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" 2’: ‘ "H"! * ‘A‘mfi . lllllllllllllllmllllllflglgglm 3 1293 This is to certify/that the thesis entitled Seeking Professional Help: The Experiences of Three Wives of Elderly Alcohol Abusers presented by Sheila Hamilton Livingston has been accepted towards fulfillment of the requirements for Master of Science degree inNursing é/ W gm l/ Major professor Date 11/6/90 0-7 539 MS U is an Affirmative Action/Equal Opportunity Institution l LIBRARY Mlchlgan State University v—~ PLACE IN RETURN BOX to ram ave this checkout from your record. TO AVOID FINES return on or before data duo. ll DATE DUE DATE DUE DATE DUE MSU Is An Affirmative Action/Equal Opportunlty lnctIMIon emails”: SEEKING PROFESSIONAL HELP: THE EXPERIENCES OF THREE WIVES OF ELDERLY ALCOHOL ABUSERS BY Sheila Hamilton Livingston A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN NURSING Department of Nursing 1990 ABSTRACT SEEKING PROFESSIONAL HELP: THE EXPERIENCES OF THREE WIVES OF ELDERLY ALCOHOL ABUSERS BY Sheila Hamilton Livingston This study was undertaken to explore the life experience of three wives of elderly alcohol abusers who sought professional help for the first time. The aim of this study was to describe the interactions, thoughts and feelings that led up to the choice to seek help. Additionally, the life experience after the first help- seeking attempt was described. From the words of the three women common themes were isolated. Using these common themes, a core pattern of experience was described representing the meaning of life for the three women. The methodology for this study was based on grounded theory. The three wives were volunteers who had been married for at least 25 years to men when they perceived to be alcohol abusers. The husbands had to be at least 55 years old in order to represent the aging population. Interviews were held with open ended questions which explored the wives' perceptions. DEDICATION This thesis is dedicated to all wives of alcohol abusers, especially those I have known and loved. ACKNOWLEDGMENTS I offer my deepest gratitude to my husband, P.J. and my sons Brian, Michael, John, and James. Thanks for all of your love, understanding, and support. I know that I spent many family time hours on this project and you were behind me the whole way. I love you all. Special thanks to my colleagues and dear friends, Mary Beth Sommers, RN, MSN, and Linda Keilman, RN, MSN. I couldn't have made it without you! Thank you to my committee: Barbara Given, RN, Ph.D. Andrea Bostrum, RN, MSN Clare Collins, RN, Ph.D. Sharon King, RN, Ph.D. Thanks also to Jill Adams, my typist! iv TABLE OF CONTENTS LIST OF TABLES viii LIST OF FIGURES ix CHAPTER I THE PROBLEM 1 Introduction 1 Background 3 Purpose 8 Importance 9 Study Questions 10 Definition of Major Concepts 10 Help-Seeking 10 Alcohol Abuse 11 The Life Experience of the Wife of an Elderly Alcohol Abuser 17 Assumptions 21 Limitations 22 Overview of Chapters 24 CHAPTER II CONCEPTUAL FRAMEWORK 25 Introduction 25 Rogers' Theory 25 Alcohol Abuse in the Elderly Husband 31 The Wife's Response to Alcohol Abuse 37 CHAPTER III REVIEW OF THE LITERATURE 46 Introduction 46 ALCOHOL ABUSE IN THE ELDERLY 46 Prevalence of Alcohol Abuse in the Elderly 47 Criteria for Identification of Alcohol Abuse in the Elderly 51 Stages and Patterns of Alcohol Abuse in the Elderly 55 Predictors of Alcohol Abuse in the Elderly 61 Summary 64 Implications from Recent Literature 65 V WIVES OF ALCOHOL ABUSERS 67 The Disturbed Personality Theory 68 The Decompensation Theory 73 The Stress Theory 76 The Psycho—Social Theory 80 The Interactional Approaches: Systems Theory and Social Learning Theory 88 Co-Dependency 97 Summary 105 Implications from Recent Literature 108 CHAPTER IV METHODOLOGY 111 Introduction 111 The Study Overview 111 The Study Design 112 Study Questions 114 Conceptual Framework 114 Objectives of the Study 115 Sample 116 Protection of Human Subjects 118 Operational Definitions 120 Instrumentation 120 Data Collection Method 122 Validity and Reliability 124 Data Analysis 130 Summary 132 CHAPTER V DATA ANALYSIS 134 Introduction 134 The Sample Description 135 Mary - CASE A 138 Jane - CASE B 140 Sally - CASE c 143 Description of Methods 146 Results of the Data Analysis 147 THEME I 148 THEME II 150 THEME III 151 THEME IV 153 THEME V 154 THEME VI 157 THEME VII 158 Methodology - Quality of Design 163 Internal Validity 163 External Validity 167 Reliability 167 vi CHAPTER VI DATA ANALYSIS Overview Discussion THE DISCUSSION OF FINDINGS AS RELATED TO THE CONCEPTUAL FRAMEWORK Logical Mapping DISCUSSION OF FINDINGS RELATED TO THE RELEVANT LITERATURE Alcohol Abuse in the Elderly Wives of Alcohol Abusers NURSING IMPLICATIONS Research Practice Education SUMMARY APPENDIX APPENDIX A APPENDIX B APPENDIX C APPENDIX D Demographic Information HELP-SEEKING SURVEY APPENDIX E Field Notes Case A Case B Case C REFERENCES vii 173 173 174 180 187 189 189 191 199 199 203 207 209 210 221 223 225 233 235 237 237 237 237 238 239 Table 1 Table 2 Table 3 LIST OF TABLES Dunham's Four Patterns of Alcohol Abuse in the Elderly 60 Socio-Demographic Information About The Three Husbands and Wives 136 The Common Themes Which Described the First Professional Help-Seeking Experience for Three Wives of Alcohol Abusers 161 viii Figure 1 Figure 2 Figure 3 LIST OF FIGURES Application of Rogers' Theory to an Elderly Alcohol Abuser Application of Rogers' Theory to an Alcohol Abused Marriage Logical Mapping of Common Themes ix 35 40 188 CHAPTER I THE PROBLEM INTRODUCTION "Eleven years ago, I started therapy with a psychologist after my husband was arrested for driving under the influence of alcohol. The psychologist introduced me to Al-Anon and within the year I began to learn to handle my life differently. For the first time in my life, I began to see I had a choice. What a miraculous concept. I was building myself into a whole person even though my husband's alcoholism progressed rapidly for the next six years. My husband has now had five years of sobriety. We learned this is a family illness and there can be family recovery if at least one family member tries to find alternatives. I am finally doing it differently, and for me it is a better way. At least, finally, I had a choice." Cindy (Black, 1982, pg 151) Reaching out and making that first contact with a helping resource is a big step. The act of picking up the phone, dialing the number and asking to speak to someone who can help only takes seconds. The processes which lead up to making that call for help--the debates with oneself, the mood changes experienced, telling yourself you can handle the problems alone, the never-ending continuous cycle of depression, anger, hope, guilt--all have taken their psychological and physical toll on you and your family. So, for many wives of alcohol abusers, it may be months or possibly even years before help is sought. For the wife of 2 an elderly alcohol abuser professional help may have been sought once, many times, or not at all. At some point the wife who has been in an alcohol abused marriage for any length of time may choose to seek help for the first time. The choice to seek help is seen as a problem-solving approach to change a problematic life experience. The focus of this study will be to investigate the life experience of three wives of elderly alcohol abusers that led to the choice of seeking professional help for the first time. Experiences, which consist of alcohol abusive interactions that led to the first attempt at help-seeking will be explored. This exploration will be done in an attempt to understand the common areas of experience of alcohol abuse in three marriages. The alcohol abuse will have evolved to the point where the wife makes the choice to change her marriage by seeking help in an attempt to improve the quality of the life experience. The quality of the life experience since that help-seeking choice was made will also be explored to see the change if any in the alcohol abuse in the marriage. Comparisons of the similarities will be done to look for a unique pattern of interaction that describes the phenomena of this experience for these three women. Nursing's role in the discovery of the lived experience is most appropriate. The Social Policy Statement of the American Nurse's Association (1980) specifies that the phenomena of concern to nurses are those human responses to actual or potential problems. It is in understanding the patterns and rhythms of a life experience that a nurse can facilitate a client toward health and well-being. Promoting overall health and well-being, is that not where nursing's essence belongs? Health is an active interaction with the environment to pattern a reality that creates a sense of well-being with a future view (Rogers, 1982). The meaning of health and well- being however is as different as the many individual clients and their experiences. Understanding and promoting health and well-being then can only come from understanding the human life experience. Perhaps the ongoing challenge to nursing can be met through the development of nursing theory through qualitative and descriptive research. The major goal of this study then will be to explore, compare and describe the experiences of three women married to elderly alcohol abusers that led to the choice to seek help, and how that choice has affected their life experience today. 532391911051 One of the greatest scientific achievements of this century is the increasing life expectancy of Americans. In 1900, only 4% of the population were 65 years or older, as predicted to the year 2000 that 12.2% will be 65 and older (Zimering & Domeischel, 1982). In the past five years there 4 has been a 28% increase in the number of people in the United States aged 65 and over (Christopherson, Escher & Bainton, 1984). Demographers predict that by the year 2000 the number will have increased from the present 25.5 million to more than 30 million (Christopherson, Escher & Bainton, 1984). In recent years there has been a growing number of elderly and their special health needs. This growing number of elderly citizens are expecting to lead their remaining years in a state of positive well-being. Therefore, there is a growing concern with the process and problems of aging in general. With this concern there is a great deal more attention being turned to the use and misuse of drugs and alcohol by older persons (Petersen & Whittington, 1981). It is estimated that 2% to 10% of persons over the age of 60, and up to 20% of some nursing home populations, suffer from alcoholism (zimering & Domeischel, 1982). Alcohol abuse is a matter of increasing concern in the nation today. Barnes (1982) reviewed a number of studies for existing data on prevalence of alcohol abuse and found as many as 20% of the sample populations were heavy drinkers. Warheit and Auth (1983) found that 5.7% to 9.8% of the population are at risk for alcohol-related problems. In an article by zimering and Domeischel (1982), it was estimated that the cost of alcoholism yearly to the national economy was $31.7 billion, including lost production, health 5 care, motor vehicle accidents, criminal justice system expenses, alcohol research and training, and social service costs. Alcoholism is ranked as the 4th major fatal illness in the nation. In a typical American community, one out of six families in your neighborhood is affected by alcoholism (Black, 1982). Alcoholism is a disease that knows no boundaries. Alcoholism can affect children, teens, adults, blue collar workers, professional people, clergy, and the elderly. Only 3% to 5% of the alcoholic people in the United States are the stereotyped skid row drinkers (Black, 1982). The average alcoholic is a man or woman with family, job and responsibilities. As many as 10% of the elderly are classified as heavy drinkers (Peterson & Whittington, 1981). Whereas Warheit and Auth (1983) categorized only 2.4% of those over 50 years old as having alcohol related problems, Barnes (1982) found 6%-9% prevalence of alcohol abuse in the elderly. In a study by LeGreca, Akers and Dwyer (1988) on alcohol consumption behavior of older adults, 1 out of five reported drinking alcohol daily, 3.5% had experienced drinking related problems in the past year, and 6.3% scored as heavy drinkers. A household survey carried out in Western New York by the Division of Alcoholism and Alcohol Abuse (1979) reported that approximately 1/4 or men in their 503 are heavy drinkers, and even larger proportions, 41% of men 50 6 to 59 are heavy drinkers. So not only was there a considerable population of elderly in 1979 with drinking problems, these figures could suggest that this trend will increase in the future as that 41% of heavy drinkers in the 50-59 year old group age. Alcoholics are unable, with any predictability, to control their drinking and/or whose drinking causes problems in major areas of their lives (Black, 1982). Alcoholism is defined as a chronic, primary, hereditary disease process which progresses from an early physiological susceptibility into an addiction characterized by tolerance changes, physiological and psychological dependence, and loss of control over drinking (Milam & Ketcham, 1981). As people develop the disease of alcoholism, it is most normal for the spouse to become increasingly preoccupied with the behavior of the alcoholic. This preoccupation has been referred to as co-alcoholism (Black, 1982). Abnormal family dynamics frequently occur as a consequence of the alcoholism and co-alcoholism. Family members respond to the behavior of the alcoholic by developing responses that cause the least amount of personal stress to themselves (Wegscheider, 1983). These responses often unwittingly function to promote or enable the progression of the alcoholism. The enabling responses of the family members, especially the spouses, often supply the means or 7 opportunity to the alcoholic to continue with the progression of the disease (Steinglass, 1981). Some of these responses might be covering up, making excuses, ignoring, cleaning up after, lying, and suppressing feelings. The result of these enabling responses is that the alcoholic does not see or address the consequences of the drinking behavior (Black, 1982). Researchers (Jackson, 1954, 1956, 1959, 1962: Orford & Guthrie, 1968: James & Goldman, 1971; Moos, Finney & Gamble, 1982) have found that the responses exhibited by the wife of an alcoholic are a manner of coping in response to the husband's alcoholism. This coping or enabling behavior, can be considered to be dysfunctional. Although these enabling coping behaviors may offer an immediate protection for the alcoholic crisis in the marriage, they in fact allow the alcoholism in the husband to progress. A person does not make a conscious choice about becoming alcoholic or co-alcoholic and without the evolution of alcoholism in an individual's life he or she may have made other choices. As the problems surrounding alcohol abuse cause more and more inconsistency and unpredictability in the marriage and home, the behavior of the spouse's non- alcoholic family members typically becomes an attempt to restabilize the marriage and family (Black, 1982). Members of an alcoholic marriage and family then choose to respond in manners which make life easier and less painful for them. 8 At what point does the wife of an alcohol abuser first seek to change the enabling responses, and seek to change the quality of the life experience and progression of the alcoholic patterns in the marriage? Often, spouses and families become caught in the alcoholism and co-alcoholism cycle and cannot see that their responses are dysfunctional. This study therefore was designed to explore the past life experiences of three women married to elderly alcohol abusers that led to the evolution of the first professional help-seeking attempt. Additionally, this study was designed to see if that help-seeking attempt changed the patterns of alcohol abuse in the marriage. Finally a comparison will be done to observe for the similarities in the three life experiences. A common pattern of response among these three women will be described. EEEEQ§§ The purpose of this study will be to examine the first professional help-seeking attempt of three women who are married to elderly alcohol abusers. The past life experiences which evolved to the point where the choice to seek professional help will be explored. Additionally any changes in the quality of that life experience since the first help-seeking attempt occurred will be explored. A comparison of the three life experiences will be done to 9 describe the similarities that occurred. The common pattern of response which best describes these three women will be suggested. A qualitative descriptive approach was chosen for this study. The reason this approach was selected was because the perception of the lived experience is what gives life meaning. It is in mutually discovering the meaning of life with a client that a nurse can facilitate the goal of health and well-being. IEEQIEQBQQ This study will be meaningful in several ways. First, although work has been done dealing with the wife of an alcohol abuser in general (Lewis, 1937; Futterman, 1953: Jackson, 1954, 1956, 1959, 1962; Orford & Guthrie, 1968; James & Goldman, 1971; Steinglass, 1981; Moos, Finney & Gamble, 1982; Jacob & Leonard, 1988) there has been little research done on the wife of an elderly alcohol abuser in particular. Secondly, this author can contribute to the study of alcohol abuse by viewing the elderly as being a unique group, with unique patterns of alcoholism, and co- alcoholism, possibly requiring special approaches. Third, this author may contribute to the study of gerontology by increasing the understanding that alcohol abuse is a problem faced by the elderly. Fourth, contributions to 10 nursing will be made in the area of qualitative research. There appears to be a small amount of qualitative research done by nurses in the literature. Yet qualitative research may support nursing as being unique in health care. Fifth, health care providers can benefit from understanding the meaning of any lived experience in order to mutually develop goals and design interventions. W121]: 1.) What past life experiences were perceived to lead to the evolution of the first professional help-seeking attempt on the part of the wife who believes her elderly husband to be an alcohol abuser? 2.) According to the wife, how did that first attempt at help-seeking change the life experience? e i 0 Ma' n e t Help-seeking will be viewed as a strategy that is directed at managing or altering a problem causing distress. Help-seeking is a problem-solving strategy in which the wife of an alcohol abuser seeks out information and support to reappraise the problematic alcohol abused marriage, and/or 11 learns new behaviors and skills by which to better manage or to change the alcohol abuse problems. This definition is based on stress and coping work done by Lazarus and Folkman (1984). Since alcohol abuse in a marriage can span periods of many years, wives can engage in a series of successful or unsuccessful attempts to obtain professional assistance. The help-seeking strategies to be described in this study will be the first time professional help was sought. Help-seeking can also be considered to be both professional and nonprofessional. Professional help-seeking approaches would include seeking help from professional counselors, family physicians, nurses, alcohol and drug rehabilitation centers, any community based resources in which a fee for service is given, and any nationally recognized organizations which deal in alcohol abuse such as Al-Anon. Nonprofessional approaches might include seeking help and support from family and friends. Although a wife of an elderly alcohol abuser might gain a great deal of support from informal sources, this study is designed to describe professional help-seeking. Al£2h21_AhQ§§ Alcohol abuse has been, and still is tragically and fundamentally misunderstood. Confusion stems back from 12 myths and misconceptions from thousands of years ago (Milan 8 Ketcham, 1981). Milam and Ketcham describe a common myth of an alcoholic as a ”...moral degenerate who choose a life of abasement and through lack of will power and maturity allows himself to lose his job, his family and his self respect...the typical alcoholic would rather be drunk than sober, who lacks confidence and maturity, who is riddled with guilt and shame over past sins and misdeeds, yet lacks the strength of character to change his ways and has no guiding purpose or motivation in life." (1981, pg. 9) Even today in health care and other helping professions, the term alcoholic takes on a variety of different meanings. Miller and Mastria (1977) have defined the different schools of thought; 1). those that claim alcoholism is a physical disease related to such factors as nutritional deficiencies or hereditary influences, 2). those that claim that alcoholism is mainly a function of socio- cultural variables, 3). and others that claim abusive drinking is caused by personality defects, such as self- destructive impulses, "oral" dependency needs, or an extreme need for power and autonomy. Other reasons for confusion in defining alcohol abuse stem from the wide variety of drinking patterns and behaviors of the person who abuses alcohol and to the many different drinking styles. Some drink daily, some in episodes, and others stay dry for long periods of time between binges (Miller 8 Mastria, 1977). Alcohol abusers use a wide variety of alcohol (beer, wine whiskey, and others) to achieve the same effects. 13 In order to fully understand alcohol abuse, it is necessary to examine several definitions. An individual may have "one too many" on an occasional basis, but not habitually abuse alcohol. One out of every 10 alcohol users, however does become an alcohol abuser (Miller 8 Mastria, 1977) who drinks too much too often. Experts and laymen alike try to classify the alcohol abuser in terms of their various symptoms. The difference between a heavy drinker, a problem drinker and an alcoholic, all who abuse alcohol to different degrees, is often questioned. A heavy drinker can be defined as anyone who drinks frequently or in large amounts. A heavy drinker may be a problem drinker, an alcoholic, or a normal drinker with a high tolerance for alcohol (Milam 8 Ketcham, 1981). A problem drinker can be described as a person who is not an alcoholic but whose alcohol use creates psychological and social problems for him or herself, and/or others (Milam 8 Ketcham, 1981). The problem drinker may be one who drinks in response to a problem situation. Alcoholism is defined as a chronic, primary, hereditary disease process which progresses from an early physiological susceptibility into an addiction characterized by tolerance changes, physiological and psychological dependence, and loss of control over drinking (Milam 8 Ketcham, 1981). The alcoholic, then, is the person who has alcoholism regardless of whether he is initially a heavy drinker, a problem 14 drinker, or a light to moderate drinker. The alcoholic's increasing problems and heavy drinking stem from the physical addiction and should not be confused with problem drinking, or heavy drinking in the non-alcoholic (Milam 8 Ketcham, 1981). The main differences between heavy and problem drinkers, and true alcoholics are that: 1). the true alcoholic has an increased tissue tolerance to the alcohol, 2). a physical dependence on the alcohol with physical symptoms, and 3). an irresistible need for the alcohol when it is withdrawn. Tolerance refers to the fact that a person gradually needs more and more alcohol to attain the same "high" that he/she once received from lower doses (Miller 8 Mastria, 1977). Thus, alcohol itself forces the alcoholic to become more and more dependent on its use. The eventual result is physical addiction. Once an individual becomes physically addicted, he/she must continue to drink or else experience unpleasant withdrawal symptoms. The progression of alcoholism can begin with the individual drinking socially to relax, or after a quarrel or disappointment. The alcoholic becomes more and more dependent on this pattern, imbibing larger quantities to get the same effect while concealing his or her actions (Milam 8 Ketcham, 1981). As alcoholism progresses, drinkers enter a second phase where they sometimes experience blackouts, morning tremulousness, remorseful hangovers, and job and 15 family difficulties. In spite of changing drinking habits, homes, and even jobs, they are unable to control their drinking. In the final stages, alcoholics cannot tolerate liquor as they used to, nor does it give them the same feeling of euphoria (Milam 8 Ketcham, 1981). Where is the point where an individual crosses over from social drinking to alcoholism? There is no specific point, but rather a continuum. The continuum may be considered to range from negative susceptibility at one end to positive susceptibility at the other end. Between are the areas of lower to higher susceptibilities. Low susceptibilities describe those who abstain altogether from drinking, have no tolerance for alcohol, do not use drinking as a problem-solving approach, have little hereditary background for alcoholism, and have healthy liver functioning. Those with high susceptibilities have increasing amounts of tolerance to alcohol, have used alcohol in response to problems, have a strong hereditary background, and have a defect in the liver metabolism for alcohol. Therefore, an individual could start socially drinking at age 21, and with high susceptibility become a true alcoholic by 22. Those with lower susceptibility could start drinking at 21, and have a slow increase in tolerance and dependence, and not present symptoms until age 50. Also, those who have fluctuating drinking patterns can effect this point by drinking and abstaining periodically 16 while the tolerance and dependence builds. For the purposes of this study, the broader definition of alcohol abuse will be utilized. Therefore, the elderly alcohol abuser by definition could be either a heavy drinker, a problem drinker or a true alcoholic. The elderly alcohol abuser will be identified through the perceptions of the wife. The rationale for use of this broad definition is associated with the fact that any instance of alcohol abuse can be perceived to be problematic, and therefore warrants study. The wife will be asked to describe the characteristics and patterns of the husband's alcohol abuse which occurred prior to the first help-seeking attempt and how they may have since changed. The characteristics of alcohol abuse include any predisposing factors that might exist such as abnormal metabolism or family history. The characteristics or alcohol abuse will also include any behavioral, physical, psychological and social factors as perceived to be problematic by the wife. Additionally any characteristics specific to alcohol abuse in the elderly as determined from the literature will be explored. Appendix A contains many of the characteristics of alcohol abuse as described by Milam and Ketcham (1981) from their framework on stages of alcohol abuse. Patterns of alcohol abuse are the actual drinking behavior that are repeated over time in a continuous 17 fashion. As the drinking behavior develops, changes occur which grow out of multiple previous experiences. The life long drinking pattern of the alcohol abusing husband will be described by the perceptions of the wife. Since help-seeking is seen as a problem-solving strategy, description of the life long drinking pattern will be important to see if the first help-seeking attempt facilitated any change in the of drinking behaviors. O r e The lived experience of the wife of an elderly alcohol abuser is considered to be a phenomenon. The interactions of the alcohol abusing husband and wife over time give the marriage a unique identity. The experience of the wife is inseparable from the alcohol abusive experience of the elderly husband because of the constant interactions in the marriage. The part of the whole life experience which is related to the alcohol abuse in the marriage may be perceived to be problematic by the wife. As the experience moves onward in life the mutual interactions in the marriage may give rise to change. This change might come from the choice of seeking professional help for the alcohol abuse in the marriage. 18 The lived experience of being the wife on an elderly alcohol abuser consists of both past and present interactions. The past experience consists of the actual living through the interactions which contain the wife's responses, thoughts and emotions. Through the wife actually living these responses, thoughts and emotions come knowledge and skills gained. This knowledge and skills can give rise to choices as the life experience proceeds forward. These choices can give rise to change. The present life experience of the wife of an elderly alcohol abuser has developed from the continuous mutual interactions, thoughts and feelings from the past experience. The mutual interactions have given rise to changes from the past. Choices were made by the wife which caused a change in life experience. The identity of the life experience in the present is different from that of the past. The responses, thoughts and emotions of the wife today have developed through time. This constant change of the life experience for the wife of an elderly alcohol abuser is an ongoing evolutionary process. Even though there may be some responses, thoughts and emotions that are similar to those of the past they are not exactly the same. Changes in the interaction of the wife and the alcohol abusing husband have occurred. Some of these changes evolved from choices the wife made. 19 Past work by researchers on wives of alcohol abusers has viewed wives from a variety of different perspectives. No research has been identified that has viewed the wife of an alcohol abuser from the perception of her lived experience. Much of the early research was based on clinical observation alone (Lewis, 1937: Price, 1945: Whalen, 1959). Wives were initially described as aggressive domineering women who wished to control their marriages (Lewis, 1937: Price, 1945). Some researchers felt that wives of alcohol abusers had a certain personality type (Whalen, 1959; Kalashian, 1959; Deniker, deSaugy, 8 Ropert, 1965). Other researchers believed that wives would fall apart if their husbands became abstinent (Futterman, 1953; Macdonald, 1956). The picture of these wives has gradually changed over the last 50 years. In opposition to the previous theories, Jackson (1954, 1956, 1959, 1962) felt that the personalities of the wives of alcohol abusers fluctuated relative to their husbands' involvement with alcohol. Jackson's work has not only received support (Bailey, Haberman, 8 Alksne, 1962: Baily, 1963, 1965, 1967; Kogan 8 Jackson, 1965: Moos, Finney 8 Gamble, 1982; Finney, Moos, Cronkite 8 Gamble, 1983), but her work was one of the first that examined the actual responses of the wife. Researchers have shown that wives' methods of coping with change when their husbands' alcohol abuse changes 20 (Orford 8 Guthrie, 1968; James 8 Goldman, 1972; Moos, Finney 8 Gamble, 1982). Additionally researchers have indicated that the level of disturbance of wives from an alcoholic marriage is not different from that of wives from problem marriages (Deniker, deSaugy 8 Ropert, 1964: Bailey, 1965). Wives of alcohol abusers can be considered to have basically normal personalities of different types. They may suffer personality disturbance when their husbands are actively drinking. Along with the personality fluctuations are changes in the wives' methods of coping. As the focus in research changed from viewing wives of alcohol abusers separately to one of focusing on the alcohol abusive marriage as a unit, a more interactive approach, the concept of roles evolved. The belief is that each person in an alcohol abusive family plays a role (Steinglass, 1978, 1981: Black, 1982). The players of these roles seek to maintain the homeostasis of the family unit. Different interactional patterns have also been identified for alcohol abusive marriages depending on the alcohol abusing husbands' drinking pattern and place (Jacob 8 Leonard, 1988). Wives married to episodic and/or binge drinkers experiences less problem-solving and had more negative attitudes than wives whose husbands were steady drinkers at home (Jacob, Dunn 8 Leonard, 1983; Dunn, Jacob, Humman 8 Seihamer, 1987). This researcher however will define the wife of an 21 alcohol abusing husband for this study based on her life experience as previously described. This will give the results of this study a much more humanistic qualitative appearance. The life experience of the wife of an elderly alcohol abuser will be considered to consist of both past and present interactions, which contain responses, thoughts and emotions. These constant interactions have given rise to change. Often this change has come about from the.- choices that the wife has made. These choices lead to change in the life experience. The three wives involved in this study will have been married to alcohol abusing husbands for at least five years. This will allow for change of the life experience. The wife must have sought professional help for either herself, her husband or both at least once. The husband must be at least 55 years old in order to show those alcohol abusers progressing into older age. 8511 S 1). The life experience a wife of an elderly alcohol abuser is a phenomenon which is shared by other wives of elderly alcohol abusers. 2). Alcohol abuse progresses and changes over time. 22 3). The wife's life experience cannot be separated from the husband's alcohol abuse. 4). The wife has developed responses, thoughts and emotions to the alcohol abusive interactions which give rise to the development of knowledge and skills. 5). The knowledge and skills derived from the past life experience give rise to choices. 6). Choices can give rise to change and the repatterning of the life experience. 7). The life experience constantly moves forward, never repeating itself. 8). The health and well-being of the wife can only be truly defined by the wife. Limitatigns 1). The sample of women will be three in number with no attempt at random selection. 2). The marriage of the alcohol abuser and the wife will be 23 at least of 5 years duration. The wife may be separated, but not divorced. 3). The age of the alcohol abuser must be at least 55, and not less. The purpose of this limitation is to be sure that only the elderly population will be studied. The age of 55 was chosen as the limitation in order to allow for those alcohol abusers who would be entering their elderly years. 4). The identification of the husband as an alcohol abuser will be left up to the perceptions of the wife, and will not be verified or validated by any other means. 5). The method of data collection will be a onetime interview format with the wife only. 6). There is a potential for interviewer bias as there will only be one interviewer. 7). All data collected will depend on the wife's recall, and are not verifiable. 8). Human beings are complex. Factors such as personality, environment, mental capabilities, values, and lifestyle are acknowledged to be important but are beyond the scope of this study. 24 9). Subjects are a volunteer sample. Those individuals who do not volunteer may be in some way systematically different from those who do, thus limiting the generalizability of the findings. W This study is presented in six chapters. In chapter I, the introduction, the purpose and importance of the study, the research questions, definitions of variables, assumptions and limitations of the study, and this overview of the following chapters is presented. In Chapter II a conceptual framework in which the main concepts will be developed within the chosen nursing theory will be presented. A review of the relevant literature will be presented in Chapter III. The research design and methodology are included in Chapter IV. Data analysis and results are contained in Chapter V. In Chapter VI the study findings, conclusions, recommendations and nursing implications are presented. CHAPTER II CONCEPTUAL FRAMEWORK mm The conceptual framework for this study has been developed to provide a systematic way to understand the wife of an elderly alcohol abusing husband. This conceptual framework utilized is based on Martha Rogers' theory for nursing (1970). Concepts discussed will include alcohol abuse in the elderly, and the response of the wife of an elderly alcohol abusing husband, which includes help- seeking. In this chapter, implications for nursing will be presented based on Rogers' theory and the nursing process. W Rogers considers her theoretical basis for nursing as a conceptual system of theories that are both humanistic and optimistic. The focus of Rogers' conceptual system is that of Unitary Man, which provides a broad perspective of man and environment and the person's response to various life events (Rogers uses the term "man" when referring to person.) Nursing is the science that studies Unitary Man. Rogers' (1970) theory of nursing provides a method of organizing abstract concepts and demonstrating their 25 26 relationships. There are four major concepts that compose Rogers' conceptual system; 1) energy fields, 2) open systems, 3) pattern and organization, and 4) four dimensionality. According to Rogers, energy fields are the fundamental units which constitute both man and environment. Energy fields are both dynamic and unifying. There are two energy fields: the human energy field and the environmental energy field. The energy field is always greater than the sum of its parts and cannot be viewed in terms of parts because parts do not exist. Unitary Man is viewed as a dynamic, unified energy field; rather than a being that has an energy field. The human and environmental energy fields flow through each other and are open. Therefore, if the fields are open then they extend to infinity and cannot be separated from each other. Man and environment cannot be separated. Rogers (1980) stated that the relationship between the human field and the environmental field is one of mutual interactions and mutual change. Man and environment are not to be separated but perceived simultaneously. Pattern and organization give identity to the energy fields. The nature of the pattern and organization continuously changes and are increasingly unique, more diverse, and complex. Change proceeds by continuous repatterning of both human and environmental fields and 27 reflects mutual, simultaneous interaction between the two fields at any given point in space and time. Rogers (1980) indicates that the existence of organization and patterning is a phenomenon and that the nature of life's pattern and organization is a constant process of evolution. Four dimensionality is described as a nonlinear domain. Unitary man is a four dimensional being in a four dimensional environment. A "point in time” that is present for one human interacting with the environment, is not necessarily present for another human. This concept can be thought of as the "relative present" or the "infinite now". To summarize, Unitary Man is defined as (1970, 1980) an irreducible, four dimensional energy field identified by pattern and organization and manifesting characteristics different from those of the parts, which cannot be predicted from knowledge of parts. Interaction between the human energy field and environmental energy field is such that both are repatterned mutually, continuously, simultaneously, and with increasing complexity in a four dimensional time matrix along a space-time continuum. Rogers has several main principles from her conceptual system called the Principles of Homeodynamics. These principles postulate a way of perceiving Unitary Man. The Principle of Resonancy refers to the nature of change occurring between human and environmental fields. Both are identified by wave pattern and organization manifesting 28 continuous change, accelerating, and decelerating, from lower frequency wave patterns to higher frequency wave patterns. The Principle of Helicy postulates the direction of the change. The nature and direction of the human and environmental change is unidirectionally forward, continuously innovative, accelerating and decelerating, probablistic and characterized by increasing diversity. Though there may be many similarities in experiences and reactions in life, they are never the same, and are non- repeating. The Principle of Complementarity refers to the inseparableness of the human and environmental fields. Man and environment have continuous and mutual interactions. This mutual process is a contradiction to the notion of causality. In a universe of open systems, mutuality is explicit, human and environmental fields change together (Rogers, 1980, 1982). Rogers nursing theoretical system is based upon five basic assumptions of man which are nursing's main concern (1970). The five assumptions are: 1) wholeness, 2) openness, 3) pattern and organization, 4) unidirectionality, and 5) sentience and thought. Whelton (1979) summarized these basic assumptions: 29 (1) Wholeness - there exists an individual integrity, and individual physical and psychological uniqueness, that is the person. (2) Openness - there is a constant interaction between the person and his/her environment. This exchange is ultimately affected by and effects all other interaction in the universe. (3) Pattern and Organization - as the person develops, he/she increases in complexity, his/her life-style and habits grow out of multiple previous human/environment interactions. (4) Unidirectionality - events in a person's life are unique, they do not come again or repeat themselves. (5) Sentience and Thought - a person has the ability to understand his/her world and his/her experiences in the world. In summary, the Principles of Homeodynamics postulate the nature and direction of unitary human development. The Principle of Resonancy refers to the nature of the change, the Principle of Helicy to the direction of change, and the Principle of Complementary to the inseparability of the human and environmental fields. Additionally, Rogers nursing theoretical system is based upon five assumptions of man. These assumptions are: 3O 1) wholeness, 2) openness, 3) pattern and organization, 4) unidirectionality, and 5) sentience and thought. These assumptions about human beings are the basis for a conceptual system which guides the nurse in practice. The abstractness of this theoretical perspective is what enhances its applicability to nursing practice. The major concepts of the theory explore what man is, his relationships to the environment, and the life process itself. These concepts are fundamental to the understanding of the wife and the elderly alcohol abusing husband. Rogers (1970) clearly believed in the growth process of man throughout the life process in addition to visualizing man as being able to effect change in his future rather than adapting to environmental influences. These beliefs of Rogers have implications for the wife of the elderly alcohol abuser. According to Rogers' theoretical basis, the wife has the potential to repattern her responses to the elderly husband's alcohol abuse, and seek help to grow, and to enhance the quality of her life process. The relationships of Rogers' theoretical concepts to the elderly alcohol abusing husband, and to the responses of the wife will be explored in the next two sections. These relationships will further substantiate the use of Rogers' theory for this study. 31 The abstract concepts of Rogers' theory can be utilized to explain alcohol abuse in the elderly. As man ages, he accelerates, and decelerates unidirectionally along time and space becoming more complex. Additionally, the elderly man's interaction with the environment is constantly being patterned and repatterned. Events in the elderly man's life never repeat themselves, so the elderly become more unique. Therefore, to define alcohol abuse in the elderly, this researcher proposes the need to look at the elderly and their problems as being increasingly unique and complex. The elderly husband who abuses alcohol is a dynamic unified energy field. This elderly man is greater than the sum of his parts. Therefore, this man's life experience is greater than just the alcohol abuse. Many other factors will contribute to the total life experience. The energy field that is the elderly husband who abuses alcohol is open, an flows through other energy fields such as those of his wife, family members, and the environment. Therefore, the elderly husband's life experience cannot be separated from his wife, or from the environment. The experiences of the husband and wife consist of mutual interactions and must be perceived simultaneously. 32 Pattern and organization give identity to the elderly alcohol abuser. Part of this man's identity then is the individual pattern or habit of drinking alcohol. The nature and pattern of this organization continuously change, and become increasingly more unique, diverse nd complex. Therefore the drinking habits of the elderly man will change over time, and become more diverse, and unique. This change in drinking habits reflects mutual,simultaneous interaction with the wife, family, and environment. The drinking patterns or habits evolve over time. As the life experience patterns and repatterns over time, the alcohol abuse itself will become more complex and diverse. The dependency and tolerance to alcohol will change and become a more unique experience than that of younger alcohol abusers. The symptoms and stages of alcohol abuse as known to the general alcohol abuser may not be totally accurate criteria to define the problem of alcohol abuse in the elderly. The elderly's experience with alcohol has probably evolved past the average person's experience. The main criteria used to define the stages of alcohol abuse fail to take into consideration the changing physiology and life styles of the elderly. The elderly man who abuses alcohol is a four dimensional being in a four dimensional environment. The point in time that is present for this man who is 33 interacting with the environment, is not necessarily present for another. The wife of this elderly alcohol abuser may not perceive an interaction in the same way. The wife may attempt to stop the alcohol abuse that the husband is seeking to maintain. Rogers' Principles of Homeodynamics can be applied to the elderly alcohol abuser. The Principle of Resonancy, which refers to the nature of change, describes the elderly alcohol abuser and the environment as being identified by pattern and organization. Interactions between man and environment are always changing, accelerating, and decelerating, from lower to higher frequency patterns. The elderly alcohol abuser is always changing from interactions with the environment. His alcohol abuse will affect the life experience and environment at different degrees as it evolves. The elderly husband's susceptibility changes from an increased tolerance to a lower tolerance with the increased complexity of the aging process. The alcohol abuse will become more complex, unique, and diverse as time goes forward. The Principle of Helicy which postulates the direction of change, suggests that the nature and direction of change is unidirectional, continuously forward. The elderly alcohol abuser may have life experiences that are similar to previous experiences, but they will never be the same. 34 Therefore alcohol abuse will evolve in sequential stages with increased complexity. The Principle of Complementarity refer to the inseparableness of the human environmental fields. Therefore, as the life process of the elderly alcohol abuser evolves it is continuously interacting with human and environmental fields. This mutual process is a contradiction to causality. So alcohol abuse may not be caused by one specific factor with specific symptoms but rather is evolved out of repatterning of personal, human, and environmental interactions. With increased complexity, uniqueness, and diversity of the aging process, the usually recognized symptoms associated with alcohol abuse may not be present, and symptoms patterned from the general health process of the individual may be more suggestive of the evolution of alcohol abuse. Rogers' basic nursing assumptions can be applied to describe the elderly alcohol abuser. The concept of wholeness refers to the individual uniqueness and integrity that is the person (see Figure 1). Openness refers to the potential extent of human and environmental interactions (this is indicated by broken lines in Figure 1). Pattern and organization refer to that which gives the person identity (name, past occupation, drinking patterns, stage of alcohol abuse). The pattern and organization is derived from multiple human and environmental interactions over 35 unidirectional four dimensional space time alcohol abuse patterning Thin lines indicate human/environmental fields of interactions which are infinite. Circles indicate the pattern and organization that identifies the alcohol abuser. oi drinking habits - min change in tolerance and pm 8 dcpendency renaming increased complexity - pattemin evolutrion of stages of alcohol abuse process of abuse continues to evolve Figure 1: A lication of Rogers’ Theory to an Elderly cohol Abuser 36 time. Unidirectionality refers to events encountered by the person that are not repeated. Sentience and thought refer to the capacity of the person to think, to understand, to experience, and to perceive his world. Sentience and thought is an important assumption to consider. The elderly alcohol abuser has the capacity to think about and understand his alcohol abuse. This assumption gives the person the ability to learn about alcohol abuse and to make choices. The past experiences regarding the alcohol abuse can lead towards continued abuse or cure, depending on how these experiences are perceived. Additionally, with these past abusive experiences, feelings such as guilt, depression, remorse, and denial can evolve. These feelings and any choices made will contribute toward future human and environmental interactions. To summarize, the elderly man who abuses alcohol can be defined as an irreducible, four dimensional energy field identified by pattern and organization. Pattern and organization, which include drinking patterns and stages of alcohol abuse give identity to this man. Interaction between human and environmental energy fields gives rise to mutual change or repatterning that is simultaneous and continuous. The elderly man who abuses alcohol will evolve along a space-time continuum becoming more complex, diverse, and unique. The life experience of an elderly alcohol abuser may have evolved past that of most alcohol abusers, 37 and is therefore more difficult to define and identify. Based on Roger's Principles of Homeodynamics, the basic assumptions, the elderly alcohol abusing man is conceptualized to be a unique individual, who has multiple human and environmental interactions that are never repeated. These mutual interactions give rise to change, or repatterning of the life experience. The elderly alcohol abuser has the ability to understand and perceive his world. Therefore he will have feelings and be able to make choices about this life experience. The next section will be an application of Rogers' theory to the responses of wives of elderly alcohol abusing husbands. Rogers' principles and basic assumptions will be reviewed with respect to the wife's response. T W 's s on e o u Even though many researchers and authors focus on the drinker, wives of alcohol abusers have also been the subject of many clinical reports and experimental studies (Edwards, Harvey 8 Whitehead, 1973). Intense marital conflict, marital separation, and divorce are frequent concomitants of alcohol abuse (Miller, 1976). Research has demonstrated divorce rates of chronic alcohol abusers range from 49% to 79% (Miller, 1976). The majority of those divorces reported 38 excessive drinking as the major cause of the marital conflict (Miller, 1976). The interrelationship between marital difficulties and alcohol abuse is so close that it seems hard to determine which came first, marital tension or excessive drinking. Marital tension and alcohol abuse seem to feed each other. In any event, most clinicians agree that a change in the relationship between the alcohol abuser and the spouse can be conducive to sobriety. The picture of the wife seems to be changing from that of an aggressive woman who married an alcohol abuser to fulfill her need to dominate, through that of one whose personality fluctuated with the stresses involved in marriage to an alcohol abuser, to that of a woman who may or may not react to the stress of her marriage with personality dysfunction (Edwards, Harvey 8 Whitehead, 1973). Wives of alcohol abusers are now considered to have basically normal personalities of different types, rather than one particular type. They may suffer personality dysfunction when their husbands are active alcohol abusers. However, these personality disturbances lessen when the alcohol abuse of their husbands decreases or becomes abstinent. Along with the personality fluctuations are changes in the wives' behaviors in response to their husbands' drinking and with their roles in the family. Responses of the wife to alcohol 39 abuse are very much like the responses to most any life crises (Moos, Finney 8 Gamble, 1982). Consistent with Rogers' conceptual system, the concepts of the elderly alcohol abuser, and his wife who interacts with the alcohol abuse cannot be separated (see Figure 2). As previously stated, alcohol abuse is seen as a unidirectional process that progresses by patterning and repatterning through space and time. As the alcohol abuser's susceptibility changes to an increase in tolerance and physical and psychological dependency to alcohol, he will pattern and repattern the drinking behaviors to support this process through space and time. The wife of the alcohol abuser cannot be segregated because, according to Rogers, she would be considered an integral part of the environment. The alcohol abuser and his wife are continuously interacting in a unidirectional way. The wife's responses are seen as a continual interaction with the alcohol abuser to protect the wife from the crisis of the alcohol abuse in the marriage. The wife's responses are continuously patterned and repatterned based on the husband's unidirectional progress of the alcohol abuse. Help-seeking is seen as an attempt at repatterning the life experience. The marriage relationships of an elderly alcohol abusing husband and the wife can be considered a system or "group field” (Rogers, 1982). A group field is a separate 40 group field In . z - with environmen - husband and wife interacting individually Thin lines indicate human/environmental fields of interaction which are infinite. Cirlces indicate the pattern and organization which identifies the husband and wife. The circles overlap to indicate a group field. change in ginking habits and evolution of alcohol abuse change in behavioral response to decrease stress - supporting abusive process repatterning , Eases? evolvrng omrng more complex. diverse. and unique \ Figure 2: Application of Rogers’ Theory to an Alcohol Abused Marriage 41 unique energy field which is made up of two or more individual energy fields. The group field can interact with the environment mutually and simultaneously as an individual unique system with its own identifiable pattern and organization, manifesting characteristics different from the sum of the parts. The husband and wife are also each a separate field. Environment is defined as an irreducible, four-dimensional energy field identified by pattern and organization, manifesting characteristics different from those of the parts, and encompassing all that outside any given human field. The husband and the wife then can be considered to be the environment to each other, as well as the environment being all outside of the marriage group field. Repatterning of human/environment interactions within the marriage can be expected to occur as the husband and wife interact with each other and the environment. The marriage partners seek to accomplish developmental tasks associated with marriage, family, and individual life cycles which are necessary for maximum health. As the marriage changes over time, accelerating and declining, the husband and wife may have common life experiences and reactions but the exact situation never recurs. Therefore, the alcohol abused marriage system is patterned and repatterned by human and environmental interactions that occur over time. 42 Rogers' basic nursing assumptions can be applied to describe the alcohol abused marriage, or group field. The concept of wholeness refers to the marriage as an open unit with members, the husband, and the wife (see Figure 2). The concept of openness refers to the extent of interaction within or outside the marriage (this is indicated by broken lines in Figure 2). Pattern and organization refers to that which gives the marriage identity (surnames, habits, drinking patterns, responses to drinking patterns). The pattern and organization are derived from multiple human and environmental interactions over time. Unidirectionality refers to events encountered by the marriage, within and outside, that are not repeatable. Sentience and thought refer to the capacity of the husband and wife to think, to understand, to experience each other, and to perceive each other. The relationship between the husband and the wife in the alcohol abused marriage at any given point in time and space is irreversible, non-repeatable, rhythmical, and characterized by pattern and organization and by increasing complexity. Within the context of the marriage, the elderly wife has perceptions, judgments, and reacts to her husband with certain responses, and his alcohol abuse in a way that is familiar (patterning) and has evolved over time (repatterning). Because the wife has the ability to think and perceive her environment, she is able to make choices 43 about the direction her own life experience leads. The wife of an alcohol abuser has the ability to decide to repattern her interactions, and responses. Therefore the wife of an elderly alcohol abusing husband can decide to seek professional help for herself and for her husband. Based on Rogers' Principle of Helicy, change within the marriage evolves in sequential stages and increases in diversity. Repatterning of the wife's responses can be expected to occur as the husband who abuses alcohol seeks to continue his alcohol abuse. Because of the complexity of the interactions in the alcohol abused marriage system, some of the responses of the wife will in fact actually support the drinking behaviors of the husband. The wife's responses will be characterized by patterning and repatterning to protect and to cause the least amount of stress within the marriage. The decision to seek help occurs as the interactions with the alcohol abusing husband become more complex. The husband's alcohol abuse will have evolved to a particular stage, with individualized drinking habits or patterns. Help-seeking behavior is an attempt by the wife to repattern her life experience. That is why responses of wives of elderly husbands who abuse alcohol can be identified and described by nursing professionals and will change over time. Rogers' Principle of Complimentarity refers to the inseparability of the human and environmental fields. The 44 marriage of the elderly alcohol abusing husband and his wife is considered a group field with each member, the husband and the wife, being an individual field. Therefore, the wife can be thought of as a part of the environment to the husband. Rogers emphasizes the continual mutual process between the human and environmental fields: human and environmental fields changing together. Keeping in mind Rogers' concept, if the wife has a change in her behavioral responses toward the husband's alcohol abuse, then as a mutual dynamic interactive part of the husband's environment, these response changes will impact the husband and his alcohol abusive behaviors. In summary, Martha Rogers' theoretical basis for nursing is utilized to conceptually describe the responses of the wife of an elderly alcohol abusing husband. The wife is considered to be a woman, who may have any type of personality, who is responding to the alcohol abuse of the husband like any other family crises, with responses. The purpose of these responses is to alleviate stress from the marriage system. Help-seeking is seen as an attempt to repattern the life experience. Based on Rogers' conceptual system and Principles of Homeodynamics, the partners in a marriage of an elderly husband who abuses alcohol and the wife are conceptualized to be a group field. This group field is made up of two separate fields. There are multiple human/environment 45 interactions, one which is the interaction with each other as a husband with alcohol abuse and his wife. The help- seeking behavior of the elderly wife interacting with the alcohol abusive husband is considered to be one pattern of human and environmental interaction, and as such, identifiable and describable for nursing. Responses of the wife will change over time as the alcohol abuse of the husband continues, and increases in complexity. This researcher's results will contribute to nursing knowledge by assisting nurses to identify, describe, possibly explain and make predictions about patterns of human/environmental interactions. An understanding of help- seeking and responses of the wife of an elderly alcohol abuser is necessary to design nursing interventions that facilitate the health of the wife and consequently the potential health of the husband. In the next chapter the review of literature relevant to this study is presented. Included will be a review of wives of alcohol abusers, and alcohol abuse. CHAPTER III REVIEW OF THE LITERATURE Introdugtion The purpose of this chapter is to report on the literature that is pertinent to this study. The areas of literature to be reviewed are alcohol abuse in the elderly, and wives of alcohol abusers. An additional discussion will be presented for both areas to review the implications from current studies and their relationship to the present study. The topics covered under alcohol abuse in the elderly are the prevalence, criteria for identification, stages and patterns, and predictors. ALCOHOL ABUSE IN THE ELDERLY Alcohol abuse in the elderly continues to be a neglected area of research in the field of gerontology (Petersen 8 Whittington, 1981). In the field of nursing there was not any research identified that pertained to alcohol abuse in the elderly. Scholarly literature in the field of drug and alcohol abuse concerning the elderly has been previously overlooked because of the preoccupation with these problems among young and middle-aged people (Petersen 8 Whittington, 1981). 46 47 Existing data on the prevalence of alcohol abuse in the elderly indicated that there was a low rate of problems among this group (Graham, 1986). Graham (1986) suggested that as the generations who are younger continue to age, higher rates of alcohol abuse will occur. There will be more elderly who have liberal views on the use of alcohol (Graham, 1986). Additionally, Graham (1986) suggested that there has been difficulty identifying alcohol abuse in the elderly because they are often isolated, or protected and the symptoms are often confused with those of aging problems. Therefore, the real prevalence of alcohol abuse in the elderly is unknown. Those working in the health field and related areas have begun to take more seriously the use and misuse of drugs and alcohol by older persons. Petersen and Whittington (1981) noted that the number of writings on this topic from 1975 to 1980 are almost as many as those writings in the three decades prior to 1975. Prevalgnge of Alcohol Abuse in the Elderly Much of the initial research of alcohol abuse in the elderly deals with the prevalence (Bailey, Haberman 8 Alksne, 1965; Zimberg, 1974). Since the awareness of alcohol abuse in the elderly developed only recently a large 48 portion of this research has dealt with identifying its magnitude. Bailey, Haberman, and Alksne (1965) in a household prevalence survey of 3,959 dwelling units in New York City found that there was a second peak prevalence of alcoholism in the 65-74 year old age group which was almost as high as the level of the first peak prevalence they found in the 45- 54 year old group. Interestingly, the prevalence among the 55-64 year old group was markedly lower than either of the two adjacent age groups. This decline in the prevalence from the 45-54 age group to the 55-64 age group may account for the belief that alcoholism decreases with age. This would be reinforced by the failure of many surveys to include subjects over 60 years of age. zimberg (1974) reviewed studies and found evidence that 23 percent of patients over age 60 in a psychiatric observation ward were clearly alcohol abusers. Other studies reviewed by zimberg of general medical hospitals produced rates of 15-38 percent for men and 4 percent for women having alcohol problems. A household study carried out in Western New York by the Division of Alcoholism and Alcohol Abuse (1979) reported that approximately 1/4 of men in their 60s were heavy drinkers, and even larger proportions, 41 percent of men 50- 59 were heavy drinkers. These findings were not consistent with Bailey, Haberman and Alksne (1965) who found a markedly 49 lower prevalence in the 55-64 year old group. Since this Western New York study was done in 1979, perhaps the high rate of prevalence in the 45-54 year old group found in Bailey, Haberman and Alksne has aged and is now reflected in the older group. So not only is there a considerable population of elderly now with drinking problems, these figures suggested that this trend will only increase in the future. Barnes (1982) reviewed the number of studies (including her own household survey in Western New York State) and found the prevalence of heavy drinking among older people to be approximately 6-9 percent (compared to 20 percent heavy drinkers in the total sample). Similarly, 54 percent of people aged 18-49 had one or more alcohol related problems compared to 30 percent of those aged 50—59 and 9 percent of those 60 and over. Warheit and Auth (1983) categorized only 2.3 percent of those over 50 years old as being at high risk for alcohol related problems. This was compared to 5.7 percent of those aged 30-49 and 9.8 percent of those aged 18-24 who were at high risk for alcohol-related problems. In a study on alcohol behavior among older adults, LaGreca, Akers, and Dwyer (1988) found that 1 out of 5 of their respondents reported drinking some kind of alcoholic beverage nearly daily or daily. Also, 3.1 percent of the total sample (4.3 percent of the drinkers) experienced a 50 drinking related problem in the past year and 6.3 percent scored as heavy consumers in the past year. The typical quantity measure showed that a little over 5 percent drank four or more drinks per day. Retrospective self reports also revealed that most of the respondents continued the pattern of drinking behavior established before they were 60. Most either remained abstainers or maintained the same general level of drinking. Some changes, however, did occur in that 3.9 percent decreased drinking whereas almost 5 percent began drinking, increased drinking, or became heavy drinkers. The actual prevalence of alcohol abuse in the elderly is really unknown. The previous studies range the numbers from 2-10 percent with estimated prevalences being considerably higher for elderly individuals who are patients of general medical wards and psychiatric patients. Diagnosis of alcohol abuse in the elderly is complicated, as the alcohol problem is likely to be denied and hidden by the elderly and often even by the family members (Petersen 8 Whittington, 1981). Elderly drinkers may not even be aware that they have an alcohol problem, and they may suffer from symptoms which they do not realize are related to their drinking (Petersen 8 Whittington, 1981). Physicians are often unwilling or unable to recognize elderly alcohol abuse, and care facilities may not address it as a problem (Zimberg, 1974). Criteria that help professionals identify 51 alcohol abuse may not be accurate or valid for the elderly. The next section will cover literature reviewed on criteria for identification of alcohol abuse in the elderly. e ' den WWW A factor in recognizing the problem of alcohol abuse in the elderly is the common criteria used for diagnosing alcohol abuse. The following researchers suggest that different criteria may need to be applied for the elderly. Clark and Midanik (1980) reviewed studies on alcohol abuse and found the following criteria typically used in operational definitions of alcohol abuse in general population surveys: 1) high levels of alcohol consumption, 2) symptoms of alcohol dependence or withdrawal, and 3) adverse consequences or life problems resulting from alcohol intake. Clark and Midanik (1980) suggest that these criteria fail to take into consideration the changing physiology and life styles of the older population These criteria may not be appropriate to identify elderly alcohol abusers. Rosin and Glatt (1971) reported on 103 elderly alcoholic patients, with a hypothesis that elderly alcoholics have less frequently observed withdrawal symptoms than the general alcoholic population. They reported only 1 52 person with delirium tremens out of the 103. Also, Rosin and Glatt found that most elderly alcoholics do not require detoxification. Thus using a criteria of symptoms of alcohol dependence and withdrawal may not be appropriate for the elderly. Rosin and Glatt (1971) found that health problems rather than social problems were more indicative of alcohol abuse in the elderly. Self neglect, falls, excessive incontinence, and confusion were more often observed than marital and job related problems. Zimering and Domeischel (1982) recognized that the elderly alcohol abuser consumes less alcohol than the younger alcohol abuser, however they are more likely to drink daily. One of the main reasons for the decrease in alcohol consumption is the liver's inability to metabolize alcohol as it should (Zimering * Domeischel, 1982). Therefore, smaller amounts of alcohol will produce the same effect in the elderly as large amounts will in younger people. This liver change can come from aging as well as from years of alcoholism (zimering 8 Domeischel, 1982). Additionally, zimering and Domeischel (1982) explained that there is less tolerance for alcohol due to the elderly person's lower body water content and less lean body mass which affect the distribution of the alcohol. Therefore in recognizing the problem of alcohol abuse in the elderly, one 53 must recognize that the elderly may consume lower amounts of alcohol than the younger alcohol abuser. Graham (1986) reviewed existing instruments for identifying and measuring alcohol abuse in the elderly population. She concluded that these instruments were inappropriate for use with elderly populations because of differences between the elderly and the younger populations on which these measures were standardized. Graham (1986) found five domains commonly used for all ages in measuring alcohol abuse: 1) level of consumption, 2) alcohol related social and legal problems, 3) alcohol related health problems, 4) symptoms of drunkenness or dependence, and 5) self-recognition of the problem. The extent to which these domains, as currently measured, apply to the elderly population may be inappropriate. The first domain, the level of consumption, has been the most commonly used measure. It may be misleading to interpret proportions consumed without adjusting for age. Four drinks per day may be relatively benign for a robust 30 year old man but very damaging to a 100 pound, 70 year old woman. Graham recommended that valid measures of alcohol abuse for the elderly need to be developed. Studies need to be done to identify problem levels of consumption for different age groups. Using the same cutoff to define alcohol abuse regardless of the age does not give an accurate comparison. 54 The second domain, alcohol related social or legal problems has focused on the kinds of problem experienced by nonelderly men, including employment and marital problems, drinking and driving, and legal and financial problems. For a retired, widowed, elderly man who has few social contacts and no car, he has fewer opportunities to have problems in these areas. Graham (1986) described more appropriate indicators for the elderly which might include 1) housing problems, 2) falls or accidents, 3) poor nutrition, 4) inadequate care of self, clothing, and living quarters, 5) lack of physical exercise and 6) social isolation. According to Graham the third domain of health problems related to alcohol abuse, was suggested to be the best way to identify elderly alcohol abusers. However these markers must be standardized for the elderly population. We need to know the probability that certain health problems can be used to identify alcohol abuse in the elderly. Health professionals can be more effective in directing the elderly alcohol abusers toward treatment if there is clear evidence of alcohol related health problems that are separable from age related health problems. Dependence measures the fourth domain. This measure has been less useful for identifying alcohol abuse among the elderly. Dependence and drunkenness symptoms may be denied, attributed to something else or unrecognized according to Graham (1986). 55 The fifth domain of identification of alcohol abuse, self recognition of alcohol-related problems, seemed to be much less likely among the elderly. Graham felt this may be because of denial or because alcohol-related problems are mistaken for or confounded with age-related problems. The previous literature has indicated that the criteria for identifying alcohol abuse in the general population may not be appropriate for the elderly. Health problems have been suggested as more indicative of elderly alcohol abuse (Rosin 8 Glatt, 1971; Graham, 1986). Tolerance and dependency to alcohol appear to be less. Criteria for assessing alcohol abuse in the elderly population appears to warrant development. Studies need to be done to determine valid and reliable measures. The next section includes a review of literature on the stages and patterns of alcohol abuse in the elderly. t e nd Patterns co s W At present there has not been any literature identified which looks at staging of the alcohol abusive process relative to age. There are however, several studies on patterns or drinking habits of the elderly. One important question which has been raised is whether or not elderly 56 alcohol abusers developed their alcohol problems during old age or earlier in their lives. Zimberg (1974) described elderly alcohol abusers as belonging to one of two groups: 1) those who began drinking at an early age (early onset), and 2) those who began drinking later in life (late onset). Those associated with late onset alcohol abuse seemed to use alcohol as a coping mechanism to adapt to the problems of aged individuals (zimberg, 1974). Problems and stresses of aging include depression, bereavement, retirement, loneliness, marital stress, and physical stress. Elderly persons ccould indeed be alcoholics, but could also be problem drinkers. Those alcohol abusers in the late onset group responded readily to treatments which included anti-depressants, socialization and problem-solving programs (Zimberg, 1974). Early onset drinkers started early in life. It was commonly believed that by the time this group reached old age, they had many physical and psychological problems from long-term drinking. Part of this group was either in nursing homes or psychiatric hospitals. These long-term drinkers were considered "burned out". Others from the early onset group never made it to old age because they died from physical effects of drinking, accidents, and suicides. However, Zimberg suggested that it is becoming more apparent that there are many long-term elderly drinkers whose health status has not overly deteriorated and who are still 57 functioning in society as they always have. zimberg suggested that those elderly alcohol abusers who did not deteriorate had fluctuations in their drinking patterns or simply had the ability to tolerate the long-term drinking. Rosin and Glatt (1971) found that late onset alcohol abuse was associated with the stresses and problems of aging. Late onset alcohol abusers did not seem to have the deep-rooted psychological problems or the personality characteristics of younger alcohol abusers. Rosin and Glatt (1971) suggested that these late onset drinkers seem to use alcohol as a coping mechanism to adapt to the problems of aged individuals. Glantz (1981) was particularly interested in the late onset group of alcohol and drug abusers. The late onset group of alcohol abusers constituted about one-third of all alcohol abusers as compared to two-thirds for early onset. Glantz formulated a model to make predictions about the most probable patterns of drug and alcohol abuse in the elderly, and to identify some of the factors which are likely to be antecedent to drug and alcohol abuse among the aged. Glantz specifically hypothesized that elderly drug and alcohol abuse is related to coping problems. He suggested that there are a number of social and psychological factors which contribute to the development by some elderly adults of a reliance on psychoactive substances as a coping mechanism which may then lead to abuse. 58 Hochhauser (1981) on the other hand, attempted to conceptualize substance abuse problems among the elderly late onset group within a learned helplessness framework. After experiencing a variety of uncontrollable events (death of a significant other, relocation, health problems, retirement) the elderly person may come to believe that he/she is being controlled by environmental events. As helplessness is learned, there may be increased emotional problems (depression and anxiety), cognitive deficits ( a belief that thing cannot be changed) and motivational deficits (a tendency to give up). In an effort to cope with learned helplessness and its consequences, the elderly may resort to the use, misuse, or abuse of substances. The research of Dunham (1981) reported the inordinate degree of change in drinking patterns associated with aging in a sample of 310 residents of Miami, Florida, who were 50 years of age and older and living independently in congregate housing. The author employed a self-reported retrospective measure of life-drinking behavior that focused on key events in an individual's drinking history and that was general enough to allow reasonably accurate recall of events. The variables of interest were the age at which these middle-aged and older subjects first began to drink regularly (once a month or more often), the ages at which they drank the heaviest, the ages that they drank the least, the ages that their drinking was most typical of their total 59 drinking years and their current drinking activity. At each point respondents were asked to give a general estimate of the amount and frequency of drinking. Dunham found that there were six distinct patterns of drinking behavior (excluding abstinence) over a lifetime. Although Dunham noted six patterns, only four applied to the elderly alcohol abuser. Dunham's four patterns of alcohol abuse in the elderly (Table I) include: 1) the "rise-and-sustained" pattern, where the heavy drinker continues into old age, 2) the ”light-and-late-riser" pattern, where the drinking is very light throughout one's life and rises when one reaches old age, 3) the "late-starter" pattern, where the person does not drink regularly until later in life when they rise to heavier drinking, and 4) the "highly—variable" pattern, where drinking rises and falls during life. Dunham described the rise-and-sustained pattern and the highly- variable pattern as those most likely fitting into the early onset alcohol abuser as described by zimberg (1974). Those late-start and light-late-risers were probably in the late onset group. In summary, the elderly alcohol abuser can be described as belonging to one of two groups. The first group called "early onset" are those who began drinking at an early age. By older age some of these people were either in psychiatric hospitals, nursing homes or had multiple health problems Table I: Dunham’s Four Patients of Alcohol Abuse in the Elderly Rise-and-Sustained Hea LI ht In Non nk Years 0 IO 20 30 40 50 60 70 80 90 Light-Late-Rlscrs Heavy Moderate Li ht In Non nk Years 0 10 20 30 40 50 60 70 80 90 Late-Starters Heavy Moderate Li ht In Non nk Years 0 IO 20 30 40 50 60 70 80 90 Highly-Variable Heavy Moderate LI ht In Non nk Years 0 10 20 30 40 50 60 70 80 90 61 (zimberg, 1974). Others from this group have managed to maintain some health and have functioned in society. This may be due to fluctuating drinking patterns and/or protection and help from family members (Zimberg, 1974). The second group of elderly alcohol abusers are called "late onset”, and did not start drinking until later in life. Members of this group are thought to drink in response to the stressors and life problems of aging (Rosin 8 Glatt, 1971: Glantz, 1981). Another belief is that the elderly drink in response to uncontrollable events such as the death of a loved one, or retirement (Hochhauser, 1981). Dunham (1981) proposed four groups which describe the drinking patterns or behaviors of the elderly: 1) the "rise- and-sustain" pattern, 2) the "light-and-late riser" patterns, 3) the "late starter" pattern, and 4) the "highly variable” pattern. Dunham described the rise-and-sustained pattern and the highly variable pattern as fitting into the early onset alcohol abuser group. Those late-start and light-late-risers are in the late onset group. The next section will include a review of literature on predictors of alcohol abuse in the elderly. WW Over the last 10 years researchers (Smart 8 Liban, 1981; LaGreca, Akers 8 Dwyer, 1988) have begun to look for 62 predictors of alcohol abuse in the elderly. Smart and Liban (1981) reported on the results of a household survey of 993 persons aged 18 and over in an area near Toronto, Canada, regarding the predictors of drinking problems and dependency symptoms at various age levels, including the elderly. The results indicated that far more problem drinking was found in younger than elderly persons, but that elderly problem drinkers were most difficult to predict, probably because of their lower alcohol consumption. The authors' expectation that drinking predictors especially the frequency and volume of consumption, would be different for elderly persons was not supported. Serious dependency symptoms were best predicted by volume and frequency of consumption at all levels of age. The elderly problem drinker was most likely to be male, born outside of Canada, not retired, in the lower socio-economic group and drinking several times a week but not in very large quantities. Christopherson, Escher, and Bainton (1984) studied reasons for drinking, and past and present drinking patterns among the elderly in rural Arizona. Interviews were conducted with 444 individuals aged 65 plus. Responses to a list of 20 reasons for drinking were divided into six groups: social, mood change, food, health, personal coping and interpersonal coping. Respondents were grouped into categories on the basis of their quantity and frequency of alcohol consumption. These categories were abstainers, 63 light drinkers, moderate drinkers and heavy drinkers. Approximately 80 percent of the respondents drank for the more acceptable or "right" reasons (social, mood change, food or health). Only 12 percent indicted that they often drank for one or more of the coping reasons. Light, moderate, and heavy drinkers were differentiated according to reasons for drinking, as were the various age groupings. Findings indicated that the rural elderly's alcohol use was generally at an acceptable and nonabusive level and style, that alcohol use diminishes with age, and that drinking patterns and reasons generally remain consistent into old age. Therefore the evidence in this study for either drinking or abstinence as a stable and largely predictable aspect of one's overall lifestyle seemed much more convincing than the notion of an increase in alcohol consumption in response to the crises, frustrations and deprivations of old age. LaGreca, Akers, and Dwyer (1988) studied the relationship between life events and alcohol behavior. The authors investigated 1,410 persons over the age of 60, in two retirement homes, and two age-heterogeneous communities. The hypothesis that higher frequency, greater quantity, or problem drinking occurs in this age group as a response to significant life events was not supported. Additionally, social support networks were not significant mediators for the impact of life events on alcohol use. 64 Therefore, researchers (Christopherson, Escher 8 Bainton, 1984: LaGreca, Akers 8 Dwyer, 1988) have found that drinking behaviors in the elderly may be a stable and largely predictable aspect of one's overall lifestyle. The hypothesis that problem drinking occurs in response to stressors or significant life events has not been substantiated. The next section will include a summary of all the previously reviewed literature on alcohol abuse in the elderly. Summary In summary, researchers have begun to take more seriously the use and misuse of alcohol by older persons. ‘Many initial studies have dealt with identifying the prevalence of alcohol abuse in the elderly, which has ranged form two to ten percent. The actual prevalence is unknown because alcohol abuse in the elderly is complicated, hidden, or unrecognized. Criteria used to define alcohol abuse may need to be different for the elderly. Levels of consumption may be less. Tolerance and dependency may be a different experience. Adverse consequences resulting from alcohol intake seem to be related to health problems and levels of self care and functioning. Valid measures for alcohol abuse in the elderly need to be developed and standardized to aid 65 health professionals in being more effective in directing elderly alcohol abusers toward treatment. Drinking patterns or behaviors in the elderly can be divided into two groups: 1) early onset, and 2) late onset. Those in the early onset group started drinking at an earlier age and have managed to maintain their functioning into their later years. Those in the late onset group were believed to drink in response to the stresses of aging. This however has not been substantiated. Drinking behaviors in the elderly may reflect one's overall lifestyle. The next section includes implications from the recent literature and their relationship to the present study. W The previously reviewed literature on alcohol abuse in the elderly relates to this present study in several ways. First because alcohol abuse in the elderly is hidden or unrecognized, identifying appropriate candidates for this study will be more difficult. Some wives may not wish to be interviewed, others may not realize that they actually have been experiencing alcohol abuse in their marriages. Second, there is not standardized criteria to define alcohol abuse in the elderly. The alcohol abuse of the husband will be determined by the wife's perception. The direction of the questions of the interview in this study 66 will be mainly based on criteria developed for the general population. Additional criteria will be added based on the previously reviewed literature. This will be only an attempt at identifying alcohol abuse in the elderly, and may not necessarily be completely valid. Research needs to be done to develop valid and reliable measures of alcohol abuse in the elderly not only to improve research, but in order to identify those elderly who are in need of treatment. Third, although there has been some studies on drinking behaviors or patterns in the elderly, these studies were all cross sectional. Longitudinal research is needed to determine whether or not the late onset group who abuse alcohol is in response to the stressors of aging, or whether drinking is a lifestyle pattern that is carried into old age, and becomes abusive due to the normal changes of aging. Also, longitudinal research is needed to determine exactly what happens to the early onset group who is able to maintain their lifestyle into old age. Although this study will be able to identify the drinking patterns of the husband based on the perception of the wife, explanations as to why these patterns evolved in an abusive way will be merely hypothetical because this is a cross sectional design with a small sample group. Finally, the state of research for the elderly who abuse alcohol seems to be in more of an exploratory stage. The problem appears to have been identified, but hypotheses 67 and models to explain and predict alcohol abuse in the elderly need to be generated. Nurses in particular need to address alcohol abuse in the elderly with research in order to develop measures for care. That is why this study is of an exploratory nature. The next section will be a review of literature on wives of alcohol abusers. This section will include discussions on the Disturbed Personality Theory of wives of alcohol abusers, the Decompensation Theory, the Stress Theory, and the interactional approach of looking at wives of alcohol abusers as part of a family system and through social learning. In addition the topic of codependency will be reviewed. A discussion which will relate the literature findings to the present study will be included. WIVES OF ALCOHOL ABUSERS Wives of alcohol abusers have been the subject of many clinical reports and experimental studies (Edwards, Harvey 8 Whitehead, 1973). In reviewing the literature up to this date, there have been no studies of behaviors of wives of alcohol abusers specifically in the elderly population. Additionally, there have been no studies identified by nurses. Therefore, the studies and literature reviewed do not reflect age as a variable, but simply look at wives of alcohol abusing husbands. 68 The picture of the wife as depicted in the literature seems to be changing from that of an aggressive woman who married an alcoholic to fulfill her need to dominate (Lewis, 1937), through that of one whose personality fluctuated with the stresses involved in marriage to an alcohol abuser (Jackson, 1954), to that of a woman who may or may not react to the stress of her marriage with personality dysfunction (Kogan 8 Jackson, 1965a). The emphasis is shifting from focusing on the individual alcohol abusing husband and the individual spouse to that of the marriage as an interactional system in which alcohol is a problem (Steinglass, 1981). The following discussions include reviews of literature on the Disturbed Personality Theory, the Decompensation Theory, the Stress Theory, the Psycho- social Theory, the interactional approaches of family systems and social learning, and codependency. he is bed Perso a t heo The Disturbed Personality Theory was the first postulated to describe wives of alcohol abusers. This Disturbed Personality Theory was based on the psychoanalytical view which characterized women with certain personalities who tended to select alcohol abusers or potential alcohol abusers as their mates. These women drove their husbands to drink to satisfy their own pathological needs. They were often described as hostile, and 69 controlling women, who would fall apart if their husbands became sober. These theorists were most often social workers or psychiatrists directly involved in the treatment of alcoholics and their wives and as a result, the majority of the studies which back this framework are little more than clinical impressions of wives seen in treatment (Edwards, Harvey 8 Whitehead, 1973). Lewis (1937) wrote one of the first articles devoted to describing wives of alcoholics. Such a wife found an outlet for her aggressive impulses in her marriage with a man who was partially dependent and who created situations that forced her to punish him. Lewis believed that the husband often took on a feminine role, and that the therapist's job was to help him become more masculine. Price (1945) studied 20 wives of alcoholics and described the wife as being a typically dependent person who became hostile or aggressive toward the husband. The wife interpreted the husband's drinking as a rejection of her, or lack of love, or to get even because the wife had been too demanding, or had assumed more responsibility than the husband. The wife then made her husband feel more inadequate, which caused a continual repeat in this process. Price theorized that the alcoholism of the husband was proof of the wife's superiority and the husband's inadequacy. Therefore, the wife would fight treatment for the husband. Whalen (1959) described wives of alcoholics seen in a 70 family service agency. She concluded that they had married to fulfill certain personality needs of their own and that their husbands possessed particular psychological characteristics that enabled them to fill these needs. Whalen placed these wives in four categories: 1)”Suffering Susan," who, to punish herself, chose a husband who would make her life miserable; 2)"Controlling Catherine," who needed to dominate someone and so chose a weak, inept husband; 3)"Wavering Winnifred," who, to be loved, sought a weak husband who needed her desperately; and 4)”Punitive Polly," who needed an emasculated husband to control and punish. Whalen proposed that such women often, but not always, chose an alcoholic. In an attempt to compare alcoholic's wives with a control group, Deniker, deSaugy, and Ropert (1965) compared 100 alcoholics and their wives to 100 non-alcoholics and their wives. The 100 alcoholics and their wives were divided into two groups,s 50 psychiatric alcoholics (those with chronic disorders chiefly psychiatric in nature) and 50 digestive alcoholics (those with chronic hepatodigestive disorders). Deniker, deSaugy, and ropert concluded that most of the character traits manifested by the alcoholic couples had little specificity and could be observed in any neurotic couple. One significant finding was that the wives of psychiatric alcoholics unconsciously maintained their husbands' alcoholism, and needed treatment themselves. 71 However, wives of digestive alcoholics, if aided by professionals, could frequently help their husbands to recover. Thus the authors indicated that there might be two types of wives, and that a wife's personality type might be related to her husband's type of alcoholism. Lemert (1962) looked at dependency in marriages of alcoholics as the variable between two groups: those in which drinking was a problem before or at marriage and those in which the problem developed after marriage. The first had a much higher incidence of dependency attributes, however, dependency was not demonstrated to be a common factor in any of these marriages. This information causes questioning of the idea of dependency of the husband and wife to each other in the disturbed personality theory. Corder, Hendricks and Corder (1964) attempted to broaden the knowledge about alcoholics' wives by measuring personality characteristics of wives motivated to join Al- Anon. There were 43 volunteers, representing 75 percent of the active membership of two Al-Anon groups and a control group of 30 women married to nonalcoholics, matched in a mean age, educational and economic levels. The group form of the Minnesota Multiphasic Personality Inventory (MMPI) was administered and the mean T- scores were compared on 9 clinical and 4 validating scales. The Al-Anon group scored slightly higher than the controls who were not Al-Anon members on 4 clinical scales, but both groups were within 72 normal range for each scale. These results, the authors said, seemed to bring into question the characterization of the wives of alcoholics as severely neurotic and disturbed. The most limiting factor in this study was again the use of a small sample and highly motivated women who joined Al- Anon. In another examination of the disturbed personality theory, Haberman (1964) studied 156 wives from various social agencies. He looked at variations in psychophysiological symptom scores in the wives during their husbands' periods of drinking and periods of abstinence. The women all revealed fewer symptoms when their husbands were abstaining. These studies share several limitations. First, aside from Deniker, desaugy and Ropert 91965); Lemert (1960); and Haberman (1964), these researchers (Lewis, 1937: Price, 1945; Whalen, 1959; Corder, Hendricks 8 Corder, 1964) used relatively small numbers of wives. Second, it is not possible to know whether the wives described were representative of the total population of alcohol abusers' wives. Some of these studies (Lewis, 1937; Price, 1945: Whalen, 1959) were actually clinical impressions of wives seen in treatment. Studies such as Lemert (1960) and Corder, Hendricks, and Corder (1964) provided conclusions that did not support the Disturbed Personality Theory. Taken as a whole, studies of the Disturbed Personality 73 hypothesis do not provide any similar results which would demonstrate a unique personality type for wives of alcoholics. The Disturbed Personality Theory about wives of alcoholics was proposed at a time in which traditional sex roles and role relationships were the norm. No similar theory about husbands of alcoholic women has ever been proposed. It may be that the Disturbed Personality Theory can be seen as a social reaction to women who took on nontraditional roles to maintain their families during the alcoholic crises. This was then interpreted as psychopathology by traditional clinicians. The next section is a review of the literature on the Decompensation Theory. W The Decompensation Theory is a corollary to the Disturbed Personality Theory. The Decompensation Theory states that, if an alcoholic man is able to successfully stop drinking, then his wife will decompensate. This decompensation is said to occur because marriage to an actively drinking alcoholic was thought to be a defense against unconscious psychological conflict. Removal of this defense was thought to result in a disintegration of the woman's personality integration, with resultant severe psychological problems, such as a major depression or psychosis. 74 Futterman (1953) concluded that there was much clinical evidence, although he did not describe what it was, that wives of alcoholics, because of their needs, seemed unconsciously to encourage their husbands' alcoholism. The wives tended to identify with their strong dominant mothers. These wives unconsciously felt inadequate and so chose a weak, dependent husband. When this marriage relationship was disturbed by a decrease in the husband's drinking, the wife would fall apart. Following Futterman's (1953) concept of decompensation, Macdonald (1956) studied 18 women admitted to a state mental hospital who were wives of alcoholics. He found 11 cases of decompensation associated with a decrease in the husband's drinking, one associated with an increase, and six in which there had been no change in the husband's drinking pattern. Macdonald's study was one of the first attempts to investigate empirically a hypothesis suggested by psychoanalytic theorists. It gave some support to Futterman's (1953) theory that personality decompensation in the wife would follow abstinence in the husband. Kalashian (1959) described wives of alcoholics who were in treatment as needing to play a maternal role. This study ‘was based on women who were still in marriages in spite of being able to manage financially alone. Something other than financial support must make the marriage worthwhile. Because she felt needed, the wife was able to deny herself. 75 Kalashian also suggested that the wife's defensive response to her husband's drinking made him hostile, which caused her feelings of guilt, so the wife would indulge the husband to reduce guilt. Like Futterman (1953) and Macdonald (1956), Kalashian found that the husband's recovery could present a problem to the wife leading her to anxiety, depression, phobias, and somatic disorders. Clifford (1960) compared 25 wives of alcoholics unable to maintain a durable remission with 25 wives of alcoholics abstinent for a long period. Clifford found from the results that the wives of abstinent alcoholics had, in many cases, caused their husbands to seek treatment by threatening to abandon them. This group showed concern for the effects of alcoholism on their children, accepted some responsibility for these alcoholic problems, questioned their own adequacy and social worth, and felt indispensable to their husbands. However, this same group seemed disappointed at the changes in their husbands' personality after rehabilitation. The wives of relapsed alcoholics indicated no awareness of possible damage to their children, accepted no responsibility for their husbands' drinking, seemed impervious to feelings of inadequacy and social status, and did not feel indispensable to their husbands. These wives seemed cynical about efforts to help their husbands. 76 There are two major problems considering the validity of the Decompensation Theory. First, the subjects of the studies have usually been women in treatment or couples in treatment. This could represent an atypical population, and says nothing about the fate of the wives who recover without the wife's getting involved in treatment. The second problem with interpreting such clinical observations is the lack of consideration of alternative explanations. For example, if a spouse has had to overfunction for a number of years, and suddenly again has a mate on whom she can rely, she may then be able to attend to her own needs, conflicts, and problems, with the result looking like decompensation. An alternative explanation is that the readjustment of the roles and role definitions that accompanies recovery is difficult, and may result in a difficult period for both partners. The next section discusses the literature reviewed for the Stress Theory. The Stress Thegry Jackson (1954, 1956, 1959, 1962) was the first advocate of the Stress Theory. She theorized that in their efforts to handle problems associated with alcohol abuse, family members came to feel guilty, ashamed, inadequate and isolated from social support. Wives were especially 77 affected because, in their own and in society's eyes, they had failed in their major role. Jackson (1954) studied wives of alcoholics who belonged to Al-Anon over a three-year period as an empirical test for her theory. She attended and made recordings of each meeting. In addition to the 50 Al-Anon members participating in the study, Jackson interviewed wives whose alcoholic husbands were hospitalized. Jackson's results indicated that the wives and families seemed to pass through stages in reacting to alcoholism in the husbands or fathers. These stages are: Stage 1 - wives and families attempt to deny the problem. Stage 2 - they attempt to eliminate it in the face of social isolation, alienation, and the wives' feelings of inadequacy. Stage 3 - disorganization; few problems met constructively, and the wives accept their husbands drinking problem as permanent. Stage 4 - attempts to reorganize the family: wives' resentment of husbands' behavior changes to pity, and wives take on many responsibilities of the husbands. Stage 5 - efforts are made to escape the problem, separations. 78 Stage 6 - families are reorganized without the husband. Stage 7 - husbands recover and families once again reorganize. Jackson found that wives and families, especially wives, behave in a manner which they hope will meet the crisis and permit a return to stability. Wives, Jackson stated, are at all times affected by their own personalities, their previous role and status in the family, the previous history of the present crisis and the past effectiveness of their own actions, and also by cultural definitions of alcoholism. Thus, behaviors of wives of alcohol abusers are described in large part as a function of changing patterns of interaction and not solely as a consequence of personality disturbance, or personality type. Jackson pointed out a limitation of the study being concerned with only those families seeking help. But Jackson succeeded in presenting the wive of alcoholics in different light. The concepts of stress, crisis, and roles could be used in explaining the wives behaviors instead of neurotic and decompensating behaviors. Jackson pointed out in her 1962 article the similarities between alcoholism and the achievement of sobriety, and other situations such as the husband's mental illness and recovery, and war duty and return of the veteran husband in their effects on the wife. 79 Alcohol abuse was seen as a family crisis like other family crises. Lemert (1960) attempted to replicate Jackson's (1954) study on a wider cross-section of the population. A 49 item scale was used without reference to reliability and validity information of the scale. Lemert was unsuccessful in verifying Jackson's sequence of events in wives' adjustments to the crisis of alcoholism. In a different approach, Orford and Guthrie (1968) asked 80 alcoholics' wives about their methods of coping with their husbands' alcoholism. By factor analysis they identified five coping styles: 1) safeguarding family interest, 2) withdrawal within the marriage, 3) attacking, 4) acting out, and 5) protecting their alcoholic husbands. James and Goldman (1971) tried to integrate these findings with Jackson's (1954) concepts of stages. No coping style of the wife was found to be unique to any one stage. In support of Jackson, James and Goldman found that 78 percent of wives in their sample had married before their husbands became excessive drinkers and that the wives' threats to leave were the most effective means of inducing abstinence in their husbands. The frequency with which any coping style was used was highly correlated to the stage of alcoholism in the husbands. The wives' reactions seemed to correspond to the changes in their husbands' conditions. 80 Studies by Orford and Guthrie (1968) and James and Goldman (1971) represented a new approach to looking at wives of alcoholics. They considered coping styles in identifying and measuring the wife of an alcoholic. The Stress Theory made two major contributions to the understanding of alcoholism and marriage. First, the model clearly suggests that wives engage in a range of behaviors in response to drinking. Second, these behaviors were seen as coping behaviors, rather than psychopathology. Jackson (1954, 1955, 1959, 1962) clearly introduced the field to a more humane view of the difficulties of living with an alcoholic. The next section is a discussion of the literature that represents a fusion of the Disturbed Personality Theory, the Decompensation Theory, and the Stress Theory. o-S Beginning with Jackson in 1954, the trend in studies of the wives of alcoholics was to question and criticize much of the earlier impressionistic clinical literature and to suggest concrete and testable hypotheses concerning the functioning of wives in these marriages. These studies (Bailey, Haberman, 8 Alksne, 1962) set the stage for a fusion of ideas and the development of the psycho-social perspective. 81 The fusion of the three theories began to appear with studies by Bailey, Haberman and Alksne (1962). Their studies, like those of Clifford (1960), sought to determine the differences between wives of alcoholic husbands who are abstinent and those whose husbands are still drinking. However, Bailey, Haberman, and Alksne added a third group of wives who had terminated their marriages. The three groups were matched on education and length of marriage. The 69 wives were given interviews based on their perceptions which included psychophysiological symptoms and neurotic symptoms. The scores of these three groups were compared with a representative community sample from another study. All 69 wives experienced considerable economic, social, or psychological deviance in their marriages. However, the degree of deviance appeared to be significantly related to marital outcome, the separated family revealing the greatest disturbance. The families which remained together with the husband achieving abstinence tended to be upwardly mobile and highest in occupational status. Of the 23 abstinent husbands, 17 wives had been helped by Alcoholics Anonymous and 14 wives had been helped by Al-Anon. This suggested that alcoholic families who recover do not appear in the caseload of social workers and psychiatrists, as they may have turned to self-help groups instead. Therefore, studies based on such caseloads may not be representative of the population, such as those studies supporting the Disturbed 82 Personality Theory (Lewis, 1937; Price, 1945; Whalen, 1959). Wives of still-drinking husbands reported relatively little stress beyond the drinking itself and showed little anxiety about socio-economic matters. The authors suggested perhaps circumstances had not motivated these wives to take action about their alcoholic husbands. Almost two-thirds of the wives of alcoholics reported a high level of psychophysiological symptoms at the time of the interview compared to 35 percent in the representative community sample. However, only 55 percent of this two- thirds were the separated wives, and 43 percent were those wives with sober husbands. Therefore, the data lend support to the Stress Theory. Kogan, Fordyce and Jackson (1963) conducted a study questioning whether the wife of the alcoholic necessarily displays personality disturbances and investigated the rate of occurrence and uniqueness of personality disturbance in a selected group of wives of alcoholics compared to a group of wives of non-alcoholics. Measures from the MMPI indicated that although significantly more wives of alcoholics exhibited personality dysfunction than did wives of non- alcoholics, the total number of disturbed subjects was less than half on any measure. Personality patterns thought to belong to wives of alcoholics were not demonstrated. The authors implied that the personality of the wife of the alcoholic should be treated as a variable for future 83 research. Also, the authors questioned whether there should be a unique concept describing the "wife of an alcoholic". Hogan and Jackson (1963) tested the assumption that wives of alcoholics have unique personality types. They found no differences between the perceived roles of the ideal wife and the ideal husband, when compared to wives of alcoholics and wives of non-alcoholics. In 1964, Hogan and Jackson further examined the alcoholic wives responses with an additional group of alcoholic wives. The authors found that 80 percent of the wives perceived their own personalities as being much the same whether their husbands were drinking or not. Bailey (1965) carried out an extensive study with 262 wives of alcoholics. Her chief findings were that Al-Anon members knew more than did other wives in the sample about alcoholism and had gained more self-understanding in relation to their husbands' drinking. Using the same 262 wives, Bailey (1967) elicited histories of their marriages by means of a structured interview. The resulting data revealed a continuum: the longer the time since the wife had been exposed to her husband's drinking, the less likely she was to report symptoms of her own psychophysiological impairment. Also, women who had not been divorced or separated were less likely to be disturbed. Therefore, the least impairment was reported by currently married women whose husbands were not 84 abstinent. The conclusion was that there was a wide range of psychophysiological disturbances in these wives, but that data did not support the hypothesis that most would decompensate emotionally if their husbands stopped drinking. In examining two social variables, Al-Anon membership and educational level, Bailey found that wives who belong to Al-Anon suffered psychophysiological symptoms to a lesser degree than those who did not belong to Al-Anon and had at least a high school education. Thus again, data support the inclusion of a stress component in a psycho-social theory. Hogan and Jackson (1965a) further attempted to examine the psycho-social hypothesis. They attempted to estimate the relative effects of assumed pre-existing personality traits and of ongoing stress on personality function in wives of alcoholics. Selected measures derived from the MMPI responses of 26 wives of inactive alcoholics, 50 wives of active alcoholics, and 50 wives of non-alcoholics were compared. The results indicated that the wives of non- alcoholics had the lowest rate of personality disturbance, and wives of actively drinking alcoholics had the highest. Wives of recovered alcoholics were in the mid-range position. However, the authors also found that women married to non-alcoholics and those married to alcoholics did not differ significantly in their MMPI scores, thus supporting the Stress Theory. 85 In an attempt to define some societal variables which tend to contribute to personality dysfunction, Hogan and Jackson (1965b) compared the life history reports of 45 alcoholics' wives to a matched group of non-alcoholic wives. Those who reported an undisturbed childhood seemed more able to deal with marriage, even to an alcoholic, without personality disfunction. The authors suggest that both early experiences and current relationships were involved in the interaction between life experience and personality function. Moos, Finney, and Gamble (1982) designed a study to achieve a broader understanding of spouse functioning by examining the impact of the alcoholic partner's characteristics and other factors such as life change events, social support, and coping responses. The study sample was divided into three groups: spouses of recovered, and relapsed alcoholics compared to spouses of community members. The spouses of recovered and relapsed alcoholics were drawn from alcoholics treated at one out of five different residential facilities. The community group was selected from the same census tract as the treated families and were matched by several significant variables. The authors mailed self-administered questionnaires, examining behavioral and functional characteristics using the Health and Daily Living Form, Family Environmental 86 Scale, and the Work Environmental Scale. After the original questionnaires were sent out, there were follow-up questionnaires sent six to eight months later. At the end of two years, there were 105 participants. The test, one way ANOVA and ANCOVA found no differences between the three groups. The Student-Newman Keuls Multiple Range Test was done to find significant differences between socio- demographic characteristics. The only significant finding was that spouses of recovered alcoholics were less depressed than the other two groups. The researchers concluded that spouses of alcoholics are basically normal people who are trying to cope with disturbed marriages and behaviorally dysfunctional partners. Findings are consistent with crises, especially when the partner is drinking heavily. The recommendation was to train the spouses in coping skills and family cohesion. Again, this supports the psycho-social approach for wives of alcoholics. Finney, Moos, Cronkite, and Gamble (1983) designed a study of spouses of alcoholics and those married to spouses with a variety of other functional impairments (heart attack, renal disease, unemployment, depression). The researchers followed 105 spouses over an 18 month period following residential treatment of their partners for alcohol abuse. The model was tested using path analysis to determine the effects of seven predictor variables (spouse ethnic status, education, initial spouse functioning, 87 partner impairment, environmental stressors, spouse coping responses, and family social environments) on the functions of 105 spouses over an 18 month study period following residential treatment for alcohol abuse. The researchers indicated that partner impairment was usually the strongest determinant but that almost all other predictors had a significant impact on one or more dimensions of spouse functioning. The authors felt that the results supported both the stress hypothesis and coping perspectives on spouse functioning. The psycho-social research on wives of alcohol abusers seems to indicate that these women have basically normal personalities and are not a unique group. Personality fluctuations may occur if the husband is actively drinking. The wives of alcohol abusers may actually suffer personality dysfunction while their husbands are actively drinking, but if their husbands have been abstinent for a period of time the wives experience a much lower rate of dysfunction. Additionally, wives of alcohol abusers who ar abstinent experience less depression. The next section is a discussion of the literature reviewed on the interactional approaches to alcohol abuse. 88 When W In the 1970's the trend at looking at spouses of alcoholics as individuals began to shift toward considering the marital and family system as a unit. General systems theory-based models and social learning theory-based models have taken a more interactional approach to conceptualizing alcoholic marriages. The main premise of the general systems theorists (Steinglass, 1981) is that alcoholism is an integral component of the family's functioning. Thus, while an individual may have developed alcohol problems prior to his or her marriage, once the alcoholic enters a marriage, a new system develops. Each person in the family system has certain roles that he or she fulfills. The possible roles in a family are limitless, but an alcoholic family member may occupy the sick role in the family. The homeostatic balance in the family is believed to depend upon this role. Therefore, if the alcoholic member stops drinking, the homeostasis of the family is threatened. Systems theorists (Steinglass, 1981) would predict then that the actions of the family would be directed toward reachieving homeostasis, which could result in family efforts to help the person return to drinking, or could 89 result in the development of sick behaviors in another ‘family member. It is interesting to note that this model and the decompensation hypothesis both predict that the spouse of an alcoholic could exhibit problem behaviors after the alcoholic stops drinking. Social learning theory approaches also consider the positive role of alcohol in the marriage, by examining reinforcing consequences of drinking that maintain the drinking behavior. In general, social learning theorists (Sobell, Sobell 8 Sheahan, 1976) view problem drinking as a learned behavior, which occurs in response to certain discriminable cues, and which is maintained both by positive reinforcement and avoidance of aversive consequences. Alcoholic couples are postulated to have poor communication and problem-solving skills (Sobell, Sobell 8 Sheahan, 1976). They engage in positive exchanges at a low rate, and evolve, over the years, a mode of interacting that involves attempts to control each other coercively, such as through threats or nagging. As the aversive situation escalates over the years, communication becomes more ambiguous, vague, and inconsistent. As a result of these poor communication skills and ineffective methods of control, a large backlog of problems accumulates. On these dimensions, communication and problem-solving skills alcoholic couples resemble other couples experiencing marital distress. The differences between alcoholic and 90