Unique Aspects of Female-primary Alcoholic Relationships

Abstract

Objective

This descriptive paper assesses the applicability of knowledge about alcoholic relationships to treatment-seeking alcoholic women.

Methods

One hundred and nine heterosexual couples were recruited between 1997 and 2000 for a randomized clinical trial of treatments for female alcoholics. Measures included the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders IV, Timeline Followback Interview, Areas of Change Questionnaire, Dyadic Adjustment Scale-Revised, Spouse Behavior Questionnaire, and Drinking Patterns Questionnaire.

Results

Couples reported moderate levels of relationship distress the women claimed that relationship issues were important antecedents to their alcohol consumption. Male partners reported frequent use of active and passive strategies for coping with their wives drinking.

Conlcusions

Results suggest that findings on marital distress are applicable to both populations, but that findings on reasons for drinking from male-primary alcoholic couples may not be fully applicable to female-primary alcoholic couples.

Previous research on alcoholic marriages has focused on male alcoholics and their female partners,^1–4 but US national survey data suggest that women account for one third of Americans with alcohol use disorders, or about 4.4 million women.⁵ This suggests the importance of studying the generalizability to women of findings about males with alcohol use disorders. Recent research suggests that women with alcohol problems differ from men on reasons for use, spousal coping, and relationship functioning, and therefore it may be inappropriate to apply previous research findings on male alcoholics to women. Currently, Little is known about differences and similarities between male-primary and female-primary alcoholic relationship. [The term female-primary alcoholic couple refers to a heterosexual intimate relationship in which the female partner is the primary (or treatment-seeking) alcoholic, whereas the term male-primary alcoholic couple refers to those in which the male partner is the primary (or treatment-seeking) alcoholic.] The present descriptive study assesses the applicability of knowledge about alcoholic relationships to treatment-seeking alcoholic women. We will discuss the similarities and differences between male-primary and female-primary alcoholic relationships with specific focus on relationship satisfaction, spousal responses to drinking, and relationship-related reasons for drinking. Implications of our findings will be discussed in terms of the extent to which research on male-primary alcoholic relationships can generalize to female-primary alcoholic relationships and implications of the differences for research and practice.

MALE-PRIMARY ALCOHOLIC RELATIONSHIPS

Alcohol use disorders have negative consequences not only for drinkers, but also for their partners, who tend to express more negativity (eg, unhappiness, anger, guilt), have poorer communication and problem-solving skills, and have lower levels of marital satisfaction than partners of nonalcoholics.⁶ Leonard and Roberts⁷ reported that alcohol problems play a maladaptive role in marital relationships, with female spouses of alcoholic men having lower levels of relationship satisfaction than female spouses of nonalcoholic men. Alcoholic men tend to exhibit frustration and initiate conflict when interacting with their female spouses. On average, they also have difficulty coping with anger regardless of intoxication.8–10 Additionally, male alcohol use disorders have been correlated positively with marital violence at high levels of marital conflict, but not at low levels.¹⁰ A considerable proportion of the domestic violence that occurs in the United States is associated with alcohol.^10–13

SPOUSE COPING WITH ALCOHOL PROBLEMS

Partners cope with alcohol use disorders within the context of an intimate relationship. Some research has suggested that spouses (both men and women) of alcoholics frequently describe using avoidance as a way to cope with the drinking.¹⁴ In broader research on the impact of alcohol or other drug problems on the family, Orford et al^15,16 defined 3 common coping responses to problematic drinking: tolerant coping (putting up with drinking or accepting use), engaged coping (actively trying to change or control drinking), and withdrawal coping (distancing oneself from or avoiding the drinker). Tolerant-inactive coping was found to be correlated with anxiety, guilt, and negative physical and psychologic symptoms for nondrinking female partners of male alcoholics.¹⁶ Thus far, research assessing male coping with female alcoholic partners is a relatively unexplored area.

RELATIONSHIP RELATED REASONS FOR DRINKING

Studies (eg, Refs. 2, 17) have found that the reasons women give for drinking often are related to relationship issues. For instance, Lammers et al¹⁷ found that alcoholic women associated their drinking with sexual problems in the relationship, the need to be more assertive with their mate, and with better relationship functioning. Additionally, alcoholic women have reported lower confidence about resolving marital problems and higher rates of drinking in response to marital conflict than male alcoholics.² This elevated use of alcohol in response to marital problems parallels women’s tendency to report using alcohol to alleviate stress or depressed feelings.¹⁸

PRESENT STUDY

The present study evaluated relationship satisfaction, spousal coping and response to drinking, and relationship-related reasons for drinking reported by female-primary alcoholic couples enrolled in a treatment outcome study. Results will allow researchers and clinicians to form judgments about the appropriateness of applying knowledge gained from research on male-primary alcoholic relationships to the growing population of female-primary alcoholic relationships.

MATERIALS AND METHODS

Participants

Data for the present study were collected before treatment from a sample of 109 heterosexual couples interested and eligible for participation in a randomized controlled trial for the female’s alcohol use disorder.¹⁹ Inclusion criteria were (1) female aged 18 to 75 with current alcohol abuse or dependence; (2) married, living as married for at least 6 months, separated with hopes of reconciliation, or in a committed relationship of at least 1 year’s duration; (3) alcohol consumption by the female in the past 60 days; (4) both partners willing to participate and consent; (5) neither partner showing signs of current psychosis or organic brain syndrome; (6) no incidents of domestic violence requiring medical attention in the prior 12 months; (7) no instance when the man or woman stated in private that he or she was uncomfortable participating in couples treatment with the partner due to fear of domestic violence; and (8) neither partner meeting criteria for other substance dependence (other than nicotine) with physiologic dependence. Of 124 couples who completed an intake clinical screen, 3 couples were excluded due to domestic violence, and 1 couple was referred out because of concurrent drug dependence. An additional 11 couples withdrew before the second baseline assessment, leaving 109 couples for the present pretreatment analyses.

Ninety-five percent of the females and 96% of the males were white. The mean age of female participants was 44.94 (SD = 9.17), whereas the mean age of their male partners was 48.16 (SD = 10.42). Of the 109 couples, 88.1% were married, 5.5% living together, and 6.4% committed to their partner, but not living together. Mean annual household income was $93,313 (SD = 57, 894; median = $79,000). Thirty-one percent of the women reported full-time employment compared with 84.4% of their male partners. Mean years of education for women was 14.43 (SD = 2.69) and mean years of education for men was 15.22 (SD = 3.02).

Eighty-nine percent of the women (n = 97) met criteria for current alcohol dependence. Of the 12 women who did not, 1 met criteria for current alcohol abuse (1%), 4 met criteria for alcohol dependence in early lull remission (3.7%), 5 met criteria for alcohol dependence in early partial remission (4.6%), and 2 met criteria for alcohol dependence in sustained partial remission (1.9%). About 30% (n = 31) of the men met criteria for current or past alcohol dependence. The mean percent of drinking days for the women during the 90-day pretreatment time period was 65.24 (SD = 28.55); the mean drinks per drinking day was 8.17 (SD = 4.97). The mean percent of drinking days for their male partners during this time period was 33.49 (SD = 32.21), and their mean drinks per drinking day was 3.50 (SD = 2.58).

Procedure

All procedures were approved by the University Institutional Review Board, and informed consent was obtained from clients and their partners. Participants were recruited through community newspapers and outpatient treatment facilities and were screened by telephone (n = 442). Couples who met preliminary inclusion criteria were invited to in-person clinical screening interview (n = 124) conducted by a clinical psychologist, social worker, or masters level clinician to determine eligibility and obtain informed consent. Couples then completed a baseline research evaluation (n = 109), administered by a trained research interviewer. Couples were interviewed together during the pretreatment clinical screen and baseline interviews with the exception of domestic violence assessments and the Structured Clinical Interview for DSM-IV (SCID) interviews, which were conducted individually. After these 2 sessions, participants who completed the baseline evaluation were randomized to individual or couples therapy focused on the woman’s drinking problems.

Measures

SCID²⁰

The SCID is a reliable and valid structured interview used to establish psychiatric diagnoses according to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV). The Alcohol and Drug Use section assesses both lifetime and current substance abuse and dependence. The SCID has superior validity over other diagnostic interviews, and reliably diagnoses substance abuse/dependence (eg, Refs. 21, 22).

Timeline Followback Interview for Alcohol and Drug Use^23,24

The Timeline Followback Interview for Alcohol and Drug Use (TLFB) is a structured interview that assesses drug and alcohol use over a given period of time. The current study collected data from the women and their male partners for the 90-day period immediately preceding the baseline evaluation to calculate frequency (percent drinking days) and intensity (mean drinks per drinking day) of the drinking for both partners. The TLFB interview has been found to have good reliability and validity as a measure of alcohol use.²⁵

Areas of Change Questionnaire²⁶

The Areas of Change Questionnaire (ACQ) assesses the amount of change partners desire in specific areas of their relationship. This self-report measure consists of 34 questions with the prompt “I want my partner to:” and the same 34 questions with the prompt “It would please my partner if I:”. It yields an amount of total change desired by each partner (“want” scores) and also measures one partner’s perceptions of the other partner’s desire for change, and a total change score wanted by the couple. Lower scores on the ACQ reflect higher relationship satisfaction, and previous research has indicated that distressed couples average a score of 28 compared with a score of 7 for nondistressed couples.²⁷

Dyadic Adjustment Scale^28,29

The Dyadic Adjustment Scale (DAS) is a 32-item questionnaire that assesses multiple domains of relationship functioning and yields 4 subscales with high internal consistency as evaluated with Cronbach α: dyadic cohesion (α = 0.85), dyadic satisfaction (α = 0.91), dyadic consensus (α = 0.91), and affectional expression (α = 0.77). Possible scores range from 0 to 151 with higher scores, reflecting better relationship satisfaction and functioning.

Marital Happiness Scale³⁰

The Marital Happiness Scale (MHS) is a simple Likert scale rating of marital happiness, which was part of the DAS administered at baseline. This single item asks respondents to rate their degree of happiness with their relationship from “extremely unhappy” (score of 0) to “perfect” (score of 6). McCrady et al³¹ reported good internal consistency of monthly MHS ratings (Cronbach α = 0.94) over 6 months of monthly ratings.

Spouse Behavior Questionnaire^32,33

This modified version of the Spouse Behavior Questionnaire (SBQ) was adapted from the original James and Goldman (1971) version. Details of modification can be found in Kahler et al.³² The SBQ consists of 55 items that assess behaviors partners have used to cope with their partner’s drinking. The SBQ yields 4 subscales with adequate to high internal consistency as evaluated with Cronbach α in the current sample: Confrontation/Control (11 items; α = 0.83), Avoidance of Confrontation (8 items; α = 0.82), Detachment (6 items; α = 0.68), and Positive Consequences of Sobriety (5 items; α = 0.62).

Drinking Patterns Questionnaire³⁴

The Drinking Patterns Questionnaire (DPQ) is a clinical tool used to identify high-risk situations for drinking that assesses drinking antecedents in 9 categories (environmental, work related, financial, physiologic, interpersonal, marital, parents, children, and emotional). These 9 areas are assessed by 228 items that respondents rate from 0 (did not drink in this situation) to 2 (major drinking situation). The category structure of the DPQ has empirical support.³⁵

RESULTS

Relationship Satisfaction

The couples were experiencing moderate to high levels of relationship distress before treatment, with no significant difference between the men and women’s levels of dissatisfaction (Table 1). They reported moderate levels of relationship happiness and high levels of change desired in their relationships. A DAS score of 107 is the typical cutoff for a “happy relationship”; 57% of the females and 54% of the males scored below 107. Thirty-six percent of the females and 40% of the males rated their relationships as unhappy; 4.7% of the females and 5.6% of the males rated their relationships as “extremely unhappy.” On the ACQ, the female alcoholics’ mean “want” score was in the distressed range, as was their male partners’ mean want score. The mean “couple total change” score of 17.39 reflected significant dissatisfaction in these relationships. Overall, the ACQ scores reflect a high desire for relationship change by each partner and are similar to those of distressed couples.²⁷

TABLEl.

Marital Functioning of Female-primary Alcohol Relationships

Measure	Total N=109	Higher Scores Reflect	Range (Possible)	Mean	SD	t Value for Sex Com- parison
Areas of Change	101(F)	More	0.to 102	21.74	4.91	0.522
Questionnaire (ACQ)	101 (M)	dissatisfaction	0 to 102	20.90	14.68
	101 (Cpl)		0 to 68	17.39	12.60
Dyadic Adjustment	107 (F)	Better	0 to 151	100.73	22.04	-0.768
Scale (DAS)	107 (M)	functioning		102.88	18.90
Marital Happiness	106 (F)	More	0 to 6	3.06	1.51	0.401
Scale (MHS)	107 (M)	happiness		2.97	1.57
Spouse Behavior
Questionnaire (SBQ)
Confrontation/Control	104 (M)	More	0 to 5	0.74	0.74
Positive Consequences	108 (M)	frequent	0 to 5	2.81	1.01
Avoidance of Confrontation	104 (M)	use of	0 to 5	1.60	1.18
Detachment	102 (M)	strategy	0 to 5	1.14	0.98

Spousal Responses to Drinking

On the SBQ, the men reported low levels of use of Confrontation/Control (eg, restricting use of money so she cannot buy alcohol) and Detachment (eg, having regular meal times regardless of her presence) strategies, but somewhat more frequent use of Avoidance of Confrontation (eg, staying out of her way when she is drinking). The men also reported more frequent use of Positive Consequences of Sobriety as a coping strategy (eg, doing things together that she enjoys when she is not drinking). These scales were divided into active strategies (Confrontation/Control and Positive Consequences of Sobriety scales) and passive strategies (Avoidance of Confrontation and Detachment scales). A paired sample t test revealed no significant difference between the men’s scores on the active and passive scales.

Relationship-related Reasons for Drinking

Forty-seven percent of the women (n = 44) ranked marital situations of high importance (1 to 3 on the 9-point scale) as reasons for drinking. Marital situations most frequently endorsed as reasons for drinking by the women were: following an argument with her partner (79%), when she was angry with her partner (84%), when her partner was drinking or offered her a drink (71%), when she and her partner were having a good time (82%), and when her partner and she were celebrating something (81%). The marital situation least frequently endorsed as a reason for drinking by both the alcoholic women was drinking after physical violence or when concerned about physical violence (13%). Additionally, very few of the women endorsed partner accomplishments as a reason for drinking (18.4%).

DISCUSSION

The goal of the present study was to assess the degree to which current knowledge about alcoholic relationships, derived largely from samples of male-primary alcoholic relationships, applies to a sample of treatment-seeking alcoholic women in committed heterosexual relationships. We examined relationship satisfaction, spousal coping and response to drinking, and relationship-related reasons for drinking in a sample of female alcoholics and their male partners involved in a randomized clinical trial.

Overall, these female-primary alcoholic couples were experiencing moderate levels of relationship distress; both females and males expressed substantial desire for relationship change. These results are consistent with previous literature, showing that alcohol use disorders are associated with low marital satisfaction.^4,7,9 Interestingly, ratings of relationship satisfaction were similar between clients and partners in these female-primary alcoholic relationships, whereas in a previous study of male-primary alcoholic relationships, the female partners were less satisfied than their alcoholic spouses.³¹ Regardless of this possible bias, these results seem to echo previous findings with male alchoholics, and therefore it seems that research on marital distress and dissatisfaction in male-primary alcoholic couples could be applied to female-primary alcoholic couples. Clinically, the results suggest that attention to relationship distress is an important component of therapy for both female-primary and male-primary alcoholic couples, but that some women entering treatment for their drinking may have a fairly well-functioning relationship in which her husband or male partner might be a significant source of support for her.

Results on spousal coping with partner drinking can be framed in the context of Orford et al’s^15,16 3 familial coping mechanisms: tolerance, withdrawal, and engaged. The tolerance coping strategy is similar to the Avoidance of Confrontation scale, on which these men scored relatively high. The withdrawal coping strategy is assessed by 2 SBQ subscales: the Detachment scale, on which these men scored somewhat low, and the Avoidance of Confrontation scale, on which these men scored higher. This indicates an unclear pattern of withdrawal coping. The engaged coping strategy is assessed by 2 SBQ subscales: the Confrontation/Control scale, on which these men scored low, and the Positive Consequences of Sobriety scale, on which these men scored high. These findings suggest that the men used engaged coping strategies only as a response to sobriety, and were not as engaged when their partners were actively drinking. Kahler et al³² found female nonalcoholic spouses of male alcoholics most frequently endorsed Positive Consequences of Sobriety coping strategies (eg, “Making it a point to do things together that he enjoys when he is not drinking”), followed by Avoidance of Confrontation. This suggests that the current sample of male partners of female alcoholic were similar to a previous sample of female partners of male alcoholics. However, to our knowledge these results are the first to address male spousal coping in response to female problem drinking and the first to show that male partners of alcoholic women use engaged coping strategies primarily in response to sobriety. Although previous studies have included both male and female partners of alcoholics and found no sex differences,²⁴ those findings were limited by small samples sizes. Further research needs to examine sex differences in coping with partner drinking, and it would be premature to conclude that research conducted with male-primary alcoholic couples is or is not applicable to female-primary alcoholic couples. Previous research does not suggest that one partner coping strategy is more effective than another in supporting abstinence. However, it is possible that the male partners have a paucity of coping strategies to draw on when their wives are drinking, and that therapy might well address alternatives to withdrawal that might help the men feel more able to cope with relapses.

Marital situations most frequentiy endorsed as reasons for drinking suggested that the women were drinking both to cope with negative marital circumstances and to enhance positive relationship conditions. Results support the finding that women drink in response to marital conflict,² but the present results are the first to suggest that women alcoholics drink in response to both marital conflict and marital harmony. Previous research on men’s drinking has not suggested relationship issues as important reasons for drinking, suggesting that attention to relationship issues may be more important in women’s than men’s treatment for alcohol use disorders.

The primary limitation of the present study is the generalizability of the sample. Most couples were white, and may represent higher functioning couples owing to the voluntary participation of the male partners. An additional limitation is the reliance On self-report measures for drinking, relationship functioning, and coping responses. Despite these limitations, this study represents a new wave of research addressing relationship issues specific to alcoholic women and their male partners. With the growing number of female alcoholics in the population, it has become increasingly important to focus research attention on topics unique to these women and their relationships. Although additional research is clearly needed, this study is the first to empirically describe relationship issues among alcohol-dependent women in treatment, with explicit reference to male-primary alcoholic relationships. On the basis of these results, it seems that research on relationship-related reasons for drinking conducted with samples of male alcoholics and their female partners is not fully generalizable to couples in which the female is the primary alcoholic. However, research concerning relationship satisfaction and marital distress seems to apply to both male-primary and female-primary alcoholic couples and findings underscore the intimate linkages between alcohol dependence and disruptions in relationship functioning. Further research is needed to clarify sex differences in coping strategies for partner drinking.