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LIBRARY
Michigan State
University

 

 

 

     

Aelationship Addiction in Womeny
A Proposed Conceptual Framework

LuAngela Ce?) ne

A Scholarly Project: Subnitted to Michigan State University
in partial fulfillment of the rewirements for the degree of

Master of Science in Nursing

Running Head: RELATIGJSHIP AIDIC’I‘ICN

Acknowledgements

A warm and special thank you to Barbara Given, committee
Chairperson, who saw the promise in me and encouraged its gradual
unfolding. Her persistance and perfectionism facilitated me to
maximize my potential. Thank you to Clare Collins, who
selectively self—disclosed ideas that helped to validate my own
experience and challenged me to be thorough and concrete in my
presentation and articulation of ideas. In fond appreciation,
thank you to Linda French who listened, loved, corrected and
cared. You know me well, and our trips back and forth to Lansing
will be forever memorable. I appreciated your insistance upon
clarity throughout the manuscript.

I wish to thank Jackie wylie, my supervisor at Bronson School
of Nursing for her continued support and encouragement. Thank you
to Julie McEvers, my colleague and partner and to all faculty at
Bronson for their continued interest and support. Special thanks
to Judy Buss, my typist who endured many revisions and much
printer aggravation.

Most of all, thank you to my loving, supportive family: My
lover and best friend, Terry, for his understanding and tolerance
of my strong udll and determination at two in the morning. My
daughters Autum and Angeline, for their endurance of ”early bed
times so mommy can work on her paper”. Never again udll we skip a
bedtime story! My mother, for her careful editing. My father,
for his faith in me. My sister Mickie, for her listening ear and

soul support. My sister Lynnette, for her understanding of

Co-Dependence. And my brother Antonio, for a sincere appreciation
of graduate work and scholarly endeavors. I love you all.
Finally, for those who sat with me at meetings daily

listening to my obsession with this work, thank you. You, too,

are my family.

ii

Relationship Addiction

1

Copyright 1988 [uAngela Cervone

Relationship Addiction

TABLE OF CONTENTS

Chapter I

Abstract

Introduction to the problem

Background

Statement of the problem
Mat is relationship addiction
How does addiction differ from dependence
Being a mean

Rationale for selectional topic

Limitations

Significance of topic to nursing practice and theory

Sutmary

diapter II: Review of the Literature
Healthy relationships
Ebw women relate
Concept of addiction
Definition
Process
_ Figure 1
Figure 2
Figure 3
Proposed pathogenesis and possible etiologies
The addictive experience
A sociological perspective
A spiritual quest
Critique of the literature
Sumary '

Chapter III: Conceptual Framework
Conceptual framemrk
mger's Life process and theory
Elationship addiction within the context of Life

process model

Etiological Factors - Figure 4
Figure 4a
Figure 4b
Figure 4c

Descriptive Characteristics - Figure 5
Sunnary

2

Relationship Addiction

Chapter IV: Implications for Practice, Education,
and Research
The primary care setting
Role of the CNS in advanced practice
Role of the CNS in education
Role of the CNS in research
Conclusion
References

3
68

69
80
83
87
91
94

Relationship Addiction
4
. ABSTRACT
In this scholarly project, the concept of relationship
addiction in women is fully discussed. Etiological factors are
proposed and resulting descriptive characteristics are postulated.
Gilligan's theory of men's psychosocial development is
considered as a possible predisposing factor. These concepts are
then applied within Nurtha Rogers' nursing theoretical framework.
'Ihe significance of the topic within the field of nursing is
addressed. Concepts are all integrated and applied to the role of
the clinical nurse specialist in the primary care setting. The
necessity of public and health provider education is addressed.
'lhe iuportance of research to validate the presence of the problem
and substantiate evidence for effectiveness of treatment measures
is proposed. Finally, concerns regarding the popularity of the
topic are addressed and recoumendations for research proposed.

Relationship Addiction

5

m1
'mmmrmmmmrm

Relationship Addiction
6

The concept of addiction is, at its best, a misunderstood
catch-phrase used indiscriminately in social circles today. For
some working in the area of chemical dependency, addiction is that
final physiologically involved stage in which all body systems
biologically depend upon the substance to maintain life. For the
drug or alcohol addict himself, addiction becomes an experience; a
way of life involving loss of self replaced by a substance defin-
ing self. For the bulemic, addiction involves relationship
between the self and that needed but never satisfying substance
called food. For the compulsive gambler, compulsive worker, or
the compulsive spender, the addictive experience is, once again, a
relationship between an owned emptiness and an experience which
never satisfies the insatiable hunger within. For the
public,addiction because a word used in passing to saphasize a
habitual eagagennmt in a pleasant pastime. (“I'm addicted to
those Goo Goo Clusters.“ 'I'm just addicted to this TV’showz')

It becomes easy to understand then how the concept of
addiction can become so misconstrued based on the varied contex-
tual definitions. It is important, to clarify this concept -
addicition-in a generic sense and to outline those character-

istics which validate its presence regardless of context. (he

Relationship Addiction
7
purpose of this scholarly writing, then, will be to clarify the
concept of addiction and to outline characteristics consistent
within any contextual framework.

(hoe a basic understanding of addiction has been established
the concept will then be applied more specifically to relation-
ships. Relationship addiction is an even more obscure area of
study than any of the aforementioned addictions. Little has been
written in the area of relationship addiction with the exception
of self-help literature and some case study presentation in the
psychology literature. Covert representation of the characteris-
tics of relationship addiction lie within Homer's work on (Inject
Relations, (Rorner, 1978 and Homer, 1979) but no specific
reference is made to the concept 'addiction".

Pathogenesis will then be proposed for the addictive process
and multiple variables explored in their relationship to the
developing pathology of addiction, more specifically, relationship
addiction. the major variable predisposing one to this difficulty
may be gender. An in-depth discussion of women and patterns or
relatiq will be discussed.

After integration of concepts and a thorough review of the
literature, these concepts will be applied within Martha Roger's

nursing theoretical framework.

Relationship Addiction
8
The overall goal of this scholarly writing is to develop a
conceptual framework of relationship addiction as it applies
specifically to women. This will be done in an attempt to 1) more
clearly define concepts upon which to base valid and reliable
quantative and qualitative methods of research and 2) to provide a
base for delineating valid credible means by which the CNS may
facilitate wellness in women experiencing relationship addiction.
Background

 

An interest in the concept of relationship addiction begins
as one becomes aware of the distinct difference conversationally
between men and women. Content, for the most part of many women,
professional or non-professional seems to be centered arourd
relationships with others: Friends, lovers, children, parents,
men. Men they are in love with, dating, sleeping with, caring
for, married to, getting to know, wanting to meet, wanting to
avoid: Men. This author began to wonder how mudn self esteem of
a woman": is the result of, or the reason for, how she relates to a
man. VII-n one attends social functions, it becomes apparent
that win-n cluster in the kitchenor on the porch chatting about
and watching "their“ men interact with other men. (he senses a
feeling of satisfaction among them, a contentedness and a

nurturing tone as they conmnent on the behavior of the men. The

Relationship Addiction

9

men, on the other hand, interacted much more actively with content
matter centering around sports, news, and work.

The author elicited an informal poll and asked various people
at various times annd settings what they hungered for in a
relationship. Men responded generally with 'I want someone to be
mine. I want someone to belong to me.“ Women, on the other hand,
responded with "I want to belong to him. I want to be
somebody's.‘ The first, seemed to connote security in owning, in
enveloping; a fairly powerful and active role. The latter seenned
to connote security in being owned, being enveloped; a much mre
passive role. At what price, the author began to inquire. Annd
what do women learn to assist than in getting these needs met?
Since increamd passivity and powerlessness affords a better
chance for belonging to, how far are woman willing to go to ensure
the outcome?

The huger for intimacy and mean closeness seems to be tied
strongly to the female gender. Gilligan (1982) proposes that
women'sdevelopment distinctly differs from men's in that connec-
tion booms primary in defining self for women, whereas separa-
tion because primary in defining self for m. Mitchell (1975)
speculates that this emotional attachnent of the female gender is
innate rather than learned behavior. mgardless of the origin for
the behavior, most authors agree that in most cultures, women

become emotionally attached in relationships more so than

Relationship Addiction

10

men. “Wonnnen (often) define themselves in terms of their relation-
ships with others' (Washborn, 1971, p. 53).

One's concern for women in relationships grows in watching
many women sacrifice their integrity, self-esteem, and self-
respect for crunbs of pseudo-intimate moments which later often
ended in disaster and despair. Men seem to walk away from
relationships, although hurt, with a network of support annd varied
interests, whereas women seem to have lost their soul. Men's loss
seems to be exterior and life goes on. Women's loss seems to
permeate their being and a general rebuilding of the self is
often necessary. .

From personal experience and careful observation the
author's assumtions are these:

1. fibre women than men experience a loss of self in

relationships.

2. Women endure trials and tribulations within the
relationship more so thann men in an attempt to ensure
getting sectional nneeds met.

3.— lbst women experience dependennce upon menn due to socio-
cultur'ally learned behaviors (perhaps some inate
behaviors). Some authors postulate men's dependency
needs are greater but more easily met and/or hidden

than women's. (Dowling, 1981)

Relationship Addiction
ll
4. Some £52313 experience the dependency at such great
lengths so as to limit appropriate judgment, produce
inappropriate behavior, and interfere with health (the
symphonic interaction between human and environment).
Usually these people are those whose dependency needs
were not met at an early age. Halpern (1982) addresses
this through the concept of Attachment Hunger: That
process which occurs between mother and child by which
the child learns to trust that needs will be met in
infancy. If this process is not completed and success-
ful, attaclment hunger persists throughout life and
becomes the basis of addiction. The roots of such a
theory lie in object relations theory;

Because women are socialized as depenndent annd passive, they
may be at a higher risk than men in enntering into an addictive
relationship with another person. Since nurturing, social
support, and emotional intimacy are all interactional events
important to the substance of most women's self-esteem, it seems
apparcnt that the “drug of choice" for nnnost wonnnen prone to an
addictive nature might be one that involves another person -
either the relationship (defining herself in terms of the
relationship), the person (defining herself in terms of the other
person), or elements of the relationship (romance, sex,

competition).

Relationship Addiction
12
For these reasons, in this scholarly writing ”relationship
addiction“ will be discussed as an occurrence annong women.

Statement of the problem.

 

What is relationship addiction? Very little concept devel-
opment has been done in this area. In nnost literature, addiction
is inmediately associated with drug/alcohol use. Peele lnas begun
to address the topic from a sociological perspective (1975,1985) ;
Tennov (1980) and Norwood (1985) from a psychosocial perspective;
annd Halpern (1982) annd Salzman (1981) frann a psychodyrmic point
of view.

Does dependence differ from addiction? How so? There seems
to be a dividing line between the two. A distinction needs to be
made annd a conncrete formula proposed to be able to distinguish
where the pathology of addiction begins. No such clear distinc-
tion has yet been addressed in the literature. Pathology must be
defined to appropriately direct research and practice.

Finally, how does being a woman affect one's propensity to
such a disorder? Does the need for connection (Gilligan, 1982)
affect the predisposition of a woman to the addiction process? Or
does it merely provide a channel for the addictive disorder to
manifest itself in, provided other etiological factors are in
place. (attachment hunger, Halpern, 1982; unreasonable parental

achievement expectations, Woodman, 1987)

Relationship Addiction
13
It is imperative to clearly define the concept and to
delineate those characteristics (both descriptive and etiological)
associated with the concept to provide a framework from which to
work in establishing credible research in the area of relationship
addiction.
What is relationship addiction? (he must first address the

 

concept of addiction prior to specifying type. A broad definition
of the term ”addiction” is fomd in Tabers (1977) which states
"Ehslavement to some habit...“ (p.A33). Peele (1975) defines
addiction as:

A pathological habit...a malignant outgrowth...an

extreme unhealthy manifestation of normal human

inclinations...An experience...“ which grows out of

an individual's routinized subjective response to

something that has special meaning for him...

something, anything, that he finds so safe and

reassuring that he cannot be without it. (pp 15—16)
Peele clarifies in a later text (Peele & Brodskey, 1985), “The
difference between not being addicted and being addicted is the
difference between seeing the world as your arena and seeing the
world as your prison.“ (p.64) A very important classification is
made in the latter experiential definition. The concept of choice
and lack thereof is implied. Thus, perceived lack of choice

becomes an important criteria in definition. The element of

Relationship Addiction
l4
escapism is also inherent in addiction. Salzman (1981) states,
”The techniques of defense, denial, rationalization and many
others...reflect the hunan desire for easy, magical solutions and
man's inability and unwillingness to endure discomfort or tolerate
anxiety." (p.340) He goes on to say that “Although dependence,
orality, masochism, and passivity play a large role, obsessional
devices to control and manipulate oneself and the environment are
eve: more iuportant in behaviors of excess.‘ (p. 341)
hbodnan (1987) adds another refreshing dimension to the
concept of addiction. She addresses the concept with a Jungian
approach proposing the insatiable tunger to be of a spiritual
origin with surrender as its salvation. The hula: soul of the
addict seeks the higher self and gets lost in elusive and
unsubstantial endeavors along the my. Relief and recovery come
only through 'death and resurrection‘' (p.61)...death to old ideas,
old gods (substances, objects), old habits, old fears (inability
to tolerate life's discomforts). Surrender to its principle
(usually occurring at one's 'bottom'—lowest point in addiction)
brings bout resurrection: The new self—realistic, tumble,
capable, in essence the higher self.
Addiction, therefore, is a pathological state which can be
identified by the presence of the following characteristics:
1. An insatiable anotional hmger

2. An emptiness within

4.

S.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

Relationship Addiction
15

A perceived lack of choice in anything associated with
the object of addiction use.
A perceived lack of power and/or satisfaction without the
object of addiction.
A periodic sense of power and/or satisfaction with the
object of addiction.
A sense of remorse following indulgence in the object of
addiction.
An inability to tolerate emotional discomfort
An overwhelming desire to control the circunstances
involving the object of addiction.
A sense of safety when engaged in interaction with the
object of addiction.
Gasessional thoughts about and cravirgs for the object of
addiction.
Spiritual starvation.
Habitual involvement with the object of addiction.
(Impulsive, self-defeating behavior associated with the
object of addiction.
Defense mechanisms of denial and rationalization utilized
in association with use or abuse of object of addiction.

Constant attempt to protect self from environment.

Relationship Addiction
16

"Object of addiction" indicates any substance, situation,
activity, person, or thing which becomes the addicted person's
vice.

Relationship addiction, then, can be perceived as habitual
involvement in a relationship which interferes with symphonic
interaction between human and environment manifested by persistant
craving and obsessional thoughts about a person, relationship, or
elements thereof whereby choices seem to be lackirg and powerless-
ness and enslavement to the situation prevail.

The objects of relationship addiction may include:

1) The relationship itself: The woman may find
her identity emnesmd in the relationship.

Her elements of identity are dependent on the
interaction that occurs in the relationship.

2) The partner himself: The woman may find that
suddenly her preferences have changed. She
enjoys the interests of her partner and begins
to use likes, beliefs, of the partner to define
her self.

3) Components of the relationship: Romance, sex,
abuse (emotional and physical) and competition.
The thrill of these occurrences within the

relationship are often enticirg in that they

Relationship Addiction
17
usually‘ produce strorg feelings. It has been
suggested that addiction to strorg feelirg
itself is viable with some biochemical changes
proposed.

Bennett (1976) suggests that I'addiction to strong feelings
can occur as a result of a surge of Norepinephrine (NE) in the
brain at the time. The effect of the NE is a state of arousal
which can later be sought for by the individual and obtained when
expressing strong feelings.” Women addicted to these experiences
do so in an habitual effort to escape painful reality, or in
attempts to succeed at masterirg the task (abme). Habit rather
than definition of self is more often the issue in this group.

How does addiction differ from dependence? A distinction
nust be made between dependence and addiction. Tb 'depend' is
described by mbster (1961) as 'to be contirgent; to require
something as a necessary condition" (p.604). Dependence is
defined as “the cpality or state of depending upon somethirg else"
(Webster, 1961, p. 604). Dependence, therefore, becomes a part of
everyhy life. (he depends upon his automobile to function
properly to drive himself to work. (he depends upon food for
replenishirg the body's nutritional stores. mople depend upon
one another for needs to be met — physically and emotionally.

Relationship Addiction
18
' Dependence is a part of the human condition often tempered with
independence to ensure balance.
Salzman (1981), in attempts to distinguish between dependence
and addiction, states:
Dependency on drugs or devises may arise for many reasons
and serve many purposes which can be classed under two
headings: analgesia or stimulation. In either case,
drugs are taken to alleviate painful feelings or to
stimulate and enhance pleasurable effects. The individual
does not suffer from the behavior, but enjoys it. The
development of drug addiction is related to the pleasant
effects of the drug combined with the individual's capacity
to deny the deleterious effects. (p.342).
The same is true in situational addiction where one becomes
addicted to a person or event. Hence, dependence is for the most
part a pleasant event, where healthy interaction still occurs be-
tween person and environment. Addiction begins to occur when the
person experiencing pleasure from.the situation begins to
experience deleterious effects, denies them, and continues the
habit. Healthy interaction between person and environment is
impaired. Choices seem limited. The individual experiences

powerlessness.

Relationship Addiction

19

Therefore, for purposes of clarification in this paper

I'dependence" will be described as a non-pathological human

phenomenon evidenced by the following characteristics:

1.

2.
3.
4.
5.

6.

7.

8.
9.
10.
11.
12.
13.

A sense of needirg contained with an ability
to get needs met.

A perceived ability to choose.

A sense of self power remains.

Minimal indulgence, no renorse.

A dislike for but tolerance of discomfort.
Feels in control of self ; no need to control
outside matters. 1

Experiences some vulnerability, but generally experiences
the world as a safe place in which to exist.
Minimal obsessional thinking.

Spiritually content.

A lack of habitual or compulsive behavior
Inability to make decisions readily
Passivity

Some healthy interaction with environment.

Dependency, if placed on a continuun, proceeds addiction and

may be a precusor to addiction. All dependent people, however,

are not at risk for developirg addictive behavior. Dependence is

Relationship Addiction
20

not the pathogenesis for addiction. Another etiological factor
must be present (attachment hunger, unreasonable parental
achievement expectations).
Being a Woman: Evidence has been presented earlier in this paper
supportirg the notion that women may be more vulnerable to
relationship addiction. The three primary ideas that support
this, stated briefly are that:

1) Women's development may differ from men's in that
connection seems to be an integral part of beirg and
defining self whereas separation seems necessary in male
development. (Gilligan, 1982)

2) Women are socialized to-be nurturirg aid to value
interpersonal contacts and relationships more so than
men. (Washburn, 1977)

3) Women are socialized to be dependent on men hence
creating a climate conducive to a progression from
dependence to addiction and a need to find self-identity
in reference to a man. (Norwood, 1985, Washburn, 1977)

For the above stated reasons, these concepts and constructs

surroundixg relationship addiction will be applied to women. The
author does not deny the possibility of the occurrence of
relationship addiction in men. However, informal observation by
the author and others (Halpern, 1981, T‘ennov, 1980, Norwood, 1985)
has provided data which supports the occurrence of the problem

Relationship Addiction
21
more frequently and more intensely in women. Since men experience
separation as a normal part of their development, and since men
are ascribed roles promoting the separation sociologically, the
major predisposing factors central to the etiological construct
appear to be absent in men. Being “human" then, is central to the
phenomenon under study in this scholarly writirg.

For purposes of clarification in this paper, the concept
”when addicted to relationships“ will be defined as follows:
Woman experiencirg obsessive thoughts about a person, relationship
or elements thereof, whereby‘the experience interferes with daily
functionirg of the mitary beirg. The man's experience includes
a perceived lack of choice regarding actions or thoughts, with
persistant cravings for the person, relationship, or elements
thereof and an enslavement to the habits that perpetuate
deleterious effects of the relationship. Denial of deleterious
effects is often present. The experience leads to increasing
interference in harmony between the environment and the person
thereby limitirg health and wellness until the situation resolves
or replays itself.

Rationale for selection of topic:

It is obvious from.popular non-fictional literature sales
(Norwood, 1985; Cowan, 1985; Dowlirg, 1981) that women in
problematic relationships with men is a significant societal

problem. Informal observation of personal interations, media, and

Relationship Addiction
22

literature further validate the presence and extent of the
problem. Treatment centers, which traditionally facilitated
recovery of only the substance addict, are now acknowledging and
treating people for situational addictions. Further societal
significance of relationship addiction will be addressed in the
review of the literature.

Limitations

 

The literature is scarce in reference to relationship
addiction. Therefore information will be drawn from the areas of
substance abuse, including addiction and co-dependence literature,
women's studies, includirg developmental theories, and popular
psychology and self-help literature. A very real limitation is
that little has been done theoretically in reference to '
relationship addiction, with the exception of Peele (1975),
Halpern (1982) and Homer (1978). No valid and reliable
quantitative research has been done in the area. No tools have
been developed. Although case studies are cited in each book, no
real glalitative research has been described. It therefore seems
appropriate to begin to clarify the concept to facilitate
utilization for research.

Significance of topic to nursing practice and theory

Since nursirg has been defined as, "the diagnosis and

treatment of hunan responses to actual or potential health

problems' (ANA Publication, 1982) , it seems appropriate to study a

Relationship Addiction
23
problem which actively impacts upon symphonic interaction between
the unitary being and the environment. A goal in nursirg is to
maximize health and wellness (symphonic interaction between person
and environment). Tb do so, one must develop a framework within
which to place a concept. This scholarly writing will attempt to
develop that framework from.which to work in doing research to
validate the experiences of relationship addiction and later, to
substantiate treatment effects.
Samurx
In sulmary, in chapter one the author has provided an
introduction to the concept of relationship addiction. An
overview'of the broad concept (addiction) and the specific concept
(relationship addiction) has been discussed. Possible intervening
variables (woman's development, pathogenesis) have been proposed.
An in-depth review of the literature will follow and the
development of a conceptual framework with a Rogerian base wdll be
proposed. Finally possibilities for research will be reviewed

with m arplication to advanced nursing practice.

Relationship Addiction
24

CHAPTER II: REVIEWG'H'IB LITERATURE

Relationship Addiction
25
In this chapter, the author wdll review'and critique the
literature associated with relationship addiction. The topic of
healthy relationships will be addressed briefly to provide a base
from which to work. A discussion of how women relate will follow.
The concepts of addiction and relationship addiction will then be
discussed in depflh including definition, characteristics, and
proposed etiological factors.
Au Healthy Relationships
Shaeffer (1986), a psychotherapist whose interest lies in the
area of relationship addiction defines working, functional rela-
tionships in terms. of "healthy belongirg'. The goal -ih loving is
not dependency on another, but healthy belonging'. (Shaeffer,
1986, p. 1). She goes on to describe the experience of healthy
belonging. The experience of healthy belonging is one in which
the individual in a relationship:
1) Allows for individuality.
2) Experiences both oneness and seperateness from.a lover.
3) Brings out the best qualities in both partners.
4) Accepts endings.
5) Experiences openness to change and exploration.
6) Invites growth in the other.
7) Experiences true intimacy.
8) Feels the freedom to ask honestly for what is wanted.

9) Experiences giving and receiving in the same way.

Relationship Addiction
26
10) Does not attempt to change or control the other.
11) Encourages self-sufficiency of partners
12) Accepts limitations of self and partner
13) Does not crave unconditional love
14) Finds comitment acceptable
15) Has a high self-esteem
16) Trusts the metriory of the beloved; enjoys solitude
17) Ebcpresses feelirgs spontaneously
18) Welcomes closeness; risks vulnerability
19) Cares with detacl'unent
20) Affirms quality of self and partner
(Sueffer, 1986, p. 3-4)
Overall, the experience includes maintaining of self while
risking vulnerability and closeness to other. A healthy sense of
self-respect, contained with a desire and need for connection,
occurs.
From (1956) addresses the concept of healthy relationships
in a note theoretical sense by discussirg love as an art: a
learned experience which most people have not yet learned. He
passes this on three premises. “Most people see the problem of
love primarily as that of being loved, rather than that of loving,
one's capacity to love.“ (Pronm, 1956, p. 1) The first premise,
then, is that energy is consumed in attempting to be loved rather

than in learnirg to love. The second premise is that societal

Relationship Addiction
27

perception is such that it believes the difficulty lies not in the
inability to love, but in findirg “the right object to love or be
loved by.” (p. 2) The third premise is that "falling in love“ is
often confused with love and true intimacy. Short-lived intimate
merits do not create the ground work for the experience of loving
over time. Fromn proposes that love is an art that must be learn-
ed by masterirg first the theory and then the practice. The prac-
tice of any art, includirg love, “requires discipline, concentra-
tion, and patience.” (Emma, 1957, p. 91-92). This is followed
by “a supreme concern with the mastery of the art" (p. 92) -
that is, the art must be 'of supreme importance" to the apprentice
in order to achieve mastery (p. 92).

So, whereas Slaeffer provides a somehhat simplified framework
of the makings of a healthy relationship, From proposes a much
more theoretical approach in defining the makings of love. From
discusses content (theory) as well as process (practice). Froum's
work seems much more substantial as a theoretical base from which
to work in studying the process of love.

B. mm Relate

Gilligan (1982) proposes that women relate differently than
men. The roots in this difference lie in early childhood devel-
opment as proposed by Cnodorow (1974). Gilligan gives a sunmary
of childhood developnent that proposes, cross culturally, women's

early childhood care promotes female identity formation through

Relationship Addiction
28
connection and attachment with others, whereas male identity
formation is the result of separation to establish firm ego
boundaries. Chodorow (1974) further proposes that "women (do not)
have weaker ego boundaries than men' (p. 167). Instead she
states ”Girls emerge from this period with a basis for 'empathy'
built into their primary definition of self in a way that boys do
not" (p. 167). file goes on to say, 'Girls emerge with a stronger
basis for experiencirg another's needs or feelings as one's own
(or thinkirg that one is so experiencirg another's needs and
feelings)“ (p. 167).
Gilligan (1982), connenting on Chodorow's reflection, states:
Consequently, relationships, and particularly
issues of dependency, are experienced differently
by men and men. For boys and men, separation
and individuation are critically tied to gender
identity since separation fran the mother is
essential for the development of masculinity. For
girls am! women, issues of femininity or feminine
identity do not depend on the achievement of
separation from the mother or on the progress of
individuation. Since masculinity is defined
through separation while femininity is defined
through attachment, male gender identity is
threatened by intimacy while female gender

Relationship Addiction
29
identity is threatened by separation. Thus males
tend to have difficulty with relationships, while
females tend to have problems with individuation.
(ID-8)

In a recent study, Pollak and Gilligan (1982) found that men
perceive danger in situations of affiliation whereas women
perceive danger in situations of achievement. In this study,
Pollak ard Gilligan utilized Thematic Apperception Test cards to
elicit a response in male and female college students. Stories
were written by the students correlating with the picture on the
TAT. Four pictures were chosen for the study: two implying
affiliation between a man and a woman and two implying “impersonal
achievement situations“ (p.41) The study reports “statistically
significant sex differences in the places where violence is seen
and in the substance of violent fantasies as well' (Gilligan,
1982, p.34.) The stories written by the students were analyzed.
Men perceived affiliative (connective) situations with fear.
Women, on the other hard, perceived achievement situations with
fear all interpreted them as potentially harmful — a threat to
connection with others.

Women's need to connect and affiliate is central to her
experience as an individual. Furthermore, Gilligan proposes, her
conunittment to care for, help, and not hurt is central to her

decision making process in moral dilenmas.

Relationship Addiction
30

Gilligan goes on to test this premise in clinical testing
situations utilizing a moral dilemma from a series of moral
dileumas developed by Kohlberg. Her results fourd in this
dilemma, and in other moral descriptions, that males tend to
arrive at a moral conclusion mathmatically and logically in a very
separate sense, claiming clearly what is right and just, whereas
females tend to arrive at a moral conclusion by restructuring the
dilemma to allow for responsiveness ard connectedness. Gilligan
proposes that presentation of the Kohlberg dilemma testing may
be biased in that the idea presented by the test subject is never
heard or recognized as a reconstrued dilemma, but is judged “less
than“ on the male moral development scale.

Gilligan (1982) also studied women u'dergoing an abortion
decision and found the statements of the women centered arourd
connection with self and that the process entailed conflicts of
caring for herself and/or others more so than “right“ or “wrong“
decisions. Again, connection and care are the main concerns to
women.

File interpretation of responsibility, she concludes is “a
limdtation of action, a restraint of aggression...fle seeks rules
to limit interference and thus to minimize hurt.“ (p. 37) Female
interpretation of responsibility “proceeds from a premise of
connection“ (p. 58) and connotes action taken to ensure

connection. Considerirg this proposed primacy of connection in

Relationship Addiction
31
relationships for women, it is easy to understand their
vulnerability to relationship addiction.

In sunmary, Gilligan proposes a mique means of experiencing
self and relating to others as a woman. She sees definition of
self and moral decision making as a unique process encompassing
such factors as connection and caring. A pathological element
present (attachment hunger, unreasonable parental achievement
expectations) in coubination with women's developnental
characteristic of needed connection makes relationship a prime
object of addiction.

C. Concept of Addiction

 

It seeua only appropriate to begin discussion with the origin
of the addiction process concept. The concept of addiction has
been studied since the time of Freud in the early 20th century.

Classic work on addiction came to the forefront in the
literature via alcohol addiction in the 1950's and 1960's. It
becomes important, then, to review this literature for an
appropriate base from which to work.

Jellenick, (1960) known to many therapists and authors in the
area of substance abuse as the father of the disease model of
alcoholisn, defines alcoholisn as, “any use of alcoholic beverage
that causes any damage to the individual, society, or both.“ (p.
33). Jellenick breaks down the concept of alcoholisn into five

categories ( p. 33-35) as follows:

1)

2)

3)

4)

5)

Relationship Addiction
32

Alpha alcoholism - a purely psychological addiction where
there is continued dependence and reliance upon the
effect of alcohol to relieve bodily or emotional pain.
The person experiences “undisciplined“ drinking and a
“loss of control“ at times when drinking. There is an
inability and sometimes an unwillingness to abstain. [ow
productivity ensues and financial distress appears.
Deluge lies in disturbance of interpersonal relations.
Often there are no signs of the progressive process. (he
may go 30-40 years without progression.
Beta alcoholisn - Clinical signs include polyneuropathy,
gastritis, cirrhosis. 0ftm these occur without paysical
or psychological dependence. Instead, there seems to be
an extreme sensitivity to alcohol and its detrimental
effects on the body.
Gama alcoholisn -' an increased tissue tolerance to
alcohol occurs with adaptive cell metabolism. me
experiences withdrawal without the drug and a loss of
control with the drug. There is progression from psycho-
logical to physical dependence. Health problems arise
with physical dependence.
Delta alcoholism - same as gauma plus inability to
abstain.

Epsilon — periodic inability to abstain.

Relationship Addiction
33

Che might question the relevence of such staging data for
alcoholisn within the context of this scholarly writing. The
importance of this data lies in society's misperception of a
dysfunction occurring only when one is diagnosed with ganma, delta
or epsilon alcoholism. The truth lies in that many in society
function “normally“ as an alpha or beta alcoholic with no
perception of the effects of the substance on the mind, body, or
relationships. It is proposed by others (Norwood, 1985,
Schaeffer, 1987) that many wunen experiencing relationship
addiction come fran such functional alcoholic homes.

The literature is quite consensual on defining addiction
whether in reference to drugs or alcohol. Swinson and Eaves
(1978) explore drug addiction and habituation and describe them as
follows:

mug addiction includes:

1. An overpowering desire or need to continue taking the

drug and to obtain it by any means.

2. A tendency to increase the dose.

3. Psychological and physical dependence on the effects of

the drug.

4. Withdrawal synptoms when drug is removed.

5. The effect is detrimental to individual and society.

(Po 56)

Relationship Addiction
34

Drug habituation includes:

1. A.desire to continue taking the drug for a sense of

improved well-being.

2. Little or no tendency to increase the dose.

3. Psychological dependence, no physical dependence or

withdrawal.

4. Detrimental effects on the individual himself only.

(9.56)

Swinson and Eaves (1978) descriptors can be applied within
the framework of relationship addiction. Usually the person
experiencing relationship addiction is consumed by the experience
and will give up important healthy functioning events in order to
obtain more ad more time, energy,md presence of the other
person. Bennett's (1976) proposed “addiction to strong feeling“
could apport physical dependence upon the situation'and may
suggest a physiological withdrawal when Norepinepherine is no
longer available in large quantities at the synapse sights.
Finally, any obsession disorder to this degree affects society by
one's dysfunctional interaction with the enviromnental field. It
could be speculated, then, that relationship addiction is a valid
and credible addiction that possibly meets even drug addiction
criteria.

The process of addiction was proposed in 1960 when Jellenick

delineated a progression. The process consists of a general pro-

Relationship Addiction
35

gression of symptoms from the early stages of denial, through
remorse over drinking, through attempts to control drinking into
the middle stages where physical changes begin to occur (liver
enzymes elevated, blood pressure elevated) into the late stages of
the disease, where all attempts to control drinking are exhausted
and tolerance is very low; Death, insanity or recovery are
iminent. (Refer to Figure 1 page 36)

The process of addiction in codependents (those closely
associated with the ci'iemically dependent person) follows a similar
progression with the major focus as the alcoholic, rather than the
alcohol itself. The partner denies the reality of the drinking
and experiences remorse over discord with the alcoholic. The co-
dependent then develops medical pnoblems and may begin to utilize
prescription drugs to remedy the situation. Finally in the last
stages, suicidal threats and attempts are made. Again, death,
insanity or recovery are iminent. (Refer to Figure 2 page 37)

Norwood (1985) takes the progression process one step further
and applies it to relationships (Refer to Figure 3 page 38). The
progression and outcomes are virtually the same, but the obsession
is not focused on a drinker, necessarily, but on a man and/or the
relationship.

The idea of addiction in relationships is not all new; Peele
(1975) discusses this possibility as early as 1975. He embraces

the idea that addiction to love is a far more serious problem

Relationship Addiction

36

Figure xl

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Figure 1: Process of Progression of Alcoholism
as proposed by Jellenick. (1960).
Taken from Johnson, v. (1980). I'll quit tomorrow. N.Y.:

Harper and Row Publishers

Relationship Addiction
37

._*-“"‘ __ cu ..
~O”-~.“u

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Figure 2: Process of Progression of deependence

As proposed by Glatt

Relationship Addiction

38

mamas-imminent

    

 
   

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Figure 3: Proposed Progression of Relationship Addiction

(Norwood, 1985)

Relationship Addiction
39

merely because of its prominence and secrecy (it is not openly
discussed). Tennov (1980) masterfully addresses the problem of
romantic love. Sue coins the word “limerence' to describe “being
in love“ and discusses obsession in her limerent subjects ranging
from 20% to 100%, at which time complete inmobilization of the
subject occurs. Subjects have left positions, dropped classes,
stopped eating, and become socially recluse for a period of nonths
to years depending on the severity of the obsession and limerence.
T'ermov asserts that the problem is not gender specific (pp. 220-
221). It seats women discuss the issue more openly, but many men,
particularly middle-aged professionals, responded to Tennov in
confidence following publication of a newspaper and magazine
article.

Norwood (1985) studies specifically women and their
responses. A column characteristic of the women described by both
Temov and Norwood was their “together“ appearance. Host wunen
going through such experiences appear to be very astute, alert,
intelligent and capable. They appear to be very independent.
Norwood postulates that the independent nature of the women may be
a survival mechanisn learned growing (.9 in dysfunctional, often
alcoholic, homes. The children in such families generally grow up
quickly to learn to care for and protect themselves and their
siblings. Dependency needs were not met in childhood and were
surpressed or repressed in adulthood. when a dependence begins,

Relationship Addiction
40
it is not so easily tempered with independence ad a balance
achieved. The addiction process often sets in as an attempt to
“consume“ the affection and attention denied for so many years.

Proposed pathogenesis, possible etiologies ard descriptive

 

characteristics: How the trouble began-is often necessary to

 

discover, if one is interested in proposing treatment possibil-
ities. Substance abuse ard codeperdent literature are proposing
that relationship addiction often occurs in a grow receiving
increasing attention today: Adult Childrm of Alcoholics. These
children grow up learning to function independently at a very
young age and exhibit many addictive behaviors related to sub-
stances, food, gambling, relationships, and/or work. (Black,
1982, Norwood, 1985, maeffer, 1987).

Sane psychologists see alcoholian ard chemical depezdency as
an oversiuplified answer to describing addictive behavior in
relationships ard instead propose that roots for relationship
addiction lie within dysfunctional development in the attaciunent
phase within object relations theory. (Halpern, 1982). Horner
(1979) (kfer to Figure 4 page 41) describes the stages of
develonent to include Stage 1: Normal Autism, Stage II Normal
Symbiosis, ard Stage III, Identity, iject Constancy atd Healthy
Self Esteem. (p. 26). The process which occurs between State I

/ and Stage II is the Attachment process: that process where the

infant attaches and experiences the world as a part of himself.

Relationship Addiction
41

Stage of _ Stage of Identity and
Normal Autisn Normal Symbiosis abject Constancy

 

 

 

 
   

Process Process
of
Attachment Separation

O
H.

(Attactment Phase) ( Separation Phase)

Apperdix 4: Object Relations Development Theory.
(Horner, 1984)
The above model displays the process of identity formation as
discussed by Homer. A proposed etiological factor is that of
attachnent hunger which occurs as the result of m uncatpleted
attachment phase. Note here, also, that Gilligan's model proposes
a possible gerder distinction in the separation phase.

Relationship Addiction
42

Trust is the core issue in the attachment phase. The process
proposed to occur between Stage II ard Stage III is separation and
irdividuation. Through a series of steps, the child progresses or
“hatches“ (p. 30) from the normal symbiotic relationship to become
more autonomous through a series of steps. Inpedement in this
process at the attachment phase, where deperdability is not
available to the infant, leaves the irdividual with an insatiable
yearning or “attacment hunger“ (Ralpern, 1982, p. 14). The
separation was is then hanpered and a reactive separation and
irdividuation occurs, but the insatiable hunger and neediness
continue throughout life if mtreated. Because the irdividuation
and separation is reactionary, the person may at times appear
highly productive and irdepeldent. The neediness, however,
renaim though well-masked by the irdependence.

Caution must be taken here to note that Gilligan's proposed
developnental gerder differences may be in conflict with the
latter stages of object relations theory. Separation process may
differ between male and female. The important aspect to consider
is the: a dysfmctional attachment phase (same for male ard
female) may be the pathogenesis involved.

Integrating the ACA ard attactment hunger issue, then, it
becomes obvious that many children growing up in alcoholic homes,
were probably victims of an attachment disorder. The parent may
have been ill enough to not be present physically, certainly pro-

Relationship Addiction

43
moting dysfunctional attachment, or the parent may have been
emotionally unavailable in the early stages of their disease,
thereby also promoting an attachment disorder for the child.

Another etiological perspective to examine is one addressed
by Woodman (1982) where she proposes that mrealistic parental
expectations of a child (hyper-responsibility ard hyperproduct-
ivity at an early age) help to create an enptiness in the child.
The child begins in search of the “answer“ to the emptiness ard
begins to follow an addictive path utilizing may objects or
situations in the process.

All etiological perspectives conclude in the hmger or apti-
ness within as the primary characteristic of the addictive
experience.

The Addictive brperience. Peale (1983) sets criteria by
which to identify the addictive experience. (p.65) He states the
experience:

1. Eradicates Awareness.

This primary stardard involves absorption 93 2233

 

cuneiousness “...so as to eradicate awaremss of pain,
tension, anxiety, ard problems which bring these on.“ (p.65)
2. Destroys Other Involvements ard Gratifications.

The addictive experience dominates one's life to the
exclusion of other relationships ard satisfying events.

3. Provides Artificial Sense of Power ard Self-Esteem.

Relationship Addiction
44

(he uses the addictive experience to gain a temporary
sense of control that dissipates quickly, following the
event, when powerlessness and diminished self worth set in.
This then in turn leads the addicted person to
reproduce the experience in attempts to regain a
temporary sense of control.
4) Not Pleasurable.
“A person turns to an addiction to obliterate other
experience, not to enhance it.“ (Peale, 1983, p. 65). The
addiction results :29 a_n_ unpleasant experience of reality.
5) Predicwle.
The experience, drug or other wise induced, results in a
predictable outcome, usually teaporary relief. (p.65)

 

Balpern (1982) proposes five signs of addiction in a

relationship:

1. Wen though your objective judgment (and perhaps the
judgment of others) tells you that the relationship is
bad for you ard you cannot expect any improvment, you
take no effective steps to break with it.

2. You give yourself reasons for staying in it that do not
hold water or that are not really strong enough to
balance the negatives in the relationship.

3. When you think about ending the relationship, you feel

dread, even terror, and you cling to it even harder.

Relationship Addiction
45

4. Vhen you take steps to end it, you suffer acute

witldrawal symptoms, including physical distress, that

can only be relieved by reestablishing contact.

5. when the relationship is really over (or you fantasize

that it has erded) , you feel the lostness, aloneness, and

emptiness of a person eternally exiled—often followed or

even accompanied by a feeling of liberation. (p. 10)

Race, again, a comparison with the process of alcoholism is

made. Ralpern not only addresses the attaclnent hunger etiology

basis for relationship addiction; he integrates the etiology into

the experience ad. links it to the similar experience of

alcohol in.

Sueffer (1987) lists irdicators for the experience of

addictive love:

People in addictive relationships experience the

following:
1.
2.
3.
4.
5.
6.
7.

8.

They feel consumed.

They cannot define ego bourdaries.

They exhibit sadomasochism.

They fear letting go.

They fear risk, change, ard the mknown.
They experience little irdividual growth.

They do not experience true intimacy.

They play psychological games.

Relationship Addiction
46
9. They give to get mmething back.
10. They attempt to change the other.
11. They need the other to feel complete.
12. They seek solutions outside the self.
13. They demard ard expect unconditional love.
14. They refuse to comit themselves.
15. They look to others for affirmation and worth.
16. They fear abandonment when routinely separated.
17. They recreate old, negative feelings.
18. They desire, yet fear, closeness.
19. They attempt to take care of others' feelings.
20. They play power games. (p. 38-39)

She goes on to clarify each of the statements with a brief
description. Again, although a somewhat sinnplified structure, it
provides guidelines for classifying a relationship as addictive or
non-addictive. Most assuredly, research needs to be done to
validate the presence of these characteristics in addictive
relationships.

A Sociological Perspective. It is important to note here
that the addictive substance or event itself is _n_o_t_ the problem.
Peele ( 1983) states:

...Addiction is based on the experience the person derives

from a drug. The person's need for that experience, ard

the way in which this experience fits in with the rest

Relationship Addiction
47
of the person's .life...Addiction does not come from the
drug: it begins with the person, his or her sitution,
ard that person's search for a given experience. (p.59—60).
Many sociologists are becoming irncreasingly corncerned with
the rise in the occurrence of addiction in society. In some
advertisements, “An addictive appeal (may be) created“. (Peele,
1983, p.71) Most advertisements display a product (alcohol or
medicinal drugs primarily) to help one cope with the dissatisfac-
tion in their lives. Some government-sanctioned betting is
advertised in such a way. So although it is not the activity or
substance that is harmful, a person addictive in nature may be
particularly. vulnerable in such a culture that: prosotes “quick
fixes“ for discomfort, maximized in a fast-paced western world.
Covert social approval for love or Relationship addiction is
displayed in films, popular nusic ad television. It is certainly
apparent in popular files that the women is the subject of such
pathology. A film depicting the addiction in relationships well
was “Splendor in the Grass“ where the young women is so obsessed
with in: high school boyfriend that his disinterest leaves her
immobilized and somewhat insane.
Tennov (1980) addresses primarily the addiction to romance.
She coins the experience “limerance“...that occurrence of being in
love with ard walkirng on air. Limerance alone is not the problem.
Many people in relationships experience limerance in an

Relationship Addiction
48

unobtrusive manner. The literature clearly indicates however,
that in some instances limerance is accompanied by obsessive
thoughts about the relationship to the point of interference with
daily living. (Ralpern, 1982, Peele, 1975, Norwood, 1985:
Washbourn, 1977, Peele, 1978, Tiennov, 1980). Phlpern (1982)
states, “Most addictive relationships start with limerances.“
(p.27) He goes on to clarify that when the limerance is
accompanied by Attachment Hunger, the addiction process is in
place. Peck (1978) sees limerance as an “act of regression“
(p.88) representing the union early in life in the wont: of a
mother. He sees it as mfouded in reality. The hunger for such
an experience is clearly understandable with the addicted person
searching for a safe place, a refuge from discomfort, and self
identity.

The public expresses addiction unknowingly. Popular music
reeks of limerance and lament. One popular rock song is presently
entiled “Addicted to love“. Some films portray relationship
addiction accurately. And certainly, any daytime television
viewer will observe obsession and compulsive behavior in sex ard
romance on familiar afternoon sagas. Most American people are
exposed to relationship addiction regularly. Many experience it
themselves.

mrther validation of relationship addiction being a general
concern to the public might stand in acknowledging the difficulty

Relationship Addiction
49
obtaining the popular'literature in this area. This author
attempted for several months to obtain library copies of Peele and
Brodsky (1975), T'ennov (1980), and Peele (1985). All three were
being utilized nost of the term and when obtained, were found in
very g condition. Norwood's (1985) book is a very popular item
in bookstores. The public is interested. Popular literature and
magazines address the topic. Magazine articles promote self help
affirmation rituals, and self help grows such as Dave Addicts
Anonymous are becoming accessible.
A Spiritual_gfi.ngst
me refreshing perspective of the addictive experience is a
paradoxical one proposed by Woodnan (1987). “The positive side of
addiction is that many addicts are profoudly religious people.
They have imnnense energy and are not satisfied with the world as
it is...they want meaning in their lives.“ (p. 59-60) awe fatloms
that an empty role exists and the soul feels empty. “They go
through death and (then) resurrection“ as they quiet the soul and
surrender to “the feminine principle...that slow rhytl'm of the
earth.“ The awareness comes that “you are not God and cannot
control your life“ (p. 61) in the moment of truth when the addict
lets go of his power (which has not helped, obviously, at this
point) and begins to trust.
The paradox of death and resurrection is an old, familiar
one. Any recovering addict or alcoholic will tell you he has

Relationship Addiction
50
experienced this. It is a message of hope for those still in
distress.

Critique of the Literature. Difficulty lies in the fact that
most of the literature available on relationship addiction is
speculative at best. Primiarily, the topic is being addressed in
popular literature and self help books. A sound sociological
perspective is presented by Peele (1975, 1983, 1985). A.specula-
tive case method presentation is offered by Norwood (1985), Tennov
(1980), and Halpern (1982). Altlough case method presentation was
offered by the above stated autlors, no systematic approach was
described in terms. of data collection or analysis. Schaeffer
proposes a nnmoer of descriptors for the experience of
relationship addiction, but provides no rationale for her arrival
at such descriptors and proposes no means of validating the
experience or the recommended solutions. Anphilosophical approach
is provided by From (1974), Washbourn (1977) and Peck (1978)
speculating differences between love and limerance. No
substantial qualitative or quantitative research has been done in
this area. This author found no quantitative research for
substance abuse applied to situational addiction. The concept is
in the early stages of development, although romantic obsession
has been expressed through literature since the earliest of time.

There needs to be at this time, sound concept development to

provide a framework for exploration and description, thereby

Relationship Addiction
51
promoting detection, prediction and prescription for nurses and
other appropriate professionals treating the individual with an
addictive problem.
Summary
In this chapter, the auttor has smmarized literature
relating to the concept of addiction to conclude specific
characteristics of the concept “relationship addiction". Women's
developnent was discussed as a possible predisposing factor, and
possible etiological theories proposed. A sociological and a
spiritual context was reviewed. Overall, literature fran
differing disciplines re: varying perspectives was fomd to be
consistent in describing the experience of addiction.
Chapter III will amly the concepts discussed within a
nursing conceptual framework. The remainder of the scholarly
writing will then address potentials for research and practice.

Relationship Addiction
. 52

CHAPTER III: CQCEPI‘UAL FRAMHNCRK

Relationship Addiction
S3

Conceptual Framework

 

Having reviewed this concept of relationship addiction, it
now becomes important to place this concept within a theoretical
structure of nursing. The context in which one perceives the
concept will give further direction in describing, exploring,
predicting and prescribing for relationship addiction. The
purpose of applying the concept within a nursing theory is to
provide a structure, a consistent framework from which to study
and practice.

Roger's Life Process Theory. In 1970, Martha E. Rogers

 

published her first in-depth work proposing a nursing theory
focusing on man as a mitary being. Sue proposes that “man" or
the 'hunan field“ is an irreducible, four dimensional energy field
identified by patterning and manifesting characteristics that are
specific to the whole and cannot be predicted from knowledge of
the parts (Rogers, 1970). Man as an energy field greater than the
sun of his parts is the theme central to Rogers' theory.
Environment is described as an “irreducible four dimensional
energy field identified by patterning and integral with the human
field'. (Malinski, 1986, p. 193). Man and environment are in
constant interaction with one another. Health is seen as an
expression of the life process. Fbgers' believes it to be part of
a dictotonnous notion ”arbitrarily defined, culturally infused, and

value laden.“ (Rogers,197o, p. 85). Nursing is described as both

Relationship Addiction
54
an art and a science: An art in that the practice of nursing is
used in service to man; a science in that it is a body of abstract
knowledge arrived at by scientific research and logical analysis
(Rogers, 1970, Malinski, 1986), Rogers (1970) states:
Professional nursing practice seeks to promote symphonic
interaction between man and the environment, to strengthen
the coherence and integrity of the human field and to direct
and redirect patterning of the human and environmental fields
for realization of maximum health potential. (p.122).

Health then, for clarity's sake within this paper, will be
synonymous with symphonic interaction between man and environment.
In order to make Rogers' Theory come alive, one must be

conunitted to understanding the concepts annd principles therein.

If the Life Process theory is perceived as an alternative language
or perspective, one can more easily conceptualize life in the
context of her theoretical framework. Four concepts are basic to
this framework: ennergy fields, openness, pattern, and four
dimensionality. Energy fields are described by Rogers in the
following exerpt from Malinski's book 'gploration on Martha

 

Roger's Science of Unitary Human Beings.”
Energy fields are postulated to constitute the
fundamental unit of both the living and the nonlivirng.
Field is a unifying concept. Energy signifies the

dynamic nature of the field. Energy fields are infinite.

Relationship Addiction
55

Two energy fields are identified: the human field

and the environmental field. Specifically, human

beings and environment are energy fields. They do

not‘have them. Moreover, human and environmental

fields are not biological fields or physical fields,

or social or psychological fields. Neither are human

annd environmenntal fields a sumnation of biological

physical, social, and psychological fields. This is

not a denial of other fields. Rather, it is to make

clear that hunm annd environmental fields lnave their

own identity and are not to be confused with parts.

(Rogers, 1986, p. 4).

'Openness' is that concept describing the integrality of the
hunan and environmental fields. Energy fields are always open,
therefore 'change is continuously innovative." (Rogers, 1986, p.
S) . This opemess indicates simultaneity therefore invalidates
causality. Hence, in application to the relationship addiction
model proposed, one must perceive all characteristics proposed,
both etiologic and descriptive in simultaneous occurrence.

Rogers (1986) describes 'pattern' as:

...the distinguishing characteristic of an energy field

perceived as a single wave. Pattern is an abstraction.

It gives identity to the field. The nature of the

pattern changes continuously. Each hunan field pattern

Relationship Addiction
56
is unique annd is integral with its own unique

environnnnental field pattern. The term "pattern"

is used only to refer to an energy field.

Manifestations of field pattern emerge out of

the hunnan and environmental field mutual process.

(Rogers, 1986, p. 5).

Manifestations of field patterns emerging out of the bum annd
ennvironnmental field mutual process are a part of the prinnciple of
helicy.

"Pour dimensionality" refers to the non-linear domain of
hunnun and environmental fields. Both field are witout spatial or
temporal attributes.

Principles of Homeodynnamics are building blocks for this
proposed framework. Principles of Homeodynamics describe the
nature annd direction of change manifested by unitary beings (mann)
in mutual process with the environment. (Rogers, 1970) . There
are three principles currently proposed by Fbgers. They are:

1) mama—my - Continuous change from lower to higher
frequency wave patterns in hunan and environmental
fields.

2. m - Continuous innovative, probabilistic increasing
diversity of hunan and environmental field patterns

patterns characterized by non-repeating rhythmicities.

Relationship Addiction
57

3. Integrality - continuous mutual hunnan field and

 

environmental field process. (Malinski, 1986, p.194)
An important aspect of Rogers' theory is that change is unidirect-
ional in nnature, irreversible and nonrepeatable. "Change proceeds
by the continuous repatterning of both man and environment by
resonating waves." (Rogers, 1970, p.102).

Relationship Addiction within the Context of Life Process
Eel Primarily, it becomes important to take note of addiction
in context with other associated behaviors. Figure 1 shows linear
continuuns describing such contextual placennnennt. It is important
to note the similarities anong the three continuunns. At either
end of the spectrunn social isolation occurs. .Whether addicted to
substances or relationships, one narrows outside stimuli to the
object of obsession. Man's interaction with environment is non-
sympnonic at the two extremes. Note, also, the prepositions.
"With" is nost indicative of sympl'onic interaction.

Figure 1 on next page.

Relationship Addiction
58

Substances: Drugs & ETC}!

 

g g fl 1 L
Avirs ion Independence Sodial DepeRience Adfi’tion
to from interaction on to
with

Situations: ENennts, People, Relationships

 

L L I I f L g
Aversion Indepéndent Interdependence Dependent Add idted_
to from on to

Relationships

 

1 1 L .. 1 l k
Avdidance Independent InterdéLpendent Dependent Add feted
of from with on to

Figure 1

Since the context of behavior is the same or similar anong
all three types of addiction, for the purposes of placenent within
the Life Process model, onne definition is proposed:

Environmental Addiction: Whereby the hunnann field becomes

 

patiologically dependent on the environnnnnental field for his
substance, diminishing his coherence and integrity so that he
experiences being indistinguishable fronnn the environment.
Further elaboration of the five levels of interaction with
the environnment can be seen in Figure 2. "Aversion to" or
Avoidance of" usually involves fear. The fear pushes the energy
field far out into the environment to protect man from that which

he fears. The quantity of the interaction is minimal. The

Relationship Addiction
59

quality is that of low level interaction whereby man is aggressive
and directs and imposes himself upon the environment. Addiction
to, on the other hand, visually describes the above stated
definition. Environmental field protrudes far into the unitary
being field due to the decreased integrity and coherence of man.
Quantity of the interaction again is minimal. Quality is low
level whereby man is passively impinged upon by the environment.
A main prenise, then, in environmental addiction is that mann
beconnnes enslaved by and defined through elennnennts of his
environment thereby minimizing quality interaction.

Figure 2 follows on next page.

Relationship Addiction
60
In terms of Principles of Homeodynamics, reasonancy continues
to occur during the addiction process, as it does in any process.
As the person approaches and moves into recovery, it is proposed
that higher frequency patterns would be occurring at a more rapid
pace than during the onset and peak of the addiction process.
Helicy would also continue to occur, but it proposed that
patterns repeat themselves in closer proximity to one another,
showing a slowed unidirectional progression (Figure 3) as the
addiction process interferes with symphonic interaction between
mann and environment. It is important to note at this time that
the events occur simultaneously and not as a result of. Cause and
effect are not applicable in Rogers' theory. Addiction and
decreased symphonic interactions occur simultaneously and in

relationship to one another.

.oirectional . o-ression

(”AW/m (In). on, .n\\' “919A. 0'. .1 M055 t'l'fil“\
“w: w in in 9919, 4111/ 'J'n'um'nwvnv WW}

 
  
 

 

   

impaired

symphonic Recovery Symphonic
interaction Interaction
(addiction)

Figure 3

Relationship Addiction
61

A diagram showing the etiological characteristics of
environmental addiction can be seen in Figure 4. Etiological
possibilities are shown impinging upon unitary being and
environment. (Women's developnnent is seen as predisposing
primarily in unitary being, but also in environment.)

Etiological factors impinge upon either the unitary being or
the environment.(see Figure 4) and can be separated into three
sources. (See Figures 4 a, b, c). The internal frequency source
(4a) and the internal/external frequency source (4b) directly
interact with the unitary being. The external frequency source
(4c) directly interacts with the environment. Frequency refers to
wavelength resonancy originating*within the identified source.

The quantity of arrows impinging upon unitary being show the
loss of coherence and integrity of unitary being's field. He
struggles to control the environment which he feels invades his
field and predicts behaviors for him. Perceived powerlessness and
perceived lack of choices occur. Power and control become major
themes. He experiences ennptiness and an insatiable hunger along
with a despair and purposelessness in living (spiritual
starvation). Safety and satisfaction occur only in the nnoments of
indulgence followed by and entangled with moments of bitterness
and remorse. Ego boundaries get lost, hence the constant attempt
to protect self from the environment. (See Figure 5 for Resulting

Characteristics Describing the Addictive Experience.)

Relationship Addiction

62

Internal Frequency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

lnternaUExternal External Frequency
Source Frequency Source Source
Unreasonable Parental Societal Misconceptions
[ Attachment Hunger ] Expectations re: Female Experience
9 " 9

Female Development; Female Development; Female Development;

Connection Needs Connection Needs Connection Needs

Q !
Diminisln Coherence ”gang‘s,” Misdirects Patterning pi
and lntegrity ol Envnronment to Expect
Certain Behaviors
, Non-Symphonic lnteraCtion v
Unitary Being i {M 'i Environment]
. i
Health and Human
Potential Minimized
i
Undireaional
Progression
Slowed

 

 

 

Figure 4 - Etiological Charaderlstics
A proposed diagram (or possible etiological factors involved in depicting dysfunctional attributes of environmental

addiction. Adapted from I. Givens' 'Dominant Themes in Rogers’ Concepts of Nursing Focused on Professional
Nursing Prattice and W9': Aim and Goals.‘

Figure 4

 

 

Relationship Addiction

63

INTERNAL FIEOUfllCY SOURCE

 

Btacnment Hunger

 

O

 

Female Development:
Connection Needs

 

 

 

 

 

OmnnConerence
and integrity oi

 

 

 

 

V

Figure“: lnternalFrequencySeurceolItielegicalCharacteristic

wmmmeunnaqbemgtaenvirenmental addiction:
humulhemanteunm ThuecnnMganduumouuanuleiunmntmi
miurybehgandcompnseedebgialmermioefmeimemalMum
m Attachment hungerdimutishescenerenceointegntyottneperson: coupled
with connection needs. the attachment hunger may potentiate diminished
Miocene” o! the urinary being. thereby resulting in undefined ego
Manes (see Figure 5).

Figure 4a

Relationship Addiction
64

INTERNAL/EXTERNAL FREQUENCY SOURCE

 

Unreasonable Parental Expectations

 

 

 

O

 

Female Development:
Connection Needs

 

 

 

 

 

e
Misdirect Healthy Patterning oi

 

 

 

 

V

I Unruly Being

 

 

 

Figure 4b: lntemalltxternal Frequency Source of
Etiological Characteristics

itiological factors predisposing the unitary being to environmental addiction:
Internalllxternal Frequency Source.

These existing predispositions arise from both internal sources (connection needs)
and from external sources (unreasonable parental expectations). Both. however.
my deal with the unitary being and therefore comprise etiological
characteristic of the internallexternal frequency source. Unreasonable parental
expectations directly influences the patterning of the unitary being. In conjunction
with connection needsothe need to appease to facilitate that connection.
unreasonable parental expectations may result in compulsive behavior that never

satisfiesthe emptiness within due to unmet sell expectations (see Figuie 5).

Figure 4b

Relationship Addiction
65

EXTERNAL FREQUENCY SOURCE

 

Societal Mispercaptions re:
Female Experience

 

 

 

O

 

Female Development:
Connection Needs

 

 

 

 

 

Misdirect Healthy Patterning of

 

 

 

! 7
Environment

 

 

 

 

 

Figure Ac: External Frequency Source of Etiological Characteristic

Etiological factors predisposing the environment to facilitate environmental
addiction in the unitary being: External Frequency Source.

These existing predispositions arise primarily from external sources (environment)
although female development 0 connection needs is an internal function. Coupled.
they deal with the environment and therefore comprise the external frequency
source. Societal misperceptions of the female experience (lower level of decision
making ability in moral dilemmas. less autonomy and ego development. inferiority)
in conjunction with women's connection needs. results in the vulnerability of
women in an aggressive society. These societal misperceptions misdirect the
patterning of the environment to expect certain behaviors from women
(dependent roles). This coupled with the connection needs of women may result in
unhealthy societal behaviors: emotional or physical abuse. sexual abuse.

sadomasochism.

Figure 4c

 

 

 

 

 

 

 

 

 

Relationship Addiction

 

 

66

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oiminish Coherence misdirect Healthy Misdiiect Healthy
9 integrity of Patterning of Patterning of
\ / T
‘IM A “WWW“ E m"
. ‘ (Addictionl
Refilling in
T ‘ I r
constant attempt to insatiable emotional hunger overwhelm desire to I detnmantal effect to
protect self liom emptiness within control circumstances individual o society
environment spiritual starvation involving object
°‘ W compulsive soil defeating
obsessive thou¢tts perceived lacli of choice , m mm“ “'6'"
, "W perceived “a of M vvitrtdraiael behavior dialect of addiction
delertsa mechanisms issues of: pathological habit
dared control 0 power destroys other
"WW MW“. lflEOfOSlS

 

 

 

 

 

 

 

 

 

porioac sense of satisfaction.
pointer. r saletywhen indulging,
sense of remorse following

 

 

Figure 5:

l

 

 

 

 

 

inability to tolerate
errtotional discomfort
Habit is an attempt to
escape discomfort

 

 

Descriptive Characteristics of the Addictive Experience

Integrates and identifies all characteristics describing the

addictive experience.

All characteristics occur simultaneously

and in conjunction with the aforementioned etiological factors.

 

Relationship Addiction
67
Sumnerx

In this chapter, the author has applied the concept of
addiction and characteristics thereof within the theoretical
framework of Roger's Life Process Model. A definition for
“environmental addiction” was formulated. Etiological factors and
descriptive characteristics were described and depicted within the
context of Roger's Model.

Relationship addiction is a fairly recent concept which women
may be particularly vulnerable to because of developmental tasks
and learned sociological behaviors. The process of relationship
addiction is similar to that of substance addiction. Addiction
within the context of nursing can be seen as environmental addic-
tion. It interferes with symphonic interaction between man and
environment. Since nursing's role is to promote symphonic
interaction, her involvement in the addiction process includes
strengthening the integrity of the hunan field and redirecting
patterning of both the environment and the human field. Further
research needs to be done to begin to direct nursing practice,
education, and research in the area of relationship addiction.

In the following chapter, nursing's role in Advanced Practice
will be discussed concerning environmental addiction. Public
Education will be proposed. The author sdll address the
importance of qualitative and quantitative research in the area of

environmental addiction.

Relationship Addiction

68

m N:
IMPLICATIQB Fm PRACTICE, MTHN, AND Rflsm

Relationship Addiction
69

In prior chapters of this scholarly writing, the concept of
relationship addiction was described and defined and etiological
factors proposed. The concept was then placed within a nursing
framework to substantiate evidence for its relevence within the
field of nursing. Impaired symphonic interaction which occurs
simultaneously with the addictive process limits the health and
well—being of the individual. This interference with health
becomes of primary importance to the advanced nurse clinician as
she attempts to promote the coherence and integrity of the
individual and to direct and redirect healthy patterning of the
individual aid the environment. In the 4th and final chapter.
previously discussed concepts and frameworks will be applied to
the appropriate roles of the CNS within the context of the primary
care setting. Discussion of appropriate means of practice.
education, and research will be addressed. A.brief conclusion
including the author's recomtiendations and concerns will follow.
The Primary Care Settng

The primary care setting is the port of entry to the health
care M. It is typically an office or a clinic setting in
which health screening is done to detect for lack of symphonic
interaction between the client and the environment. (Illness or
dysfunction). Clients utilize the primary care setting to

maintain and promote health, prevent illness and restore wellness.

Relationship Addiction
70

The health care provider within the primary care setting serves as
a coordinator of health care, treating appropriate conditions and
referring those conditions inappropriate for treatment in the
primary care setting. The primary care setting is then, the most
frequently used means of accessing the health care system. It
then becomes apparent that this setting would be important in the
detection of this often neglected, health interfering problem
called relationship addiction. It is important to note here that
detection of such a disorder is a difficult task since most
clients experiencing any environmental addiction may present with
somatic manifestations of psychological distress and often the
patterning of these symptoms is overlooked.

How would one present to the primary care system with such a
disorder? The aforementioned descriptive characteristics are the
predominant cues indicating the problaii exists. In a blatent
case, a couplete health history including a thorough health
pattern assessment (Gordon's tool, revised, see page 71), may help
to identify the presence of etiological factors and descriptive
characteristics. To evaluate the Internal/External Frequency
Source at in-depth fully history and Role-Relationship assesstient
must be completed. Such an assessment may expose a history of
unreasonable parental expectations. The unreasonable expectations
may be evident initially as the client exposes her own unreason-

able expectations of self, unaware of the significance or

Relationship Addiction
71

Gordon's Health Pattern Assessment

Self-perception-self concept pattern

b.

How would you describe yourself? Most of the time, feel good
(not so good) about yourself?

Changes in your body or the things you can do? Problem to
you?

Changes in way you feel about yourself or your body (since
illness started)?

Find things frequently make you angry? Annoyed? Fearful?
Anxious? Depressed? What helps?

Bier feel you lose hope? Not able to control things in life?
What helps?

W

a.
b.

c.
d .
e.

f.
g.

h.

i.

(j-
k.

1.

Live alone/ FamilY? Family structure (diagram)?
Any family problems you have difficulty handling?
(nuclear/extended)
How does family usually handle problems?
Family depend on you for things? How managing?
If appropriate: How family/others feel about your illness/
hospitalization?
If appropriate: Problems with children? Difficulty handling?
Belong to social groups? Close friends? Feel lonely
(frequency)?
Things generally go well for you at work? (School?) If
appropriate: Income sufficient for needs?
Feel part of (or isolated in) neighborhood where living?
How do you normally relate to women? to men?
mat happens when you and your significant other disagree?
How nuch time do you sperrl thinking about the iuportant people
in your life? Does this ever intervere with your ability to
function normally? Does it ever cause you emotional
discomfort? How so? mat is that like for you?
me was your relationship with your parents like?)

Coping stress tolerance pattern

a.
b.

Ce

(1.

Any big changes in your life in the last year or two? Crisis?
Who's most helpful in talking things over? Available to you
now?

Tense a lot of the time? What helps? Use any medicines,
drugs, alcohol?

When (if) have big problems (any problems) in your life,how do
you handle them?

Relationship Addiction
72

e. Most of the time, is this (are these) way(s) successful?

(f. Any obsessive thoughts or ideas? About what? What do you do
about them?)

value belief pattern

a. Generally get things you want out of life? Important plans
for the future?

b. Religion important in your life? If appropriate: Does this
help when difficulties arise?

c. If appropriate: will being here intervere wiuh any religious
practices?

(d. Describe your idea of being spiritually content.)

Taken from: Gordon, M. (1987). Manual of nursing_diaggosis. St.
Louis: McGraw Hill. Additions in parenthesis.

Relationship Addiction
73

implications of such behavior. Careful assessment of previous
roles and relationships may provide evidence of unreasonable
parental expectations in the woman's childhood. The client's
investment in the connection needs identified as normal to female
development by Gilligan may be confirmed by careful assessment of
the Role-Relationship, Self-Perception/Self-Concept and Coping-
Stress health patterns. The Clinical Nurse specialist would find
this apparent in how the woman describes herself in relationship
to others. A general theme of 'need for comection' will normally
be apparent in any woman. It is the conbination of this need with
other etiological factors, (attachment hunger, unreasonable
parental expectations, societal misperceptions) that may produce
the environmental addictive experience.

To assess for attacl'rnent hunger in the Internal Frequency
Source the 08 must extensively collect data in the Role—
Relationship, Self-Perception/Self-Concept, Coping Stress, and
Value-Belief Health Patterns. It is important to discover what it
is that the woman values as a source of strength. What are her
needs? that satisfies these needs? How does she get these needs
met? How does she deal with a dependence-independence conflict?
Do any such conflicts exist in her life?

To evaluate the External Frequency Source, the CNS must
assess the clients environment and if at all possible, interview

family members or significant others to establish whether or not

Relationship Addiction
74
misperceptions exist re: the female experience. How do those
members of her environment perceive women? What are their
expectations of them? What roles do they assume in the
relationship?

Assessment of the above mentioned three frequency sources
must be coupled with an in depth interview consisting of
exploratory and non-exploratory response modes directing the
content of the health interview to expose the presence of any of
the descriptive characteristics. A thorough assessment of health
patterns and medical history will provide enough data to ascertain
whether a umber of descriptive characteristics seem to be present
or not. Once a descriptive characteristic is identified, it is
strongly urged that the CNS be very specific in attempting to
illicit information pertaining to other characteristics. If the
client is Wt protective or defensive during the interview,
if eye contact is limited, verbals/non-verbals inconsistent,
distancing present, and partial information extrated, protection
may be an issue. Further barriers may include the defense
mechanic-s of denial and rationalization. Withdrawal or isolating
behavior may be noted. Mood swings may also be evident resulting
from a periodic sense of satisfaction and power alternating with a
sense of discouragement and remorse. Self-defeating behaviors
will become apparent throughout the interview. Careful assessment

of the Role-Relationship pattern will reveal limited social and

Relationship Addiction
75
community involvement and diminished outside interests. A
persistant theme throughout the interview will be the client's
perceived inability to control events. Careful assessment of
Self-Perception/Self-Concept will-reveal the clients belief that
she has no power and that choices are~liudted. The woman may make
brief mention of experiencing a sense of being imprisoned by some
force or nature. Anger may be evident while discussing a certain
topic. The CNS must be astute enough to isolate this topic area
and gather further information about the clients response to the
possible object of addiction. The anger may be indicative of
power and control issues surrounding the object of addiction.
Client verbalizations may project a) over whelming desire to
control circumstances surrounding the object of addiction. A
thorough assessment of the coping/stress health pattern may reveal
an inability to tolerate emotional discomfort. Occasionally the
client will acknowledge that a habit exists either directly
(verbalization of) or indirectly (recurring theme of habitually
returning to substances or situations that may be harmful). An
astute CNS may be able to identify a covert expression of
obsessive thoughts and cravings.
Finally, an emotional insatiability becomes apparent to the
CNS as each suggestion made by the CNS is minimized, by the
client. Careful assessment of the value/Belief health pattern

reveals a hunger for spiritual meaning in life. Generally, the

Relationship Addiction
76
client may present as one seeking truth and meaning in the
experience of life.

The sum of such characteristics results in a detrimental
effect to the individual and society. The experience is
simultaneous in occurrence (ethiological factors, descriptive
characteristics, non-symphonic interaction between the unitary
being and environment). The overall result is the minimization of
health and human potential and a slowing of unidirectional
progression in the helicy process (as seen in Figure 3, pg. 60).

On most occasions, however, the above stated characteristics
are not apparent upon presentation. Bren Lpon interview, the
client may deny some of the subjective swptbmology referred to
above. Often this is due to the clients own lack of awareness
regarding the problem. Frequently the defense mechanisn of denial
is firmly in place in m attempt to protect the individual from
the painful experience. The client most frequently presents with
a number of ill-defined complaints: Headaches, backaches, general
malaise, gastric distress, persistent abdominal cramping ard
diarrhea, sleeplessness, nutritional changes, menstrual
irregularities, depression, anxiety. All are column concerns of
the unaware individual experiencing situational addiction.

Such concerns are often unattended to in the primary care
setting. “Patients with somatization disorders are frequently

unrecognized and misdiagnosed." (JAMA, 1985, p. 3075) Each

Relationship Addiction
77
somatic complaint is addressed seperately, thereby overlooking the
pattern of symptomotology. ”Highly skilled physicians repeatedly
fail to recognize patients with somatization disorders.” (Quill,
1985, p. 3075).

"Somatization disorder (Briquet's Syndrome) is a
polysymptomatic disorder that begins early in life, chiefly
affects women, and is characterized by recurrent, multiple somatic
complaints..." (Zoccolillo and Cloninger, 1986, p. 532) Quill
(1985) also describes the disorder:

For the patient with a somatization disorder, symptoms

and illness become a way of life. They become a form of

comnunication, a means of expressing eruption, and a way

of controlling the environment. The patient presented

herein shows the typical outcome of the disorder when

unrecognized over time -- nunerous operations and

procedures, drug allergies, drug dependence, and a

life dominated by medical experiences. The potential

for iatrogenic disease is enormous, for these patients

have great faith in the powers of aggressive medical

intervention to alleviate their problems. Physicians

often share this faith, and unless the pattern of

multiple diverse symptoms, work-ups, and medical

interventions without lasting improvement is recognized

the patient and physician together may do more harm

Relationship Addiction
78
than good in their search for elusive organic diagnoses.

(p. 3076) -

Quill continues:

Despite the chaotic, often violent personal life

experiences that these patients endure, they do not

present to their physicians with anxiety, depression,

or trouble coping, but rather with nuuerom physical

symptoms. Their symptoms tend to be atypical, and

they have a history filled with‘uultiple, varied

medical experiences. They believe their problems

to be entirely physical, so they seek out internists

and surgeons rather than psychiatrists. (p. 3076)

Since somatization disorders are 'seen predominantly in
women," (Smith, Manson, Ray, 1986, p. 69) significance becomes
important in that women manifesting such a disorder may be
experiencing an enviromental aidiction.

Careful review of the above stated literature reveals a
covert manifestation of some of the descriptive characteristics
previously mtioned. There is an obvious inability to tolerate
emotional discomfort, hence the somatization of such discomfort.
There seem to be an insatiable hunger for answers, although
proposed psychological interventions would probably be offensive

to the client resulting from an in tact denial defense mechanism.

Relationship Addiction
79

Since affective responses are not always obvious in the
somatizing client, one must also address the issue of the client
presenting with depressive or anxiety disorders that are often
overlooked. Katon, Kleinman, and Rosen (1982A) propose that many
depressive, anxiety, and obsessive-compulsive disorders are
overlooked in the primary care setting. They cite studies
indicating that "the primary care physician failed to diagnose
depression in so: of the cases.“ (p. 128) Their contention is
that the clients present with somatic manifestations of
depression, are misdiagnosed, am the treated symptomatically.
The result is I'potential iatrogenic harm to the patient“ (p. 127)
and unnecessary health care costs. Proper diagnosis is essential
to appropriate treatment of the patient.

It is imperative to note that affective disorders may be
responses to manifestations resulting from the experience of
environmental addiction. Careful detection of depression or
anxiety will provide direction for further data collection related
to the area of the addictive experience. The clinical nurse
specialist must, then, be astute in the detection of somatic or
affective disorders and pursue further appropriate assessment to
detect for the possibility of relationship addiction in
association with these disorders.

Somatic and affective disorders must be distinguished from

relationship addiction. Although characteristics of relationship

Relationship Addiction
80
addiction may be present in the individual presenting with vague
and ill defined complaints, all affective and/or somatic disorders
are not necessarily indicative of the presence of a relationship
addiction problem. Somatization disorder is defined as, 'a
chronic, fluctuating disorder beginning before the age of 30 years
and presenting as multiple physical complaints without adequate
explanation, seen predominandfin wasn't.“ (Snith, abnson and Ray,
1986, p. 69). Affective disorders include “depression, mixed
anxiety and depression, anxiety state, and affective psychosis.‘
(Raton, Kleimtan, and Rosen, 1982, p. 128). Althoth
manifestations of either or both these disorders may be present in
the relationship addicted individual, one would need to question
further to identify whether or not the indicated characteristics
of relationship addiction (Figure 5, page 66) were also present.
Therefore, one must carefully assess and analyze data to determine
whether the somatic or affective complaints are associated with
relationship addiction or are simply their own seperate
manifestations.
care also must be taken to acknowledge that not all

relationship addicted individuals will present*with somatic or
affective disorders. Therefbre, the lack of symptomotology
associated with somatic and affective disorders does not indicate
the ruling out of relationship addiction. Again, the clear

indicator is the presence of the descriptive characteristics

Relationship Addiction

81

(Figure 5, page 66.)

As stated previously, the health care provider detects a
sense of general dissatisfaction with life on the part of the
client. Although the provider poses many options and solutions to
the above ill-defined connnplaints, the client finds reasons to
discount all proposed solutions. 'Well, I've tried that before
and it just doesn't work,“ is often a stanndard reply. Oftenn this
help-rejecting behavior is an indicator that the true problem has
not been identified or addressed. The provider may find herself
irritated with this behavior. It is important to recognize it as
a manifestation of the addiction problun ard to address it as
such. This help-rejecting behavior gives direction for problem
identification and therefore, subsecpent appropriate intervention.
Another important prominent behavior seen in this client is
“doctor shopping" whereby the client searches for answers to an
unknown problennn by visiting a nunnber of health care providers. To
each dne divulges page; of the problem, but rarely discloses the
entire picture. Again, this may be due to her lack of awareness
of her own experience.

Occasionally, if the addiction problenn has progressed over an
extensive period of time, the client may present with signs of
physical abuse or a blatent alcohol or drug addiction problem
along with multiple ill-defined complaints. This is not to imply

RelationShip Addiction
82
that substance addiction is consistently related to situational
addiction, although Boyd and Mast postulate a possible causal
relationship between women's drug use and their relationships with
man:

Our observations suggest that an important causal

factor for women may be an inability to cope

constructively with feelings of anger and depression

related to their dealings with men. The patterns

we observed of female drug use fluctuating in

response to a partner's actions might be anticipated

in light of the low self-esteem of these women and

is compounded by women's dependence on men in

general for validation for their actions and

themselves. (1983, p. 12)

In sunmary, this relationship addicted individual often has
direct contact with a health care provider at a primary care
facility. It is therefore imperative to the health care provider
at such a facility to be knowledgeable in the detection of such a
disorder. Presentation may not always include the descriptive
characteristics mentioned in previous chapters. Instead, the
unaware individual may present with a number of ill defined
complaints, help rejecting behavior, a history of “doctor
shopping“ and dysfunctional relationships with health care

providers. The inndividual may have a propensity for eliciting

Relationship Addiction
83
irritation in the health care provider due to the help rejecting
continents and behavior. Finally, a blatent manifestation of
physical abuse or substance abuse may be apparent.

The Health Care Provider in the primary care setting must be
astutely aware of how'one may present with an environmental
addiction disorder. The clinical nurse specialist in primary care
must be able to carefully extract and analyze data that may be
indicative of patterns innplying somatic or affective disorders and
further assess to distinguish the presence of, or ruling out of,
relationship addiction in these cases. She must carefully assess
the Role-Relationship, Self-Perception/SelfFCbncept, coping-
Stress, and Value-Belief health patterns to detect the presence of
etiological factors and/or defining characteristics. The
pronnninent inplication within the primary care setting in reference
to relationship addiction is that of the necessity of detection.
Once detected, referral is usually made fer appropriate treatment
with continued coordination of care provided by the CNS in the
primary care setting.

than is it appropriate for referral or intervention? At what
point does one intervene in the primary care setting for the
relationship addicted individual? Some criteria or guides need to
be established to facilitate the appropriate timing in
intervention. This is particularly necessary since many women may

experience this problem to some degree. Critical points need to

Relationship Addiction
84

be specified to assist the care giver in appropriately analyzing
the women's position on the addiction-isolation continuum.
(Figure 1, pg 58) Criteria should be established for points
between “dependent on“ and “addicted to“ on this continuum.
The key compenent indicating the need for intervention might be
the women's expressed dissatisfaction with herself, her
relationships, or her ability to function purposefully and
comfortably (emotionally), within her environment. Upon further
assessment, if obsessive thoughts are innpairing her judgment and
abilities, the care provider must consider intervention. If
somatic disorders resulting from repressed relationship addiction
are interfering with nnormal routines (sleep, eat, work) one must
consider therapeutic intervention. If an affective disorder
results from the characteristics described, particularly withdrawl
(depression) or obsessional thoughts (anxiety), intervention must
be considered.

Appropriate CNS intervention also depends on the readiness of
the individual. A woman may presennt with concern about her
relating abilities, or about a poor self image. Awareness of the
presence of a problem, named or unnamed,often indicates readiness
for learning on the part of the client. nAlthough this individual
may nnot be so impaired by the problenn as another in acute crises,

readiness to learn/often indicates an openness to intervention.

Relationship Addiction
85

More difficult will be dealing with the client presenting
with an obvious addictive problem.with denial firmly in place.
Often the presentation of such an individual is a loquacious
female, with a controlling verbal and non-verbal message insisting
that “everything is great!“ This individual will probably need to
enter into some crises before the problem becomes apparent. It
has been said that pain.is the alcoholic's best friend, for it
brings him into taking actionn on dealing with the problem.
Likewise it is true with the relationship addicted woman.

The CNS, therefore must be astute in not only recognizing the
presennce of such a problem, but also in discerning its
interference in the quality of the woman's life and in assessing
her openness and readiness for intervention. If interference in
the quality of life is present and the woman is open to treatment,
further information on the problemncan be disseminated and a
referral made. If, however, the woman fervently denies the
existance of the problem Lpon confrontation, one must wait for
client readiness.

Role of the CNS in Advanced Practice

Many roles would be appropriate for the Clinical Nurse
Specialist in the primary care setting. Probably the most obvious
and important role of the CNS would be that of the Assessor.
Detection of the addiction problem is imperative and, as stated

previously, the primary care setting presents an ideal opportunity

Relationship Addiction
86

for such detection. As assessor, the CNS must be knnowledgeable
regarding the problennn and typical presentation of client. This
knnowledge would assist her in synthesizing the data to formulate
the appropriate impression. Astutenness in this role would lead
her to efficiency in her role as a clinician, where she would
formlate nursing diagnoses and interventions appropriate to the
primary care setting. nursing diagnoses nnnost frequently utilized
may be: Ineffective Individual Coping, Reactional Depression,
Anxiety: (Severe, deerate, Mild), and Independence/Dependence
Conflict. Initially she will serve as a counnselor, providing
stabilizing hunan support, but primary intervention for this
problenn will probably be most effective through referral to the
appropriate resource. Such resources dealing with this problem
may be scarce. Sauna investigative work may need to be donne to
uncover the appropriate resource ensuring an agency's (or
therapist's) clear understanding of the addictive process, women's
connection nneeds, and possible underlying etiological pathologies.
The 08 would continue to follow the client as a coordinator of
her care by closely collaborating with the referral agency or
therapist. Throughout the detection, referral, and follow-up
process, the clinical nurse specialist would advocate the clients
involvement in her own care. She would pronnnote self
responsibility for recognition of described behaviors and for
follow through regarding reconnmendations made by the referral

Relationship Addiction
87

agency or therapist. As she provided follow—up care, she would
evaluate the effectiveness of treatment. However, since there has
not yet been a tool developed to measure and assess the level of
situational addiction, evaluation would be a somewhat subjective
account. The following may be included in attempts to evaluate
progress of the problem: Are verbals/non verbals now consistent?
Is use of denial and rationalization diminished? Is client
discussing and owning the problem? Does cliennt recognizes
apparent choices? Has self defeating behavior diminished? Can
client verbalize feelings experience discomfort? Is mood sanenrhat
trusting and less defensive? Does client recognize the usefulness
of talking about the problem? Can client acknowledge that she
does not have control over object of addiction. Can client see
her own progress? Again, collaboration with the referral agency
or therapist and the client would provide a clearer perspective on
progress made.

Throughout her interaction with the relationship addicted
client, the CNS in the primary care setting will function
primarily in a supportive capacity, coordinating efforts to
identify and label the problennn and to facilitate recovery.
Advanced nursing practice in primary care allows opportunities for
developing a “helping relationship“. The “psychotherapeutic
relationship“ will be developed between the client and the

therapist more adequately prepared to intervenne in this area.

Relationship Addiction
88
Appropriate interventionists may be psychiatrists, psychologists,
social workers, counselors, or clinical nurse specialists
concerned with the addictive process and its possible etiological
components. (This author proposes that the appropriately educated
CNS may be the best cpalified interventionist due to her Rogerian
conceptual approach.) It is also preferred that the
interventionist be female and/or fully cognizant of Gilligan's
proposed theory to facilitate intervention consistent with this
theory. If appropriate and indicated, the family may also be
referred for therapy.
Role of the CNS in Education
Clearly, a knowledge deficit about relationship addiction
exists at the public level. As previously mentioned, reviewing
media, literature, music and the performing arts makes this
perfectly clear. Furthermore, health professionals have limited
awareness of the existance of such a problem and a lack of
urderstanding regarding the implications of such a problem. The
C16 would function as a leader and change agent in the comunity
by publicly speaking to target populations. She would discuss the
concepts with prominent women's groups in the coulnunity and offer
her expertise to create public awareness through the media (radio
and television interviews). Women's Health Centers are becoming a
popular channel for lay education. The CNS could provide

information to lay women through such a center. Education impacts

Relationship Addiction
89

greatly at the college level. Speaking to groups of students
would be an effective means of disseminating information.
Conmunity education programs could be provided through the school
system to provide information to parents of adolescents that may
be prime candidates for relationship addiction. Education to
parents may also provide insight as to the results of unreasonable
parental expectations.

Since the public has become increasingly aware of this topic
through popular literature, education in the commity would need
to consist of not only the components of the experience of rela—
tionship addiction, but viable options for dealirg with it. Care
mmt be taken to inform potential victims that with the trendy
status of the topic, quick-fix solutions are often proposed in
some self-help literature and by some therapists. The topic is
popular, but superficially addressed. There are no studies to
validate the effects of such proposed (pick-fix solutions. The
woman interested in recovery must be made aware of the importance
of finding appropriate and gialified professional assistance. The
woman must be informed that, if comitted to recovery, the journey
will be long and difficult, but with appropriate assistance, she
will be supported and recovery will be possible. It is important
to note here that many women may not be interested in recovery.
Since the process of changing behavior patterns is often tedious,

energy consuming, and long-term, such an intense process may not

Relationship Addiction
90
be of interest to many clients. Motivation and committment must
be present on the part of the client.

Health care providers particularly those in the primary cre
setting, need to be educated also. Education should be centered
around the significance of such a problemnand the importance of
its detection. Since many clients present as 'vague and ill-
defined complaints", detection of such a problem may help to alter
this behavior in some clients. A clients perception of
interaction with the health care system may change. Certainly,
this behavior change would be beneficial to the health care
provider by reducing the anomt of irritation elicited by such
energy consuming hnteractions..

nursing schools need to address the issue to provide nursing
students with the skills necessary to detect such a problem.
Nursing schools particularly with conceptual frameworks built npon
Rogerim theory, need to incorporate such concepts inn) the
curriculum.

At the undergraduate level, an integration of the concept of
environmental addiction, proposed etiological factors, and
descriptive characteristics must occur in an Lpper division
Psych/Mental Health course. Practicun experiences in this course
might include a clinical component in a chemical dependency 28 day
(or long term) treatment program. Many women experiencing

chemical dependency have other environmental addiction problems

Relationship Addiction

91
occurring, particularly in relationships. Another option for
practicunn experience might be working within a mental health

clinic that treats women for such problems. Some students may be
interested in observing or co-leadirg groups in these areas.

At the graduate level, primary focus should be on detection.
Knowledge of detection in any graduate tract (Family, Gerontolo-
gical, Adult Med-Surg, Women and Children, Coununity, PSYCh/Mflntal
Health) muld be innportant since screening skills are so in depth
at the graduate level. Graduate Psych/Mental Health Nursing
content may include more on treatment of such disorders.

Practicun aperiances would be tract specific with an aphasia on
screening for and detection of such a disorder within the context
of each clinical site chosen.

Presently practicing W's need to be educated in detection of
the addictive problem also. Inservicee provided for staff nurses
on etiological factors and descriptive characteristics may
facilitate early recognition of such a problem and appropriate
referral. Life long education for nurses could incorporate
detection of such a problem into a workshop or course specifically
in addiction. Annother possible course or workshop would be one on
dealirg with difficult clients since the environmentally addicted
woman often presents with vague and ill-defined complaints.

Since the problem is conceptully constructed of nursirg theory, it

is amropriate that all nurses be educated regarding the concept

Relationship Addiction
92
of environmental addiction uhich applies to any type of addiction
and manifests itself in the descriptive characteristics
constructed in Figure 5, Chapter 3.

Finally, clients need to be educated and informed. The
uninformed client needs to be informed regarding the prominence of
the problem in women. The CNS may carefully explore areas with
the client that may be potentially hazardous. It is the clients
acknowledgement of such a problemnthat opens the doors to further
education and recovery. Client education would include simplified
components of Gilligan's theory of female development, thoughts,
feelings and behaviors indicative of and perpetuating the problem,
and appropriate avenues for recovery. If appropriate, faily
education may also be indicated.

Major responsibility for public and professional eduction
lies with the CNS in this proposed model. The unique perception
of the unitary beitg as an entity itself row in non-symphonic
interaction with the envirornment in the addictive experience
allows the CNS the vantage point from which to address the
addiction problem.

Role of the CNS in Research

This author found no research in the literature addressing
situational or relationship addiction. The only method utilized
was case presentation in Norwood, (1985) TBnnov, (1980) and

Halpern, (1982). In all three books there was no consistency or

Relationship Addiction
93
method described in interpreting or analyzing each case.

NUrsing research on Relationship Addiction needs to be done
to l) validate the existance of such a problen (survey
research), 2) explore the meaning of such an experience to a
number of individuals (phenomenological qualitative research), 3)
describe the experience (descriptive qualitative research), 4)
predict outcomes of the experience (giantitative, post-test only
control group design) and 5) prescribe reliable treatments for the
problem (pretest, post-test, control group design).

Phenomenological and descriptive research need to be
instituted initially to provide and validate a theory base. “A
primary goal of qualitative research is the generation of theory."
(Parse, 1985, p. 4). survey'and quantitative research then follow'
to explore arr! predict specific constructs within the theory.

The author cautions the reader against biasing the afore-
mentioned qualitative studies as minimally’important in comparison
with quantitative research. Although quantitative research is
well reputed and respected, it is only qualitative research that
can offer the simultanaeity paradigm which more closely aligns
with Roger's theory of unitary being, the whole being greater than
the sum of its parts. Parse (1985) states, "The qualitative
approach offers the researcher the opportunity to study the
emergence of patterns in the whole configuration of Men's lived

experiences. It is an approach in which the researcher explicitly

Relationship Pddiction
94
participates in uncovering the meaning of these experiences as
huuanly lived." (p.3). Parse also addresses the conInonly noted
misclaimer of qualitative research...that referred to as 'bias" in
quantitative research. She states, 'Qualitative research takes
into account the researcher's frame of reference (paradigm) and
makes this frame of reference explicitly part of the research
report.“ (p.3) (he nut take into account all threats to
reliability ard validity in each tool and experimental design.
Therefore both gnalitative and giantitative research must he
done to effectively address the discovery of meanning associated
with the experience of relationship addiction in men. Both
methods are valuable, each providing a distinct purpose.
Phenomenological research sew most appropriate to begin
with annd would be the most favored method of qualitative research.
The addictee's perspective of the experience and ascribed meaning
to the experiennce seun most relevent in reviewing this unexplored
area of environmental addiction. Sinnce the phenomenological
method is directed toward uncovering the meaning of a phenomenon
as truly experienced (Parse, Coyne, Snith, 1985, p. 5) it seems
appropriate to apply this method. The descriptive method would
also be instituted in order to describe data gathered in
relationship to the conceptual framework. This method is more
structured and allows for description of the experience within the

context of the proposed conceptual framework.

Relationship Addiction
95
Quantitative methods would follow'specifically addressing, as
stated previously, prediction of the experience, and effectiveness
of prescriptive measures. Retrospective studies would provide
data for the question: What is the incidence of childhood
experiences of lack of attachnent and/or unreasonable parental
expectations in those clients experiencing relationship addiction?
Other mestions might innclude: Hnat role does female develoment
play in the development of relationship addiction? What is the
incidence of relationship addiction mung women annd enonng man?
What is the occurence of each.descriptive characteristic in the
relationship addicted wunun? war is the met frequent object of
addiction—the partnner, the relationship, or components of the
relationship? Quantitative studies would med to be done to
validate the effects of such an experience. Are health and human
potential minimized? Bowso? Is unidirectional progression
slowed? A correlational stuiy between the hunnen field motion
(helicy) and environmental addiction must be done to validate this
proposed theory. Finally quantitative methods would be indicated
in validating effectiveness of prescriptive measures: Does
redirecting healthy patterning of the unitary being and the
environment.affect health and human potential? What are effective
means for repatterning? What are effective methods of

strengthening the coherence arnd integrity of the unitary being?

Relationship Addiction
96

Many questions are unanswered in the area of environmental
addiction. The proposed conceptual framework will offer direction
for beginning research arnd further study.

Conclusion

In conclusion, Relationship Addiction in women is a popular
social issue often neglected arnd undetected in Health Care
Facilities. 'n'nough major announts of attention have been afforded
to this area through recent popular literature, little
substantiative work has been done in the area. No clear
theoretical constructs have been developed and no research has
been done. This scholarly writing proposes a framework for
theoretical development and research in the area of relationship
addiction in women. 'lhe author proposes beginning with
qualitative research to provide a baseline of data and to validate
theoretical constructs presented within this writirng. Further
writing, critiquing (none of which has been done presently), and
conceptualizing are reconmnended.

The author has some concerns regarding the topic. the, as
stated earlier, is the neglect in the health care systenn to
identify the problann's existance or to acknowledge the validity of
such a problem. Education, research arnd role modeling in the area
may stimulate a change in the attitudes of irndividual providers.
Certainly, more clinical nurse specialists in primary care

settirngs emulating the assessor role and addressing the problem

Relationship Addiction
97
would facilitate an overall awareness of the validity of such a
probleu.

The second concern is that of the popularity of the concept.
With the enormous amounts of attention given to the topic in
popular literature, everyone claims to be an expert on the topic.
Literature is a money'maker as are therapists claiming to be
experts in the area. The consunner is vulnerable and uninformed as
to the innplications of such a problem and the difficult anti
lengthy recovery process. The self help literature often proposes
simplified solutions to coeplicated problae. Furthermre, since
no research has been done, it is difficult to evaluate the success
of proposed interventions. Once again, the author proposes the
institution of research in the area to begin to move out of the
popular arena and into credible territory. Clients deserve
effective treatment. mucation out be done in an attemt to
direct the consunner to credible resources.

In summary, the concept of relationship addiction has been
explored and placed within a nursing theoretical framework.
Significance of the topic within the field of nursing has been
established. The inportance of detection in the primary care
setting has been discussed and roles appropriate for clinical
nurse specialist in this setting have been proposed. The concept
has been addressed in terms of roles appropriate to advanced

nursing practice, education, annd research. Finally, the author

Relationship Addiction
98
has reconnmended that. research be done to validate theoretical
constructs annd has voiced conncerns regarding neglect of detection,
topic popularity, annd lack of substantiated treatment base
possibly interfering with appropriate therapy in vulnerable
clients.

The purpose of this scholarly project was to clarify the
conncept of addiction by outlining specific characteristics annd to
propose pathogenesis resulting in these specific characteristics.
The model proposed in Chapter III clearly identifies these
specific descriptive characteristrice (Figure 5) and pathogenetic
etiological factors (Figures 4, 4a, b, c). A definition of
relationship addiction has been proposed (page 16.) annd a clear
distinnction has been made in differentiating dependennce from
addiction. addence has been provided to support the assunnptions
proposed earlier (page 10,11). The idea of women being more
vulnerable to predisposition of this problennn (relationship
addiction) has been supported throughout the paper. A conceptual
framework has been developed annd presented specifically applying
the conncept of relationship addiction to womm within a Rogerian
nursing theoretical framework. Concepts have been defined within
this framework to allow for the beginnings of qualitative annd
quantitative research. A base has been provided for detection of

relationship addiction within the primary care center. Roles for

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99
facilitating wellness in women experienncirg relationship addiction
have been proposed for the CNS.
The concept of relationship addiction in women is an

infant in developuent. It is the hope of this author that the
conceptual framework proposed will offer a base from which to work
at further theory construction. Hopefully each study will provide
nourishment in the growth of the concept to a substantiated and

credible theory.

Relationship Addiction
100 .
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