Substance Abuse Treatment and the Stages of Change

Substance Abuse Treatment and the Stages of Change by Connors, Donovan, and DiClemente discuses methods of substance abuse treatment within the stages of change model. Within the context of the stages of change model, the book explains assessment methods, treatment planning, as well as various types of therapy (e.g., individual therapy, group therapy, and marital/couple/family therapy). The book also includes a chapter on populations with special needs and relapse.

Substance Abuse Treatment and the Stages of Change describes treatment according to the Delphi survey. The Delphi survey states that treatment is the “application of planned procedures to identify and change patterns of behavior that are maladaptive, destructive, or health injuring; or to restore appropriate levels of physical, psychological, or social functioning.” (Connors, 2004) According to Connors, Donovan, and DiClemente the stages of change model was developed in order to gain a better understanding of why people usually respond differently to treatment. That is, some addicts may refuse treatment or deny that they have a problem, others may admit a problem, but refuse to enter into treatment, while others take the necessary step to ensure their sobriety.

The stages of change model, developed by Prochaska and DiClemente, describes how people change addictive behavior across five stages. The five stages are as follows: precontemplation, contemplation, preparation, action, and maintenance. Addicts in the precontemplation stage often deny that they have a problem and are resistant to treatment. These individuals are usually pressured into treatment by others (e.g., spouses, parents, or the legal system). Those in the contemplation are distressed by their addictive behaviors and have a desire to make a change. They have often attempted to change and failed in the past. Addicts in the preparation stage have decided to make a change and are attempting to begin regulating their drug use. People in the action stage have developed a plan to quit using drugs and are implementing it. Recovering addicts are in the maintenance stage. These individuals have stopped using drugs are striving to prevent relapse.

The stages of change model can also be viewed as a spiral model. In the spiral model of stags of change, changing is seen as a more fluid process. For example, one may revert back to the contemplation stage after having been in the action stage for some time. Although these setbacks are frequent and undesirable, Connors, Donovan, and DiClemente note that they may serve as a learning process that will strengthen future attempts to change. Furthermore, they note that people rarely revert all the way back to the precontemplation stage.

Connors, Donovan, and DiClemente point out that there are various ways that may help a therapist determine in which stage a client is. For example, simple drug screens (urinalysis and blood test) can determine if a client is still using. These clients will likely be in the precontemplation or contemplation stages. Drug screens may also be helpful for confronting a client who contends to be in the maintenance stage when he or she is not. Other methods for determining in which stage a client is include the change questionnaire, the ASI, the ASU, and the CAGE. Structured and unstructured interviews are essential for determining the stage of a client, as well.

I found Substance Abuse Treatment and the Stages of Change very informative. Although I was somewhat familiar with the stages of change model, I did not have a contemplate understanding of how to approach treatment planning according to which stage a client is in. The book offered practical advice for ascertaining in which stage a client is, as well as what treatment methods would be most helpful according to the respective stage. I highly recommend this book for anyone interested in helping others overcome addiction.

 

CODEPENDENCY

Codependency is an addictive process, a disorder just like any other addiction. Codependency can be described as a dysfunctional pattern of living in which one overreacts to things going on outside of oneself and under reacts to what is going on inside of oneself. Codependency may involve compulsive behaviors and dependence upon approval from others in order to achieve a sense of safety, identity, and self‐esteem. Codependents may put all their efforts into those around them, neglecting to fully take care of themselves, especially emotionally. Codependency is a disorder that, if left untreated, can lead to other addictions such as eating disorders, substance dependence, workaholism and compulsive spending.

As a general rule of thumb, those who are substance dependent (addicts) are usually codependent and those who are in the family system of the addict (close relations and family members) are usually codependent.

Timmen Cermak, M.D., suggests that co‐dependency is a personality disorder. His reason is that when specific personality traits become excessive and maladaptive and cause significant impairment in functioning or cause significant distress, this warrants a personality disorder diagnosis. Dr. Cermak, T.L. “Diagnosing and Treating Co‐Dependence.” Minneapolis, MN: Johnson Institute, (1986). proposes the following diagnostic criteria for this disorder:

1. Continued investment of self‐esteem in the ability to control both oneself and others in the face of serious adverse consequences.
2. Assumption of responsibility for meeting others’ needs to the exclusion of acknowledging one’s own.
3. Anxiety and boundary distortions around intimacy and separation.
4. Enmeshment in relationships with personality disordered, chemically dependent, other codependent, and/or impulse‐disordered individuals.
5. Three or more of the following:

a) Excessive reliance on denial

b) Constriction of emotions (with or without dramatic outbursts)

c) Depression

d) Hyper vigilance

e) Compulsions

f) Anxiety

g) Substance Abuse

h) Has been (or is) the victim of recurrent physical or sexual abuse

i) Stress‐related medical illnesses

j) Has remained in a primary relationship with an active substance abuser for at least two

years without seeking outside help1

 

The aim of this study was to examine the role of codependency in the relationship between the adolescent’s attachment to parents, and adolescent problem behavior. The study participants were 315 adolescents, 15 to18 years old, 190 female and 125 male from Latvia primary and secondary schools. The participants completed three self-report questionnaires regarding attachment to parents (Inventory of Parent and Peer Attachment – IPPA, Armsden & Greenberg, 1987), codependency level (Spann-Fischer Codependency Scale, SFCDS, Fischer, Spann &Crawford, 1991), and problem behavior (YSR 11/18 – Youth Self Report, Achenbach &.Rescorla, 2001). Multiple regression analysis revealed that codependency mediates the relationship between insecure attachment to parents and internalized behavior problems for female and male adolescents. A similar effect was found in regard to externalized behavior problems for female adolescents. The findings suggest the necessity for a differentiated approach for treatment of female and male adolescent behavior problems, and the necessity of parent management training programs taking in account the adolescents’ gender in order to improve the communication and attachment quality of adolescents and their parents.

1. Because it is selfish, I cannot put my own needs before the needs of others
2. I try to control events and people through helplessness, guilt, coercion, threats, advice-giving, manipulation, or domination
3. It makes me uncomfortable to share my feelings with others
4. It is my responsibility to devote my energies to helping loved ones solve their problems
5. What I feel isn’t important as long as those I love are okay
6. I feel compelled or forced to help people solve their problems (i.e., offering advice)
7. I am very open with others about my feelings, no matter what they are (R)
8. I keep my feelings to myself and put up a good front
9. I push painful thoughts and feelings out of my awareness
10. My mood is fairly stable and unaffected by the problems and moods of those close to me (R)
11. I try to control events and how other people should behave
12. Feelings often build up inside me that I do not express
13. I always put the needs of my family before my own needs
14. No matter what happens the family always comes first
15. I become afraid to let other people be who they are and allow events to happen naturally
16. I often put the needs of others ahead of my own
17. I feel that without my effort and attention, everything would fall apart
18. I live too much by other people’s standards
19. I keep my emotions under tight control

 

FACTORS: Interpersonal control:

2, 6, -10, 11, 15, 17, 18

 

Self-sacrifice:

1, 4, 5, 13, 14, 16

 

Emotional suppression:

3, -7, 8, 9, 12, 19

The purpose of this study was to investigate the relationships among attachment styles, psychological separation-individuation, codependency, and emotional blackmail (EB) strategies of college students in Taiwan. EB is a form of emotional abuse; perpetrators of EB often manipulate or control the victims by using guilt or obligation or by directly or indirectly threatening to punish the victims in some ways (e.g., abandonment, indifference, self-injury, pathologizing, spreading rumors) if the victims do not comply with their wishes (Forward, 1997). This type of emotional abuse is often ignored as it is more “invisible” than other types of interpersonal violence (e.g., rape or physical abuse). However, many perpetrators of various types of interpersonal violence use EB to keep victims silent (Leclerc & Tremblay, 2007). Victims of this type of emotional abuse usually feel stuck in their relationships with the perpetrators and suffer from a wide range of psychological sequelae (e.g., low self-esteem, depression, and anxiety) (Forward, 1997).

Three factors—insecure attachment, poor psychological separation-individuation, and needs for codependent relationships—appear to be associated with the use of EB strategies. Those with more insecure attachment patterns appear to develop more dysfunctional relationships during adulthood (Finzi-Dottan & Karu, 2006; Mikulincer et al., 2002; Su et al., 1990), have higher needs for control (Beesley & Stoltenberg, 2002), perceive their coping strategies to be less effective (Wei et al., 2003), and experience more emotional struggles (Goldberg, 2002), compared with their counterparts. Similarly, those with less clearer self-other boundary (thereby, poorer psychological separation-individuation) and higher needs for codependency may not have developed positive strategies to reconcile conflicting needs in relationships and may have higher needs for controlling others (Choi, 2002). However, no studies to date have examined all of the aforementioned factors and how they may contribute to the use of EB strategies.

Codependence as a relational problem that often, but not necessarily always, occurs in conjunction with familial alcoholism. Previous research has shown that various etiological factors resulting from recurring stressful circumstances experienced in childhood or adulthood may contribute to this relation. Another factor arises out of the “submission script” that may be assumed by women living within a culture that typically promotes unequal power between women and men. To examine the prevalence of codependence and its predictors, a cross-sectional study was conducted among a population of 845 young women seeking primary health care in Mexico City. Odds ratio prevalence (ORP) was used to estimate the strength of possible association between codependence and exposure to several factors. A prevalence of 25% of codependence was found. Multivariate analysis revealed that women with a submissive cultural script were nearly eight times more likely to develop codependence than those without this programming.

Other relevant factors were having a partner with probable alcohol dependence, a father with alcohol problems, physical and sexual mistreatment by a partner, and a history of emotional mistreatment.

dependencies and abuse risk.

First, researchers have demonstrated consistently that emotional and economic resources across multiple ecological contexts are necessary to reduce women’s abuse risk. Women are unsuccessful in staying away from their abusive partners most often because of their lack of economic resources, weakened social support networks, and low self-efficacy in creating a different life for themselves and their children (e.g., Chronister & McWhirter, 2003). Researchers also have demonstrated that cognitive aspects of women’s emotional dependency influence the relationship between their abuse experiences and economic dependency (e.g., Chronister & McWhirter, 2004, 2006). That is, not only do abusers directly sabotage women’s attempts to gain employment and access economic resources, but they also systematically denigrate and criticize women, destroying their confidence and efficacy for identifying and pursuing economic opportunities (e.g., employment, vocational training) that may, in turn, facilitate their emotional and economic independence (Chronister & McWhirter, 2003).

Despite the connection between Codependency has been defined as a set of maladaptive and compulsive interpersonal behaviors. The construct of codependency, however, has been confined mainly to alcohol-related fields and understudied in general psychological research. Reluctance to accept codependency as a valid psychological construct may be, in part, due to the inconsistency of and lack of operational definitions of the term. The concept of codependency emerged as a construct in the early 1940s as a grassroots movement of Alcoholics Anonymous in association with spouses of alcoholics and the label of codependency was introduced by Melodie Beattie in 1987. Since that time, few psychologists outside the chemical dependency field have explored the association of codependency and other psychological mechanisms.

Conceptually, codependency encompasses both ones emotional well-being, as well as how one relates to others. Therefore, codependency should be associated with several psychological constructs, including both intrapersonal and interpersonal variables. Although limited research has demonstrated a relationship between codependency and variables such as self-esteem and relationship functioning, little is known about how codependency is related to intrapersonal and interpersonal functioning outside of the context of alcohol research. The purpose of this study was to extend previous research on codependency by exploring the relationship of codependency to depression, attachment style, dyadic adjustment, and social intimacy. Participants were 198 general psychology students (65 male, 133 female) at a northwest metropolitan university. All participants were in a relationship at the time of the study. Participants completed questionnaires assessing codependency, depression, adult attachment, dyadic adjustment, and social intimacy.

Results of a hierarchical regression analysis indicated codependency was predicted by depression, anxious attachment, relationship satisfaction, and social intimacy. Attachment avoidance, however, was not a significant predictor. Results of this study provide preliminary evidence for the association between codependency and depression, anxious attachment, relationship satisfaction, and social intimacy. Further, this study suggests adds to the literature defining the construct of codependency, indicating

that codependency can, in part, be defined in association with interpersonal and intrapersonal variables.

Specifically, high levels of codependency were related to depression, fears of abandonment and rejection,

dissatisfaction with ones current relationship, and low levels of closeness with others.

 

 

6

FAMILY THERAPY: DILEMMAS OF

CODEPENDENCY AND FAMILY

HOMEOSTASIS

Another source of the clinician’s dilemmas in treating the family system

is derived from a phenomenon that has been encompassed by the term

codependency. Codependency is a concept that is reflective of a mutually dependent,

but complementary role relationship among members of a family

that is maintained by a homeostatic mechanism as a response to changes

made or impacted on by a given member of the family. In its adaptive form,

its function is to preserve the family from destructive influences and alterations

and to prevent disintegration by keeping a dynamic balance within

the family’s system. In its maladaptive form, it rigidly prevents the family

from making the necessary adaptations to normative changes that generally

occur and need to occur across the family’s life cycle. Because this central

concept in family functioning focuses on maintaining an optimum balance

This chapter is an adaptation of “Codependency,” by D. J. Scaturo, inj. J. Ponzetti Jr. (Ed.), International

Encyclopedia of Marriage and Family (2nd ed., Vol. 1, pp. 310-315), copyright 2003 by Macmillan Reference

USA; and “The Concept of Codependency and Its Context Within Family Systems Theory,” by D.

J. Scaturo, T. Hayes, D. Sagula, and T. Walter, 2000, Family Therapy, 27(2), 63-70, copyright 2000 by

Libra. Adapted with permission.

99

http://dx.doi.org/10.1037/11110-006

Clinical Dilemmas in Psychotherapy: A Transtheoretical Approach to Psychotherapy

Integration, by D. J. Scaturo

Copyright © 2005 American Psychological Association. All rights reserved. Copyright American Psychological Association. Not for further distribution.

within the family system, the notion of equilibrium itself suggests that the

nature of family therapy is fraught with the dilemmas involved in avoiding

either “too much” or “too little.”

CODEPENDENCY AND THE ALCOHOLIC FAMILY SYSTEM:

POPULAR DEFINITION AND USAGE

The concept of codependency in the family system had emerged originally

from the study and treatment of alcoholism (Gorski & Miller, 1984).

In the alcoholic family system, codependency may be defined as a particular

family relationship pattern in which the alcoholic is married to a spouse who,

despite being a nondrinker, serves as a helper or facilitator to the alcoholic’s

problem behavior (Scaturo, 2003a; Scaturo & McPeak, 1998). The spouse,

therefore, plays a role in the ongoing chemically dependent behavior of the

alcoholic. The spouse’s behavior may, unintentionally, foster the maintenance

of the drinking problem by enabling the drinking pattern to continue.

For example, the codependent spouse may make “sick calls” to the alcoholic

spouse’s workplace following drinking episodes, thereby delaying the problem

from coming to the foreground more quickly. Thus, the spouse is said to

be a codependent of the alcoholic’s chemically dependent behavior.

Although there are a variety of theoretical perspectives on alcohol abuse

and its treatment (e.g., Scaturo, 1987), Bowen (1974) was one of the first

family therapists to conceptualize alcoholism as a symptom of family dysfunction,

encompassing the behavior of both the alcoholic and the

codependent. Accordingly, the family is a system in which a change in the

functioning of a given family member (e.g., the alcoholic) is followed by a

compensatory change in another family member (e.g., the codependent).

Furthermore, every family member is viewed as taking a part in the dysfunction

of the dysfunctional member. Excessive drinking takes place when anxiety

in the family is elevated. In family therapy, attention is first given to the

overall degree of anxiety in the family, and anything that is able to interrupt

the escalating anxiety is viewed as helpful. Thus, psychoeducational efforts

to teach codependent spouses about family systems functioning can intervene

and help control their reciprocal role in their spouses’ drinking behavior.

In this regard, Bowen (1974) contended that it is far easier to assist the

overfunctioning spouse to reduce the overfunctioning than it is to help the

dysfunctional family member increase his or her level of functioning. Clinical

attention given to the enabling behavior of the codependent, therefore,

has been a significant contribution of family systems theory to the field of

addictions (Scaturo et al., 2000).

Beattie (1987) popularized the concept of codependency for the general

public in the self-help literature (Starker, 1990). She defined codependency

for the lay reader as follows: “A codependent person is one who has let

100 DIVERSE APPROACHES TO TREATMENT

Copyright American Psychological Association. Not for further distribution.

another person’s behavior affect him or her, and who is obsessed with controlling

that person’s behavior” (Beattie, 1987, p. 36). She noted that the

expression has been used as “alcohol treatment center jargon” and “professional

slang,” and she acknowledged that the term, as it was used, had a

“fuzzy definition.”

The popularization of the term, codependency, has had both positive

and negative consequences for the fields of psychotherapy and family therapy.

On the positive side of the ledger, the self-help literature in general, and the

popular usage of the term codependency in particular, have been helpful in

raising public awareness of the complex interrelationships that take place

within alcoholic families. It has provided, in relatively simple, straightforward,

and understandable terms, an appreciation of the role that everyone

assumes in a family where a severe psychological disorder such as alcoholism

occurs. For example, a wife and children may “cover” for their alcoholic husband

or father’s inability to keep up with the everyday demands of the home

and workplace because of his excessive drinking. No one in an alcoholic

family is immune from the devastating effects that alcohol has on them, and

others in the family may inadvertently contribute to the maintenance of an

alcohol problem. Indeed, enhancing a general understanding of these complex

family behaviors is an important contribution to the realm of public

mental health education.

Bibliography

Connors, G.J., et al. (2004). Substance Abuse Treatment and the Stages of Change. New York: The Guilford Press.