The Responsibility Trap

Preface

THIS BOOK IS the outgrowth of seven years of work in which we have made an attempt to integrate our own understanding of alcoholic dynamics within the framework of systemic family therapy. Since we share both a commitment to the principles of Alcoholics Anonymous, as well as a commitment to approaching problems from a systemic viewpoint, it has always been a source of concern for us that the fields of alcoholism treatment and family therapy seem so polarized in their respective views on the nature of alcoholism as a symptomatic process. Our hope is that this book can provide a bridge between those two viewpoints as well as some new ways of looking at alcoholism that can be clinically useful and relevant to other practitioners.

There is a great deal in this book that is not new. We have drawn heavily on the work of Murray Bowen and David Berenson in particular, and their ideas have become so ingrained a part of our thinking and our clinical practice that sometimes the boundaries between their thinking and our own have become blurred. The work of Gregory Bateson and Ernest Kurtz provided a basic intellectual and spiritual context that we adopted as essential to our work. We have aimed at an integration of the ideas of many different people in both the alcoholism field and the field of family therapy, and we have attempted to look at the contextual issues raised by alcoholism at many different levels.

As is probably typical, our work and thinking evolved because we were stuck. We were finding it entirely too difficult to facilitate movement toward sobriety in the families we worked with and we found that symptomatic behavior often shifted after sobriety to another family member. Because more often than not we saw the female members of families in the beginning of treatment, we decided to put a few of them together in a group and see what happened. These groups, described in Chapter 9, became a research laboratory from which we learned and within which we experimented with different ideas and different approaches. The group experiences were tremendously exciting and rewarding and led to some general understanding of the kind of reciprocity that occurs in alcoholic systems, which we then took back to our work with couples and families. Gradually, our focus shifted to the issues of families in postsobriety phases of treatment, and this focus deepened our understanding of the delicate processes of adjustment and rebalancing that occur once the family environment is free of alcohol.

This book is not meant to represent a theory of alcoholism treatment, nor are we suggesting that our approach to treatment is the only effective one. For us, the constructs that we outline have been useful in organizing our thinking, and thus informing our action. They are the result of clinical observation, not rigorous research. They represent a beginning, a point of departure. Ultimately, we would like to see our thinking evolve further in response to concrete research and the feedback of others on some of the interactional paradigms we describe.

We see what we see because of the particular personal and professional perspectives we bring to our work, and having finished this phase of our own explorations, often we experience a need to be able to stand back and look again, see differently, see more. Often, it seems as if an understanding of alcoholism is truly in its infancy and that simpler, more effective solutions must be within reach.

Writing a book is certainly a communal event and takes place with the help of a whole host of people who may not even know they’re involved. Putting words on paper is only the end result of a very complex process that takes place over time with the input of many people. For the two of us, the collaborative process has truly been an enriching experience, both intellectually and clinically. If our ideas and even our identities tend to blur now and then, the fusion is a small price to pay for the intense experience of shared accomplishment.

We have many people to thank. While we couldn’t list the names of each of our clients here, we should, since their struggles have really been ours, and ours theirs. It is not unusual for clients to grow more and achieve better integration than their therapists and we thank our clients, particularly the men and women in our groups, for keeping us humble.

The person most significant to our development, both personally and professionally, has been Monica McGoldrick. She has been a mentor and a generous source of encouragement and help. She has provided a forum for the development and presentation of our work, and as a woman who is a leader in her field, she has been a consistent model of the ability to share power. We thank her here, not only for her help with this project, but for her help with many other projects for which she was not adequately thanked.

Other people have been so much a part of the fabric of our lives that no work would have been possible without their belief, encouragement, and support. Pat Webb, Mary Nolan, Jeff and Marsha Ellias-Frankel, Norman Levy, and Jennifer Hanson are primary figures who nurtured us, listened interminably to our obsessive preoccupation with our work, as well as to our chronic complaints about the demands of trying to live, work, and write all at the same time. Our other friends are to be thanked for tolerating our unavailability and what became, at times, very one-sided relationships. Finally, our families, as well as all those significant people in our pasts who helped shape our self-experience are thanked for their love and support.

For technical assistance, we are grateful to the staff at the library of the Center for Alcohol Studies at Rutgers University and the staff of the Monmouth County Office of the National Council on Alcoholism. Finally, Renita LaBarbera, who typed the many evolutionary phases of the manuscript, has been an invaluable collaborator on this project.

PART I

Theoretical Constructs

CHAPTER 1

Alcoholism: A Systemic Perspective

THIS BOOK focuses on the identification and treatment of dynamics that occur in families and in relationships affected by alcoholism. To provide a framework for looking at these problems it is important to clarify how we think about alcoholism, because, ultimately, the way we think about a problem directs what we do about it.

The clinical and etiological aspects of alcoholism are issues that have been debated and researched in great depth and at many levels from many different scientific and sociological perspectives.¹ The collective results of this research are as yet inconclusive. Every day new aspects of study, particularly in the areas of neurochemical and biomedical research, seem to suggest different evidence about the very complex and multifaceted dimensions of alcoholic behavior. At present, there exists no unitary or agreed-on definition in the scientific or medical community relative to questions of etiology or clinical progression that are generalizable to all problem drinkers in all situations. Present theories tend to point more to differences than to similarities. The effects of certain patterns of drinking, however, tend to be more predictable and identifiable than their causes, and ultimately, in clinical treatment, it is the effects of drinking behavior to which we must address ourselves. Consequently, instead of asking why a person drinks, we try to understand what changes occur for the individual and those around him when drinking occurs in certain problematic ways.

This particular approach to alcohol problems derives from our orientation as family therapists who operate within the larger framework of general systems theory.

One contribution of systems theory to the mental health field has been to remove our thinking about human behavior from the frame of causality. In systems terms it is more relevant to view complex human behavior from the perspective of interactive process than it is to attempt to identify a specific cause or reason for behavior that can be located within a specific individual. Even supposing, for instance, that a genetic or hereditary predisposition exists in a given individual that may render him susceptible to alcohol addiction, numerous other factors in his environment in interaction with that particular biological reality will ultimately affect whether or not he drinks alcoholically.

A systemic perspective on alcoholism suggests that we view alcoholism not as an individual problem but as an interactive one that affects and is affected by interaction and change at many systemic levels.²

While this focus on interaction is our primary context for viewing alcohol problems, we feel that it is equally important to have a basic understanding of the nature of alcoholism as it is defined medically and scientifically because it represents a specific type of symptomatic process. Alcoholism calls for family therapy approaches that may differ from those that are applied to a general range of nonaddictive, interactional, and communication problems in families. Intervention with the family system of an alcoholic may represent necessary, but not sufficient treatment, and it is important for the clinician to integrate many different levels of information and understanding about alcoholic behavior processes and events into her general repertoire of clinical technique.

It is only recently that the family therapy field has begun to acknowledge the need to develop a clinical approach to alcohol-affected families that addresses the specific dynamics set in motion by alcoholic drinking. Peter Steinglass’s comment that growing research and clinical interest in the alcoholic family has tended to outpace the development of conceptual models useful in viewing alcoholism from a family perspective (1980:21) speaks to a gap in our understanding of alcoholic dynamics as well as a lack of specific technique that relates to those dynamics. This book represents one attempt to bridge that gap.

The purpose of this chapter is to outline the basic assumptions about alcoholism that direct our treatment and to set the stage for the specific theoretical constructs that follow in chapters 2, 3, and 4. In the interest of conciseness, we assume a basic understanding of both alcoholism and family systems on the reader’s part. We will mention relevant principles only briefly as they relate to our own theoretical constructs.

What Alcoholism Is: Premises and Assumptions

Our primary assumption is that alcoholism represents a systemic, that is, circular process. The behavior of ingesting a psychoactive drug affects and is affected by change and adaptation at many different systemic levels including the genetic, physiological, psychological, interpersonal, and spiritual.

Drinking behavior occurs within a larger social or systemic context; it is shaped by cultural influence and at the same time it represents a type of feedback or commentary about the larger context in which it occurs.

Abuse of alcohol or addiction is a multidetermined phenomenon. Alcohol use may become problematic at different times for different people under different conditions for different reasons. While some patterns are more typical and generalizable, no one set of deterministic or clinical variables holds true for all people who drink.

These assumptions represent our understanding of alcoholism as a process or sequence of events that evolves over time. They do not attempt to explain what causes alcoholism nor do they view alcoholism as a secondary symptom that masks other psychodynamic problems. They suggest that alcoholism is both a cause and an effect of systemic changes that are or become dysfunctional.

Secondly, these assumptions do not speak to the issue of whether or not alcoholism is a disease. This particular question has been the subject of a great deal of controversy and polarization in the mental health field. While the model of classification and progression developed by Jellinek (1960) is generally accepted by most professionals in the alcoholism field as a standard rule of thumb for defining and classifying alcoholism as a distinct disease syndrome, other professionals tend to view alcohol addiction from a more psychological or sociological orientation.

If one accepts the premise that alcoholism is a multilevel phenomenon, it seems clear that the controversy over definition of the problem relates to specific orientations that may define one level of the problem as more dominant than another, and it relates to our capacity to use language in a way that invests certain words with political and psychological power.

If one views the alcoholic process in terms of its effect on human tissue and in terms of the very real organic damage alcohol may cause in the body, alcoholism is certainly a medical problem that has diseaselike effects. If viewed strictly on the level at which addiction represents a compulsive behavior, a more psychologically oriented person may define alcohol abuse as a behavior disorder. Approaching the issue from a holistic perspective, Alcoholics Anonymous defines alcoholism as a disease of the mind, body, and spirit. But, whether or not one thinks about the process of alcoholism specifically as a medical disease, it still has diseaselike effects. It does damage to the healthy integration and functioning of an individual and the larger environment at all levels. In its most extreme forms, it is fatal. Certainly, the therapist needs to develop an understanding of appropriate responses to the medical complications always associated with end-stage drinking just as the physician can be of greater help to his patient in the early stages of alcoholic drinking if he understands the more psychological components of the process.

In the sense that it refers to a state of damage, dysfunction, and lack of healthy balance or equilibrium within the individual and within the larger system at many levels, we prefer to use the term disease with respect to alcoholism. It is a word that has a therapeutic psychological valence for our clients when used in a context in which ultimate responsibility for all behavior is assumed to rest with the individual. At the very least, it conveys our belief in the very serious, destructive, and potentially life-threatening effects of a failure to interrupt the process.

Alcoholism as an Interactional Process

We make the assumption that alcoholism constitutes a sequence of interactional events which occur between the drinker and the alcohol, the drinker and himself, and the drinker and others. The physiological and psychological effects of alcohol, over time, set in motion changes that shift the way the drinker interacts with himself and with others in his environment. In turn, interaction with others shapes the way the drinker drinks.

One way that alcoholism or drug abuse differs from most problems treated from a family systems perspective (e.g., schizophrenia) is that it is a behavior which introduces another substance into the informational circuitry affecting a system. The symptomatic individual interacts and exchanges information not only with others in her environment but, in effect, she interacts with the substance as well.

Alcohol is a psychoactive drug with properties that provide mood and behavior altering experiences when ingested into the body. It provides feedback to the drinker in the form of physiological effects that permit certain experiences such as warmth, relaxation, euphoria, and loosening of inhibition. The relationship with the alcohol becomes one in which, at least intermittently, the drinker is given information about himself that is more palatable or acceptable than his experience of himself in a sober state. Consequently, his feeling state is being continually modified by the added dimension of a relationship with a mood altering chemical.

This factor significantly distinguishes systems in which drug or alcohol abuse is a factor from ones in which it isn’t, but more importantly, it adds a dimension of subjective, experiential information that is crucial to the understanding of the disease process.

In other words, when one works with most families with a symptomatic member, the communicational sequences that surround or constitute the problem are primarily contained within that family system and the larger contextual structures within which it operates. When the family member is alcohol-involved, however, another dimension of information and communication is introduced into the system—communication based on the distorted feedback about self that one family member receives from her interaction with a substance.

To work effectively with an alcoholic system, it is critical to understand this subjective aspect of the individual’s relationship with alcohol. Both Vernon Johnson (1973) and John Wallace (1977) talk about the individual’s relationship with alcohol as one that is compelling because it is confusing. Johnson indicates that the drink functions initially to cause a shift in self-experience—the new drinker is on to a good thing. The fact that he can make himself feel better is a real discovery—in due time he knows that when he comes home and feels like this, with one drink he can feel like that (1973:11). Over time, however, the drinker needs to drink more to achieve the same self-correction, and the more he drinks, the more subtle changes in himself and his environment begin to exact a greater price for his drinking. Increasingly, the effects of drinking become negative, but they are not consistently so, so that the drinker experiences what Wallace refers to as an epistemological quandary (1977:7)—he does not know how to know about himself given the subtly changing perception, feeling, and cognition (1977:8) and the discontinuity of the experience with the alcohol itself.

Eventually, the behavior that is motivated by an attempt to achieve a corrected experience of self shifts as the drinker experiences the need to correct the negative effects or feedback of the drinking itself. As Johnson says, the drinker now starts from a position of feeling bad and drinks to try to get to normal."

The struggle that Johnson and Wallace describe is one in which the individual uses alcohol to achieve an experience of herself or a feeling that appeals to her as more correct or comfortable than the one which she experiences in a sober state. This fact presumes that on some level she tells herself that the feeling or experience that she has is not consistent with how she ought to or could feel. In other words, her need or impulse to self-correct is based on certain premises about herself, about who she is and how she should be. These premises, of course, are based on interactional feedback received and incorporated from others in her environment. One could argue then that alcohol functions initially to reduce a kind of cognitive dissonance in self-experience. In the end, it creates more of that dissonance than it reduces.

Approaching the problem from another systemic level, the anthropologist Gregory Bateson (1972) views this subjective aspect of the relationship with alcohol as directly related to a false set of beliefs about self and about the world that are inherent in the thinking of Western culture. Bateson suggests that the major flaw in the thinking of the alcoholic is a kind of pride—an assertion that one can change, control what one wants to control—as he says, a repudiation of the proposition, I cannot. Bateson suggests that the alcoholic’s pride becomes the context for a struggle to achieve domination over self and others (1972:321). The subjective experience of the alcoholic in Bateson’s terms might look something like this:

Joe A takes a drink.

The drink enhances or diminishes some self-perception that reduces Joe’s sense of disharmony with self or others.

Joe takes another drink.

The effect is intensified. Joe comes to feel that he can regulate his emotional status by taking a drink. He gains a false sense of his own power that enables him to feel differently about himself and to operate differently with others.

Joe drinks too much to the point where his attempt to control his own emotional status leads to loss of control. Over time, Joe denies or forgets that loss of control and continues to relate to alcohol in such a way that he feels he can regain his empowered self by losing it to the relationship with the alcohol. He feels equal to the alcohol because he still thinks that he is in control. The more he tries to be in control, the more he loses control to the alcohol. The more he periodically and intermittently loses control and experiences negative feedback about self in terms of the fact that he is out of control, the more he drinks to prove that he is in fact in control. Over time, the singular event of taking the drink becomes a sequence of events in which a fundamental shift occurs in Joe.

In the beginning, according to Bateson’s typologies of relationships,² Joe relates symmetrically to the alcohol. He feels equal to it. Over time, as the consequences of drinking behavior shift his self-perceptions from positive to more negative, and as his views of self are challenged by those around him, he drinks increasingly as a way of asserting his power over the alcohol—that is, his power over himself. The relationship to the alcohol becomes a complementary one at this point in which the alcoholic seeks to assert that he is, in fact, one-up, in face of all existing evidence that he is actually one-down, or out of control of the relationship. In the initial phase of drinking, when the relationship to the alcohol is experienced as symmetrical, or equal, drinking is an attempt to correct self-perceptions evolved over time during sober states. Eventually, as the perceptions of self become more distorted during the course of the compulsive drinking to correct sober self-perceptions, the alcoholic begins to use the alcohol to correct the corrections—in other words, he drinks more compulsively to change the reality that he is, in fact, out of control of his drinking.

Addiction may be hypothesized to occur at the point where the alcoholic insists that she controls the action of the alcohol instead of experiencing that the action of the alcohol alters or controls her.

In the sense that the person who interacts with alcohol feels and acts one way when he is involved with alcohol, and another way when he isn’t, his experience of self as well as his behavior acquires an oscillating quality. He becomes the Dr. Jekyll/Mr. Hyde so often described by those who relate to alcoholics.

Over time, the oscillations of self-experience become distortions of self-experience prompting the alcoholic to rigidly deny the sober aspect of self while insisting that the perceptions and experiences of the drunk state are true representations of self. In the face of mounting negative evidence to the contrary, she denies that the feedback resulting from her interaction with alcohol is now negative rather than positive. She continues to drink in a frantic attempt to achieve self-corrections. Her drinking acquires the nature of a struggle with alcohol to force it to provide the perceived correct sense of self.

As the alcoholic’s feelings about himself may oscillate from extremes of self-loathing to grandiosity, depression to euphoria, so interactionally, his relationship to alcohol may shift from a symmetrical correction of self-perception to a complementary correction of the one-down status of someone in a relationship who must insist he is one-up (to others) to the alcohol.

Over time, these shifts from one state to the other become more extreme as the alcoholic’s sober behavior increasingly begins to resemble drunk behavior so that the self-perceptions sober and drunk become more alike than different. Eventually, complete breakdown, represented by physical collapse or a succession of extreme consequences for drunkenness, occurs.

The primary characteristic of the interaction between the drinker and the alcohol, then, is the drinker’s attempt to correct or regulate how she feels or experiences herself. She develops assumptions about how she should be or feel—as well as the conviction that she can or should change those feelings—from her interactions with others in the environment. In turn, the drinker’s interaction with the alcohol influences the behavior of others toward her.

For instance, if in relationship to person B, person A feels tense, anxious, angry, inadequate, or any other emotion that person A experiences as unacceptable or inadequate based on his perception of how person B experiences him, then one option is in some way to alter behavior or to alter something about the self that gives rise to the discomfort. The classic example of this self-altering or corrective behavior is the person who walks into a social situation feeling tense, anxious, and uncomfortable, and immediately heads for the bar to take a drink. The drink has the effect of correcting tension and shyness, and eventually person or persons B are reacting to a much altered person A who is livelier, more charming, more outgoing and relaxed. A new level of interactional sequences is thus established based on the altering or corrective influence of alcohol. Two different versions of person A have attended the party that night—the tense, uncertain and fearful person A, and the corrected, relaxed, life of the party person A.

It seems clear that the interactional context in which person A operates both affects and is affected by the process of A’s continued self-corrective drinking. The tense, withdrawn person A progresses to the outgoing, charming person A, who eventually becomes the passed out person on the couch. Not only person A’s feelings, responses, and behaviors have been altered during the course of the evening, but the responses and reactions of those relating to A will have been altered as well. By the end of the evening the host who so glibly kept pouring the drinks and who enjoyed A’s quick wit and irreverent humor may eventually become the caretaker who drives him home or otherwise assumes responsibility for his nonfunctional state. Over the course of time, should this sequence of events continue to occur, the relationship between A and the host will be irrevocably altered—the context of their interaction will shift depending on the host’s desire to continue his caretaking of the drunk person A or on his perception that the drunk person A is not worth the trouble of having around.

Thus, the drinker’s drinking or self-altering behavior takes place within a given interactional context and the roles or alterations that evolve on the parts of the others involved with the drinker change as the progression of the drinking process provides new behaviors to respond to. These drinking events take place discreetly at given specific points in time—that is, once a week, or once a day—but they also evolve a pattern over time as the events of each drinking sequence slowly shape the self-perception of the drinker and the attendant responses of others in the interactional system. Just as the drinker’s self-perception is changed by alcohol, the self-perception of others in the system changes and adapts in response to interaction with the drinker.

As the alcoholic drinks and successive events of self-correction occur, people relating to the alcoholic develop adaptive behaviors in response to the cyclical, discrepant, discordant representations of self presented as the alcoholic shifts from sober to drunk states. Once drinking has become a central focus of concern in a given system, other members of the system are adapting to the full sequence of behavior constituted by the oscillation from sober to drunk back to sober again. Their responses and adaptations will tend to enhance or minimize the likelihood that oscillations in the drinker will become either a sustained pattern of behavior or will recede in frequency. In most cases, the more dysfunctionally adaptive the system becomes, the more the drinker will drink, and the more the drinker drinks, the more dysfunctionally adaptive the system will become.

As a result of the adaptive nature of their behavior, their roles as reactors rather than actors, others in the system begin to acquire the same types of attitudes, feelings, and behaviors that are characteristic of the alcoholic, even though they don’t drink. Their self-perceptions become inextricably linked to the actions of the drinker, and their adaptive behaviors represent their own attempts to self-correct in the face of the feedback generated by the alcohol-affected person.

What becomes clear is that in the system organized around alcohol, all members of the family or larger system are essentially alcohol-affected—that is, their self-corrective behavior is always generated by patterns of feedback that originate in a relationship with alcohol.

It must be noted that drinking may occur over phases that differ in different systems and that trigger mechanisms may be different for different families and different individuals. Life cycle events, developmental pressures, work, peer relationships, traumatic events or losses, shifting power hierarchies and family structures may all provide different trigger events in different families. The trigger for drinking or self-correction may be inside or outside the family system, but the system’s response will always affect the drinking and the drinking will always affect the system.

Finally, the individual’s notion of correct self is influenced by a series of messages or communications transferred from the macro level of social values and institutions to the micro level of interpersonal interactions within the given family context. Thus, notions about correct self are defined by cultural norms, peer group norms, gender and sex role norms, and, finally, family norms that are a collective expression of all the others.

Issues in Alcoholic Systems: Implications for Treatment

If we view the act of drinking in its extreme and repetitive forms as having a self-corrective function for the drinker, the fact that he experiences a need to self-correct represents a statement to the larger system in which he operates that something is wrong. If one observes the interactions that typically characterize alcoholic families, it is possible to evolve some statements about the social context, the interpersonal interactions, and the internal dynamics that serve as the framework for the corrective functions of alcohol.

In terms of the social context, from which one derives norms regarding appropriate hierarchies related to power in the family, it can be observed that in alcoholic families, to an extreme degree, there exists a serious inability to define appropriate hierarchial roles as well as a very covert struggle for power and control. Often there are no clear boundaries around the parental subsystem in the family so that children may be triangled into the parental relationship to the extent that they may replace one or both of the parents in fulfilling the parental functions. Within the spouse system, there is often significant confusion regarding the rules defining the relationship. While there is an attempt to define the relationship along very traditional lines in terms of sex role socialization such that the male is assumed to be the head of the household and the independent one, while the woman is assumed to be the dependent one and the emotional caretaker in the family, in fact, the emergence of alcoholism as a symptom creates adaptive modes of functioning in which these roles may be very much reversed, but persistently unacknowledged.

In the social context, the major effects or adaptive consequences of alcoholism seem to emerge in the dimension of sex role socialization and gender role function. It appears to us that one of the self-corrective or adaptive functions of alcohol may be that it either permits expression or allows suppression of impulses, feelings, and behaviors that violate traditional sex role norms. Given the system’s focus on the alcoholism as the problematic behavior, these norm violations are never directly acknowledged.

The effects of this power/dependency conflict and the adaptive shifting of behaviors around expectations regarding sex role behavior are most clearly manifested interactionally in the alcoholic system around behaviors that may be characterized as either over- or underresponsible. In its self-corrective function, alcohol permits not an assertion of self so much as an evasion of responsibility for self. Therefore, in response to the individual’s relationship with alcohol, or to the individual’s tendency to have engaged in avoidance of self-responsibility prior to drinking, interactional roles in the family become reciprocally balanced around extremes of behavior that are either over- or underresponsible. Drinking may create an extreme reciprocity in terms of these two roles, or the extreme role reciprocity may be maintained by the drinking. There is strong reason to believe that patterns of reciprocal over- and underresponsible behavior transmitted between family members intergenerationally may in large part set the stage for the emergence of alcoholism in succeeding generations.

Finally, the individual for whom alcohol functions as a self-correcting substance typically takes great pride in the idealized image of herself that the alcohol permits, or she may need to self-correct because some idealized image of herself that she does hold to be true is not, in fact, validated by reality-based feedback from external events or people in her relational system. The more her idealized sense of self is threatened, the more adamantly she asserts its validity and, therefore, the more she needs to drink. Since an individual’s idealized or inaccurate belief about self has typically been generated as a protection