAs, separateness from the male or
female perception were used as the dependent variables, and in the other two,
connectedness from the male or female perception were used as the dependent variable.
Repeated Measures Analysis for Separateness and Male Alcohol Consumption
The three way interaction of spouse x male perception of male alcohol
consumption x male relationship satisfaction was significant (Wilk’s Lambda=.626; F(2,
29)=8.65;p˂.01). Figure 6 shows the group in which male relationship satisfaction was
low. For this group, when males did not think they had a drinking problem, male
separateness was lowest (3.56), and female separateness was higher (4.05). When males
did think they had a drinking problem, male separateness was low (3.71), and female
separateness was highest (3.88).
For the group in which male relationship satisfaction is in the mid range, when
males did not think they had a drinking problem, male separateness was highest (3.85),
and female separateness was lowest (3.10). When males did think they had a drinking
problem, male separateness was 3.94, and female separateness was around 3.87.
For the group in which male relationship satisfaction was high, when males did
not think they had a drinking problem, male separateness was around 4.02, and female
35
separateness was lowest (4.04). When males did think they had a drinking problem, male
separateness was lowest (4.10), and female separateness was highest (4.49).
Tests of within-subjects contrasts were performed and showed that this three-way
interaction had a small (.37) effect size (Cohen, 1988).
Post hoc analyses (paired sample t test) were performed and showed that the
difference between male separateness and female separateness when males did not think
they had a drinking problem and male relationship satisfaction was low was almost
significant t(8)= -2.09 (p<.10). There was no significant difference between male and
female separateness when males thought they had a drinking problem and male
relationship satisfaction was low. The difference between male and female separateness
when males did not think they had a drinking problem and male relationship satisfaction
was mid range was almost significant, t(6)= 2.08 (p<.10). There was no significant
difference between male and female separateness when males thought they had a
drinking problem and male relationship satisfaction was mid range or when males did not
think they had a drinking problem and male relationship satisfaction was high. There
was a significant difference between male and female relationship satisfaction when
males thought they had a drinking problem and male relationship satisfaction was high,
t(11)=-3.02 (p˂.05).
Repeated Measures Analysis for Separateness and Female Alcohol Consumption
The main effect for female perception of female alcohol consumption (Figure 7)
was significant (Wilk’s Lambda=.786; F(1, 27)=7.37;p˂.05). Tests of within-subjects
36
contrasts were preformed and showed that female perception of female alcohol
consumption had a small (.21) effect size (Cohen, 1988).
The three way interaction of spouse x female relationship satisfaction x male
relationship satisfaction (Figure 8) was significant (Wilk’s Lambda=.692; F(4,
27)=3.01;p˂.05). For the group in which male relationship satisfaction was low and
female relationship satisfaction was also low, male separateness was low (3.67), and
female separateness was lowest (3.92). When female satisfaction was in mid range, male
separateness was highest (3.62), and female separateness was 3.90. When female
satisfaction was high, male separateness was lowest (3.50), and female separateness was
highest (4.83).
For the group in which male relationship satisfaction was mid range and female
satisfaction was low, male separateness was lowest (around 3.75), and female
separateness was lowest (2.79). When female satisfaction was in mid range, male
separateness was 3.95, and female separateness was highest (4.24). When female
satisfaction was high, male separateness was highest (3.95), and female separateness was
highest (3.13).
For the group in which male relationship satisfaction was high and female
satisfaction was low, male separateness was lowest (3.42), and female separateness was
around 4.17. When female satisfaction was in mid range, male separateness was highest
(around 4.33), and female separateness was 4.28. When female satisfaction was high,
male separateness was 4.20, and female separateness was highest (4.47).
Tests of within-subjects contrasts were preformed and showed that this three way
interaction had a small (. 31) effect size (Cohen, 1988). Post hoc analyses (paired sample
37
t test) showed no significant difference between male and female connectedness scores
when male and female relationship satisfaction were both low. There was no significant
difference between male and female separateness scores when male relationship
satisfaction was mid range and female relationship satisfaction was low. The difference
between male and female separateness when male relationship satisfaction was high and
female relationship satisfaction was low was almost significant, t(2)=-3.00 (p˂.10).
There was no significant difference between male and female separateness when male
relationship satisfaction was low and female relationship satisfaction was mid range,
when male and female relationship satisfaction were both mid range or when male
relationship satisfaction was high and female relationship satisfaction was mid range.
There was only 1 couple in the group in which male relationship satisfaction was low and
female relationship satisfaction was high so this difference could not be analyzed. There
was a significant difference between male and female separateness scores when male
relationship satisfaction was mid range and female relationship satisfaction was high,
t(4)=4.28 (p˂.05). There was no significant difference between male and female
separateness when male and female relationship satisfaction were both high.
Repeated Measures Analysis for Connectedness and Male Alcohol Consumption
The three way interaction of spouse x male relationship satisfaction x male
perception of male alcohol consumption (Figure 9) was significant (Wilk’s
Lambda=.813; F(2, 29)=3.34;p˂.05). For the group in which the male did not think he
had a drinking problem and male relationship satisfaction was low, male connectedness
appeared to be at the lowest (2.70), and female connectedness was 3.14. When male
38
relationship satisfaction was mid range, male connectedness was 3.63, and female
connectedness appeared to the lowest (3.35). When male relationship satisfaction was
high, male connectedness appeared to be the highest (around 4.28), and female
connectedness was also highest (3.44).
For the group in which the male did think he had a drinking problem and male
relationship satisfaction was low, male connectedness was 3.00, and female
connectedness was 3.18. When male relationship satisfaction was mid range, male
connectedness was 3.67, and female connectedness was 3.38. When male relationship
satisfaction was high, male connectedness was highest (4.23), and female connectedness
was highest (4.21).
Tests of within-subjects contrasts were preformed and showed that this three way
interaction had a small (.19) effect size (Cohen, 1988). Post hoc analyses (paired sample
t test) were performed and showed that there was no significant difference between male
and female connectedness when males did not think they had a drinking problem and
they had low relationship satisfaction or when males did not think they had a drinking
problem and their relationship satisfaction was mid range. There was a significant
difference between male and female connectedness when males did not think they had a
drinking problem and their relationship satisfaction was high, t(3)= 4.83 (p<.05). There
was no significant difference between male and female connectedness when males did
think they had a drinking problem and their relationship satisfaction was low. The
difference between male and female connectedness when males did think they had a
drinking problem and their relationship satisfaction was mid range was almost
significant, t(8)= 2.07 (p<.10). There was no significant difference between male and
39
female connectedness when males did think they had a drinking problem and their
relationship satisfaction was high.
Repeated Measures Analysis for Connectedness and Female Alcohol Consumption
The three way interaction of spouse x female relationship satisfaction x female
perception of female alcohol consumption (Figure 10) was significant (Wilk’s
Lambda=.825; F(1, 27)=4.68;p˂.05). For the group in which the female did not think she
had a drinking problem and female satisfaction was low, male connectedness was lowest
(2.84), and female connectedness was lowest (2.24). When female satisfaction was mid
range, male connectedness was 3.60, and female connectedness was 3.76. When female
satisfaction was high, male connectedness was highest (4.28), and female connectedness
was also highest (4.09).
For the group in which the female thought she had a drinking problem and female
relationship satisfaction was low, male connectedness was lowest (2.89), and female
connectedness was also lowest (3.16). When female relationship satisfaction was mid
range, male connectedness was 3.78, and female connectedness was 3.76. When female
relationship satisfaction was high, male connectedness was highest (3.80), and female
connectedness was also highest (3.80).
Tests of within-subjects contrasts were preformed and showed that this three way
interaction had a small (.15) effect size (Cohen, 1988).
Two other three way interactions approached significance: spouse x male
relationship satisfaction x male perception of female alcohol consumption (Wilk’s
Lambda=.831; F(2, 27)=2.75;p˂.10) and spouse x male relationship satisfaction x female
40
perception of female alcohol consumption (Wilk’s Lambda=.879; F(1, 27)=3.40;p˂.10).
Tests of within-subjects contrasts were performed and showed that these three way
interactions had effect sizes of .17 and .12 respectively.
Based on an independent-samples t-test, there was a significant difference in the
scores for the female perception of female connectedness when the female thought she
had a drinking problem (M=2.24, SD=.86) and when she did not think she had a drinking
problem (M=3.16, SD=.72); t(17)=-2.49, p <.05.
Post hoc analyses (paired sample t test) were performed and showed that the
difference between male and female connectedness when females did not think they had
a drinking problem and female relationship satisfaction was low was almost significant,
t(6)= 2.05 (p<.10). There was no significant difference between male and female
connectedness when females did not think they had a drinking problem and female
relationship satisfaction was mid range, when females did not think they had a drinking
problem and female relationship satisfaction was high, or when females thought they had
a drinking problem and female relationship satisfaction was low. There was no
significant difference between male and female connectedness when females did not
think they had a drinking problem and female relationship satisfaction was mid range or
when females did not think they had a drinking problem and female relationship
satisfaction was high.
The intake paperwork for the couples was assessed for an analysis of their
presenting problems. According to this information, the one couple that came to therapy
with alcohol use as their presenting concern had a male in the high use/high satisfaction
group.
41
CHAPTER 5
Discussion
Summary of Findings
The purpose of this study was to explore the relationship between differentiation
and relationship satisfaction with alcohol/substance use as a mediating variable. Bowen’s
family systems theory posits that symptoms show up in family systems when there is an
inability to balance emotional closeness and distance in relationships. Alcohol use is the
symptom that was explored in this study. In relation the theory and the symptom of
alcohol use, the following three hypotheses were proposed:
H1: Couples with higher differentiation are less likely to use/abuse alcohol/substances.
According to Bowen, individuals use alcohol/substances because they are anxious
about experiencing emotions within relationships. In contrast, those with higher
differentiation levels have less of a need to use alcohol/substances because they are not
experiencing anxiety about their relationships.
H2: Alcohol/substance use decreases relationship satisfaction.
Past research shows increased relational distress and instability due to
alcohol/substance use.
H3: Alcohol/substance acts as mediators in the relationship between differentiation and
relationship satisfaction.
To test these hypotheses, data on distance regulation, alcohol consumption, and
relationship satisfaction were collected from 45 couples at on on-campus training clinic.
42
The data were analyzed using correlations and structural equation modeling.
SEM models produced a poor fit to the data, suggesting that the relationship between
variables was not linear and that the need to capture a “balance” of separateness and
connectedness was confounding the results. Therefore, repeated measures ANOVAs
were performed, and they produced significant results. Three way interactions from
RMAs showed that alcohol can be what appears to be a successful distance regulator in
this sample of couples seeking therapy. Post hoc analyses performed to test significant
relationships between groups included t tests, paired sample t tests and one way ANOVA.
The study produced surprising results because the relationship between
differentiation and alcohol/substance use was not linear. However, the results suggested
for the first time that alcohol can successfully serve as a distance regulator as shown by
the problem drinking/higher satisfaction/higher separateness/higher connectedness
scores. This result suggests that previous research that was based on linear relationships
with the idea that low differentiation was related to alcohol consumption may have
masked significant findings.
The following section will review and discuss the results of testing each
hypothesis:
H1: Couples with higher differentiation are less likely to use/abuse alcohol/substances.
This study did not find support for hypothesis 1. In contrast, results show that for
some, differentiation and alcohol use were both high concurrently. In the 3 way
interaction with spouse x MALE PERSPECTIVE OF MALE ALCOHOL
CONSUMPTION x MALE RELATIONSHIP SATISFACTION, RMA results (Figure 6)
show that when males thought they had a drinking problem and they had low satisfaction,
43
females had higher separateness scores than males. Also, when male relationship
satisfaction was low and males did not think they had a drinking problem, there was a
larger difference between male and female separateness scores than when males did think
they had a drinking problem. Males and females both had high separateness scores when
males thought they had a drinking problem and male relationship satisfaction was mid
range. Females also had higher separateness scores than males when males thought they
had a drinking problem and their relationship satisfaction scores were high. Male
separateness scores were lower than female separateness scores in both cases (regardless
of whether or not the male thought he had a drinking problem). The same trend was true
for those in the group in which male relationship satisfaction was high. For the group
with mid-range relationship satisfaction, male and female separateness scores were very
similar when the male thought he had a drinking problem. When the male did not think
he had a drinking problem, male separateness scores were higher than female
separateness scores.
Therefore, results do not show that couples with higher differentiation are less
likely to use alcohol. There is a gender difference here showing that females in
relationships in which males had a drinking problem had higher differentiation scores
than their partners.
Figure 7, the two way interaction of spouse x FEMALE PERSPECTIVE OF
FEMALE ALCOHOL CONSUMPTION shows that when females did not think they had
a drinking problem, male separateness was higher than female separateness. When
females did think they had a drinking problem, male separateness was lower than female
44
separateness. This finding does support the hypothesis in terms of the females because
females with higher differentiation did not have drinking problems.
Figure 9, the three way interaction of spouse x MALE RELATIONSHIP
SATISFACTION x MALE PERSPECTIVE OF MALE ALCOHOL CONSUMPTION,
shows that when males did not think they had a drinking problem and their relationship
satisfaction was high, male connectedness scores were higher than female connectedness
scores. The same was true for males with mid-range relationship satisfaction. For males
with low relationship satisfaction, male connectedness was slightly lower than female
connectedness.
When males thought they had a drinking problem and their relationship
satisfaction was high, male and female connectedness scores were similar. When male
satisfaction was mid range, males had slightly higher connectedness scores than females,
and when male relationship satisfaction was low, females had slightly higher relationship
satisfaction scores than males.
Therefore, results show that alcohol use did not depend on differentiation level.
There were couples in each group (in which males thought they had a drinking problem
and in which males did not think they had a drinking problem) with high differentiation.
H2: Alcohol/substance use decreases relationship satisfaction.
This study did not find support for hypothesis 2. In contrast, results show that
alcohol use and relationship satisfaction were both high in some cases.
The three way interaction of spouse x MALE RELATIONSHIP SATISFACTION
x MALE PERSPECTIVE OF MALE ALCOHOL CONSUMPTION (Figure 9) shows
45
that when males thought they had a drinking problem and their relationship satisfaction
was high, male and female connectedness scores were similar.
H3: Alcohol/substance acts as mediators in the relationship between differentiation and
relationship satisfaction.
This study did not find support for hypothesis 3. The model tested to understand
the role of alcohol/substance use in the model produced a poor fit. The proposed
explanation for the poor fit is that the relationship among the variables was not linear.
We expected to see low differentiation, high alcohol use, and low relationship satisfaction
as evidence that alcohol was serving as a distance regulator for the couples. Instead the
results show that high differentiation, high alcohol use, and high relationship satisfaction
all occurred at the same time in some cases, which still suggests that alcohol served as a
distance regulator for the couples.
Figure 8, the three way interaction of spouse x FEMALE RELATIONSHIP
SATISFACTION x MALE RELATIONSHIP SATISFACTION shows that when male
relationship satisfaction was low, female low and mid range relationship satisfaction were
similar with little difference between male and female separateness. When female
satisfaction was high, male separateness was lower than female separateness.
For the group in which male relationship satisfaction was in mid range and female
relationship satisfaction was low, male separateness was higher than female separateness.
The same was true when female relationship satisfaction was low. When female
relationship satisfaction was mid range, male separateness was lower than female
separateness.
46
For the group in which male relationship satisfaction was high and female
relationship satisfaction was low, male separateness was lower than female separateness.
The same was true when females had higher satisfaction, although there was less of a
difference between the two scores. When female relationship satisfaction was mid range,
male and female separateness scores were similar.
Relation to previous literature
The results from the study provide evidence for Bowen’s Family Systems Theory.
The group in which the male thought he had a drinking problem and in which males had
high satisfaction, male separateness was highest, and female separateness was also
highest, provides evidence that alcohol use could have been a successful distance
regulator. Originally, it was hypothesized that those who had low differentiation would
drink excessively, but since we see that healthy separateness (high differentiation),
excessive alcohol consumption, and high relationship satisfaction are all happening at the
same time, it can be concluded that alcohol could be regulating the emotional distance in
the couples so that it looks as if these couples are well differentiated and is part of the
reason that they can be satisfied in their relationship.
An alternative explanation may be found in what Kerr and Bowen called
functional vs. “basic” differentiation Kerr and Bowen (1988) explain that people have a
“functional” level of differentiation and a “basic” level of differentiation. The basic level
is fixed and is determined by the genetics and environment in which a person is raised.
The functional level changes depending on an individual’s current environment.
47
Therefore, the functional level of differentiation can be changed by stress. This could be
what it happening with the participants in this study.
According to previous research, alcohol is associated with disrupted
communication and higher likelihood of dissolution. Although communication and
dissolution were not outcome measures in this study, it can be concluded from the results
that alcohol use even at a level that is considered a problem according to the medical field
is not necessarily associated with dissatisfaction in intimate relationships.
Research from Steinglass, Davis, & Berenson (1977) pointed to the fact that
recovery of an alcoholic can lead to a destabilizing effect in the family system. The
results of the current study support this idea because if alcohol, as a distance regulator, is
removed, the system could become unstable and would require a different distance
regulator.
Leonard and Mudar (2004) found that couples expected to experience greater
intimacy with one another when they drank. Intimacy was not measured in this study,
but it can be concluded from the results that couples can experience higher connectedness
even when their drinking is high.
Singh, Bhattacharjee, and Kumar (2009) found evidence for poor support within
alcoholic families, and Jacob, Ritchey, Cvitkovic, and Blane (1981) found negative
interactions such as hostility, blame, and criticism when drinking. Support and negative
interactions were not measured in this study so we do not know whether or not our
findings relate to these findings. However, we do know what alcohol is not the cause of
lowered relationship satisfaction in intimate relationships.
48
Derrick et al. (2010) found that wives in relationships in which both partners
drank heavily expected intimacy to increase when drinking. The results of the current
study also point to the idea that alcohol can be used to increase connectedness in an
intimate relationship. Steinglass, Davis, & Berenson (1977) reported a similar result in
that couples were able to express emotions more freely while drinking.
Strengths and Limitations
This study is limited because of a small sample size. Also, the questions from the
Self Evaluation of Drug Use Screen were difficult to use in the model since the scale
went from negative effects of alcohol to positive effects. Another limitation is that the
subjects for the study were all self-referrals to therapy so there is no nonclinical sample
with which to compare the sample.
However, this study has several strengths such as the fact that it is dyadic. Since
we were able to obtain both perspectives (male and female) of differentiation, alcohol
use, and relationship satisfaction, we were able to evaluate the subjects’ differentiation,
alcohol use, and relationship satisfaction as well as their perspective of their partners’
differentiation, alcohol use, and relationship satisfaction. Most research in this area uses
self-report surveys from one person. This limits the researchers’ view of how alcohol
may play in role in the relationship. Since we collected the same information from both
couple members we were able to “see” how drinking impacted both members of the
couple and how it impacted their perception of the other.
49
Clinical Implications
The goal of most relationship therapy is to increase satisfaction with the current
relationship unless the couple has come in saying they want to divorce. For most couple
and family therapists, substance abuse or misuse is considered an impediment to healthy
relationships. The results of this study, however, suggest that even when alcohol use is
considered high, it may be a way for the couple to balance closeness and distance in order
achieve higher levels of satisfaction. If this is the case, than asking the person who, in
our assessment, is drinking too much, to stop drinking, may actually decrease satisfaction
for a time. Therapists can use the information from this study to understand that even if
alcohol or substances are at an unhealthy level, they may not be a cause of dissatisfaction
in the relationship. On the contrary, the use of alcohol and substances may be stabilizing
the relationship by acting as a successful distance regulator.
The primary intervention in Bowen’s Family Systems Theory is insight.
Therefore, using this theory as the basis for the study of alcohol use leads to the
intervention of providing insight for the client as to how alcohol functions in their
relationship (how they use it to relate to one another). Once the couple is aware of the
way that they use alcohol, they have more choices about behavior. Since the results
provide a better picture of the mechanism that underlies alcohol use in intimate
relationships, interventions can be designed accordingly. It may be more helpful to help
the couple understand the function that alcohol plays in their relationship as opposed to
trying to “get rid of” the symptom.
For couples with low satisfaction, understanding what role alcohol plays in their
relationship helps them understand the real problem so that they can work on that. For
50
example, if a couple is using alcohol to increase intimacy and emotional closeness, it
would be helpful for a therapist to explore why it is difficult for the couple to experience
intimacy and emotional closeness.
Future Research
Future research should explore these relationships using longitudinal data in order
to understand more fully how substance use functions in relationships and how treatment
of substance use alone may impact relationship functioning. Other valuable future
research would include exploration of the relationship between emotional intimacy and
alcohol use.
Research suggests that there is a genetic component to alcohol use and that
parental alcohol use is a risk factor for alcohol use and dependence in children
(Lieberman, 2000). From research, we also see that 40-60% genetic variance contributes
to the heritability of alcohol dependence ( Prescott &Kendler, 1999; Schuckit, Smith, &
Kalmijn, et al., 2000). Bowen’s Family Systems Theory, which its concept of the
multigenerational transmission process, provides a theoretical foundation for the study of
the generational effects and transmission of alcohol use. According to Bowen, in
families there is a process of transmission of differentiation levels in families. Children
emerge from their families of origin with higher, equal, or lower differentiation levels
than their parents depending on the level of fusion or cutoff in their relationships with
their parents. This, in turn, can affect alcohol use. Future research should focus on this
topic.
51
Also, there are many risk factors for children born to addicted parents such as
being more likely to use substances (Kumpfer, 1999), growing up in a chaotic
environment without clear rules or limits (Blanton et al., 1997; Jacob & Leonard, 1994).
There are many risk factors for children born to addicted parents. Children of addicted
parents are more likely to use substances than those of non-addicted parents (Kumpfer,
1999). In research on alcoholics, we see that alcoholic parents often provide chaotic
parenting environments with no clear rules or limits (Blanton et al., 1997; Jacob &
Leonard, 1994). They create an environment in which there is not adequate structure or
discipline, and at the same time, they expect their children to be competent in tasks
earlier than non-addicted parents (Kumfer & DeMarsh, 1986). Children of addicted
parents are at higher risk for child abuse and for placement in foster care than other
children (Reid, Macchetto, & Foster, 1999). Children of alcoholics are also at higher risk
for sexual abuse than other children (Rotunda, Scherer, & Imm, 1995). All of these
family dynamics have not been studied with Bowen’s Family Systems Theory as the
theoretical basis for study. Therefore, there is work to be done in this area.
Research should also be conducted with a theoretical basis in the area of alcohol
use during various life stages. Current research shows that during adolescence, alcoholspecific parenting including alcohol-specific rules are effective in preventing both early
onset and increases in alcohol use (Koning et al., 2003). However, this research tells us
little about the nature of the parent-child relationships in these cases. Therefore, future
research could help us understand whether effective parenting and rule setting around
alcohol use is related to a healthy balance of separateness and connectedness.
52
During the transition to adulthood, about 24% of the population does not engage
in problem drinking, 12% are chronic problem drinkers, and 13% begin drinking high
levels of alcohol but their use declines around age 24. About 9% drink heavily (have a
“fling with drinking) between ages 19 and 22 (Schulenberg et al., 1996). Future research
could use Bowen’s Family Systems theory as a basis for understanding why alcohol use
reaches a peak during the transition to adulthood.
Conclusion
In previous research, results have shown that alcohol use can be either a negative
or positive influence on an intimate relationship. The results of this study suggest that
couples can use alcohol to regulate distance—to feel either closer together or farther apart
emotionally. We also see from the results that this process is not linear, with higher
differentiation being associated with higher satisfaction, and lower alcohol use (as we
expected to see). The results of this study showed that there are some couples for which
higher differentiation was associated with higher satisfaction and higher alcohol use,
while for other couples, lower differentiation and higher alcohol use was associated with
lower satisfaction. Given this, it is important for clinicians and researchers to provide
better conceptualizations of how alcohol and the use of other substances may function in
relationships rather than assuming a linear relationship between substance use and
relationship satisfaction.
53
TABLES
Table 1: Columbus Demographics
Demographic Information for Columbus, Ohio from the US Census
Population 2011 estimate
797,434
Male persons, percent, 2010
48.8%
Female persons, percent, 2010
51.2%
Persons between ages 18 and 65, percent, 2010
68.2%
White persons, percent, 2010
61.5%
Black persons, percent, 2010
28.0%
Asian persons, percent, 2010
4.1%
American Indian and Alaskan Native persons, percent, 2010
0.3%
Hispanic/Latino persons, percent, 2010
5.6%
Native Hawaiian/Other Pacific Islander, percent, 2010
0.1%
High school graduates, percent of persons age 25+, 2006-2010
87.3%
Bachelor’s degree or higher, percent of persons age 25+, 2006-2010
31.9%
Median household income 2006-2010
$43, 122
54
Table 2: Sample Descriptive Statistics
Descriptive Statistics of Sample
Min
Male Age
Male Income
Male Relationship Length (in years)
Male # of Children
Female Age
Female Income
Female Relationship Length (in years)
Female # of Children
Race
18.00
0
0
.00
15.00
0
.58
.00
Frequency
Percent
2
12
80
4
1
1
1.9
11.1
74
3.8
.9
.9
Asian
Black
Caucasian/White
Hispanic/Latino
Mixed
Native American
Education
Less than high school
High school diploma
GED
Some college
Professional certificate
Associates degree
Bachelor's degree
Master's degree
Professional degree
Ph.D., MD, JD
Frequency
Percent
1
10
4
33
7
6
28
11
2
2
.9
9.3
3.7
30.6
6.5
5.6
25.9
10.2
1.9
1.9
55
Max
76.00
$150,000
35
6.00
65.00
$190,000
38
7.00
Mean (SD)
32.02 (11.47)
$37,114.59 ($35,882.06)
6.36 (7.62)
.97 (1.26)
30.43 (9.48)
$42,824.23 ($43,564.82)
7.12 (8.13)
1.03 (1.33)
Table 3: Descriptive Statistics of Variables
Variables
Male Relationship Satisfaction
Female Relationship Satisfaction
Male Depression
Female Depression
Male Perception of Male Alcohol Consumption
Male Perception of Female Alcohol Consumption
Female Perception of Female Alcohol Consumption
Female Perception of Male Alcohol Consumption
Female Perception of Male Alcohol/Substance Use
Female Perception of Female Alcohol/Substance Use
Male Perception of Male Alcohol/Substance Use
Male Perception of Female Alcohol/Substance Use
Male Perception of Male Separateness
Male Perception of Male Connectedness
Male Perception of Male Separateness
Male Perception of Male Connectedness
Female Perception of Male Separateness
Female Perception of Male Connectedness
Female Perception of Female Separateness
Female Perception of Female Connectedness
56
N Min Max Mean
SD
40
1
10
5.6 2.79
38
1
10
5.66 2.81
37
2
21
9.51 5.22
39
2
29
10.79 6.87
42
0
9
3.74 2.44
35
0
9
3.06 2.07
43
0
8
2.51 1.94
41
0
10
3.73 2.65
41
1
5
3.13 0.91
40
1
5
3.05 1.02
40
1
5
2.99 0.78
41
1
5
3.07 0.73
41
2.5
5
3.86 0.63
41 1.78
5
3.49 0.93
41 2.33 4.83
3.78 0.68
42 1.22
5
3.12 1.01
43
1.5
5
3.86
0.8
43
1 4.89
3.45 0.94
42
2.5
5
3.79 0.65
43 1.67
5
3.44 0.87
Table 4: Drinking Categories
No Drinking
Drinking Problem
n
Problem
%
n
%
Male Perception of Male Alcohol Consumption
25
59.5
17
40.5
Female Perception of Male Alcohol
29
67.4
14
32.6
33
76.7
10
23.3
22
62.9
13
37.1
Consumption
Female Perception of Female Alcohol
Consumption
Male Perception of Female Alcohol
Consumption
na=42, nb=43, nc=43, nd=35
57
Table 5: Depression Severity Categories
Depression
Malesa
n
%
Mild
Moderate
Moderately severe
Severe
19
11
8
3
na=41, nb=39
58
46.3
26.8
19.5
7.3
Femalesb
n
%
14
13
5
7
32.6
30.2
11.6
16.3
Table 6: Correlations of Key Variables
59
.
M
Rel
Sat
F Rel
Sat
M
Dep
F
Dep
M
Per.
of M
AC
M
Per.
of F
AC
F
Per.
of F
AC
F
Per.
of M
AC
F
Per.
of M
A/SU
F
Per.
of F
A/SU
M
Per.
of M
A/SU
M
Rel
Sat
F Rel
Sat
M
Dep
M
Per.
of M
AC
F
Dep
M
Per.
of F
AC
F
Per.
of M
AC
F
Per.
of F
AC
F
Per.
of M
A/SU
F
Per.
of F
A/SU
M
Per.
of M
A/SU
M
Per.
of F
A/SU
M
Per.
of M
Sep
M
Per.
of M
Conn
M
Per.
of F
Sep
M
Per.
of F
Conn
F
Per.
of M
Sep
F
Per.
of M
Conn
F
Per.
of F
Sep
F
Per.
of F
Conn
1
.74**
1
-.17
-.14
1
-.03
-.36*
.16
1
-.09
-.05
1
.12
0.18
.06
-.06*
.01
.12
.75**
1
.03
-.11
.06
.16
.53**
.75**
1
.21
.09
-.12
.28
.83**
.70**
.57**
1
.12
.26
-.08
-.30
-.09
-.25
-.31*
-.25
1
-.04
.04
.12
-.30
-.22
-.17
-.09
-.33*
.51**
1
-.09
-.24
-.02
.06
.50**
-.33*
-.32*
.53**
.02
.30
1
59
Continued
Table 6 continued
M
Per.
of F
A/SU
60
M
Per.
of M
Sep
M
Per.
of M
Conn
M
Per.
of F
Sep
M
Per.
of F
Conn
F
Per.
of M
Sep
F
Per.
of M
Conn
F
Per.
of F
Sep
F
Per.
of F
Conn
.24
.33*
-.23
.05
.03
-.18
-.21
.04
.40*
.48**
.07
1
.29
.33*
-.20
-.12
.10
-.12
-.28
.01
.17
-.05
.03
.30
1
.74**
.72**
-.28
-.12
.01
-.22
-.22
-.00
.18
.04
-.05
.19
.54**
1
.47**
.28
.57**
.44**
1
.58**
.69**
-.20
-.36*
.08
-.22
-.20
-.09
.09
.08
.00
.17
.52**
.79**
.53**
1
.32*
.45**
-.34*
-.30
.21
-.11
.08
.18
.26
.04
-.18
.31*
.39*
.48**
.52**
.44**
1
.48**
.66**
-.17
-.46*
.06
-.13
-.11
-.13
.29
.09
-.08
.07
.33*
.62**
.42**
.70**
.52**
1
.20*
.42*
-.12
-.21
.28
.03
.05
.20
.15
.08
-.12
.28
.32*
.34*
.37*
.39*
.53**
.41**
1
.56**
.66**
-.12
-.38*
.14
-.05
-.02
.08
.11
.14
-.07
.16
.35*
.61**
.47**
.66**
.51**
.78**
.55**
-.19
-.27
.04
-.06
-.13
-.00
.31
.08
.05
*p < .05 **p < .01.
60
.20
1
Table 7: Results from Original Model
M Depression
M Depression
F Depression
F Depression
Differentiation
Differentiation
M Depression
M Depression
F Depression
F Depression
Differentiation
Differentiation
M Differentiation Ratio
M Differentiation Ratio
M Differentiation Ratio
M Differentiation Ratio
F Differentiation Ratio
F Differentiation Ratio
F Differentiation Ratio
F Differentiation Ratio
F Relationship Length
F Relationship Length
F Relationship Length
F Relationship Length
Differentiation
Differentiation
Differentiation
Differentiation
Differentiation
Differentiation
Differentiation
Differentiation
M Perception of M Alcohol
Consumption
F Perception of F
Alcohol/Substance Use
M Perception of M Alcohol
Consumption
F Perception of F
Alcohol/Substance Use
F Perception of F Alcohol
Consumption
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
→
Estimate
.071
-.001
-.080
.017
-.018
-.064
-.028
.026
-.093
-.007
-.264
-.300
.908
-.299
.062
-.270
-4.033
-.554
-1.638
.813
-.006
-.004
-.008
.004
1.000
-.264
.966
-.192
4.009
.743
4.583
.985
P
.023
.984
.002
.428
.851
.438
.744
.710
.187
.906
.336
.208
.671
.704
.972
.680
.115
.556
.444
.300
.320
.108
.133
**
M Relationship Satisfaction
.201
*
M Relationship Satisfaction
-.268
.422
F Relationship Satisfaction
.290
**
F Relationship Satisfaction
.405
.228
M Relationship Satisfaction
-.040
.779
F Perception of F Alcohol/Substance Use
M Perception of M Alcohol/Substance Use
F Perception of F Alcohol/Substance Use
M Perception of M Alcohol/Substance Use
F Perception of F Alcohol/Substance Use
M Perception of M Alcohol/Substance Use
M Perception of M Alcohol Consumption
F Perception of F Alcohol Consumption
M Perception of M Alcohol Consumption
F Perception of F Alcohol Consumption
M Perception of M Alcohol Consumption
F Perception of F Alcohol Consumption
M Perception of M Alcohol Consumption
F Perception of F Alcohol/Substance Use
F Perception of F Alcohol Consumption
M Perception of M Alcohol/Substance Use
M Perception of M Alcohol Consumption
F Perception of F Alcohol/Substance Use
F Perception of F Alcohol Consumption
M Perception of M Alcohol/Substance Use
M Perception of M Alcohol Consumption
F Perception of F Alcohol/Substance Use
F Perception of F Alcohol Consumption
M Perception of M Alcohol/Substance Use
F Perception of F Connectedness
F Perception of F Separateness
F Perception of M Connectedness
F Perception of M Separateness
M Perception of M Connectedness
M Perception of M Separateness
M Perception of M Connectedness
M Perception of M Separateness
61
Continued
.007
***
*
**
**
**
***
Table 7 continued
F Perception of F Alcohol →
Consumption
M Perception of M
→
Alcohol/Substance Use
M Perception of M
→
Alcohol/Substance use
→
Differentiation
→
Differentiation
→
M Differentiation Ratio
→
M Differentiation Ratio
→
F Differentiation Ratio
→
F Differentiation Ratio
*p˂.10, **p˂.05, ***p˂.001
F Relationship Satisfaction
-.280
*
M Relationship Satisfaction
-.018
.966
F Relationship Satisfaction
-.905
**
M Relationship Satisfaction
F Relationship Satisfaction
M Relationship Satisfaction
F Relationship Satisfaction
M Relationship Satisfaction
F Relationship Satisfaction
.495
.632
5.882
6.323
4.433
3.000
**
**
***
***
**
.117
62
Table 8: Means and Standard Deviations from Repeated Measures ANOVA
F=1/M=1
F=2/M=1
F=1/M=3
F=2/M=3
F=3/M=3
4.0(.83)
------------3.5(.29)
3.58(.65)
3.17(.88)
3.67(NA)
-------------------------
------------------------3.92(.12)
3.69(.70)
------------3.17(NA)
------------5.0(NA)
------------4.33(NA)
------------------------3.50(NA)
3.75(.35)
3.97(.88)
------------Female Separateness and Male Alcohol Consumption
Male and Female Satisfaction Groups
F=3/M=1
F=1/M=2
F=2/M=2
F=3/M=2
3.54(.41)
------------------------3.17(NA)
4.33(NA)
------------------------4.33(.47)
4.67(NA)
4.06(.19)
-------------------------
Alcohol
Consumption
M=0, F=0
M=1, F=0
M=0, F=1
M=1, F=1
F=1/M=1
F=2/M=1
F=1/M=3
F=2/M=3
F=3/M=3
3.89(.19)
------------------------3.64(.66)
3.78(.42)
3.67(NA)
-------------------------
------------------------------------2.92(1.04)
------------2.17(NA)
------------4.0(NA)
------------1.83(NA)
------------------------4.83(NA)
------------4.30(.36)
------------Male Connectedness and Male Alcohol Consumption
Male and Female Satisfaction Groups
F=3/M=1
F=1/M=2
F=2/M=2
F=3/M=2
4.17(.94)
------------------------4.17(NA)
------------------------------------4.5(.24)
4.0(NA)
4.22(.35)
------------4.67(.43)
Alcohol
Consumption
M=0, F=0
M=1, F=0
M=0, F=1
M=1, F=1
F=1/M=1
F=2/M=1
F=1/M=3
F=2/M=3
F=3/M=3
2.89(.19)
------------------------2.67(.88)
2.44(.97)
------------------------3.44(.22)
2.67(.67)
------------3.78(.47)
3.79(.84)
3.89(NA)
2.44(NA)
------------4.33(NA)
------------2.67(NA)
------------------------2.78(NA)
------------4.03(.32)
------------Female Connectedness and Male Alcohol Consumption
Male and Female Satisfaction Groups
F=3/M=1
F=1/M=2
F=2/M=2
F=3/M=2
3.89(.63)
-------------------------------------
4.33(NA)
------------------------4.72(.08)
5.0(NA)
4.59(.39)
-------------------------
Alcohol
Consumption
M=0, F=0
M=1, F=0
M=0, F=1
M=1, F=1
F=1/M=1
F=2/M=1
F=1/M=3
F=2/M=3
F=3/M=3
2.48(.68)
------------------------2.78(.77)
3.0(1.07)
3.89(NA)
-------------------------
2.94(.71)
------------------------3.56(NA)
4.0(NA)
------------------------4.83(.08)
3.89(NA)
4.70(.13)
-------------------------
F=2/M=1
------------------------3.67(.63)
3.78(.20)
------------------------------------4.22(NA)
------------1.00(NA)
------------------------3.44(NA)
------------3.8(.56)
------------Male Separateness and Female Alcohol Consumption
Male and Female Satisfaction Groups
F=3/M=1
F=1/M=2
F=2/M=2
F=3/M=2
Alcohol
Consumption
M=0, F=0
F=1/M=1
F=1/M=3
F=2/M=3
F=3/M=3
3.61(1.07)
3.92(.35)
-------------
3.54(.41)
4.33(NA)
4.33(.47)
63
Alcohol
Consumption
M=0, F=0
M=1, F=0
M=0, F=1
M=1, F=1
Male Separateness and Male Alcohol Consumption
Male and Female Satisfaction Groups
F=3/M=1
F=1/M=2
F=2/M=2
F=3/M=2
-------------
3.83(NA)
63
3.5(.94)
Continued
Table 8 continued
M=1, F=0
M=0, F=1
M=1, F=1
3.5(NA)
-------------------------
------------------------3.42(1.30)
------------------------3.5(NA)
Female Separateness and Female Alcohol Consumption
Male and Female Satisfaction Groups
F=3/M=1
F=1/M=2
F=2/M=2
F=3/M=2
64
Alcohol
Consumption
M=0, F=0
M=1, F=0
M=0, F=1
M=1, F=1
F=1/M=1
F=2/M=1
3.44(.69)
3.17(NA)
-------------------------
------------1.83(NA)
-------------------------
Alcohol
Consumption
M=0, F=0
M=1, F=0
M=0, F=1
M=1, F=1
F=1/M=1
F=2/M=1
2.56(.51)
1.78(NA)
-------------------------
------------2.67(NA)
-------------------------
Alcohol
Consumption
M=0, F=0
M=1, F=0
M=0, F=1
M=1, F=1
F=1/M=1
F=2/M=1
2.30(.80)
1.89(NA)
3.44(.68)
3.36(.62)
4.1(.24)
3.78(NA)
2.94(1.02)
3.06(.71)
------------------------3.17(NA)
------------------------4.33(.47)
4.29(.50)
-------------------------
F=1/M=3
F=2/M=3
F=3/M=3
4.17(.94)
3.92(.35)
3.83(NA)
3.83(NA)
------------4.0(NA)
4.17(.24)
------------------------------------------------------------4.17(NA)
------------------------4.5(.24)
Male Connectedness and Female Alcohol Consumption
Male and Female Satisfaction Groups
F=3/M=1
F=1/M=2
F=2/M=2
F=3/M=2
------------------------------------4.83(NA)
-------------------------------------------------
4.5(.71)
4.42(.44)
-------------------------
F=1/M=3
F=2/M=3
F=3/M=3
3.89(.63)
2.94(1.34)
3.44(NA)
4.33(NA)
------------3.22(NA)
------------------------------------------------------------------------2.61(NA)
------------------------4.72(.08)
Female Connectedness and Female Alcohol Consumption
Male and Female Satisfaction Groups
F=3/M=1
F=1/M=2
F=2/M=2
F=3/M=2
------------------------------------2.78(NA)
3.5(1.34)
4.17(.15)
-------------------------
4.5(.71)
4.64(.28)
-------------------------
F=1/M=3
F=2/M=3
F=3/M=3
2.94(.71)
------------------------3.56(NA)
4.0(NA)
------------------------4.83(.08)
3.28(.86)
4.78(.09)
------------3.89(.65)
------------------------------------3.44(NA)
4.33(NA)
-------------------------
------------1.0(NA)
------------2.41(.71)
4.25(.35)
-------------------------
4.11(NA)
3.17(.08)
------------3.97(.47)
64
4.25(.79)
-------------------------
3.72(.24)
3.96(.28)
-------------------------
FIGURES
Figure 1: Proposed Model
65
65
Figure 2: Hypothesized Theoretical Model
Differentiation
Alcohol/Substance Use
66
Depression
66
Relationship
Satisfaction
Figure 3: Original Testable Model
67
67
Figure 4: Alternative Hypothesized Theoretical Model
Depression
--
Relationship
Satisfaction
-+
68
--
-+
Alcohol/Substance
Use
68
Differentiat
ion
Figure 5: Alternative Testable Model
69
69
Figure 6
Separateness and Male Alcohol Consumption
Spouse*MALE PERCEPTION OF MALE ALCOHOL CONSUMPTION*MALE
RELATIONSHIP SATISFACTION
MALE RELATIONSHIP
SATISFACTION=1
MALE RELATIONSHIP
SATISFACTION =2
MALE RELATIONSHIP
SATISFACTION =3
4.2
5
4.2
4
4
4
3.8
3.6
3.4
0
3
1
2
0
1
1
3.2
1
2
3.8
0
3.6
1
3.4
0
3.2
1
2
70
1
2
Figure 7
Separateness and Female Alcohol Consumption
Spouse x FEMALE PERCEPTION OF FEMALE ALCOHOL
CONSUMPTION
4.2
4.1
4
3.9
0
3.8
1
3.7
3.6
3.5
1
2
71
Figure 8
Female Relationship Satisfaction and Male Relationship Satisfaction
Spouse*FEMALE RELATIONSHIP SATISFACTION*MALE RELATIONSHIP
SATISFACTION
MALE RELATIONSHIP
MALE RELATIONSHIP
MALE RELATIONSHIP
SATISFACTION=1
SATISFACTION =2
SATISFACTION =3
5
5
6
4
4
5
4
1
3
1
3
1
3
2
2
2
2
2
2
3
1
3
1
0
0
1
2
1
2
72
3
1
0
1
2
Figure 9
Connectedness and Male Alcohol Consumption
Spouse*MALE RELATIONSHIP SATISFACTION*MALE PERCEPTION OF
MALE ALCOHOL CONSUMPTION
MALE PERCEPTION OF MALE
MALE PERCEPTION OF MALE
ALCOHOL CONSUMPTION=0
ALCOHOL CONSUMPTION=1
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
5
4
3
1
2
2
3
1
0
1
2
1
2
3
1
73
2
Figure 10
Connectedness and Female Alcohol Consumption
Spouse*FEMALE RELATIONSHIP SATISFACTION*FEMALE PERCEPTION OF
FEMALE ALCOHOL CONSUMPTION
FEMALE PERCEPTION OF FEMALE
FEMALE PERCEPTION OF FEMALE
ALCOHOL CONSUMPTION=0
ALCOHOL CONSUMPTION=1
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
4
3.5
3
2.5
1
1
2
2
2
1.5
3
3
1
0.5
0
1
1
2
74
2
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80
APPENDIX A: Demographics and Other Intake Questions
81
1. What is your age? ______
2. What is your gender?
_______________
3. How do you identify your sexual
orientation? __________________
8. What is your occupation?
__________________________
9. What is your annual income
(include the income of other
adults with whom you share
finances)? ________________
4. How do you identify your
a. Race?
______________________
b. Ethnicity?
___________________
c. Nationality?
__________________
10. What is your current relationships
status? (Circle all that apply.)
5. What religion or spiritual beliefs do
you identify with?
________________________
6. Circle your highest degree earned:
a. Less than high school
b. High school Diploma
c. GED
d. Some College
e. Professional Certificate
f. Associates Degree
g. Bachelor's Degree
h. Master's Degree
i. Professional Degree
j. Ph.D., MD, JD.
Single
Dating
Partnered
Cohabiting
Married (first time)
Separated
Remarried
Divorced
Widowed
11. What is your current relationship
length? _________
12. If ever, at what age were you first
married? _______
13. How many children do you have?
_____
14. How many children do you
currently have living with you?
a. Full-time? _______
b. Part-time? _______
7. How many hours a week are you
currently employed?
a.
b.
c.
d.
e.
a.
b.
c.
d.
e.
f.
g.
h.
i.
Less than 10
10 to 20 hours
21-35 hours
35-40 hours
more than 40 hours
82
15. How many stepchildren do you
have? ______
16. How many stepchildren do you
have living with you?
23. When you were growing up, was
there ever violence between adults
in the household?
a. Full-time? ______
b. Part-time? ______
Yes
No
If yes, was it:
17. Have you ever been to therapy
before?
Yes
No
18. Have you ever been to therapy for
the same problem you are now
seeking therapy for?
Yes
a. Emotional?
b. Physical?
c. Sexual?
24. Did you experience abuse or neglect
during childhood?
No
19. Have you ever been in treatment
for substance use?
Yes
No
If yes, was it:
Yes
No
a.
b.
c.
d.
20. Has anyone in your family ever
been to therapy before?
Yes
No
21. Has anyone in your family ever
been to therapy for the same
problem you are now seeking
therapy for?
Yes
25. Is there violence in your current
relationship?
Yes
No
If yes, is it:
22. Has anyone in your family ever
been in treatment for substance
use?
Yes
Emotional?
Physical?
Sexual?
Neglect?
a. Emotional?
b. Physical?
c. Sexual?
No
83
No
26. Have you ever thought about hurting yourself?
Yes
No
27. Have you ever attempted suicide?
Yes
No
28. Are you currently on medication?
a. If so please list the
medication:_____________________________________________
29. Is any member of your family currently on medication?
a. If so, please list the member and the
medication:___________________________________
30. On a scale of 1-10, how satisfied are you with your current intimate relationship?
1
2
3
4
5
6
7
8
9
10
not satisfied at all
very satisfied
31. On a scale of 1-10, how committed are you to your current intimate relationship?
1
2
3
4
5
6
7
8
9
10
not committed
very committed
Using the following scale, how often your partner has done the following?
1 = Never
2 = Seldom
3 = Sometimes
4 = Often
5 = Very often
______ 1. My partner doesn’t censor his or her complaints at all. She or he really lets me
have it full force.
______ 2. My partner uses tactless choice of words when he or she complains.
______ 3. There’s no stopping my partner once he/she gets started complaining.
______ 4. When my partner gets upset, my partner acts like there are glaring faults in my
personality.
______ 5. When I complain my partner acts like he or she has to “ward off” my attacks.
______ 6. My partner acts like he/she is being unfairly attacked when I am being
negative.
______ 7. Whenever my partner has a conflict with me, he/she acts physically tense and
anxious and can’t seem to think clearly.
______ 8. My partner feels physically tired or drained after he/she has an argument with
me.
______ 9. Whenever we have a conflict, my partner seems overwhelmed.
______ 10. In an argument, my partner recognizes when he/she is overwhelmed and then
makes a deliberate effort to calm down.
______ 11. In an argument, my partner recognizes when he/she is overwhelmed and then
makes a deliberate effort to calm me down.
______ 12. In an argument, sometimes I use physical force to get my way.
______ 13. In an argument, sometimes my partner uses physical force to get his/her way.
84
Use this scale for the next two sets of questions:
Strongly Disagree
Disagree
1
2
Somewhat
Disagree
3
Neutral
4
Somewhat
Agree
5
Agree
6
Strongly
Agree
7
How do you feel about your intimate relationship with your partner?
______ 1. I am satisfied with my sex life with my partner.
______ 2. My partner seems satisfied with his/her sex life with me.
______ 3. Most of the time, I want to have sex when my partner also wants sex.
______ 4. Most of the time, my partner seems to want to have sex when I also want sex.
______ 5. I care about my partner’s sexual pleasure, not just my own.
______ 6. My partner seems to care about my sexual pleasure, not just his/her own.
______ 7. I am open to talk about sex with my partner.
______ 8. My partner seems open to talk about sex with me.
______ 9. I think we are a good fit as sexual partners.
______ 10. My partner seems to think that we are a good fit as sexual partners.
How do you feel about your emotional relationship with your partner?
______ 1. I mostly feel emotionally connected with my partner.
______ 2. It seems that my partner mostly feels emotionally connected with me.
______ 3. I am available when my partner needs me emotionally.
______ 4. My partner seems available when I need him/her emotionally.
______ 5. I listen to and understand my partner’s emotions and feelings.
______ 6. My partner seems to listen to and understand my emotions and feelings.
______ 7. I feel comfortable with being emotionally vulnerable with my partner.
______ 8. My partner seems comfortable with being emotionally vulnerable with me.
______ 9. Most of the time, I am aware of my partner’s emotions, whether positive or
negative.
______ 10. Most of the time, my partner seems aware of my emotions, whether positive
or negative.
85
APPENDIX B: PHQ
86
1. Over the last 2 weeks, how often have you
been bothered by any of the following
problems?
More
Nearly
Not Several
than half every
at all days
the days day
a. Little interest or pleasure in doing things
0
1
2
3
b. Feeling down, depressed, or hopeless
0
1
2
3
c. Trouble falling or staying asleep, or sleeping too
much
0
1
2
3
d. Feeling tired or having little energy
0
1
2
3
e. Poor appetite or overeating
0
1
2
3
f. Feeling bad about yourself—or that you are a
failure or have let yourself or your family down
0
1
2
3
g. Trouble concentrating on things, such as reading
the newspaper or watching television
0
1
2
3
h. Moving or speaking so slowly that other people
could have noticed? Or the opposite—being so
fidgety or restless that you have been moving
around a lot more than usual
0
1
2
3
i. Thoughts that you would be better off dead or of
hurting yourself in some way
0
1
2
3
2. If you checked off any problems, how difficult have these problems made it for
you to do your work, take care of things at home, or get along with other people?
Not difficult at all
Somewhat difficult
87
Very difficult
Extremely
Difficult
APPENDIX C: DIFFERENTIATION
\
88
Instructions: We would like you to think about your relationship with your spouse or
partner. Then we would like you to think about your partner or spouse’s relationship
with you. You will notice that the items repeat. We are interested in your perspective on
the relationships in your family. When thinking about the items use the following scale
to say how much you agree or disagree with the statement.
You about your
Spouse/Partner
Strongly
Agree
Generally
Agree
1. Even though I’m
very close to my
partner, I feel I can
be myself.
2. I feel so
comfortable with
my partner that I
can tell him/her
anything.
3. My partner and I
have some common
interests and some
differences.
4. I am
comfortable with
some degree of
conflict with my
partner.
5. Although I’m
like my partner in
some ways we’re
also different from
each other in other
ways.
6. While I like to
get along with my
partner, if I
disagree with
something he/she is
doing, I usually feel
free to say so.
7. I feel distant
from my partner.
8. I don’t feel
related to my
89
Slightly
Agree
Generally
Disagree
Strongly
Disagree
partner most of the
time.
9. I feel like an
outsider with my
partner.
10. I feel close to
my partner.
11. Even around
my partner, I don’t
feel that I really
belong.
12. I am able to
relate to my
partner.
13. I feel
understood by my
partner.
14. I see my
partner as friendly
and approachable.
15. I have little
sense of
togetherness with
my partner.
Your
Spouse/Partner
about You
Strongly
Agree
Generally
Agree
1. Even though your
partner is very close
to you, he/she can be
him/herself.
90
Slightly
Agree
Generally
Disagree
Strongly
Disagree
2. Your partner feels
so comfortable with
you that he/she can
tell you anything.
3. Your partner
believes that he/she
and you have some
common interests
and some
differences.
4. Your partner is
comfortable with
some degree of
conflict with you.
5. Although your
partner sees
him/herself as like
you in some ways
she/he also sees that
you and he/she are
different from each
other in other ways.
6. While your
partner likes to get
along with you, if
he/she disagrees with
something you are
doing, he/she usually
feels free to say so.
7. Your partner
would say that
he/she feels distant
from you.
8. Your partner
would say that
he/she does not feel
related to you most
of the time.
9. Your partner
91
would say that
he/she feels like an
outsider with you.
10. Your partner
would say that
he/she feels close to
you.
11. Your partner
would say that even
around you, he/she
doesn’t feel that
he/she really
belongs.
12. Your partner
would say that
he/she is able to
relate to you.
13. Your partner
would say that
he/she feels
understood by you.
14. Your partner
would say that
he/she sees you as
friendly and
approachable.
15. Your partner
would say that
he/she has little
sense of togetherness
with you.
92
APPENDIX D: AUDIT C
93
For the next 3 questions, please answer once for you and once for your partner:
1. How often did you have a drink containing alcohol in the past year? Consider a
“drink” to be a can or bottle of beer, a glass of wine, a wine cooler, or one
cocktail or a shot of hard liquor (like scotch, gin, or vodka).
a. Never
b. Monthly or less
c. 2 to 4 times a month
d. 2 to 3 times a week
e. 4 to 5 times a week
f. 6 or more times a week
You
Your partner
2. How many drinks did you have on a typical day when you were drinking in the
past year?
a. 0 drinks
b. 1 to 2 drinks
c. 3 to 4 drinks
d. 5 to 6 drinks
e. 7 to 9 drinks
f. 10 or more drinks
You
Your partner
3. How often did you have 6 or more drinks on one occasion in the past year?
a. Never
b. Less than monthly
c. Monthly
d. Weekly
e. Daily or almost daily
You
Your partner
94
APPENDIX E: Self-Evaluation of Drug Use Screen
95
Think about the alcohol and drugs you might typically use and your partner might
typically use. Please answer the following questions with those in mind:
For the next 5 questions, please fill in the following table:
You
Your partner
Question #1
Question #2
Question #3
Question #4
Question #5
1.
People differ widely in how much they use alcohol and/or different drugs. Some
people avoid alcohol/drugs altogether. Some use only a little. Others use more.
Sometimes it is hard to tell how much is "too much." What do YOU think about
your present use of alcohol/drugs? Please choose the number of the statement
that is most true for you now. The choices are:
1. I definitely use too much.
2. I probably use it too much.
3. I am not sure.
4. I probably do not use too much.
5. I definitely do not use too much.
2. Regardless of what a person thinks about his or her own use of alcohol/drugs, the
important people around him or her form their own opinions. Sometimes loved
ones or friends are concerned that a person is using too much. On the other hand,
others may not be concerned at all. What do you think about how OTHER people
view your use of alcohol/drugs?
1. There definitely are important people in my life who think I use too
much.
2. Probably there are important people in my life who think I use too
much.
3. I am not sure whether any important people in my life think I use too
much.
4. Probably no important people in my life think I use too much.
5. Definitely there are no important people in my life who think I use too
much.
3. Alcohol/drug use can affect the family. For some families, alcohol/drugs have a
dividing and destructive effect. Alcohol/drug use can result in hard feelings,
arguments, sadness and distance, or even violence, making the family less happy.
For others, the use of alcohol/drugs may be part of enjoyable family times.
Overall, what has been the effect on your family of your use of alcohol/drugs?
96
1. I think it has had a very damaging effect on my family.
2. I think it has had a somewhat damaging effect on my family.
3. I think it has had no effect on my family.
4. I think it has had a somewhat positive effect on my family.
5. I think it has had a very positive effect on my family.
4. For some people, alcohol/drug use has a harmful effect on their loving
relationships and on their sexuality. It may decrease their interest in other people
or their ability to enjoy loving relationships. Some people are also less attractive
to their partners because of their alcohol/drug use. Other people find that use of
alcohol/drugs improves their loving relationships and sexuality. Sometimes use of
alcohol/drugs is also an important part of meeting potential partners. Overall,
what effect has your use had on your loving relationships and sexual fulfillment?
1. I think it has had a very negative effect.
2. I think is has had a somewhat negative effect.
3. I think it has had no effect, one way or the other.
4. I think it has had a somewhat positive effect.
5. I think it has had a very positive effect.
5. How important do you think it is for you to do something to change your present
use of each of alcohol/drugs?
1. I definitely need to do something to change my use.
2. I probably need to do something to change my use.
3. I'm not sure whether I need to do something to change my use.
4. I probably do not need to do anything to change my use.
5. I definitely do not need to do anything to change my use.
97