ARTICLES

 

Playing the second fiddle - the experiences, challenges and coping strategies of concerned significant others of partners with a substance use disorder: informing social work interventions

 

 

Peter Schultz^I; Assim Hassim (Nicky) Alpaslan^II

^IDepartment of Social Work, University of South Africa, Pretoria, South Africa. ORCiD iD: 0000-0003-2838-300X; schulpp@unisa.ac.za
^IIDepartment of Social Work, University of South Africa, Pretoria, South Africa. ORCiD iD: 0000-0002-7049-0805; alpasah@unisa.ac.za

 

 

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ABSTRACT

Substance abuse constantly wreaks havoc on families. A family member's substance use disorder (SUD) repeatedly turns a home into a volatile, toxic environment, immersing concerned significant others (CSOs) in a state of confusion and hardship, forcing them to sacrifice their own energies and resources in order to manage this aberration in their midst, often to the extent that they eventually adopt maladaptive behaviours themselves to survive. When partners with an SUD enter treatment, the interventions primarily focus on them, while the non-abusing CSO partner is regarded as an adjunct to the primary treatment and instrumental in a successful treatment outcome. The CSO's own needs usually go unrecognized and they seldom receive specialised treatment to recover from the anguish caused by a partner's SUD, depriving them of a service they are entitled to as individuals in their own right. This phenomenon explains the lacuna in treatment regimens aimed at CSOs which should also fall within the ambit of social work.

Keywords: concerned significant other, guidelines, partner with a substance use disorder, recovery, social work intervention, substance use disorder

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INTRODUCTION

"I was always there for you ... to the extent that I was never there for me ..."

(Quote from a concerned significant other of a partner with a substance use disorder)

In the American Psychiatric Association (APA) 2013 Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) (2013:483), the internationally used psychiatric diagnostic reference, "substance use disorder" (SUD) - synonymously referred to as "substance abuse" or "addiction" - is described as the negative consequences of the use of one or more substances on an individual's cognitive, behavioural, and physiological life dimensions as well as on all other relational interactions, including family life; it also entails the continuous use of the substance despite significant substance-related problems. Various scholars (McCann, Lubman, Boardman & Flood, 2017:1; Rowe, 2012:59,Toner & Velleman, 2014:147) go on to state that SUDs do not only have severe detrimental implications for the substance abuser, but also for the family. A family member's SUD affects the respective family members' social, psychological, physical, and financial functioning and wellbeing and puts them at risk of family violence. A family caught up in the whirlwind of an SUD member is perceived as a "damaged family" (Gudzinskiene & Gedminiene, 2010:163). In such a family there is an observable lack of structure; family members are physically and emotionally detached from one another; a restraint on and a lack of expression of the needs, feelings and wishes of the individual family members is noticeable; communication patterns are distorted as is the capacity for mutual understanding of each other (Gudzinskiene & Gedminiene, 2010:163). In an attempt to survive as individual family members and a family as a whole, overt and covert role reversal and changes take place, and all energies and activities are geared towards restoring the family's equilibrium and rectifying the disorganisation. Barnard (2005) concludes that the costs of the chemical substance addiction of a concerned significant other to the family are extremely high. The family's behaviour has to adapt to that of the substance abuser, as they try to keep the family together in adverse circumstances whilst denying and/or dealing with their own feelings in an attempt to survive (Gudzinskiene & Gedminiene, 2010:163; Kirst-Ashman, 2013:447, 448).

Turning the spotlight onto the relationships between persons with the SUDs and their marriage, life or cohabiting partner (in this context commonly referred to as the concerned significant other or CSO) reveals that a partner's substance abuse has a deleterious effect on these intimate relationships, with both the abusing and the non-abusing partner facing physical, emotional, social and economic difficulties that also impact negatively on their relationship satisfaction (Cranford, Floyd, Schulenberg & Zucker, 2011:211; Nooripour, Bass & Apsche, 2013:26). The partner's SUD may lead to an increase in arguments between the couple, mainly because of defective communication and as a result of emotional "dysregulation". Emotional dysregulation refers to over-reacting or responding in an emotionally inappropriate way to situations and holding skewed perceptions of the real issue at hand (Bryant, 2014:719; Lee, 2014:3), which may lead to arguments having the potential to end in intimate partner violence and abuse. All of this makes being in a relationship with a partner with an SUD a painful, conflict-inducing and stressful situation (Amato & Previti, 2013:161; Cox, Ketner & Blow, 2013:161-162; Dethier, Counerotte & Blairy, 2011:152; Gupta, Mattoo, Basu & Sarkar, 2014:81; Hudson, Kirby, Clements, Benishek & Nick, 2014:107; O'Farrell & Clements, 2012:123; Benishek, Kirby & Dugosh, 2011:81; Ripley, Cunion & Noble, 2006:172; Wood, Kiperman, Esch, Leroux & Truscott, 2017:36).

To be in relationship with a partner with an SUD is to find oneself in an environment that is sporadically, and at times even extremely, out of control. Living in an addictive home can be equated to living in a whirlwind (Perkinson, 2008:242). For the non-substance abusing partners to survive in this whirlwind, they become so preoccupied with the substance abuser that they deny themselves and their own needs. Simultaneously, they acquire a number of maladaptive skills in an attempt to deal the partner's SUD. The non-using partner takes over most or all of the substance-using partner's responsibilities. They take on the roles of the care taker and rescuer, for which they are also blamed, and in doing so "enable" the partner with the SUD to remain addictive (Cox et al., 2013:164) In maintaining the status quo of the partner's addiction through these enabling roles, the non-abusing partner becomes "co-dependent". This concept is explained by Spann and Fischer (in Cullen & Carr, 1999:506) along the following lines: "Co-dependency refers to a pattern of relating to others characterised by an extreme belief in personal powerlessness and the powerfulness of others, a lack of open expression of feelings, and excessive attempts to derive a sense of purpose through engaging in personally distressing care-taking relationships which involve high levels of denial, rigidity and attempts to control the relationship".

The person with the SUD has to go through a process of recovery enabling them to move from the substance addiction to a substance-free lifestyle characterised by psychological wellbeing, effective social functioning and quality family life (Best, Rome, Hanning, White, Gossop & Taylor, 2010:24; Kelly, Greene & Bergman, 2018:269). In addition, the social functioning and family life of the non-abusing partner also has to recover from the many scars of intimate partner or domestic violence, depression, stress, anxiety, financial stress, physical health problems and relationship challenges (Copello, Velleman & Templeton, 2005:370; Fals-Stewart, O'Farrell & Lam, 2009:380; Wilson, Rodda, Lubman, Manning & Yap, 2017:56) caused by the partner's substance use disorder.

In the discordant concerto of a partner's SUD, the CSO partners play second fiddle or a supporting role in relation to partner with the SUD. The non-abusing partners are generally not recognised as "help-seekers in their own right" (Hudson et al., 2014:172; Orford et al. in Wilson et al., 2017:57) or in need of professional help to assist them to deal constructively with and recover from a partner's SUD, as the treatment programmes for SUD sufferers often dominate the stage. In the role of playing second fiddle, the CSO partner in most instances acts as the "personal assistant" to help achieve an acceptable treatment outcome for the partner with the SUD (Copello et al., 2005; Wilson et al., 2017). The involvement of CSOs in the treatment regime is principally "for the sake of the person with the SUD" by supporting them during treatment to regain sobriety, and also after the completion of the treatment intervention to maintain their sobriety (Daley & Feit, 2013). By implication, the involvement of the non-using partners is focused on restoring the balance within the family system and assisting with the creation of an enabling environment that would facilitate maintaining sobriety and preventing relapse (Denning, 2010; Lewis, Dana & Blevins, 2011). Sadly, these treatment programmes and initiatives do not make provision for the treatment of the CSOs per se, and consequently the difficulties they encounter and the healing of the scars they acquire through the partner's SUD go unattended (Wilson et al., 2017).

In the light of this role of playing second fiddle to a partners' SUD, and the lack of treatment or recovery programmes from the ambit of social work for the CSO living with a partner with a SUD, a research journey was undertaken that entailed putting the CSO partners centre stage to obtain an in-depth understanding of the plight of CSOs living with a partner with an SUD. The following questions provided direction: How do CSOs experience living with partners with an SUD? What are the challenges they encounter in this regard? How do they cope amidst these circumstances? How would they like to be supported by social workers as help-seekers in their own right, ultimately informing social work interventions? In order to address these research questions, the following goals were formulated:

• To develop an in-depth understanding of the experiences, challenges and coping strategies of CSOs living with a partner with a SUD;

• To report on the recommendations from CSOs living with a partner with a SUD on how they would like to be supported by social workers;

• To proffer guidelines for social work intervention in assisting CSOs living with a partner with a SUD.

Theoretical framework

The selected theoretical framework for research fulfils many functions. It may serve as a foundation or framework to anchor the findings; it serves to highlight a phenomenon; it becomes the tool for explaining an issue or describing the problems and adversities experienced by individuals and families (Ambrosino, Heffernan, Shuttlesworth & Ambrosino, 2012;46; Thomas, 2017:99; Fair in Green, 2014:34; Maxwell, 2013:49-50; Teater, 2010:1). The strength-based perspective, resiliency theory and ecological systems theory were selected as theoretical frameworks for the study. The strength-based perspective, commonly referred to in social work theory and practice (Guo & Tsui, 2010:223; Lietz, 2004:33), accentuates service-users' self-determination and strengths. In working with a strength-based approach, social workers view service users, such as the partners of persons with a SUD, as resourceful and resilient in the face of adversity (Bottrell, 2009:323; Greene, Galambos & Lee 2003:76; Munoz, Brady & Brown, 2016:102). These features tie in with the tenets of resiliency theory, which can be summarised as the strengths employed by the CSO partners in playing second fiddle and - in spite of their experiences, challenges and coping strategies and help-seeking suggestions - enabling them to rise above and bounce back from adversity (Greene, 2014:397; Hammel, 2009:08; McCleary & Figley, 2017:2). The ecological systems theory situates the individual in relation to other ecosystems. It provides a better understanding of service users within their environments; it indicates how the interactions and transactions between various subsystems and system levels form reciprocally, as well as informing and influencing each other and their contributions to the causation and maintenance of social problems (Darling, 2007:204; Joly, 2016:1254). In addition, ecological systems theory highlights the strengths and resources inherently present at the various system levels, namely micro, meso, macro and exo, that could be put into service in the identification and nurturing of strengths and resilience (Ahmed, Amer & Killawi, 2017:48-49; Shaw, McClean, Taylor, Swartout & Querna, 2016:36; Winkler, 2014:475). With reference to the ecological systems theory as one of the theoretical frameworks adopted for the study, the roots of an SUD investigated systemically may lie in intrapersonal, interpersonal and environmental factors. Substance addiction affects not only the person who is addicted, but also the CSO partner, the couple jointly and the family system, as well as other meso-level micro systems (Ebersohn & Bouwer, 2015:2; Pavelova, 2014:105). Exploring the experiences, challenges and coping strategies of CSOs living with partners with SUDs highlight this multisystem involvement, inclusive of the extended family system, the neighbourhood and other critical social systems as well as the interventions required to facilitate the enhancement of social functioning of CSOs and their partners with SUDs (Pardeck, 1988:141).

 

METHODOLOGY AND RESEARCH METHODS

The research methodology and methods used in this investigation will be introduced next.

Research approach and design

A qualitative research approach was adopted for this study; it may be described as "as an emergent, inductive, interpretive and naturalistic approach to the study of people, cases, phenomena, social situations and processes in their natural settings in order to reveal in descriptive terms the meanings that people attach to their experiences of the world" (Yilmaz, 2013:312). Concerning the aspect of research design, a collective instrumental case study design and a phenomenological research design were employed, regarded as qualitative research designs (Hood, 2016:65), as well as an explorative, descriptive and contextual strategy of inquiry. The collective instrumental case study was employed as it afforded an opportunity for in-depth exploration of the experiences, challenges and coping strategies of CSOs living with partners with an SUD, across multiple cases and using various data-collection methods (Boblin, Ireland, Kirkpatrick & Robertson, 2013:1268; Creswell, Hanson, Clark-Plano & Morales, 2007:245-246; Wahyuni, 2012:72). In addition, the designs mentioned facilitated the process of gathering suggestions that could inform practice by way of the recommended guidelines for social work intervention aimed at supporting CSOs. Operating from a phenomenological stance, researchers requested participants to transform their lived experiences into consciousness and articulate the meanings and the connotations that they themselves attached to these life experiences (Bakanay & Çakir, 2016:163; Finlay, 2012:172; Hood, 2016:165; Yates & Leggett, 2016:229; Nicholls, 2009:587; Turner, Balmer & Coverdale, 2013:307). There is a lack of scholarly literature describing the experiences, challenges and coping strategies of CSO playing second fiddle in the partner's SUD and recovery, as well as a scarcity of social work interventions which focus exclusively on the support of CSOs of partners with an SUD; for these reasons an explorative research design was deemed appropriate. A descriptive research design as a strategy of inquiry allowed for a comprehensive account of the experiences, challenges and coping strategies of the sample group as well as taking into account their suggestions for social work intervention. The participants' personal and relationship contexts living with partners with a SUD were considered in addressing aspects related to their sociocultural context. In addition, by incorporating and describing the strength-based perspective, the ecological systems theory and the resiliency theory as theoretical frameworks for the study, a "theoretical context" was created that became the background for the research findings (Hennink, Hutter & Bailey, 2011:49; Maxwell, 2013:88; Wu, Thompson, Aroian, McQuaid & Deatrick, 2016:498).

Population and sampling

Existing inpatient and outpatient treatment facilities as well as voluntary support groups for persons with SUDs and their significant others were approached for recruitment of participants. Such settings, where likeminded people congregate, allow "geographical sampling" (Trotter, 2012:400), as the individuals identified at these settings acted as gatekeepers. Not only did they provide assistance in gaining entry to the research settings, but they were also instrumental in referring individuals who showed an interest in participating in this research project. Twelve CSOs (married, cohabiting partners) were purposively recruited; the entailed selecting participants who would be in the best position to provide an information-rich, experience-based and first-hand perspective on the topic under investigation and inviting them to bring their perspectives into the study (Abrams, 2010:538; Dudley, 2011:145; Reybold, Lammert, & Stribling, 2012:700).

Data collection and analysis

The first author was responsible for data collection and for this purpose a narrative writing exercise, complemented by two follow-up individual in-depth interviews were employed. for the written exercise the CSO participants were requested to write a "story" about their experiences, challenges and coping strategies in relation to living with a person with an SUD. The written exercise was complemented by a first follow-up, individual, in-depth interview, during which the content of the written narrative was further explored and clarified. In the second follow-up, individual, in-depth interview the respective CSO participants were requested to offer suggestions on how they and others in a similar position could be supported by social workers in view of living with a partner with an SUD.

The data collected were subsequently analysed according to the eight steps of thematic data analysis as suggested by Tesch (in Creswell, 2014:186). This way of analysing the data made the mammoth task of managing the large volumes of data manageable and provided for the orderly and systematic analysis of the data. The services of an independent coder were enlisted to analyse the data set independently and assist with authenticating and substantiating the findings deduced from the collected data, and in so doing enhanced the trustworthiness of the findings (Creswell et al., 2007:245).

Trustworthiness

As qualitative research primarily focuses on interpreting and describing the subjective meaning of experiences in order to develop greater understanding of a phenomenon (Fossey, Harvey, McDermott & Davidson, 2002:723; Lichtman, 2014:8-12; Rubin & Babbie, 2013:40), such interpretations and descriptions must comply with scientific standards. Actions and strategies to ensure trustworthiness, validity, rigour, subjectivity and creativity must be incorporated (Rubin & Babbie, 2013:261; Sarantakos, 2013:102; Johnston in Whittemore, Chase & Mandle, 2001:531). For the purpose of this study, Guba's classical model for ensuring trustworthiness (as referred to by various authors such as Krefting, 1991; Lietz & Zayas, 2010; Shenton, 2014) in qualitative research was followed. The four general criteria to assess research - credibility, transferability, dependability and confirmability - as they apply to qualitative research were applied. Various strategies, such as triangulation of data methods and data sources, a thick description of the research plan, process and research findings, peer debriefing, the use of an independent coder, and reflexivity were employed to enhance this study's credibility, transferability, dependability and confirmability, and to comply with the scientific standards of validity and rigour required in planning and implementing a research project and reporting the research findings.

Ethical considerations

The Departmental Research and Ethics Committee at the University of South Africa granted ethical clearance for the research project (DR&EC_2014_0008). The ethical considerations of obtaining informed consent and ensuring confidentiality and privacy in terms of managing the information and preventing possible harm to participants were applied during the research process. Participants were ensured that they were under no obligation to take part in the research study, and once they started participating, they could withdraw at any stage without prejudice. Pseudonyms were used to comply with standards of anonymity and confidentiality.

 

RESULTS

The research process will be presented in two parts. In the first part will provide the biographical profile of the participants, and the second part presents the themes focusing on the CSO participants' experiences, challenges and coping strategies in living with a partner with an SUD, as well as their suggestions for social work support.

Biographical profile of the CSO participants sampled

The 12 CSO participants resided in urban areas in the Gauteng province, South Africa. Ten CSOs were female and two were male. Their ages ranged from 23 to 61 years. The length of the relationships with their respective partners ranged from three to 35 years; seven of the CSOs were married, two were engaged, two were living together, and one was in a civil union. Nine of the CSO participants had one, two or three pre-school or school-going children. Eleven of the CSO participants were gainfully employed at the time of the fieldwork, while one was retired. At the time of the research, nine of the CSOs' partners were in intermittent states of sobriety in that they were either still using substances or had relapsed on a number of occasions. Only three of the CSO participants' partners managed to remain sober for more than twelve months. Five of the 12 CSOs have sought help for their partners' addictions, but with little success. Three CSOs admitted to having used or abused substances themselves.

Thematic presentation

The research findings will be presented under three main themes. These are the CSOs' experiences of living with a partner with an SUD; participants' challenges experienced in living with a partner with an SUD; and coping strategies employed to mitigate and manage the experiences and challenges related to living with a partner with an SUD.

CSOs' experiences living with a partner with an SUD

To many CSOs, living with a partner with an SUD proved to be an extremely stressful experience (Gupta et al., 2014; Hudson et al., 2014; McCann et al., 2017; Rodriguez, Neighbors & Knee, 2014; Wilson et al., 2017; Wood et al., 2017). Nagesh (2015) encapsulates this phenomenon as follows: "emotional stress is one of the greatest effects of alcoholism and drug use on family life." While some of the participants equated the experience living with a partner with SUD with constantly "walking on eggshells", Olga's written account succinctly typifies this view: "Your daily life becomes stressful more and more." In the first follow-up interview she touched on the effect of stress by living with a partner with an SUD:

You know all the difficulties and stress over the years have aged me, not physically as much as it did emotionally. Stress is the one thing that breaks you down more than anything else in life.

Anne described her stress as follows:

I was a mother and I would do whatever it took to keep her [my daughter] safe. He would argue with me to drive when drunk no matter what I said. I often feared for my and daughters' lives. He would disappear three o'clock in the morning and say he's going to his mother, wake up my child when she was sleeping to spite me if I did not want to give him the car keys. He was irresponsible.

Constant arguments and a partner's spells of aggression and abuse, which could be related to substance abuse, were regarded as the primary contributors to stress in a relationship (Hudson et al., 014: McCann et al., 2017; 2014; Wilson et al., 2017; Rodriguez et al., 2014). Family members finding themselves having to deal with a relative's substance abuse experience "high degrees of anger, feelings of fear, hurt, abandonment, guilt and hopelessness" (Giordano, Clarke & Furter, 2013); these have a more severe effect on those who are emotionally the closest to the person with an SUD, such as a partner with whom they share an intimate relationship (Klostermann & O'Farrell, 2013; Nagesh, 2015; Wilson et al., 2017). From participant narratives it became evident that SUD-related behaviours lead to a breakdown in communication and skewed perceptions of the real issue at hand (Bryant, 2014; Lee, 2014), which unintentionally contribute to increased interpersonal conflict and stress, and a decrease in psychological and social adjustment and day-to-day functioning within the relationship (Hudson et al., 2014). These situations contribute to reactions of anger and frustration (Nagesh, 2015; Perkinson, 2008; Wilson et al., 2017). Louna shared her feelings of anger and frustration at her partner's substance addiction:

After he had crashed the car I was furious; oh I was just so furious. I sold it there and then. I just got rid of it...I was furious...There were many a time I felt like that. There were times I became physical with him, times I would lose it...I would really lose it. Times I could not stop myself, I was so angry.

Queen revealed her hurt and anger in her written narrative and expressed the following about the arguments and violence she experienced:

There were always arguments in the house but never physical until last year. Always something got broken/hitting doors and walls [referring to Tom's behaviour when angry and under the influence of Khat] . The arguments got worse and one day he gave me a smack in my face. I was very hurt and angry for him lifting his hands to me for not getting his way . and it continued more and more frequently.

In addition, feelings of hurt and shame brought about by a partner's substance use disorder, which eventually ended in emotional detachment from such partner with an SUD, were expressed (Hudson et al., 2014; Peled & Sacks, 2008; Weiss & Willems, 2016). For some CSOs the consequence of such SUD-related behaviour was that they became isolated and felt trapped, resulting in a state of emotional entanglement in order to survive in terms of their personal safety, psychosocial wellbeing and personal growth (Denning, 2010; Gudzinskiene & Gedminiene, 2010; Perkinson, 2008; Kinney, 2012; Nagesh, 2015; McNeece & DiNitto, 2012). Paul explained the reason for the isolation he experienced which resulted from feelings of loneliness caused by his partner's SUD:

One aspect I clearly remember was the loneliness. Extreme physical loneliness...The isolation was brought about by the fact that I didn't want anyone to know what Grace was up to...I had nobody to turn to, to talk to, to have help me or Grace.

In Jane's narrative the feelings of hurt experienced due to her civil union partner's addiction came to the fore:

But I am angry! I have to now put my life on hold during her treatment because she wanted to be high. It feels like having to live in a jail and everything else is pushed aside. I sometimes wonder if it wasn't perhaps my fault. What did I do to deserve this? A woman who only got the best for the past three years and gave it all up in a heartbeat to do drugs? I am angry, disappointed and empty! I stay on because I took an oath before God that I will stay on irrespective of the circumstances. But where does one draw the line? On the one hand my heart tells me to love her like never before, but the same heart tells me to run away as far and fast as possible.

Participants' challenges experienced in relation to living with a partner with an SUD

Participants experienced a partner's SUD and related behaviour as challenging to the point of neglecting their own wellbeing and household responsibilities, including financial obligations, and their relationships with family and friends (Hussaarts, Roozen, Meyers, Van de Wetering & McCrady, 2011; Nagesh, 2015; Randle, Stroink & Nelson, 2014). The CSOs shared how the manipulative, erratic and often reckless behaviour of a partner with an SUD caused tension in the relationship (Hawkins & Hawkins in McNeece & DiNitto, 2012; Hussaarts et al., 2011; Kinney, 2012; Prout, Gerber & Gottdiener, 2015). Paul explained: "...her behaviour was so chaotic, it almost became predictable ... I wished I could control it, but there was no way." Partners' addictions also impacted negatively on the children (Lander, Howsare & Byrne, 2013; Hawkins & Hawkins in McNeece & DiNitto, 2011). Participants stated how a partner's SUDs robbed the children of the opportunity to form a close relationship with the using parent due to the latter failing to be a constructive role model and providing warmth, security and care (Kinney, 2012). Linda described her son's reactions since his father went away for long-term treatment:

Since his father left he no longer affects him that much, he has managed to gain in confidence and do well at sport. I think my son must have blamed himself also for what happened in the home. Maybe he too, just like me, felt he was never good enough.

Children of parents with an SUD are likely to generally experience a number of negative feelings including guilt, self-blame, embarrassment, helplessness, anger and anxiety (Copello et al., 2005; Lander et al., 2013).

CSOs furthermore reflected how they continuously lived under the threat of a partner's possible relapse. Paul explained: "She relapsed on the Wednesday. I was having the disappointment of 'here we go again'. It was scary ... you just don't want to go back there." They experienced that a partner's sobriety was usually short-lived and they then, after hoping things may improve, had to once again relive the hurt and trauma (O'Farrell & Schein, 2011). On finding out that his wife was abusing drugs, Mike admitted that he was initially relieved about finding out what she was plotting, but soon realised that curing her addiction was not as simple as he had thought. He asserted:

There is a huge impact on the CSO who has to play a big role in recovery. It sometimes feels that I have to make many sacrifices for the recovery programme to succeed. I remain a victim, even more so during recovery as before recovery.

This account corroborates the view of Perkinson (2008), who noted that there are feelings of relief when a CSO's partner agrees to treatment. This reprieve is in reality short-lived when the CSO is confronted with the complexities and demands of what treatment entails.

Coping strategies employed to mitigate and manage the experiences and challenges related to living with a partner with an SUD

Considering the experiences the CSOs encountered in relation to a partner's SUD, they also reported employing a number of coping strategies in order to manage and mitigate the impact of a partner's SUD-related behaviour. These attempts at coping are often referred to as "enabling" or "co-dependency," as pointed out by a number of authors (Adedoyin, Beacham & Jackson, 2014; Askian, Krauss, Baba, Kadir & Sharghi, 2016), while other authors are of the opinion that they should be considered "normal" reactions by especially the CSOs who are, in reality, "normal" persons who become more demoralised by the increasing SUD-related behaviours of their partners (Orford, 2014). Some of the CSO participants indicated how they tried to cope by concealing a partner's SUD in maintaining a façade of normality, pretending that all is well domestically, in an attempt to keep the family together and by taking over responsibilities which the partner with an SUD increasingly neglected (Askian et al., 2016), as well as lying and making excuses. Cindy described this situation as follows: "Soon I was estranged from everyone, disconnected and found peace in a separation from others. It was easier this way, less people to lie to." A number of CSOs reported that avoidance or emotional and physical withdrawal from a partner and from social life (friends and family) to avert embarrassment was the only way of coping (Gostecnik, Repic, Cvetek & Cvetek, 2010; Hussaarts et al., 2011; Kinney, 2012; Klostermann & O'Farrell, 2013; McCann et al., 2017). Elsa shared how she kept her husband's drinking problem secret:

I have tried over the years to pretend that everything is fine...that all is all right while it was obviously not... I am living a lie ... it puts a strain on any relationship. If we go out or when we entertain, I always have to check that he does not take a swig out of the bottle. You can't go out and meet friends you know ...it is a never-ending story.

In addition, and in contrast to a more submissive and covering-up approach, some of the CSOs also admitted to a more confrontational approach, threatening to leave or filing for divorce, or requesting the partner to leave. Louna mentioned that she got to a stage where

I said to him that I no longer am prepared to do this, and I am filing for a divorce. And I said to him that if you are doing drugs, you will never see your kids as I am the only stable person. That was all I could threaten him with ... I was using the kids by saying 'I am filing for a divorce and you will never see your kids.'

Despite the strong link identified in the literature between substance abuse and divorce (Gupta et al., 2014; Rodriguez et al., 2014; Rodriguez, Overup & Neighbors, 2013), none of the CSO participants who threatened or filed for divorce in reality wanted to follow through on their threats as these were meant to force a partner with an SUD to stop using the substances or go for treatment.

There were CSOs who indicated that they were forced to obtain a protection order and enlisted the help of the police as ways of coping (Gupta et al., 2014; McCann et al., 2017). Olga wrote: "I even got a protection order to try and scare him into changing his ways but that did not work. Thus, the court order [led him to] join the Mighty Wings programme". Reaching out for help by involving family, friends, general practitioners, ministers of religion, and visiting psychologists or social workers to manage and cope with a partner's SUD were also mentioned (Jason, Stevens & Light, 2016; Kinney, 2012; Lewis et al., 2011; Toner & Velleman, 2014); however, this usually had little success or constructive intervention on their behalf. Louna reached out for advice from her pastor, but admits the advice given was not helpful.

You have to understand that his drinking reached the stage where I sued him for a divorce. Prior to this I spoke to our pastor and his response was that I had to pray about it. But I have prayed even many years before this. And then I reached the stage where I stopped praying because it felt as if God was not listening to me. ... once the situation becomes desperate, you need practical guidance ... and then you become angry with the whole world because he is not stopping . and it creates tremendous conflict in me as a person and between the two of us.

The coping strategies used by CSOs to mitigate and manage the experiences and challenges they encountered in relation to a partner's SUD resonated with what Papalia, Sterns, Feldman and Camp (2007) termed "adaptive" (constructive) and "maladaptive" (non-constructive) ways of coping. The latter is explained by these authors as "striking out" at an offending partner, which can be translated as admitting defeat. An example of this behaviour is reflected in Olga's account: "I was furious ... There were many a time Ifelt like that. There were times I became physical with him, times I would lose it ... I would really lose it. Times I could not stop myself, I was so angry". In certain instances the CSO participants' coping strategies can be viewed as responding to the challenges by resigning themselves to the behaviour of an SUD partner for the sake of maintaining peace in the home, which enabled the partner to continue with the addiction. Louna shared how she took on more and more responsibilities:

When he came out of hospital I said he could come and stay with me ... I will try my best to look after him. We lived together prior to this. I became the one that looked after him; I'm the one that took care of him. I'm the one that gave up my life for him."

They also withdrew from the abusing partner, as was the case with Olga, reflecting on where she currently was in relationship with her husband, Danny:

Now, at this point I am at the end with him. I don't care what he does, if he's not here, if he disappears from the house for a few days, bonus! Peace for my soul. If he calls with a problem it's not my problem, and I gradually started moving away from him.

Sometimes they even confronted their partners out of sheer frustration at the substance abusing partners' aggression, violence and abuse-related behaviours. Jane wrote in her narrative:

Nights passed where she could not sleep, being full of energy and acting weird. The more I would enquire about her behaviour, the more we ended up in arguments. She became increasingly angry with me, something that had a negative impact on our marriage.

She further elaborated how her partner's addiction adversely affected their communication: "our conversations are not the same anymore. These conversations also can become suffocating . you are friendly with each other but before you realize it, an argument is on the verge of starting again."

 

DISCUSSION, CONCLUSIONS, AND RECOMMENDATIONS

The responses from CSO-participants in this study indicated that living with a person with an SUD is extremely stressful (Hudson et al., 2014:106; McCann et al., 2017:2; Rodriguez et al., 2014:294; Wilson et al., 2017:57); it impacts negatively upon them as individuals, changing them personally and socially. Their partners' SUD and related behaviour spark anger, resentment and frustration, which leave them feeling trapped, lonely, sad, embarrassed, humiliated, hopeless, inferior and hurt (O'Doherty, Taft, McNair & Hegarty 2016:227; O'Farrell & Schein 2011:202). The multiplicity of these feelings eventually led to emotional and physical detachment from their partners (Hudson et al., 2014:106; Lewis et al., 2011:173). The challenges they experienced revolved around poor communication, arguments, accusations, intimate partner violence, as well as the substance-addicted partner's lack of responsibility, as well as erratic, reckless and manipulative behaviour (Hudson, Kirby, Firely, Festinger & Marlowe, 2002:171; McCann et al., 2017:214; Wilson et al., 2017:56). The influence of a partner's SUD on the children and the CSO's fear of a partner's possible relapse were also mentioned as challenges. We arrived at the conclusion that various coping strategies were employed to cope with the challenges experienced in relation to the partners SUD. These included covering up a partner's SUD (Askian et al., 2016:270; Perkinson, 2008:244); turning to substance abuse themselves as a way of coping; threatening to leave or divorce the partner, or requesting the partner to leave; obtaining a protection order and enlisting the help of the police; avoiding the partner and withdrawing from social life; trying to keep the home life together, and reaching out for help. Against this background, we conclude that the coping strategies - especially of covering up, adopting the philosophy of joining in with the partner's SUD, blocking out feelings, withdrawing, and taking over the partner's responsibilities - are indulgent ways of coping, or ways of putting up with the current state of affairs or withdrawing from it, which could all be considered to be maladaptive ways of coping. They can even be labelled "enabling" coping strategies, inadvertently allowing the person with the SUD to continue abusing (Hawkins & Hawkins in Craig, 2004:176; McNeece & DiNitto, 2012:263; Perkinson, 2008:244).

The involvement of the CSO in their partner's treatment is generally regarded by them as an action by means of which they "help" a partner recover (Nagesh, 2015:373). At the initial stages of a recovery process the CSO is not aware or does not acknowledge his or her own needs for intervention and recovery. This corroborates the findings in the literature that CSOs are an important adjunct to a substance-addicted partner's treatment, becoming agents of change in their attempts to facilitate and assist an SUD in maintaining sobriety (Daley & Feit, 2013; Denning, 2010; Peled & Sacks, 2008).

Admitting that an SUD and their related behaviour affected the CSO-partners negatively, the CSO partners offered suggestions for social work intervention in support of CSOs. Topics to be covered during social work interventions include providing information about drugs and their effects on the person using them; setting of personal boundaries; safety for CSO partners and/or the children; rebuilding self-esteem; anger-management; parenting skills and marriage counselling. The research set out to proffer guidelines for social work intervention. It is acknowledged that the international literature in particular provides extensive information on the effects of an SUD on the family. Treatment and support programmes locally and abroad understand this, yet few programmes provide services to CSO partners as persons in their own right (Nagesh, 2015:373; Wilson et al., 2017:57). Based on the findings of the study, certain recommendations are made below.

Recommendation on the assessment of the CSO partners

Because CSOs in a relationship generally reach out for assistance for, or on behalf of, their partners with an SUD, or seek support in dealing with situations created by SUD-related behaviour, they seldom present as primarily seeking help for themselves. It is therefore crucial to make every effort to obtain the buy-in of CSOs when offering social work intervention and acknowledging that these interventions directly speak to their help-seeking needs. To this end, an assessment of the situation is required, addressing how CSOs have been affected and taking into consideration the key barriers to help-seeking of this service user group, such as transport challenges, availability of time, the financial cost attached to the interventions offered, child care and geographical accessibility (Wilson et al., 2017:56).

Recommendations on the intervention methods to provide social work support to CSOs, their partners and families

Irrespective of whether the CSO is seen by professionals in private practice or as part of a support or treatment programme for partners with an SUD, provision for couples/marriage counselling as well as the involvement of their children is paramount to address the situation caused by SUD-related behaviour in its totality. However, flexibility is required in terms of the time of involving the different parties, as they may not all be available or ready for intervention at the same time. Following the initial assessment of the CSO, further assessment is required of the partner with an SUD and the children (if applicable). As is the case with the assessment of the CSO, the situation as experienced by each role-player needs to be assessed as well as their ability and readiness for involvement in a treatment regimen.

Alongside couples/marriage counselling and family therapy, group work is regarded and recommended as an effective intervention method as it helps CSOs to contextualise their situation in relation to others in similar positions, and allows for expressing their feelings and experiences with others in a place where they generally feel understood and accepted (Kinney, 2012:298). It may be helpful to consider involving CSOs in group sessions before starting with couples/marriage counselling. Again, flexibility is required as not all CSOs are suitable for or want to be in group therapy, especially during the initial stages of their involvement. Intervention would then take the form of one-on-one counselling.

The goal is to assist CSOs and their families in a multidisciplinary team effort to provide a holistic and integrated service, and support families entangled in the dilemma caused by a family member's substance addiction, specifically CSO partners and the children of a partner with an SUD. It may be considered that tailor-made interventions for CSOs be made compulsory by treatment facilities.

Recommended topical aspects to be covered in the social work interventions with the CSOs

Tailor-made programmes for social work intervention to support CSOs living with partners with an SUD include the following (but these programmes should be flexible and applied according to the help-seeking CSO partner's needs):

• The identification of experiences related to living with a partner with an SUD, and creating opportunities for the sharing of such experiences;

• The identification of challenges experienced as a result of a partner's SUD, and providing social work support and guidance on how to address these challenges;

• An exploration of the coping strategies employed to manage and mitigate the experiences and challenges experienced in relation to living with a partner with an SUD, and providing guidance and suggestions on constructive ways of managing and mitigating the challenges experienced in the context of living with a partner with an SUD;

• Providing information on ways to support the partner with the SUD to enter treatment;

• Providing information on the topic of drugs and their effects;

• Providing information on how CSOs can set boundaries for themselves to accommodate their relationship with the substance-addicted partner;

• Development of communication skills and strategies for improving meaningful interaction between partners;

• Information on anger management and ways to constructively manage anger;

• Strategies for rebuilding the CSOs' self-esteem;

• Information and pointers regarding parenting and raising and protecting children in the context of a partner's SUD;

• Information on relapse in the cycle of substance addiction and recovery - CSOs' ways of dealing with it;

• Information on how the CSO can support a partner with an SUD;

• Life skills, focusing specifically on decision making;

• Guidance on and strategies for regaining self-confidence and independence as part of the CSOs' own recovery;

• Pointers and guidance on how to restore trust in the partner relationship.

Recommendations related to aftercare and support to CSO partners

As SUDs and SUD-related behaviours affect individuals, their partners and children as well as a number of community members, a multidisciplinary collaboration and network between private, public, and volunteer organisations (as microsystems interfacing at a mesosystem level) is required for assisting the CSO of a partner with a SUD in order to offer health, welfare, judicial, and protective and religious/spiritual services.

Furthermore, as is the case with the treatment programmes for partners with an SUD, it is recommended that the tailor-made interventions for CSOs should also include an aftercare or support component.

 

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