Abstract
Background
Limited research has examined the prevalence and frequency of specific problems of concerned family members and significant others (CSOs) of alcohol or substance using individuals (SUIs).
Objectives
We surveyed CSOs of SUIs to determine the prevalence and frequency of their problems and explored whether relationship to the SUI, gender of the CSO, or living arrangements altered problem prevalence and frequency.
Method
Non-substance using CSOs (N = 110) completed the Significant Other Survey, which asks about problems in seven domains (emotional; family; relationship; financial; health; violence; legal). Problem outcomes were compared based on the CSO’s relationship to the SUI (partner or spouse vs. parent), gender of the CSO (male vs. female), and living arrangements of the CSO and SUI (residing together vs. residing apart).
Results
Problems were prevalent with at least two-thirds of the participants endorsing one or more problems in all but the legal domain. They also occurred frequently, with CSOs reporting problems on one-third to one-half of the past 30 days, in all but the violence and legal domains. Problems tended to be greater for CSOs who were partners, females, or living with the SUI.
Conclusion
CSOs experience frequent problems in a wide range of life domains and the types of difficulties they experience appear to differ based on type of relationship, gender, and their living arrangement relative to the SUI.
Scientific Significance
This investigation expands our understanding of the specific problems that CSOs face. The findings have important implications for treatment and health policy regarding these individuals.
Keywords: family, family problems, substance abuse, concerned significant others, Significant Other Survey
Prevalence and Frequency of Problems of Family Members with a Substance Using Loved One
Drug abuse impacts most Americans at some point in their lives. For instance, 25% to 38% of the general population has a blood relative with an alcohol problem (1, 2), approximately 30% of adults indicate that alcohol use has caused difficulties within their families, and just under 20% report similar difficulties regarding other drug use (2).
Impact of Substance Abuse on Non-Drug Abusing Family Members
Concerned family members and significant others (CSOs) experience a range of financial and psychosocial costs as a result of their relationship with a substance using individual (SUI). Financial costs include decreases in family income that result from CSOs’ financing the SUIs’ habit (3), the SUI’s unemployment problems, the intentional or unintentional damage to household items, and the selling of household items to purchase alcohol and other drugs (4). The psychosocial problems experienced by CSOs are well recognized and include a wide range of emotional and relationship difficulties. Spouses of SUIs report high levels of psychological distress (5, 6), relationship dissatisfaction (5, 7), and interpersonal conflict (8). A preliminary study found that 100% of the CSOs who sought help dealing with an SUI reported emotional and relationship difficulties in the prior month (4). There is also a heightened risk for domestic violence in these relationships (7), with more than 50% of the reported domestic violence cases involving the use of alcohol or other drugs (9, 10). Finally, relative to CSOs whose partner has become abstinent, CSOs whose partners continue to drink are more likely to fight with their children (11).
Societal Costs Associated with Problems Experienced by CSOs
Although there are obvious personal and familial costs associated with the CSO-SUI relationship, there are also significant covert costs to society. CSOs with a substance abusing family member are more likely to seek medical services than those without such a family member (12, 13). Medical conditions such as acid-related disorders, asthma, hypertension, and sexually transmitted diseases are reported more frequently by family members who have an SUI relative to those who do not (14). Studies have reported that CSOs of substance users had annual health care costs that were 31 – 70% greater than matched controls who did not (14, 12, 15). Furthermore, health care costs for CSOs of SUIs are greater than for CSOs of individuals with other chronic conditions such as diabetes or asthma (16).
Potential Differences in Problems Experienced by Different Types of CSOs
Although it has been asserted that CSOs react differently to the SUI depending on their role in the family (17), limited research has explicitly examined the problems experienced by different types of CSOs.
Partner/Spouses versus parents
Research evidence suggests that the problems reported by CSO’s who are parents of SUIs are qualitatively different than those reported by CSOs who are in committed romantic relationships with SUIs. For example, Velleman et al. (18) found that parents reported more lying on the part of the SUI whereas partners reported more physical violence and greater pressure to provide money to the SUI. Similarly, Kirby et al. (4) found that partners experienced more financial problems during the past 30 days than parents.
Gender differences
To date, little is known about the differences in problems that female and male CSOs experience. Gender differences in health care costs have been identified. Specifically, medical costs were $370 more for CSOs of male and $525 more for CSOs of female SUIs compared to their non-drug using cohorts (16). A systematic investigation of possible gender differences among CSOs across a range of problem areas has not yet been conducted.
Living arrangement
Similarly, little is known about the extent to which problems differ between CSO’s who do and not live with SUIs. One study (4) found that lifetime financial and legal difficulties differed as a function of living arrangement. Parents reported a similar number of financial and legal problems as partners if they were living with their SUI, but more problems than partners when the SUI was not living with them.
The lack of research on these three CSO characteristics highlights the need for research to systematically compare problems reported by CSOs in these different sub-groups. In addition, clinicians could benefit from a method to assess the presence of a range of problems that may be experienced by their CSO clients. After identifying such problems, clinicians could develop a treatment plan to address those that were the most distressing and choose the treatment interventions that would best address them.
Limitation Associated with Existing CSO Research
There is an obvious lack of behaviorally-oriented assessment tools in the literature. The measures used within these studies often focus on assessing global functioning or general well-being rather than the specific types of problems experienced by CSOs. In addition, they tend to focus on a single problem domain (e.g., marital conflict) or assess the presence or absence of a problem without examining the frequency of the problem or its perceived severity in the CSO’s life.
In response to this void, Kirby and her colleagues (19) developed the Significant Other Survey (SOS), a semi-structured interview that collects information about specific types problems experienced by CSOs in seven life domains. Furthermore, it evaluates the frequency and severity of these problems.
In conclusion, while it is well known that substance abuse is costly (2), attention has typically focused on the economic and interpersonal costs incurred by the SUI rather than the non-drug using CSOs (20). Although there is a substantial body of literature describing the negative effects that the CSO-SUI relationship has on the CSO, much less is known about certain types of problems (e.g., legal) and the nuances associated with CSO problems (i.e., the specific types of problems; the frequency and severity of these problems). Furthermore, there is a limited, yet informative, research base suggesting that different types of CSOs experience different types of problems, however a broad-based systematic exploration of those differences has not yet been completed.
The purpose of this study was to (a) examine the prevalence and frequency of problems associated with seven life domains as reported by CSOs and (b) compare the problems reported as a function of three CSO characteristics: relationship of the CSO to the SUI (partner vs. parent), gender of the CSO (male vs. female), and living arrangements of the CSO and SUI (residing together vs. residing apart).
Method
Procedures
Recruitment and description of research participants
Individuals who were troubled about a family member or significant other who was using alcohol or other drugs were recruited through advertisements placed in local newspapers, public transportation, and radio. Respondents were screened during their initial telephone contact to ensure that they met inclusion criteria (i.e., were a parent or partner concerned about an adult loved one with an alcohol or illicit drug use problem; had face-to-face and/or telephone contact with the SUI on at least 12 of the past 30 days; were 18 years of age or older; had known the SUI for at least three months; and the SUI had used the problem drug within the past 30 days). Participants who met telephone screening criteria were scheduled for an in-person interview.
Data collection
CSOs provided informed consent and were screened to confirm that they did not have a substance use disorder using the Psychoactive Substance Use Disorders section of the Structured Clinical Interview (SCID). Eligible participants also completed a Significant Other Survey (SOS) interview and received $50 for their participation.
Measure
Significant Other Survey (19)
The SOS is a semi-structured 30–60 minute interview that assesses seven types of problems experienced by a range of CSOs who are concerned about an SUI. The seven problem domains include: emotional concerns (e.g., feeling angry; spending time thinking about how to help SUI); family issues (e.g., finding drugs/paraphernalia in the home; seeing SUI using drugs in the home); relationship issues (e.g., arguing with SUI; doing things for SUI that s/he should do for him/herself); financial issues (e.g., lending money to SUI; hiding money from SUI); health concerns (e.g., experiencing medical problems; taking medication); physical violence toward self, others, or property (e.g., threatening to physically attack SUI; SUI physically threatening CSO); and legal problems related to the drug user (e.g., police visits related to SUI; accompanying SUI to meetings related to legal problems). Individuals indicate the number of days they have experienced problems in the past 30 days as well as during the past six months. Research staff were trained to a criterion before administering the SOS to CSOs, and quality control activities were completed by a licensed psychologist throughout the course of the investigation (19).The SOS has been shown to have good test-retest (intraclass correlations; ICC = .45–.70) and interrater agreement (ICC = .98–1.0) for individual items and good internal consistency reliability for the problem domains (α = .61–.83). Correlations among the problem domains are low to moderate in magnitude (18).
Data analysis
Analyses were based on participants’ responses to the 60 30-day items (12 emotional, 11 relationship, 9 financial, 7 family, 6 health, 10 violence, 5 legal). Problem prevalence (i.e., the proportion of CSOs who endorsed at least one item in the domain) and mean frequency (i.e., the average number of days CSOs experienced problems in that domain in the past 30 days) were calculated. Chi-square analyses and t-tests were used to compare the prevalence and frequency of problems with respect to: (1) relationship (partners vs. parents), (2) CSO gender (male vs. female), and (3) living arrangements (CSOs not living with the SUI vs. CSOs living with the SUI). Non-parametric Wilcoxon two-sample tests were used to examine group differences for non-normally distributed continuous variables (i.e., frequency of legal and violence problems). Effect sizes, a measure of the effect magnitude that is less influenced by sample size (21), were also calculated. Small, medium, and large effect size conventions associated with the chi-square analyses and t-tests are w’s of .10, .30, and .50 and d’s of .20, .50, and .80, respectively (21).
Results
Significant Other and Substance User Characteristics
The sample consisted of 110 CSOs who were concerned about an SUI. Demographic and descriptive characteristics about the CSOs and SUIs are found in Table 1. A majority (84%) of the CSOs were a spouse or partner of the SUI, 55% were female, and 74% were residing with the SUI.
Table 1.
Significant Other and Substance User Characteristics
| Variable | Significant Other | Substance Using Individual | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Number | % | Mean | SD | Number | % | Mean | SD | ||
| Gender | |||||||||
| Female | 60 | 55% | 52 | 47% | |||||
| Male | 50 | 45% | 58 | 53% | |||||
| Race | |||||||||
| African American/Black | 95 | 86% | 95 | 86% | |||||
| White/Caucasian | 12 | 11% | 12 | 11% | |||||
| Other | 3 | 3% | 3 | 3% | |||||
| Employment | |||||||||
| Full-time | 73 | 66% | 47 | 43% | |||||
| Part-time | 25 | 23% | 23 | 21% | |||||
| Unemployed | 2 | <1% | 34 | 31% | |||||
| Other | 10 | 10% | 6 | 5% | |||||
| CSO Marital Status | |||||||||
| Married/Living as Married | 43 | 39% | 36 | 33% | |||||
| Never Married | 38 | 35% | 57 | 52% | |||||
| Other | 29 | 26% | 17 | 15% | |||||
| Age | 42.56 | 9.48 | 37.04 | 8.40 | |||||
| Years of Education | 13.28 | 1.75 | 12.08 | 1.55 | |||||
| Primary Drug of Abuse | |||||||||
| Cocaine | -- | -- | 78 | 71% | |||||
| Alcohol | -- | -- | 14 | 13% | |||||
| Opiates | -- | -- | 11 | 10% | |||||
| Cannabis | -- | -- | 7 | 6% | |||||
| Relationship Type | |||||||||
| Parent | 18 | 16% | -- | -- | |||||
| Spouse/Partner | 92 | 84% | -- | -- | |||||
| Living arrangement | |||||||||
| Not living with SUI | 29 | 26% | -- | -- | |||||
| Living with SUI | 81 | 74% | -- | -- | |||||
| Days of contact with SUI | 26.70 | 5.00 | -- | -- | |||||
Note. N = 110.
Problems within Each Domain for the Overall Sample
Most CSOs reported experiencing at least one problem in the past 30 days in every problem domain except the legal domain. All CSOs acknowledged emotional and relationship problems, followed by financial problems (91%), family problems (87%), health problems (70%), and violence (toward self, others, and property; 65%). Legal problems were least common (17%). On average, those CSOs who reported at least one problem in a given domain, reported 16.23 (SD=7.07) days of emotional problems, 12.67 (SD=7.68) days of financial problems, 11.7 (9.95) days of physical health problems, and 11.31 (SD=5.89) days of relationship problems in the prior 30-day reporting period. Family and violence problems were reported on 9.7 (SD=7.58) and 4.48 (SD=5.44) days, respectively. Legal problems were reported about 1.84 (SD=1.04) days in the 30-day period.
Problems Reported by Spouse/Partners and Parents
The percentage of spouse/partners who reported experiencing violence-related problems was significantly higher than the percentage of parents reporting violence-related problems (70% vs. 39%), χ2(1) = 6.19, p < .05, representing a small to moderate effect, w = .24. There were no other significant relationship differences in prevalence or frequency of CSOs reporting problems in any other domain. Table 2 summarizes the results for spouse/partners and parents.
Table 2.
Between Group Differences in Prevalence and Frequency of Problems Reported within Each Life Functioning Domain for Spouse/Partners vs. Parents and Males vs. Females in Past 30 Days
| % CSOs Reporting ≥ 1 Problems |
Mean # of Problem Days |
% CSOs Reporting ≥ 1 Problems |
Mean # of Problem Days |
|||||
|---|---|---|---|---|---|---|---|---|
| (Prevalence) | (Frequency) | (Prevalence) | (Frequency) | |||||
| Problem Domain | Spouse | Parent | Spouse | Parent | Males | Females | Males | Females |
| Emotional | 100% | 100% | 16.34 (7.08)† |
15.66 (7.16) |
100% | 100% | 15.18 (6.77) |
17.11 (7.25) |
| Family | 87% | 89% | 10.36 (7.66) |
6.38 (6.37) |
92% | 83% | 9.44 (8.21) |
9.93 (7.02) |
| Relationship | 100% | 100% | 11.52 (5.81) |
10.25 (6.83) |
100% | 100% | 11.03 (5.81) |
11.54 (5.99) |
| Financial | 90% | 94% | 12.46 (7.39) |
13.68 (9.14) |
88% | 93% | 12.64 (8.32) |
12.70 (7.22) |
| Health | 68% | 78% | 11.14 (10.49) |
14.25 (6.75) |
54% | 83%*** | 13.05 (10.56) |
10.98 (9.64) |
| Violence | 70% | 39%* | 5.62 (4.43) |
4.35 (5.56) |
62% | 67% | 4.01 (6.19) |
4.84 (4.84) |
| Legal | 17% | 17% | 3.00 (0.67) |
1.62 (0.87) |
10% | 23% | 1.30 (0.67) |
2.04 (1.10) |
Note. n = 92 spouses; n = 18 parents; n = 50 males; n = 60 females;
values in parentheses indicate the standard deviation;
p < .05,
p < .01,
p < .001.
Problems Reported by Male and Female CSOs
The percentage of females was significantly higher than the percentage of males reporting any health problems (83% vs. 54%; χ2(1) = 11.17, p < .001), representing a moderate effect, w = .32. There were no other significant differences by gender in problem prevalence or frequency in the other life domains.
Problems Reported by CSOs Who are Not Living with or Living with the SUI
The percentage of CSOs reporting family problems was significantly higher for CSOs living with the substance user than for CSOs not living with the substance user (93% vs. 72%; χ2(1) = 7.83, p < .01), representing a moderate effect, w = .27. There were no significant differences in prevalence by living arrangement in any of the other six life domains.
CSOs living with the SUI reported experiencing more frequent problems (i.e., a larger average number of problem days) than CSOs not living with the SUI in the following domains: emotional (M = 17.04, SD = 7.01 vs. M = 13.96, SD = 6.83; t(108) = −2.04, d = .44), relationship (M = 12.05, SD = 5.80 vs. M = 9.25, SD = 5.74; t(108) = −2.24, d = .48), and financial (M = 13.92, SD = 7.98 vs. M = 9.30, SD = 5.69; t(108) = −2.75, d = .52). Each of these between group differences is indicative of a moderate effect. No other differences in frequency of problems were statistically significant. Table 3 shows the results for CSOs living with and not living with the SUI.
Table 3.
Between Group Differences and Prevalence and Frequency of Problems Reported within Each Life Functioning Domain of CSOs Living Apart from and Living with the SUI in Past 30 Days
| % CSOs Reporting ≥ 1 Problems |
Mean # of Problem Days | |||||
|---|---|---|---|---|---|---|
| (Prevalence) | (Frequency) | |||||
| Problem Domain | Not with SUI | With SUI | Not with SUI | With SUI | ||
| M | SD | M | SD | |||
| Emotional | 100% | 100% | 13.96 | 6.83 | 17.04 | 7.01* |
| Family | 72% | 93%** | 6.11 | 8.73 | 9.31 | 7.29 |
| Relationship | 100% | 100% | 9.25 | 5.74 | 12.05 | 5.80* |
| Financial | 93% | 90% | 8.66 | 5.98 | 12.54 | 8.64** |
| Health | 69% | 70% | 7.11 | 7.86 | 8.58 | 10.56 |
| Violence | 66% | 64% | .50 | 1.05 | .25 | .71 |
| Legal | 24% | 15% | 2.07 | 1.17 | 1.71 | 0.99 |
Note. n = 29 living apart from SUI; n = 81 living with SUI;
p < .05,
p < .01.
Discussion
Prevalence and Frequency of Problems
These data support previous research suggesting that family members of substance abusing individuals experience frequent and wide ranging problems in emotional, relationship, family, financial, and health areas. Specific problems are experienced on 7 – 53% of the days during a month, and it is likely that some type of problem is experienced on most days.
A notable exception to the trend in frequent problems is the relatively lower prevalence rates of legal problems. This finding is consistent with prior research (4), but is still somewhat surprising given the extensive documentation that substance use and illegal activities co-occur (2). Most of this information has come from studies of drug abusing and dependent individuals who are in treatment. Because we accepted CSOs into the study independent of the SUI’s treatment status, it is possible that their SUIs did not have as severe substance use problems. Thus, their involvement in illegal activities may have been minimal at this point in their addiction trajectory. Underreporting due to the stigma associated with legal problems is also possible but less likely, given that nearly two-thirds of the CSOs were willing to report physical violence despite its strong stigma.
Differences Related to Characteristics of the CSOs
As expected, the type and frequency of problems tended to vary depending on characteristics of the CSOs, their relationship to the SUI, and their living arrangements. Spouses and partners reported more problems related to physical violence or aggression than did parents of SUIs, more women CSOs reported health problems than men, and CSOs who lived with the SUI were more likely to experience problems in a variety of areas compared to those who live apart.
These differences may provide clinically useful and important information. Clinicians who work with clients who are in a romantic relationship with an SUI should regularly assess for the presence of more intense types of interpersonal conflict and, given the prevalence of these problems (70%), assessment should occur periodically during the treatment process, even if the client initially denies such problems. We do not mean to suggest that clinicians should assume that interpersonal violence is not occurring in other types of CSO-SUI relationships; in fact, our data suggest that it may be present in more than one of three cases (39%). Knowing the general prevalence of these problems among CSOs can provide a helpful reference to assist clinicians to decide how likely it is that a problem exists.
Physical health problems were more prevalent in women than men (83% vs. 54%), a finding that is consistent with existing physical health statistics among both clinical and non-clinical populations (22). This may be a reporting bias, as it has been suggested that men have a tendency to under-report symptoms in order to maintain a “public posture of toughness” (23). The high percentages found in our study suggest that physical problems are quite common for both women and men CSOs.
A more complex pattern of results emerged when comparing the problems experienced by CSOs who lived with the substance users in comparison to those who did not reside with them. Our results are consistent with those of a previous study (4) demonstrating that CSOs living with SUIs report more problems than CSOs who do not. The CSOs in this study reported a greater number of days of emotional problems (e.g., difficulty eating or sleeping), relationship difficulties (e.g., arguments with the SUI, sacrificing personal activities for the SUI), and financial problems (e.g., lending money to the SUI, paying the SUI’s bills). Interestingly, these domains reflect more inter-dependent life areas than many of the other domains (i.e., family, health, legal) where no differences were observed and are more likely to be directly influenced as a result of daily interpersonal interactions between the CSO and the SUI. CSOs who are living with SUIs are likely to be more aware of the SUI’s day-to-day activities and problems (e.g., abuse of drugs; employment, interpersonal difficulties). In addition, living with the SUI may increase financial and interpersonal interdependencies of CSOs and SUIs which could further impact the range and intensity of problems reported by CSOs. Previous research (4) suggests that living apart from the SUI has less of a buffering effect for parents than it does for spouses or partners - at least with respect to financial and legal problems. It may be that while separation or divorce is socially sanctioned for spouses and partners, it is less socially acceptable for parents to detach from their children, even if their children no longer live with them.
Limitations and Future Research
This study did not include a comparison group of family members who did not have an SUI. Therefore, we cannot determine whether these problems are more prevalent for CSOs than for the general population. Some support suggesting that CSOs have more problems that the general population comes from research showing that they have impaired functioning in similar life areas (25). Increased life problems is one possible factor leading to impaired functioning. Additional controlled research on CSO problems could help enlighten the relationship between these variables.
A second limitation is that the results may not be representative of CSOs who are significantly distressed about the SUI. Participants were recruited primarily through advertising and some were probably less distressed than CSOs who are seeking treatment for their SUI. While this might limit the utility of the results for health professionals, it also has the advantage of providing a somewhat more realistic picture of CSOs in general. Similarly, we cannot determine the extent to which these findings apply to CSOs who have little contact with the SUI or who, themselves, might have a substance abuse problem.
Third, it is possible that some of the between group differences occurred by chance given the number of analyses that were performed. Specifically, we conducted analyses on seven domain scores for each of the three sub-samples and observed significant differences in three of the 21 comparisons. While these group differences may have occurred due to chance and should potentially be interpreted with a certain degree of caution, the moderate effect sizes that were associated with each of these findings suggest that they reflect meaningful differences.
Finally, the sample for some of our subgroup analyses (i.e., relationship type) may limit the generalizability of our findings. In addition, the small number of parents prevented us from examining a potential relationship (spouse/partner vs. parent) by living arrangement (living with vs. living apart from the SUI) interaction effect, a finding identified in prior research with family members (4). However, we believe that it is important not to exclude these smaller sub-samples in our overall analyses as the SOS is intended to assess the problems experienced by CSOs with a wide range of characteristics.
These limitations call for a larger scale study that would include significant others who were not in a close relationship with an SUI to determine base rates for problem reporting. In addition, the inclusion of a greater range of CSOs (e.g., with differing levels of contact with the SUI, levels of substance abuse for the CSO and SUI) would help establish the generalizability of the findings and provide more information regarding the population of CSOs. Also, larger sample sizes would allow more for detailed analysis of variables that might be related to problem prevalence and frequency. Finally, additional revisions to the SOS could improve its utility. For instance, the current SOS does not provide an overall estimate of the number of days in the past 30 that a problem was experienced. This may result in an underestimation of the frequency and severity of distress that the CSO is experiencing.
The findings related to CSO-SUI living arrangements have important implications for both researchers and family therapists. Although there is empirical evidence that family members can be trained by clinicians to identify the most appropriate times and methods to encourage their SUI to enter treatment (24), little is known about the extent to which CSO-SUI interdependence in the relationship impacts the CSO’s ability to successfully convince the SUI to enter treatment. Future research can address this issue.
Implications
Despite these limitations, this study makes an important contribution to the existing literature on the life problems experienced by CSOs who have a drug-abusing loved one. First, it supports previous research indicating that CSOs of SUIs experience problems in many different aspects of their lives, not only in the relationship and health areas that have received the most attention. Also, the importance of problems in the legal domain should not be under-estimated simply because these prevalence rates were lower than those reported for problems. Interactions with the police and requesting restraining orders to protect oneself from the SUI could be quite important even when they occur on an infrequent basis.
Findings regarding prevalence and frequency of problems generally and across specific CSO characteristics (i.e., relationship, gender, and living arrangement) have implications for community treatment providers and policy makers. The CSO’s tendency focus on the well-being of the SUI at the expense of their own well-being should not be overlooked during the treatment process (26). These findings also argue for revising existing mental health treatment policies that fail to address the treatment needs of family members who are concerned about a substance abusing loved one and who are “at best, condescended to or, at worst, actively excluded” from the mental health system (27).
Acknowledgments
This research was funded by grant DA12720 from the National Institute on Drug Abuse. The authors would like to acknowledge the contributions of Terredell Burrows, Carolyn Carpenedo, Tanya Faranda-Diedrich, Pilar Gonzales, Jennifer Gutierrez, Heather Haberle, Shannon Mason, Beth Rosenwasser, Renee Schwartz., Janear Sewell, and Julie Wosak. Thank you to Temple University’s Counseling Psychology Program, Rehab after Work, Hornstein, Platt & Associates, and Marcy Chessler for providing office space to conduct SOS interviews.
Footnotes
Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.
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