The Stigma of Addiction in Romantic Relationships
Given the interdependence of romantic partnerships, close others are among the first to experience and respond to an individual’s substance misuse. This chapter explores stigma related to substance use as it pertains to individuals’ own perceptions of themselves as a romantic partner, as well as to partners’ perceptions of the disorder and perceived stigma from outside sources. We finish by covering effective therapeutic approaches that target substance use disorders (SUDs) at the couple level, for individuals struggling with substance use disorders, for concerned partners, and for the couple together.
KeywordsMarriage Romantic relationship Intimate relationship Partners Substance abuse disorder Stigma Alcohol use disorder Addiction The Stigma of Addiction in Romantic Relationships
Substance abuse can substantially disrupt the harmony associated with positive social relationships. When someone struggles with addiction, all types of relationships can be placed under tremendous strain. In this chapter, we will focus on the dynamics surrounding substance use disorders (SUDs) and a particularly critical relationship: the romantic relationship. Given how addiction can cause feelings of betrayal, perceived lack of dependability, and, most acutely, breaches of trust, it is unsurprising that substance abuse is among the top causes of divorce .
There are substantial consequences of addiction for long-term romantic partnerships. Economically, funds can be redirected from savings accounts toward fueling the habit. Psychologically, one person’s SUD can result in the presence of mood swings, reduced sexual interest and functioning, less quality time with the other partner, general social isolation, and an increased likelihood of physical and emotional abuse. Common partner responses to SUDs in a loved one include leaving the relationship, responding in ways that potentially increase conflict, or even complicity, such that one partner covers for the other and may even provide him or her with substances, often with the ostensible goal of helping.
Although much work has focused on the bidirectional link between SUDs and relationships, [2, 3], relatively little attention has been devoted to understanding addiction stigma as it occurs within romantic relationships . Intimate partners play a significant role in treatment and relapse processes, [5, 6, 7, 8, 9], and their influence can be harnessed to combat stigma from outside sources and help in the rehabilitation and recovery processes, but it is important to consider how they may communicate and maintain stigma as well. This chapter focuses on precisely this duality.
Before beginning, let us consider “Jake” and “Ashley,” a couple who have been together since they were both 18 years old, a period of seven years. For the first few years, they enjoyed outdoor activities and traveling, as well as evenings at home watching movies, eating take out, and occasionally drinking a beer or two together. They maintained a healthy and happy, physically and sexually active relationship during this time. However, everything changed when Jake’s father passed away. Jake spent the first two weeks drinking much more than usual as a way to cope with his recent loss. He went from drinking two to three beers a week to an entire bottle of whiskey. At first, Ashley tried to be understanding of his loss. However, about four months later, she noticed that the problem had gotten worse. Jake was now drinking a bottle of whiskey every other night, and had recently started doing cocaine as well. When she confronted Jake about it, he responded, “You don’t understand what it’s like to lose your dad, I’m just trying to cope.” Ashley knew she did not know what that felt like, so she tried again to be understanding and not overbearing but told herself to remain watchful. When they went out with their friends, Ashley noticed Jake going to the bathroom frequently but figured it was merely due to his drinking. When they would come home, Jake was unable to engage in sexual activities with her. Ashley internalized this and began to think that perhaps Jake was being unfaithful or that she had done something wrong. Jake would get angry at her for accusing him of infidelity, and Ashley did not know what else to think. She sought out answers from the Internet. She found that frequent alcohol and drug usage can cause sexual dysfunction and thought that this might be the answer to her problems. When Ashley spoke to him about this, Jake got very defensive and upset. Jake was internally distressed because he knew his substance use was the source of his issues. He knew his problem was getting out of control and that he wanted to please Ashley but he also wanted to gratify his substance cravings. He realized his reliance on alcohol and drugs had affected not only him but also his partner and his ability to be a partner.
We will be returning to this hypothetical scenario in the sections that follow. Specifically, we will explore addiction stigma from both sides of the romantic partnership: from the perspective of the concerned partner and also from the perspective of the individual with a SUD. We conclude by discussing effective therapeutic approaches, including ways that the influence of partners can be harnessed to reduce stigma related to addiction.
Through the Lens of the Person Struggling with SUD
Individuals exhibit a range of feelings and emotions toward their partner. In a healthy relationship, these feelings might stem from love, passion, care, compassion, honesty, and trust. On the other hand, partners also have attitudes toward themselves. They may evaluate their adequacy as a partner, including how pleasing they think they are toward their partner and how much they perceive themselves to provide to their partner in physical, emotional, and tangible domains.
Research has identified some differences in how individuals struggling with addiction perceive themselves as a person and a partner. As the “addicted” companion, one might feel insecure, anxious, guilty, or burdensome. In a 2004 study, individuals with SUDs reported experiencing enacted, perceived, and self-stigmas . Moreover, individuals with SUDs report being perceived as untrustworthy, blameworthy, and dangerous , which have the downstream effect of hindering help-seeking behaviors [12, 13]. “Enacted” stigma refers to social repercussions, such as difficulties acquiring employment or receiving little support for treatment. These types of issues are particularly acute for those with substance abuse issues, who face even worse social attitudes than do those with schizophrenia [14, 15].
Stigma contributes to relationship distress in many ways. For example, if a partner cannot find work, he or she may feel as if he/she cannot provide or contribute to the relationship and therefore may not seem to be a “good fit” as a romantic companion. In addition, the fact that many substances of abuse are illegal complicates nonusing partners’ displays of empathy. The nonuser might see his/her loved one as a criminal rather than an individual with a medical disorder who needs treatment.
Perceived stigma refers to the “beliefs that members of a stigmatized group (such as drug addicts) have about the prevalence of stigmatizing attitudes and action in society.”  If an individual already believes that he or she is being branded as an addict, especially by his/her partner, this may influence how he/she feels about himself/herself. Fixation on feelings that one is being labeled or judged by one’s partner can deter efforts to get help. This type of stigma might prevent our hypothetical Jake from seeking treatment, or even admitting that he has an issue, simply to avoid being judged by his partner or others.
Self-stigma refers to the negative thoughts and opinions of oneself that can develop from being a part of a stigmatized group and the impact that these behaviors have: failure to seek or obtain employment, treatment avoidance, avoidance of intimate contact or relations with others. Consequences of self-stigma include lower quality of life and diminished self-efficacy [17, 18, 19]. Self-stigma also can influence self-evaluations, especially those pertaining to intimate relationships. An individual with SUDs might feel less present, less able to give his or her partner attention and love.
Even more, he or she might feel like a burden, an added weight to the nonpartner, an unnecessary and unwanted source of stress.
Indeed, most people struggling with SUDs are aware of the fact that the disorder is creating genuine difficulties in their partners’ lives as well. Because of their addiction, they might have an inability to keep a job, resulting in little to no income. SUDs can lead to job loss, resulting in a partnership that suddenly has less income. The partnership also might suffer from a sudden dearth of emotional responsiveness or a decrease in sexual interest. For example, in Jake and Ashley’s relationship, Ashley was under the impression that perhaps her boyfriend had been unfaithful or was becoming disinterested in her, when in reality his substance abuse issues had begun to affect his libido and stamina. Patterns of substance abuse might offer understanding to the problems and instability experienced in young adult marriages . One recurring theme is that, on average, people struggling with substance abuse issues do not care any less about their relationship and partner. Individuals want and expect their romantic relationships to endure, similar to relationships in which neither partner is abusing substances .
Through the Lens of the Partner
Existing literature on stigma is primarily concerned with the individual who is misusing substances. Relatively less attention has been given to those who are closely connected to that individual, even though their outcomes are intimately tied to those of the individual. Romantic partnerships are impactful on mental and physical health, and romantic partners are in a unique position of being both directly impacted by the substance use and able to facilitate positive change. Because the vast majority of individuals with SUDs refuse to enter treatment [22, 23, 24], the lives of family members are directly and negatively impacted by the consequences of the SUD.
In an intimate partnership, addiction can place a strain on the very foundation of the relationship. Addiction has the potential to spread to every aspect of shared life: leisure and quality time, social and sexual functioning, work and professional life. It also has the potential to create financial, medical, psychological, and legal problems. Furthermore, there is the possibility of cognitive biases (e.g., confirmation bias, availability heuristic) to mutate mundane daily stressors into addiction-related problems. For example, imagine that Jake is late to work one day. Ashley might assume that he was late because he was up the night before drinking. Or she might think that it is on account of the extra stress he has created by spending too much money on alcohol and cocaine. Such theories, true or not, create the possibility of increased conflict, which in turn may precipitate additional substance abuse by Jake. In this way, such theories are self-fulfilling prophecies, ones that initiate a cycle of accusation and subsequent use.
Romantic partners experience a number of emotions upon realizing that their partner has an SUD. Interviews with wives of husbands with alcohol use disorders found that the most common reactions were anger, hostility, and resentment, followed by feelings of abandonment, betrayal, helplessness, and frustration . Fear was also present, especially if the substance is one that is known to cause aggression, and fear is especially present when the relationship deteriorates and both parties become frustrated and despondent. Interviews with spouses also indicate feelings of guilt and shame based on their partner’s addiction, demonstrating that partners also experience stigma from outside sources. For example, one partner of an individual with SUDs said, “I will start by saying that living with an alcohol addicted husband or family member is extremely difficult. First of all there is the wish to hide, the shame. You go out and people see, and sometimes ask what’s wrong with him” . Other women in interviews expressed desire to eradicate the sense of feeling different on account of the substance-using partner.
Despite the negative emotions associated with the discovery and daily experience of the consequences of the SUD, partners frequently distinguish between their attitudes toward the substance use and their feelings for the person. One third of the sample in one study expressed love, sympathy, and compassion for their spouse while still being upset about the SUD: “I loved him, but hated and detested what he was doing in his life with his life”; “I love him dearly for the man he is when he is sober and I see him struggling with the disease. When he is drunk I dislike being around him as a person. He is two completely different people sober and drunk” . Spouses may also experience a degree of responsibility for their situation and for that of their partner. Common patterns include inner dialogue with various critical voices: their own (e.g., inability to prevent the addiction may be perceived as a personal failure), their spouse (e.g., who may place blame on them for the addiction), and society (e.g., who may place blame for not leaving their drunken and sometimes abusive partner and also for failing to take care of him or her) .
Moreover, viewing the struggle and consequences of the addiction might lead concerned partners to question (a) if their partner is really sick, (b) if they really require further attention, (c) if they have the capacity to be a contributing member of society, and (d) if they can change. Ashley may wonder if Jake will eventually want to change his behavior or if her relationship with him will ever go back to the way it was before the SUD began. She may wonder what she can do to help him get his life back on track, especially if he does not recognize that he has a problem. Stigma is more likely to emerge to the extent that the SUD is attributed to poor willpower, a character disorder, or a spiritual deficit rather than the result of extenuating circumstances or simply a short-term problem. As elaborated below, whether couples choose to work together to overcome the problem (the couple vs. the SUD) versus the problem being one person’s problem and the two partners against each other (the ‘addict’ vs. the partner) is an important distinction for the couple’s capacity to prevail.
The Importance of Concordance
Three overall patterns may characterize different ways that drugs and alcohol present themselves within a relationship: two abstaining or light-drinking/using partners (i.e., concordant abstinent/light partners), a single user with a nonusing partner (i.e., discrepant partners), and two equally heavy-drinking/using partners (i.e., concordant heavy partners). In a discrepant partnership, the partner may have difficulty relating to issues associated with fear around quitting and relapsing. Thus, partners in discrepant partnerships may display higher levels of stigma compared to concordant partnerships , at least within the relationship. However, partners in discrepant partnerships may have a more objective perspective with regard to the SUD and may have unique opportunities to help their partner into treatment. For example, if Ashley also misused substances, she may have a more difficult time recognizing her own problem and Jake may not see as much need to change his behavior. However, in concordant partnerships, there is also the possibility of conflict around one person’s entering treatment.
Ways That Partners Can Reduce Stigma and Help Their Partner Overcome Addiction
Partners are placed in a unique position to respond to their partner’s use patterns. Just as partner influence can cause further distress and substance misuse, it can also be harnessed to help the person struggling with addiction get into treatment. Partners have the opportunity to respond anywhere along a spectrum, with anger, resentment, and distress on one end—each of which might elicit guilt and/or shame in the partner. On the other end of the spectrum are compassion, understanding, and support—which might potentially enable the partner’s use but might also help him/her find strength to seek treatment. Indeed, romantic relationships should not be painted in broad strokes as supportive or unsupportive—they are often both . Partners may struggle to find the right balance of constructive yet thoughtful concern, and this balance differs across individuals and couples. A successful path for one person or one couple may not work for another. They may also be experiencing negative emotions themselves relating to the SUD, so remaining optimistic, patient, and supportive may be difficult. Regardless, reappropriating stigma by reframing the way both individuals think about the SUD—particularly in cases where one person has made strides toward recovery and partners can celebrate how far they have come—is likely going to be helpful for both partners moving forward.
Therapeutic Approaches for Concerned Partners and Couples Struggling with SUDs
Sometimes partners may not know where to look when they discover their partner’s SUD. Professional support can facilitate the partner’s journey to both take care of him or herself, as well as help his or her partner get into treatment. Of course, the partner may or may not want to enter treatment, and the ways in which partners communicate, behave, and take care of themselves are focal points of therapeutic techniques for substance use disorders among those in relationships. A few—community reinforcement and family therapy (CRAFT), alcohol behavioral couples therapy (ABCT), and Al-Anon—are briefly discussed here.
CRAFT  leverages the cultivation of awareness, compassion, and understanding with self-care for the concerned partner to create an environment where abstinence is positively reinforced for the individual struggling with SUDs. CRAFT also emphasizes the importance of boundaries and self-care for the concerned partners. The framework underlying CRAFT is that contextual contingencies are an important factor in promoting the individual into treatment and in reducing the concerned partner’s emotional distress. Moreover, it is worth considering that sometimes the best course of action for a partner who has put in a substantial amount of effort over an extensive period of time may be for the partner to leave the relationship. CRAFT has been found more effective for engaging unmotivated problem drinkers into treatment compared with Al-Anon, [27, 28, 29], a pattern replicated with drug-abusing populations . CRAFT has also been shown to improve concerned partners’ depression, family conflict and cohesion, and relationship satisfaction [27, 30]. Finally, CRAFT was successfully disseminated from tightly controlled research laboratories to a community treatment center .
Another highly efficacious approach for those with alcohol use disorders is alcohol behavioral couple therapy (ABCT) [32, 33, 34]. ABCT recognizes that families play a large role in the beneficial and detrimental effects of alcohol use. The approach focuses on familial/partner antecedents (e.g., daily habits or celebrations) and consequences (e.g., missed work or social obligations) of drinking as well as improving communication and problem-solving skills. Spouses are taught skills to effectively manage alcohol-related situations, including reinforcing abstinence or light drinking, eliminating or reducing situations that trigger drinking, and assertively discussing their concerns over alcohol use. Behavioral couples therapy is more effective in increasing abstinence and improving relationship quality compared with individual treatment [28, 35, 36], primarily through increasing reinforcing components of the relationship, enhancing greater support for partner change, and improving couple-level problem solving. Recently, ABCT has been efficacious for females with alcohol use disorders, [35, 37, 38], men and women in same-sex relationships, , and nonspousal family members .
Al-Anon and the the twelve-step approach  are a common resource of support for concerned partners. In maintaining that alcoholism and other addictions are diseases, Al-Anon helps alleviate partners’ guilt over being responsible for the addiction. Assigning responsibility to the disease rather than to themselves facilitates forgiveness and acceptance. Like CRAFT, Al-Anon focuses on the concerned other and emphasizes working toward personal peace and serenity rather than controlling the other person. The fellowship provided by the Al-Anon community can also be a helpful support system. A review of family-based alcohol use disorder interventions found that Al-Anon increases adaptive coping for family members with life stressors both related and unrelated to the person’s drinking [28, 36, 42]. Family members also report lower depression, anger, and family conflict and greater family cohesion and relationship quality [27, 43]. Al-Anon and Nar-Anon have largely been shown to be ineffective as approaches for bringing users into treatment [5, 27, 44, 45], which is understandable given the programs’ foci on improving the well-being of concerned others.
Within the context of romantic relationships, use and misuse of substances have significant consequences, as do moderating and quitting substance use. Relationship partners inhabit close proximal and psychological space. The thoughts, feelings, and behaviors of one partner often become woven into the fabric of the other partners’ existence. For this reason, spouses and romantic partners are among the first to experience the repercussions of an SUD, and the presence of an emergence of an SUD in a relationship can make many aspects of life challenging, especially to the extent that SUDs often jeopardize the fulfillment of primary relationship needs, including those for stability, security, connection, and tranquility. At the same time, spouses and romantic partners have tremendous potential to influence decisions related to seeking and completing treatment and are key allies in comprehensive treatment programs. In this chapter, we highlighted that partners have a unique and important perspective when intimately involved with a partner struggling with an SUD. Learning more about addiction-related stigma as it affects one’s partner, speaking out and challenging inaccuracies related to the addiction, keeping hope alive, thinking about the partner holistically, and treating him or her with respect are all ways to challenge and overcome stigma.
- 4.Gunn AJ, Sacks TK, Jemal A. “That’s not me anymore”: resistance strategies for managing intersectional stigmas for women with substance use and incarceration histories. Qual Soc Work. 2016:1473325016680282.Google Scholar
- 9.Simpson DD, Sells SB, editors. Opioid addiction and treatment: a 12-year follow-up. Malabor: Krieger Publishing Company; 1990.Google Scholar
- 12.Fitzgerald T, Purington T, Davis K, Ferguson F, Lundgren L. Utilization of needle exchange programs and substance abuse treatment services by injection drug users: social work practice implications of a harm reduction model. Practice Issues in HIV/AIDS Services: Empowerment-based Models and Program Applications 2004;10.Google Scholar
- 32.McCrady BS, Epstein EE. Overcoming alcohol problems: a couples-focused program workbook. Ann Arbor: Oxford University Press; 2008.Google Scholar
- 34.Noel NE, McCrady BS. Alcohol-focused spouse involvement with behavioral marital therapy. In: O’Farrell TJ, editor. The Guilford substance abuse series. Treating alcohol problems: marital and family interventions. New York: Guilford Press; 1993. p. 210–35.Google Scholar
- 38.Schumm JA, O’Farrell TJ, Muchowski P. A randomized clinical trial of behavioral couples therapy for women with alcohol dependence. Paper presented at annual meeting of the Association for the Advancement of behavioral and cognitive therapies: Orlando; 2008.Google Scholar
- 41.Al-Anon Family Groups. This is Al-anon. New York: Al-Anon Family Groups; 1981.Google Scholar
- 42.Nowinski JK. Family recovery and substance abuse: a twelve-step guide for treatment. Thousand Oaks: Sage Publications; 1999.Google Scholar