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. 2021 Jun 9;82(3):395–400. doi: 10.15288/jsad.2021.82.395

Patients With Alcohol Use Disorders and Their Concerned Others: Concordance of Lived Experience as a Moderator of Treatment Outcomes

Christine Timko a,b,*, Michael A Cucciare c,d,e, Kathleen M Grant f,g, Lance Brendan Young h, Fernanda S Rossi a,i, Mai Chee Lor a, Erin Woodhead j
PMCID: PMC8328236  PMID: 34100708

Abstract

Objective:

Growing up with an adult with an alcohol use disorder (AUD) is common and negatively affects adult functioning. This study examined two questions concerning the lived experience of growing up in a home with AUD.

Method and Results:

The first question asked how adults entering AUD treatment (n = 402) who had this lived experience (58%) compared to those who did not (42%) on indicators of alcohol use severity. Patients with lived experience reported alcohol use at a younger age, more times having been arrested and charged, and greater risk for future substance use. The second question examined concordance between patients and their concerned others on this lived experience (n = 277 dyads) and patients’ treatment outcomes 3 months later. The associations between patients’ lived experience and better treatment outcomes were stronger when patients’ concerned others had a concordant lived experience. When patient–concerned other dyads reported concordant lived experiences at baseline, patients had lower substance use and risk scores at the 3-month follow-up than when the dyads reported discordant lived experiences with regard to growing up in a home with AUD; effect sizes were small.

Conclusions:

Concordance and discordance on this lived experience could be considered in treatment planning for patients with AUD and their concerned others. Providers could ask about each member's childhood and aim interventions at helping dyads discuss their childhoods in ways that validate each other's needs and provide emotional support, without stigmatization. Delivery may consider relationship type (spousal or other) and be in educational or treatment sessions that include the dyad or one member.

Growing up with household members with alcohol problems is common (Lipari & Van Horn, 2017) and associated with poor adult functioning including alcohol use disorder (AUD) (Holst et al., 2019, 2020; Kerns-Bodkin & Leonard, 2008; Mellentin et al., 2016; Sørensen et al., 2011). This study examined two questions concerning the lived experience of growing up in a home with adults demonstrating problematic alcohol use. The first asked how adult patients entering AUD treatment with this lived experience compared to those without on alcohol use severity. The second examined whether patients’ concordance with their concerned others (supportive family or friends) on the lived experience of growing up in a home with problematic alcohol use or AUD was associated with patients’ treatment outcomes.

The lived experience of growing up in a household with AUD is important to study because it is a chronic stressor that leads to deleterious long-term outcomes (Drapkin et al., 2015). Studies of college students found that offspring of parents with AUD reported more negative life events, avoidance coping, drinking to cope, and depression than offspring of parents without AUD (Drapkin et al., 2015; Klostermann et al., 2011). A Swedish national registry study found increased externalizing disorders, drug use, and criminal behavior among offspring with parental AUD (Long et al., 2018).

Problematic alcohol use or AUD in the household has negative adult consequences because it interferes with meeting children's basic needs (Holst et al., 2020; Smith et al., 2016b). Households with problematic substance use experience employment and financial instability, food and housing insecurity, neglect and abuse, stigma and isolation, and incarceration (Holst et al., 2020; Smith et al., 2016b). Parental substance use has been linked with negative parenting behaviors such as less involvement, monitoring, and discipline (Su et al., 2018). Children may blame themselves for the household member's drinking and feel responsible for its resolution (Tinnfält et al., 2018).

The present study extends findings on lived experience with growing up in a home with problematic drinking or AUD by using a sample of adults entering AUD treatment. We hypothesized that patients with the childhood lived experience would have more severe alcohol use and related consequences than patients without this experience. The study also examined whether concordance with concerned others on the lived experience of being raised in the context of problematic alcohol use or AUD was associated with patients’ treatment outcomes. We hypothesized that when patients and concerned others are concordant on this lived experience the patients’ treatment outcomes would be better than when patients and concerned others were discordant. When a patient and concerned other are both raised in a home with problem drinking or AUD, they understand the chaotic and disruptive circumstances likely to have occurred. But when lived experiences are discordant, patients and concerned others may lack this shared understanding, reducing the concerned other's support of the patient or the association of the concerned other's support with treatment benefits. Although we were unable to find any studies directly related to this hypothesis, the literature shows that shared lived experience by people supportive of an individual's recovery has a particular influence on the individual's substance use and well-being.

For example, among alcohol treatment patients, support from Alcoholics Anonymous members was particularly helpful because their advice was grounded in first-person experience (Kaskutas et al., 2002). Individuals engaging in injection drug use with a network member (parent, child, sibling, spouse, or friend) who had ceased injection drug use were more likely to stop injecting over the following 6 months (Rudolph et al., 2020). Reviews of peer support groups and recovery support services in addiction treatment found benefits on substance use outcomes and their determinants such as more treatment engagement and self-efficacy (Eddie et al., 2019; Tracy & Wallace, 2016). A peer-enhanced behavioral treatment for adults with substance use problems found 6-month outcomes of more abstinent days and reduced binge drinking (Smith et al., 2016a).

The present study's findings are informative for treatment planning when providers conduct intake assessments of clients’ histories and current life contexts, and when treatment includes patients’ concerned others.

Method

Sample and procedure

The sample was 402 patients entering AUD residential treatment. Patients who agreed were screened for study eligibility (> 18 years old, spoke English, no conservator); eligible patients were asked to provide informed consent. Of 453 patients approached, 94% agreed to screening; of these, 96% were eligible. Of eligible patients, 98% were enrolled, completed the study's assessment, and received $25. Table 1 shows the patients’ demographic characteristics.

Table 1.

Patients at baseline

graphic file with name jsad.2021.82.395tbl1.jpg

Variable Grew up in home with AUD (n = 233) % (n) or M (SD) Did not grow up home with AUD (n = 169) % (n) or M (SD) χ2 or t (p) Overall sample, % (n) or M (SD)
Male 73.8 (172) 77.1 (130) 0.565 (0.452) 75.2 (302)
White 67.7 (158) 67.9 (115) 0.002 (0.960) 67.8 (273)
Age 44.48 (12.30) 43.20 (13.10) −0.999 (0.318) 44.0 (12.6)
Years education 12.97 (1.88) 13.10 (2.06) 0.959 (0.338) 13.0 (2.0)
Married 16.7 (39) 18.7 (32) 0.250 (0.617) 17.5 (71)
Employed 17.2 (40) 15.8 (27) 0.139 (0.709) 16.6 (67)
Stably housed 80.7 (188) 84.5 (143) 0.997 (0.318) 82.3 (331)
Health insurance 83.3 (194) 85.7 (145) 0.447 (0.504) 84.3 (339)
Income, U.S. $ 25,061 (27,649) 24,323 (24,745) −2.72 (0.786) 24,710 (26,419)
Age first used alcohol 13.35 (3.96) 14.54 (4.08) 2.91 (0.004) 13.86 (4.05)
No. times treated, lifetime, for
alcohol use 6.18 (10.51) 5.25 (6.01) −1.02 (0.306) 5.8 (8.9)
No. times arrested and charged, lifetime 7.80 (12.15) 5.16 (8.48) 2.55 (0.011) 6.73 (10.84)
Ever incarcerated Attended 12-step group meeting, past 6 months 65.2 (152)91.8 (214) 64.3 (109)91.1 (154) 0.039 (0.844)0.075 (0.784) 64.8 (261)91.5 (368)
No. of 12-step meetings 26.86 (35.58) 22.40 (29.73) −1.31 (0.192) 25.10 (33.31)
BAM substance use 7.02 (4.03) 6.61 (4.09) -0.994 (0.321) 6.9 (4.0)
BAM risk 16.33 (5.50) 15.22(5.54) −1.98 (0.048) 15.9 (5.5)
BAM protection 12.74 (4.24) 13.36 (3.87) 1.51 (0.131) 13.0 (4.1)
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Notes: AUD = alcohol use disorder; BAM = Brief Addiction Monitor; no. = number.

We attempted to follow patients 3 months after baseline by telephone. The follow-up rate was 79.3% for the 391 patients who were not deceased (n = 1) or incarcerated (n = 10). Those not followed (n = 81) were not located, refused, or did not attend scheduled follow-up sessions. Patients who were or were not followed did not differ on baseline race, education, employment, income, housing, and health insurance. Those who were followed were more likely to be male and were older (ps < .05).

The sample included 277 concerned others. Patients were asked to name potential concerned others (> 18 years old, supportive) and provide concerned others’ contact information. We attempted to contact a concerned other for each patient when a concerned other was identified. There were no baseline demographic differences between patients who did and did not have a participating concerned other.

Of 413 concerned others approached, 67% were enrolled, completed the study assessment, and received $25. Reasons for nonenrollment (n = 136) were no response to contact attempts (59%), declined (27%), and did not attend scheduled enrollment sessions (14%). Concerned others were mainly women (77.3%), White (68.3%), unmarried (58.5%), and employed (57.7%). The mean age was 51.9 years old (SD = 14.8), education was 13.8 years (SD = 2.0), and annual income was $42,300 (SD = $41,100). Concerned others’ relationships to patients were current spouse/partner (30.1%), former spouse/partner (2.6%), parent (25.0%), sibling (13.2%), offspring (11.4%), relative (2.6%), or friend (15.1%).

We attempted to follow concerned others 3 months later by telephone. The follow-up rate was 80.0% (n = 220) among concerned others who were not deceased (n = 2) at 3 months. Concerned others who did not participate at 3 months (n = 55) could not be located, refused, or did not appear for scheduled follow-up sessions.

Procedures were institutional review board compliant.

Measures

At baseline, patients and concerned others answered the following (yes or no): When you were growing up, that is, during your first 18 years, did you live with anyone who was a problem drinker or alcoholic?

At baseline, patients answered how old they were when they first used alcohol, the number of times they had been treated in their lifetime for alcohol use and had been arrested and charged, and if they had ever been incarcerated. They reported if they had attended a 12-step group in the past 6 months and the number of meetings.

At baseline and follow-up, patients rated their AUD on the Brief Addiction Monitor (BAM; Cacciola et al., 2013), which yields three subscales referring to 30 days before treatment. Substance use sums three items, e.g., number of days drank alcohol (0 = 0, to 4 = 16–30 days); scores range from 0 to 12. Risk factors for substance use sums six items, e.g., physical health (0 = excellent, 4 = poor); scores range from 0 to 24. Protective factors sums six items, e.g., confidence in ability to be completely abstinent from alcohol and drugs in the next 30 days (0 = not at all, 4 = extremely); scores range from 0 to 24. The BAM is reliable and valid (Blonigen et al., 2015; Ruan et al., 2017; Stockin et al., 2019; Timko et al., 2019).

Analyses

First, two groups of patients were compared on baseline characteristics: those who had grown up with problematic drinking in the home and those who had not. Second, we examined the hypothesis that concerned others’ lived experience as growing up in such a home or not would moderate the association between patient lived experience and patients’ 3-month treatment outcomes assessed by the BAM. The moderation model was analyzed using the PROCESS computational tool for SPSS Version 25 (Hayes, 2018) in which patients’ lived experience was the independent variable (yes/no at baseline), concerned others’ lived experience was the potential moderator (baseline), and BAM Substance Use, Risk, or Protective Factors at 3-month follow-up was the dependent variable. Each model controlled for the baseline value of the dependent variable. Then, each model was rerun adding the predictor of patient–concerned other relationship type (spousal or nonspousal) to determine the influence on outcomes.

Results

Baseline

Patients had indicators of chronic AUD (Table 1). They first used alcohol at age 14, had been treated for alcohol use a mean of six times, had been arrested and charged a mean of seven times, and 65% had been incarcerated. In the 6 months before treatment, the majority (92%) had attended a 12-step meeting, with a mean of about 25 meetings.

Of 402 patients, 58% reported lived experience growing up in a home with problematic drinking; 42% reported not having this experience. The two groups did not differ on demographic characteristics (Table 1). Patients with lived experience first used alcohol at a younger age, had been arrested and charged a greater number of times, and had higher BAM risk scores than patients without lived experience.

Moderation

Of the concerned others, 45% had lived experience growing up in a home with problem drinking or AUD and 55% did not. Of the 277 patient–concerned other dyads, 24% had both members report lived experience growing up in a drinking home; 23% had neither member report this lived experience; 31% had a patient who did and a concerned other who did not have this lived experience; and 22% had a patient who did not and a concerned other who did report growing up in a drinking home.

The results of PROCESS analyses to examine the moderation model showed a similar result for each BAM score reported by patients at the 3-month follow-up. The main effects for the patient and for the concerned other having grown up in a drinking home were not significant. However, the interaction between the patient's lived experience and the concerned other's lived experience was significant for each BAM score (Supplemental Table 1). (Supplemental material appears as an online-only addendum to this article on the journal's website.) Associations between patients’ lived experience and better BAM outcomes were stronger when patients’ concerned others had concordant lived experience (Supplemental Figures). These significant results for the interactions held when relationship type (spousal/nonspousal) also was included in the model for BAM substance use (p = .042) and BAM risk (p = .008), as well as for the BAM protection interaction (p = .055). When patient–concerned other dyads reported concordant lived experience at baseline, patients had lower substance use and risk scores and higher protective factors scores at the 3-month follow-up than when patient–concerned other dyads reported discordant lived experiences with regard to growing up in a drinking home. Cohen's d ranged from .28 to .42 across BAM comparisons.

Discussion

This study of dyads composed of patients in treatment for AUD and their concerned others found that concordance on the lived experience of growing up in a home with problematic drinking was related to patients’ better outcomes at 3 months after treatment entry. Patient–concerned other concordance was associated with patients’ less substance use, less risk for substance use, and more protection from future substance use (although statistical significance for protection was marginal when relationship type was included in the analytic model). The effect sizes were small for comparisons of patients in concordant and discordant dyads, which is consistent with studies in which the BAM demonstrated clinically meaningful findings (Najavits et al., 2016; Timko et al., 2019). Despite the small group differences, these findings may have implications for providers working with people in AUD treatment and their concerned others, such as to consider whether the patient–concerned other relationship is spousal or not (McCrady et al., 2019; Timko et al., 2020; Windle & Windle, 2019). The importance of helping dyads function better to improve drinking is bolstered by research on the benefits of supportive relationships to reduce substance use among childhood adversity survivors (Banford Witting & Busby, 2019; Torgerson et al., 2018; Wingo et al., 2014).

Identifying the effects of having alcohol problems in the childhood home may be particularly important for providers working with dyads in which only one member had this experience. Providers could ask about each dyad member's childhood, whether drinking-related hardships were disclosed, and if so, what the other member's responses were. Interventions could help dyads discuss their childhoods in ways that validate each other's needs and provide emotional support, without stigmatizing responses (de Montigny Gauthier et al., 2019). Stigmatization may occur partly because, as this study found, growing up in a home with AUD is associated with drinking at a younger age, criminal involvement, and more risk for future substance use. Dyads’ empowerment with knowledge and skills to deal with emotional distress that comes with relationships in which one partner has suffered childhood adversity increases the chances of healthy and stable bonds (Mokoena et al., 2019). To help patients and concerned others understand the difficult experience of growing up in a home with problematic drinking when they did not have this experience but their dyad partner did, the treatment program could offer educational forums or counseling sessions (including both members or just one) about the experience's impact. Although not suggesting to discordant dyads that having the childhood experience of a problematic-drinking home is an acceptable excuse for drinking, the aim is to help the concerned other and patient understand one another better to bolster relationship resources and reduce stressors. People who perceive past adversity as a “convenient excuse” for addiction may not fully comprehend what adversity and addiction are and what struggling with them entails. Understanding connections between past adversity and addiction may help dyads’ long-term recovery.

Even concerned others and patients’ concordant lived experience could be leveraged in AUD treatment to improve outcomes for both dyad members. When both members grew up in a home with alcohol problems, competition may occur about whose experience was harder. Or, one member may be overwhelmed by her childhood whereas the other dismisses any childhood impact on her adult functioning (Nelson et al., 2002). Treatment offered to concordant dyads could encourage sharing lived experience to improve communication, relationship, and drinking outcomes. Sharing may use some Alcoholics Anonymous principles (listen and do not “take each other's inventory,” impose views, or pretend to know all the answers). The large majority of this study's patients had recently attended Alcoholics Anonymous meetings; therefore, these principles may be familiar.

Regarding limitations, one is that the sample was dyads with people who had entered treatment; results may not generalize to dyads including people unable or unwilling to access treatment. The study used one self-report item for having grown up in a home with alcohol problems; this is the same method used in other studies and was shown to be psychometrically sound (Drapkin et al., 2015). Even so, future studies should consider more fine-grained analyses such as how long dyad members lived with someone with an AUD and how severe or chronic the AUD was.

This study found that when patients and concerned others were concordant on the lived experience of having grown up in a problem-drinking household, the patients’ treatment outcomes were better than when patients and concerned others were discordant. About one half of patient–concerned other dyads were concordant on their lived experience and about one half were discordant. We propose that both sets of dyads may benefit from treatment programs’ consideration of childhood lived experience in the context of relationship type (spousal, other family, or friend) to help the recovery of both patients and concerned others.

Acknowledgment

The authors gratefully acknowledge these contributors to the study: Cynthia Beaumont, Kristina Kennedy, Rebecca Losh, Camille Mack, Rakshitha Mohankumar, Amia Nash, Alexandra Shelley, Emmeline Taylor, and KaSheena Winston; and consultants Barbara McCrady and Gregory Stuart.

Footnotes

This research was supported by National Institute on Alcohol Abuse and Alcoholism Grant R01 AA024136 01A1 (to Christine Timko and Michael A. Cucciare) and the Department of Veterans Affairs (VA), Health Services Research and Development (HSR&D) Service Grant RCS 00-001 (to Christine Timko) and Office of Academic Affiliations (Fernanda S. Rossi). The views expressed are the authors’. No conflicts of interest are reported by any of the authors listed on this manuscript.

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