Abstract
Keywords
In the last 20 years, there has been growing evidence that heavy drinking causes serious harm, not only to the person who drinks but also to their family members and concerned significant others (CSOs) (Birkeland et al., 2018). Many people are affected and impacted by a family member's, a friend's, or a colleague's heavy drinking. Worldwide, it is estimated that there are 100 million affected family members of people with alcohol problems, and this might even be a low estimate since it only assumes one affected family member per heavy drinker (Orford et al., 2013). Studies report that 26.2–31.5% of the population is close to at least one heavy drinker (Bloomfield et al., 2019; Casswell et al., 2011; Iwen et al., 2010). Among those who are directly related to a heavy drinker, 26% are living in the same household (Casswell et al., 2011), and Bloomfield et al. (2019) found that at least 3% of the Danish population share a household with a heavy drinker.
Women are more likely to report negative consequences and harm stemming from heavy drinking in their immediate social network than are men (Huhtanen & Tigerstedt, 2012; Seid et al., 2015; Stanesby et al., 2018). Further, more women (5.8%) than men (2.5%) report living with a heavy drinker (Bloomfield et al., 2019), and, in general, more women and female relatives of heavy drinkers are represented in studies of CSOs (Benishek et al., 2011; Orford, Velleman, et al., 2010; Orford et al., 2013). Although many studies focus on women, men have been found to experience harm in the same way as women (Orford et al., 2013).
Being in a relationship with a heavy drinker is often stressful, leads to frequent conflicts, and CSOs are often exposed to aggression, psychological and sometimes physical abuse from the heavy drinker (Orford, Velleman, et al., 2010). At the same time, CSOs feel substantial responsibility for the person concerned, even while often feeling let down and demeaned by them (Orford et al., 2013). In addition, the CSO is frequently faced with issues of stigma and a sense of isolation (Corrigan et al., 2006). The persistent strain can lead to anxiety, depression, despair, and even fearfulness (Greenfield et al., 2016; Orford et al., 2013). Further, the heavy drinking behaviour may impact on the family's economic status, and families of heavy drinkers are frequently fractured because of the heavy drinker's persistent damaging and destructive behaviour (Jackson et al., 2006).
Not only family life, but also health seems to be affected by the other person's drinking. Bloomfield et al. (2019) found that people cohabiting with a heavy drinker had nearly 40% higher odds of reporting poor health compared to individuals who did not. For people friendly with a heavy drinker, but not living together with them, the odds were 23% higher compared to individuals not friendly with a heavy drinker (Bloomfield et al., 2019). CSOs are also more likely than others to seek medical services (Lennox et al., 1992; Lipscomb et al., 2003) and have healthcare costs 31–70% higher than the people not close to an individual with heavy alcohol or substance use (Ray et al., 2007; Svenson et al., 1995). It is, therefore, no surprise that Birkeland et al. (2018), in a scoping review, found that partners of people with problematic alcohol or substance use reported lower quality of life compared to the general population. Having a heavy drinker as a close relation is stressful, distressing, and emotionally exhausting. It leads to major issues because the behaviour is variable, changeable over time, unpredictable, and continuing (Casswell et al., 2011; McCann et al., 2017). Quality of life can be measured in many ways. Benishek et al. (2011) found that in a sample of 110 parents and partners of substance-using persons, 84% experienced having had at least one problem in the past 30 days related to the substance user, had suffered from emotional and relational issues, had financial, family and health problems as well as problems of violence and, even, often, with legal matters (Benishek et al., 2011). Overall, quality of life among partners is low and comparable to that of the individuals actually suffering from substance use problems (Birkeland et al., 2018).
As reported above, a series of surveys and register studies on CSOs' quality of life and self-reported health have been conducted (Casswell et al., 2011; Greenfield et al., 2016; Huhtanen & Tigerstedt, 2012; McCann, Stephenson, & Lubman, 2019; Seid et al., 2015), contributing to an overview of the prevalence and frequency of CSOs’ problems. These studies fail, however, to provide insights into and details of CSOs’ lives with a heavy drinker. Qualitative studies may be an important supplement to achieve an in-depth understanding of factors contributing to poor quality of life, self-reported health, and the challenges CSOs experience. However, due to the obstacles to obtaining personal contact with CSOs, given that many persons affected by alcohol feel stigmatised (Jackson et al., 2006), qualitative studies with CSOs are less common. Four of the qualitative studies performed so far are even based on the same cohort (McCann & Lubman, 2018a, 2018b; McCann et al., 2017; McCann, Polacsek, & Lubman, 2019; McCann, Stephenson, & Lubman, 2019). These four studies describe how CSOs adapt their coping strategies (McCann & Lubman, 2018a); how CSOs experience family members supporting a relative with substance use problems (McCann, Polacsek, & Lubman, 2019; McCann, Stephenson, & Lubman, 2019); how CSOs experience and cope with aggression and violence (McCann et al., 2017), and, finally, they describe the barriers and facilitators to CSOs' help-seeking (McCann & Lubman, 2018b). The studies reveal how stigma, difficulty in locating help, previous negative experience with help-seeking, a sense of hopelessness, and a feeling of being undervalued as a CSO, are barriers to help-seeking. A qualitative study from Brazil shows how female CSOs abandon their own life projects and focus on protecting their families (Nascimento et al., 2019). Several studies have investigated how children of parents with alcohol problems have experienced their childhoods and the consequences of living in such circumstances (Johnson & Leff, 1999; Werner & Malterud, 2016). A qualitative study of nine grown-up children found that living in a family with alcohol problems leads to disruptions of social interaction in the family, with threats, blame and manipulation, uncertainty and insecurity ensuing. Many of the children felt responsible for keeping the problems inside the family (Werner & Malterud, 2016).
During recent decades, Orford et al. (2013) have studied family members of people with drinking, drug, or gambling problems. Based on their research and the findings of other research groups, Orford and colleagues have developed a model called the “stress-strain-coping-support (SSCS) model” (Orford, Copello, et al., 2010). The SSCS model focuses on the experiences and coping strategies of family members close to a person with alcohol problems. The SSCS model is first and foremost a model of family health. It is, however, also considered to be applicable to members of other affected groups. The model describes five main components that capture the impact of being close to an individual with a serious drinking problem: the first component or assumption behind the model is that being close to a person with a serious drinking problem can be highly stressful, both for the drinker and for the close family members. The person misusing can and often does do many things that can have a significant negative effect on individual family members and family life in general. The second component of the model is the strain experienced as a direct consequence of the stressful set of circumstances associated with a close relative's drinking problem. Family members and the drinker's close social network may experience pressures, tensions and a high level of demands as a direct consequence of the drinking problem, and the family or network members are thus likely to show signs of “strain” in the form of physical and psychological ill-health.
A central assumption of the SSCS model is that family members and the social network of the individual with a serious drinking problem face the challenge of getting a grip on what is happening and knowing how best to respond (Orford, Copello, et al., 2010). The third component is thus “Ways families and networks cope”. The SSCS model describes three coping styles. The first is Tolerant-inactive coping, e.g., making excuses for the problem user, covering up for him/her, taking the blame, pretending all is well. This coping style is associated with the highest levels of physical and psychological symptoms. Engaged coping is when CSOs are trying to limit the substance misuse, making rules about it, making it clear that it is causing upset and pleading for a reduction in consumption. Withdrawal coping means that CSOs distance themselves from the situation and the drinker, leaving the drinker to himself, getting on with their own lives, putting themselves first, or ignoring the drinking (Velleman & Templeton, 2003).
The fourth component in the SSCS model is “Social support for family members”, since family members can be helped or hindered in how well they cope with situations by how other people (other family members, friends, neighbours, and professionals) react and interact. For CSOs, good social support is considered a key resource for coping, so coping and social support are closely interconnected. Finally, alongside the other four components, a fifth element of the model is “Information and understanding”, describing the family member's understanding of what is going on and the sense that they made of it (Orford, Copello, et al., 2010; Orford et al., 2013; Velleman & Templeton, 2003).
The present study aims to investigate the difficulties, prior to seeking professional help, of female CSOs of people with alcohol problems in handling the problems associated with that: being close to an individual who drinks excessively but is reluctant to reduce drinking and seek treatment. It will investigate what led to these CSOs seeking professional help at all.
Methods
The present qualitative study was conducted as part of the randomised controlled trial (RCT) of a Danish Community Reinforcement and Family Training (CRAFT) intervention (Hellum et al., 2019), and is thus a qualitative sub-study. CRAFT is an intervention targeting CSOs struggling to get their alcohol-misusing loved ones to stop using and seek treatment (Meyers & Wolfe, 2003; Sisson & Azrin, 1986). The aims of CRAFT are: (1) To motivate the drinking relative to seek treatment, (2) To reduce the alcohol misuse, and (3) To increase the quality of life for the CSO regardless of whether the drinking relative enters treatment. The RCT was a three-armed cluster RCT whose aim was to investigate the implementation of group CRAFT, individual CRAFT, and CRAFT self-help material in 24 public outpatient treatment centres in Denmark. The RCT study's primary outcome was whether the drinking relative entered treatment as well as changes in number of drinks, while the secondary outcome was changes in quality of life and depression for the CSO. The inclusion criteria for the study were: the CSO = aged at least 18 years, being a CSO of a person with alcohol problems not in treatment, having regular contact with the drinking relative, being willing to maintain that contact for at least 90 days, and being prepared to offer support in entering treatment (Hellum et al., 2019). It should be noted that not only family members but also extended family, close friends or others close to the drinking individual were included. All CSOs who contacted one of the participating treatment centres were only offered CRAFT if they fulfilled the inclusion criteria. A total of 255 CSOs were enrolled in the CRAFT study from 2018 to 2019.
Design and analysis in the present qualitative sub-study
In the present study we used a qualitative design with semi-structured interviews, and interpretative phenomenological analysis (IPA) (Smith et al., 2009) was used to analyse and interpret the interviews. IPA is a phenomenological approach used to understand how people make sense of their experiences in life, how CSOs experience being close to a person with alcohol problems, and how the need for help arose. IPA is founded on hermeneutics as used in the interpretation of experience. The researcher needs to interpret the accounts given in order to understand the participants' experiences. The final feature that characterises IPA is that it is ideographic, which means that each case is examined in detail to gain insight into the precise nature of the participant's experience. IPA tends to be applied to a limited number of participants only, because it is essential to probe each participant experience (Smith et al., 2009). The findings grounded in the analysis will be discussed in view of and put into perspective by the SSCS model, proposed by (Orford, Copello, et al., 2010).
Participants
Participants were recruited through the randomised controlled CRAFT study (Hellum et al., 2019). During the six-month follow-up interview, the participants were asked whether they would be willing to be contacted again for further questions and information within the next five years. All participants who completed six-month follow-up at a certain time and had given their consent were contacted by mail, telephone, or personal digital mail. In total, we contacted 40 CSOs, of whom 15 consented to participate in the present qualitative study. Three of these latter participants, however, did not give their consent until after we had closed enrolment in the qualitative study; hence, the present study is based on interviews with 12 CSOs.
The sample consisted of 12 female CSOs of men with what were described as severe alcohol problems. Six of the CSOs were living with their drinking boyfriend/husband, three CSOs had a drinking ex-husband (none of them living together anymore), one had a drinking boyfriend (not cohabiting), one had a drinking brother (not cohabiting), and one had a drinking stepson (not cohabiting). The CSOs were between 29 and 60 years old (mean age: 51 years). The CSOs had known the drinking relative for 2–43 years (mean: 23.5 years), and they had had the supporting role for the drinking relative for approximately 2 to 30 years (mean: 12 years).
Ethics approval and consent to participate
The study was approved by the Danish Data Protection Agency (Region of Southern Denmark 2008-58-0035 project no. 17/46074). The study was presented for approval at the Danish Ethical Committee (Project-ID: S-20170148), and the committee decided that approval was needed due to the character of the study.
All participants were informed by the interviewer, both verbally and in writing, about the procedures for participating in the study. The information covered how anonymity would be assured and that the participants could withdraw at any time from the study without any repercussions. The participants signed an informed consent document to participate in the study.
Since the topic of the interviews was sensitive and some participants were vulnerable and in difficult life situations, the interviewers were very attentive, empathic, and patient. After the interviews, the participants were informed that they would be welcome to contact the alcohol treatment centre or the interviewer if they should feel any need of support.
Interviews
We developed a semi-structured interview guide consisting of a few demographic questions and a series of open questions in two areas: their lives as CSOs and the help-seeking trajectory, and their experience with CRAFT (findings reported in another sub-study). We performed 12 individual face-to-face interviews in autumn 2019. The interviews took place in the participants' homes, workplaces, or the treatment facilities where the participant had received the CRAFT intervention. Afterwards, the participants were asked about basic demographic information before being encouraged to talk about their experiences as CSOs and of help-seeking. All interviews were recorded on a digital voice recorder and lasted between 20 and 62 minutes. One interview, with a participant from the self-help group, was unfortunately damaged during the transfer of the digital voice recorder to the computer, and only the first eight minutes of the interview could be included in the analysis.
Data management and analysis
The audio files were fully transcribed by one of the researchers and two student assistants. All the interviews were anonymised and quality controlled. Ten participants wished to read the interviews following the transcriptions, so the transcripts were sent to them for validation and comments. None of the participants had comments on the transcripts. An inductive approach was used for the analysis based on IPA theory (Smith et al., 2009). The analysis was performed and discussed by two researchers (RH and ASN). The analysis was based on several steps. First, the interviews were read several times while notes were taken, and descriptive comments made. Afterwards we developed themes within each interview and searched for connections across the emergent themes. This was done for all interviews and, finally, we looked for patterns across all the interviews, and the final themes and sub-themes were developed (Smith et al., 2009). The themes were discussed between the authors until agreement was reached.
Results
Three overall themes and one sub-theme emerged from the interviews: “The CSO's feelings and experiences of the situation prior to help-seeking”, “The relationship with the drinker”, “Reasons for help-seeking and its trajectory”, and the sub-theme “What the CSOs hoped to gain from help-seeking”.
The CSO’s feelings and experiences of the situation prior to help-seeking
Living with a relative with alcohol problems or being close to a person with alcohol problems led to severe stress and had had a negative impact on the CSOs. The CSOs described the situation as being very unsafe, causing them to be ever vigilant. Reading the signals in the household happened almost instinctively, as one of the CSOs described: We could wonder what mood he was in. What would it sound like when the door handle was grabbed and all such little stupid things. (Interview person (IP) 11)
The CSOs described how unpredictable daily life was and how verbal or mental abuse was frequent. The CSOs were exposed to threats and verbal violence. At the time of help-seeking, they were constantly rowing.
The CSOs who were living with a drinking relative not only experienced problems in the relationship but had also lost their homes as safe havens. They never knew if they could come home, relax, and feel safe. One CSO expressed this directly: It made me feel that I didn’t have a home where I could relax. So, I was always “on the job” either at work or at home. So, I was always hard at it because I never quite knew what I would come home to. (IP 4)
Other CSOs described how they had become the only ones to take care of the home, and some used the metaphors warzone or prison to describe their home environment. The loss of a safe home affected the CSOs' social lives since they did not feel that they could invite friends round or make plans for get-togethers.
Their relationship with the drinking relative impacted not only the private lives and the homes of the CSOs but also affected the CSOs' job performance and job satisfaction. One CSO said that her boss asked her to sort out her domestic situation because she was not performing well at her job: Well, my boss, he knows what I have to deal with at home, right? And I have had a staff review and development interview about my husband’s alcohol problems, right, and it is my interview, my connection to my workplace, so it hit me big time and I just got so annoyed. (IP 2)
The long-term negative impacts led to stress symptoms, and the CSOs were convinced that the stress had an impact on their bodies. One CSO tells how she had been hospitalised several times because she thought she was seriously ill, but it turned out that it was stress-related on account of living with her drinking boyfriend.
However, the CSOs pointed out they were not just worn down by their relatives' drinking per se. They were also caring and concerned about the drinking relative's health after many years of excessive alcohol consumption. Some were even worried that the drinking relative might end up dying prematurely. Two of the CSOs mentioned that they were constantly checking whether their partner was still breathing during sleep. The CSOs also conveyed how hard it was to stand by and watch how the man they loved was destroying himself by his excessive alcohol consumption.
The CSOs often felt very lonely. They were convinced that they were quite alone with their problems and did not feel they could talk to anyone else about it. Furthermore, they missed the good times that they had once had with their sober relatives. As one CSO put it: I was thinking hard about it … if he insists on keeping this up, what, what, how can I handle the situation where he’s just got to sit and get drunk every evening, while I’ve got to sit and do something else. But it feels a bit off. Uh, at least, when we are just ourselves or when we have guests, obviously. Well, then it’s really annoying that he just sits there. There again, I feel that, well, it’s me who has to prance around and give guests the heads-up, and he just sits there being foolish. So there, yes there I feel a little bit on my own, right? (IP 1)
When asked why they could not talk to anyone about it, the CSOs explained that it was a huge taboo and that they felt embarrassed. One of the CSOs admitted that it was very hard to manage all the feelings and frustrations alone. Two of the CSOs said that they had stopped talking about their husband’s alcohol problems because friends and family would constantly ask why they did not simply leave him. The CSOs explained:
I also have friends who know about the situation, and say, why don’t you just leave. Well, I don’t know why I don’t just go. I can’t. I can only register or become aware of a fear of what is going to happen. Because even though it’s really unsafe and I feel insecure, it is completely crazy, but this is what I know. So, the security of what I know is prioritised higher than escaping and being free and able to breathe. (IP 8)
Another reason it was difficult to share the experiences was that the CSO sometimes wondered whether their relative drank because of them: … is it me or who is wrong, I never think that I have been really in doubt about that, but still, you still have doubts, right, and you can be deluded, is it my fault or not my fault. (IP 4)
However, for some of the CSOs, on account of their being open about the problems, their networks helped them find professional help.
The relationship with the drinker
In the present study, the drinking relatives were husbands, boyfriends, ex-partners, a brother, and a stepson. The perceptions of these drinking relatives were, however, quite similar. Most CSOs described the huge differences between the drinking man and the sober man: When he doesn’t drink, he is charming and caring. (IP 2) But one thing is the drinker and another thing is, well, the addict. It completely flips around, and it is so terrible to see happening to a person you love. (IP 11)
While the sober man was described as a lovely person, the drinking man was described as aggressive, mad, nasty, quick-tempered, negligent, commanding, and without initiative. Often it was hard to have a conversation with the drinking man because he talked rubbish or fell asleep when he was supposed to be spending time with the CSO.
In particular, the CSO experienced communication with the drinking relative as troublesome. Almost all the CSOs described the relationship as fraught with slanging matches. Often the CSOs felt they were being blamed for the drinking, the drinking relative was being unpleasant, or he focused entirely on negative things. Furthermore, some of the CSOs said that when sober the drinking relative could not remember how unpleasant he had been when drunk. Obviously, this added to some of the CSOs’ sense of dealing with a “Dr. Jekyll and Mr. Hyde”, depending on whether he was drinking or not. This uncertainty also contributed to a profound feeling of loneliness: I simply don’t want to be near him when he drinks, because most of what he is saying might not be particularly agreeable and often he cannot remember it afterwards. (IP 3)
Not all CSOs, however, found the drinking relative unpleasant when drunk. One of the participants in the present study described how her drinking boyfriend became loving and caring when he was drunk, and another CSO was not sure she would have fallen in love with him had it not been because he drank too much sometimes: And it would not be the man I fell in love with. And so, it’s true to say, I don’t think that I would have fallen for him had it not been for the alcohol. Because, the things he had the courage to say while drinking, he would not have said at the beginning of our relationship, he would not have dared to do that without alcohol. (IP 3)
The CSOs found it difficult to discuss the drinking with the drinking relative. Two of the CSOs explained that their drinking relatives had made it clear that they would never stop drinking. One of the CSOs had thus realised that if she wanted to stay with her boyfriend, she had to accept the alcohol, too: A psychologist said to me, that I had to say both-and. For a long time, I had said either-or. But I cannot achieve that either-or with him. I’ll never get that. So, I have to say both-and if I want him. And well, I also feel like, the good days are not coming back badly. And I actually experience high living through that. (IP 9)
The majority of the CSOs, however, felt sure that their drinking relatives simply failed to recognise the existence of their alcohol problem, and that if they did, they would be able to cut down the drinking if they chose. The drinker claimed to be in control whenever the situation was discussed.
Another major concern for some of the CSOs was that they had experienced their husband or ex-partner having been drunk when alone with their mutual children. One CSO experienced that the drinking partner did not take this situation seriously and failed to recognise that the drinking and fighting between mom and dad affected the children. Rather, he claimed that it only affected him: Uh, many threats being thrown around; now he wanted a divorce and now he couldn’t stand it anymore, fucking bitch and well, some ugly, fuck you, ugly words. And he has pushed a boundary, since at first it was without the children listening and later the children also had to hear it. And of course, it does something terrible to them. And he really thinks they don’t care. (IP 11)
The CSOs recognised the warning signs heralding drinking bouts. They could tell when the relative was building up to drinking, e.g., a whole week where they were looking forward to binge drinking on the weekend and made no other plans, or they made up occasions to drink.
Some of the CSOs had experienced how their drinking relative hid alcohol in their house, garden, or nearby bushes. Discovering the hidden alcohol was often what alerted the CSO to the relative's serious drinking problem, which they found wholly unacceptable. A common reaction was for the CSOs to pick up the alcohol and start hiding it elsewhere so the drinker would not find it. Thus, it became very apparent how the relationship between the CSO and the drinker went from verbal communication to non-verbal actions.
Reasons for help-seeking and its trajectory
All the CSOs had their own personal reasons for seeking help in tackling their relatives' drinking behaviour; one CSO wanted to support her drinking boyfriend in reducing his drinking after he was urged to do so by his employer. Another explained that it was, in fact, her drinking boyfriend who encouraged her to contact the alcohol treatment centre, for her own sake. One CSO, who had an adult drinking stepson, explained that she refused to be part of the big taboo and silence about his drinking anymore and, furthermore, she was worried about his children. Another CSO had decided to leave her drinking boyfriend and wanted advice on how to take care of their son. A CSO who had a drinking brother wanted help in breaking away from her brother's benders, wanting a healthier life for herself.
Common to most of the CSOs was that, for many years, they had thought they could solve their relatives' drinking problems themselves. They had tried many different approaches to solve the alcohol problems. However, after trying to cope with their relatives' alcohol problems over many years, they had become mentally tired. This was reflected in their motives for help-seeking: I just couldn’t be doing with it anymore. (IP 1) I couldn’t be bothered anymore. (IP 2)
I couldn’t take it any more … that was the last straw … it had been too much for many years … now it was enough. (IP 5) Something had to be done. (IP 7)
Only a few of the CSOs mentioned a single occasion as the reason why they sought help. But, for instance, one CSO described how her husband got way too drunk in front of the family, kids, and friends at a birthday party, and that he had to be put to bed by two paramedics: Uh, there was an episode where we had been to a party. My husband and I, and everyone in the family, were there, and for my husband it turned into a drunken spree. Completely. And, uh, when we got home, he might have seemed OK after sleeping for a while on the way home. But a little later he got unwell, fell onto the bathroom floor and actually had to be assisted to bed and, subsequently, claimed that he had only had two and a half beers. Then I could feel something inside me saying, enough is enough. And I felt so bad about it, that children were present, and I simply thought it was totally irresponsible. (IP 5)
It was not an easy decision to seek help. One CSO said that she felt it was a taboo and was ashamed, in addition to feeling disloyal to her husband. Another CSO was ashamed that she, herself, could not get her husband to stay sober. Another CSO found it difficult to take the step to call the alcohol treatment centre, because she felt that she was not supposed to be getting help from a place like that.
It is obvious from the interviews that the drinking had had a hugely negative impact on relationships between the CSOs and their drinking relatives. Some of the couples had broken up, others had tried couples therapy, and some disclosed that they had been considering leaving the drinking husband but decided to give the relationship a last chance by seeking professional help. One CSO explained how her husband became a project in her attempts to protect the family and avoid a divorce: … and I’ve probably had this stupid project about the nuclear family because I just don’t want to be part of the statistic that says we should be separated … because our life has been riven by a lot of denial and lies and broken promises. … Well, I have spent a great deal of our married life extinguishing small fires and trying to hide and get on top of things and make sure that things go smoothly and stuff like that. And of course, I now feel that I can’t stand it anymore and I want my children out of this. (IP 11)
At the time of help-seeking, all the CSOs thus described having lost all illusions about the problems disappearing on their own, feeling exhausted and ashamed, still feeling love for the (sober) drinking relative, in addition to also trying help-seeking as a kind of last option.
What the CSOs hoped to gain from help-seeking
Not all the CSOs knew initially that they would be offered the opportunity to participate in a CRAFT intervention when they approached the alcohol treatment centre for help. Some of the CSOs, however, spoke of what they hoped to gain from help-seeking. Several of them said they hoped to acquire tools to tackle their drinking relative better. One of the CSO reflected: It’s because I feel powerless, confused, in an unsustainable situation and want help, sharing it with someone. Yes. And to get tools to deal with the situation. That’s why I sought help. (IP 2)
The majority hoped that the drinking relative would enter treatment or reduce their alcohol intake. One CSO hoped to achieve greater calmness and learn how to respond better towards the drinking relative's behaviour: Well, I had, well, it was kind of getting some tools, for me, partly, how I might act differently. Because often I am, well then it is like, a non-approving approach. Because you get annoyed. Therefore, yes, well, there was also a hope that he might enter treatment. (IP 12)
Another CSO wanted to be able to work on her own behaviour, learn to take better care of herself and even break out of the relationship, if that was the best solution for her: The fact that I could start with myself, that was like my beginning in trying to figure out what I could do about this and, uh, either my hope is to get him to change his behaviour or enter treatment or, like, as was also said, just learn to take care of myself and, and maybe break away, so get the incentive or the push to get out [of the relationship red.], if that’s what it takes. (IP 1)
Discussion
In this study we interviewed 12 female CSOs of people with alcohol problems. Because of their drinking relative, all the CSOs had sought help at a public alcohol treatment centre and were thus offered participation in an RCT study while receiving a CRAFT intervention. In the present sub-study, we wanted to investigate what went on prior to the CSOs' help-seeking, how the CSOs experienced the drinker and the drinking, what made them seek professional help, and what they wished to achieve. From the analysis, three themes and one sub-theme emerged: (1) The CSO’s feelings and experiences of the situation prior to help-seeking, (2) The relationship with the drinker, (3) Reasons for help-seeking and its trajectory; and the sub-theme What the CSOs hoped to gain from help-seeking. Our findings tend to support and add to the SSCS model proposed by Orford, Copello, et al. (2010).
In terms of the family member, the model emphasises the stress that drinking inflicts on the CSOs, and this element of the model is also demonstrated by the present study. In particular, the CSOs in our study described how their lives had become unpredictable and how they had felt constantly on the alert, watchful, lonely and insecure, as also described in other studies (McCann, Polacsek, & Lubman, 2019; McCann, Stephenson, & Lubman, 2019; Orford, Velleman, et al., 2010). It was a noteworthy finding that this feeling of insecurity and tension led to the loss of the sense of one's own home as what normally would be considered a safe place. As described in the SSCS model, the frustrations and problems in the relationship often increase proportionally with the duration and evolution of misuse, where the addicted person develops an ever-stronger attachment to alcohol and the misuse starts to compete with the family (Orford, Copello, et al., 2010). Prior studies have not, however, revealed the CSOs' depth of feeling for and worry about the drinking relative, which renders the situation even more poignant. They learn at first-hand how to secure the desired quality time together and maybe give up the hope of saving the nuclear family. The sense of diminishing relationship quality was also found in Velleman et al. (1993), who described how it gives rise to hurt, bitterness, feeling let down and anger, but also many ambivalent feelings that hark back to the good qualities the relative had shown in the past.
The SSCS model posits that the family members experience signs of “strain” in the form of physical and psychological ill-health. The SSCS model also assumes that the strains the CSOs experience are the natural consequence of the addiction problem and not the result of a weak personality or previous bad experiences in life (Orford, Copello, et al., 2010). This is confirmed by the present study in which the CSOs describe how the strain increases and builds up gradually until the situation becomes unbearable. We found no indications of the CSOs being particularly vulnerable or weak as such; rather, they demonstrated how their focus had become turned almost entirely onto the drinkers' behaviour and the family situation as a consequence of the drinking problem, and how they had tried to cope with it in a variety of ways. The CSOs in the present study described feeling ill, claiming that their physical and mental health was affected even though they were not ill, described how their job performance was impacted, and that they eventually felt overpowered and overwhelmed. As noted above, the loss of confidence in one's home as a safe place imposes a severe strain on the CSO and the family as such and is a particularly striking finding that we have not seen described elsewhere. The loss of the home as a safe base obviously leads to high levels of stress and uncertainty.
According to the SSCS model, CSOs cope with their family members' alcohol problems in different ways, which may have implications for how long they can endure the strain. We found that most of the CSOs felt that communication between them and the drinking relative had deteriorated, with frequent rowing. As described in the SSCS model, CSOs make use of different coping strategies which also affect how they communicate with their drinking relative. In general, the CSOs seek to do their best, but not all strategies are equally effective, and drinkers will respond differently to different strategies (Orford, Copello, et al., 2010). Liepman et al. (1989) describe how the drinking husband and his wife have one interpretation of their relationship during periods of drinking (wet periods) and another in periods of not drinking (dry periods). Liepman and colleagues find that the drinkers do not perceive family interactions as wanting, neither during wet nor during dry periods. In contrast, the wives report better family functioning and communication during dry periods, which leads to the wives being more motivated to engage the drinking husbands themselves in treatment during these periods (Liepman et al., 1989). This may intersect with our finding that the participant CSOs registered a marked difference between how they experience the drinking man as compared to the sober man, and how this creates a huge emotional dilemma, in addition to putting further strain on communication between the parties.
Furthermore, in the literature, the response to the CSOs from their social network emerges as crucially important. Social support is not about how many people you have around you, but the quality of the network. The main question is whether the social network supports the CSO and is on board with her way of tackling the drinker and the drinking situations, or if they encourage her to leave him (Orford, Copello, et al., 2010), as some of the CSOs in this study experienced. Our findings indicate that if the social network is aware of the situation, they tend to recommend that the CSO leave the drinking relative, which may make it even more difficult for the CSO to reach out for help in resolving the situation. Thus, CSOs often suffer in silence and so go largely unacknowledged (Orford et al., 2013). This may create a vicious circle. When the social network is kept in the dark, and the CSOs do not reach out for help themselves, they may become even more adversely affected before ultimately seeking professional help and, as argued by Orford et al. (2013), this struggle may result in serious illness. Additionally, as found by Vederhus et al. (2019), when family members of people with addictions suppress their emotions, trying to fix the problems themselves and neglecting their own needs, the family becomes dysfunctional and has a poorer quality of life.
Many people are reported not to know how or where to seek help (May et al., 2019). This was also the case for most of the CSOs in our study, who had been suffering for a long time before seeking professional help. The fifth component in the SSCS model, “information and understanding”, describes the importance to the CSO of good and accurate information about misuse, and of gaining an understanding of the condition that will lead to a more informed grasp of the situation and reduce the sense of stigma (Orford, Copello, et al., 2010). Information and understanding are a central part of help-seeking. The female CSO has been described as a person who has to live up to the image of being in control of the family while at the same time being charged with the responsibility for controlling the drinker's drinking (Orford, Copello, et al., 2010). The study by McCann and Lubman (2018b) found that promoting factors for help-seeking include previous positive experiences with help-seeking, an ability to overcome shame and isolation, being open with trusted significant others, as well as persistence. Our findings tend to support this. In the present study, the sense of taboo combined with a feeling of loyalty towards, and love for, the drinking relative, made the CSOs try very hard indeed to solve the problems themselves rather than seeking professional help. McCann et al. (2018b), who studied barriers to help-seeking for CSOs of people with alcohol or drug misuse, found that CSOs tend to look for help discreetly, often unsuccessfully trying to source information on the internet. The barriers identified in McCann and colleagues' study were, thus, not only stigma-related, which discourages help-seeking, but also included difficulties in locating informal and formal support services, previous negative help-seeking experiences, and feelings of hopelessness and of being undervalued.
It is not well described in the literature what the CSOs hope to gain from the treatment. Our study indicates that the CSOs hope to acquire tools for better tackling the situation around the drinking relative and to achieve a better quality of life for themselves. Moreover, they hope that the drinking relative will enter treatment. The authors behind the SSCS model emphasise that the CSOs may improve not only their own health but also the substance user's use of alcohol if they receive the right support, which is in line with the goals of the CRAFT intervention (Orford, Copello, et al., 2010). Therefore, it is important that the relatives get the right help at the right time. In Denmark, CSOs can seek help and advice from public alcohol treatment centres free of charge, but the help offered may vary across the country. In 2015, a Danish Clinical Guideline recommended that CRAFT should be offered by all such facilities (Danish Health Authority, 2018).
The present study adds to the evidence that CSOs of people with alcohol problems live with significant levels of stress and uncertainty. Moreover, they seem to face a quandary between love and hate for their drinking relative. As noted by several previous studies, CSOs also suffer from poor health (Bloomfield et al., 2019; Ray et al., 2007), and so they might make relatively more frequent visits to their general practitioner. Thus, general practice might be the place where CSOs in need of help are picked up on, and offered referrals to specialised help at, for instance, alcohol treatment facilities, where tailored interventions are provided, aimed at the CSOs of drinkers who are reluctant to seek treatment. Due to the vulnerability of CSOs and the complexities of their situation, it is of the first importance that professionals do not simply delve into the negative consequences of the relatives' drinking and recommend the CSO to leave the drinking relative. A study of people with alcohol use disorder showed the importance of the role of the GP, kindly and with a non-judgmental attitude, inquiring about the struggles the drinking person might have (Coste et al., 2020), and it is highly likely that the same would apply for the CSOs.
Strengths and limitations
This is the first qualitative study with a help-seeking population of CSOs who participated in a CRAFT study (not web-based), and it brings to the alcohol field important findings about an overlooked group. However, we are aware of some limitations of this study. First, a rather high rate of CSOs was unwilling to be interviewed for the present study. Thus, the willing CSOs might differ from other CSOs and be particularly interested in being interviewed, given that alcohol problems have a strong presence in their lives. Several of the interviewed CSOs reflected that it had been pleasant to be interviewed by a researcher, and that it felt like a kind of a treatment session. Second, this study sample is limited to a small Danish help-seeking population and cannot be generalised to all CSOs. Third, when the sample talked about what they hoped to gain from the treatment, they had already completed the CRAFT intervention and so their answers might be biased. There is also a risk that some of the CSOs in this sample differ from other help-seeking CSOs by virtue of having knowledge about CRAFT acquired prior to seeking treatment, due to publicity for the project. However, the publicity material revealed little about the actual treatment.
Conclusion
The present study showed that female CSOs of people with alcohol problems had suffered for a long time before seeking professional help to better handle the problems associated with being close to an individual who drinks excessively but is reluctant to reduce drinking and seek treatment. The CSOs often felt their lives were unpredictable and stressful and that they were under a lot of strain; strain that affected their health and functioning. Some CSOs even felt that they had lost the sense of their home as a safe haven. The CSOs had tried to cope for a long time using a number of different strategies; help-seeking was the last option considered. They sought help because they wanted to support their drinking relative or because they wanted to leave their drinking relative and needed tools to address the care of common children. Despite all the struggles and pain, the CSOs still had strong feelings for their drinking relative and hoped for the return of his once sober self. Our findings can be viewed as supporting the SSCS model proposed by Orford and colleagues, and as recommending that helping professionals, and in particular general practitioners, should be attentive to the patient's family background and situation, and offer a referral to relevant services if the patient is suffering due to a loved one's drinking problems.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The CRAFT study is funded by Trygfonden (Grant number: 119728), University of Southern Denmark and the Research Foundation for Psychiatric Research in the Region of Southern Denmark.
