Co-dependency and Family Interaction in Spouses of Persons with Alcohol and Opioid Dependence

CO-DEPENDENCY AND FAMILY INTERACTION PATTERN OF THE SPOUSES OF
PERSONS WITH ALCOHOL AND OPIOID DEPENDENCE SYNDROME:

A COMPARARTIVE STUDY
By
Mr. Siba Karmi
Under the Joint Guidance of
Prof. (Dr.) Basudeb Das, M.D.
Professor, Department of Psychiatry

Central Institute of Psychiatry
Ranchi, India.
And
Mrs. Mittu Muthu Varghese, M.Phil (PSW).
Asst. Professor, Department of Psychiatric Social Work,

Central Institute of Psychiatry
Ranchi, India.
DISSERTATION
SUBMITTED TO RANCHI UNIVERSITY IN PARTIAL FULFILMENT OF THE

DEGREE OF MASTER OF PHILOSOPHY IN PSYCHIATRIC SOCIAL WORK
Session: 2017-2019
DECLARATION
I hereby declare that the present study titled "Co-Dependency And Family
Interaction Pattern Of The Spouses Of Persons With Alcohol And Opioid
dependence Syndrome: A Comparartive Study" has been carried out by me, at
Central Institute of Psychiatry, Kanke, Ranchi, under the joint guidance of Prof.
(Dr.) Basudeb Das, Professor of Psychiatry and Mrs. Mittu Muthu Varghese,
Assistant professor of Psychiatric Social Work, Central Institute of Psychiatry,
Ranchi.
I also hereby declare that this is an original study and no part of this study has been
published in any journal or submitted to any other university for any degree or
diploma previously.
Place : Ranchi
Date : 30.03.2019 Siba Karmi
CENTRAL INSTITUTE OF PSYCHIATRY
KANKE, RANCHI- 834006 JHARKHAND (INDIA)
CERTIFICATE
This is to certify that Mr. Siba Karmi is a bonafide student of the Central Institute
of Psychiatry, Ranchi, pursuing the course of Master of Philosophy in Psychiatric
Social Work of Ranchi University for the session 2017-2019.
The study titled “Co-Dependency And Family Interaction Pattern Of The
Spouses Of Persons With Alcohol And Opioid Dependence Syndrome: A
Comparartive Study" has been carried out by him at the Central Institute of
Psychiatry, Ranchi, under our supervision and guidance. This dissertation is hereby
approved for submission to Ranchi University in partial fulfillment of Master of
Philosophy in Psychiatric Social Work.
Mrs. Mittu Muthu Varghese, M.Phil. Prof. (Dr.) Basudeb Das, M.D.
Asst. Professor, Department of Psychiatric social work Professor, Department of Psychiatry
Central Institution of Psychiatry, Central Institution of Psychiatry,
Ranchi, India. Ranchi, India.
ACKNOWLEDGMENT
“My teachers are my shepherd”

I am very happy to express my immense gratitude toward my parents. “For God
loved the world so much that he gave his one and only son, so that everyone who
believe in him will not perish but have eternal life”. The almighty God feels within
my heart for completion of the dissertation successfully by the grace of Jesus.
With immense pleasure and gratitude I would like to owe my heartfelt thanks to a
great many people who have contributed to the production of my dissertation and
who have made this successfully possible.
I owe to my teacher Prof (Dr.) D. Ram, Director for giving me an opportunity to

enter into this apex institution for learning with the grace of my respected teachers,
those who are involved in this learning and teaching environment as well as feeling
natural beauty of this institution to complete this research.
My sincere gratitude is to my guide, Professor (Dr.) Basudeb Das, M.D. I have been
amazingly fortunate to have a guide who encourages me carrying out the
dissertation and at the same time the guidance to recover wherever my steps
faltered. I am thankful to him for providing his valuable countless time for carefully
reading and commenting and revision of this manuscript, for encouraging me to a
high research standard and enforcing strict validation for each research result, thus
teaching me how to do research. His patience and support helped me to encourage
overcoming many crises situation and finishing this dissertation.
This dissertation is culminination of a perfect working relationship with my joint
guide, advisor and sponsor. Mrs. Mittu Muthu Varghese, M.Phil., Asst. Professor,
Department of Psychiatric Social Work to whom I am grateful to her forever. She
provided unreserved support during my dissertation and generously paved the way
for my development. I really appreciate her passion and enthusiasm foe continual
education and growth, who graciously and unselfishly scheduled additional time for
my dissertation work. Her dedication to academic and professional excellence
motivated me all through my academic journey. Thank you very much Madam for
your guided direction and your commitment to making the dissertation significant.
I am also greatly indebted to many people who in some way or other, contributed to
the progress and completion of the work contained herein. I would like to express
my deepest thanks to my teachers Dr. Dipanjan Bhattacharjee, PhD. M.Phil (Head
of Dept. of Psychiatric Social Work), Mr.Narendra Kumar Singh, M.Phil, (PSW)
and Mr. James Josheph, M.Phil, PSW for their immense support and time to time
encouragement in my endeavor.
I would like to express my sincere thanks to Mr. Hariom Pachori for his help and
support in statistical analysis of my study. I would also like to thank my friends,
batchmates, respected seniors especially Bikash Ranjan Mohanta,M.Phil (PSW),
Miss. Sani, Sadhu Ashok, M.Phil (PSW) and junior trainees who have always
showed their concern, stood with me in time of crises to complete my study. I will
be ever grateful to the study participants, the patients, spouses of patients and their
family members.
Siba Karmi
CONTENTS
S.L. No TITLE Pages
1 INTRODUCTION 1
2 REVIEW OF LITERATURE 6
3 AIM,OBJECTIVE & HYPOTHESES 43
4 METHODOLOGY 44
5 RESULT 48
6 DISCUSSION 58
7 SUMMARY AND CONCLUSION 75
8 LIMITATION & FUTURE DIRECTION 76
9 IMPLICATION 77
10 REFERENCES 78
11 APPENDICES 97
INTRODUCTION
Cermak (1984) defined codependence as "people whose lives had become

unmanageable as a result of living in a committed relationship with an alcoholic." In
this view the codependent is not all primary alcoholic, but rather is a person involved
in an intimate relationship with an alcoholic who denies, ignores, tolerates and even
enables or encourages the person with an alcohol dependence behavior to continue
in his or her destructive drinking. Potter-Efron and Potter-Efron (1989),described co-
dependent as someone who has been significantly affected in specific ways by
current or past involvement in an alcoholic, chemically dependent or other long-
term, highly stressful family environment. Its effects of which are fear, shame, guilt,
prolonged despair, anger, denial, rigidity, impaired identity development and
confusion.
Douglas and Minton. (1993) commented on the idea of ‘Co - dependency’ emerged in
the late 1970s within the chemical dependency treatment industry. However, since
the 1930s, describing the wife of an alcoholic as being disturbed has been influential
in varying degrees. The perennial influence of co - dependency suggests that it is a
social construction which has been influenced by traditional assumptions about
gender in our society. Feminist criticisms of co - dependency theory however contend
that while society demands that women be nurturing, caring, and sensitive to others'
needs, these same behaviors are viewed as unhealthy and maladaptive in co -
dependency.
Stafford (2001) developed first time the term “codependency” in the substance
abuse treatment arena. It was then referred to wives of men who abused alcohol; the
term nevertheless has gradually achieved a prominent place in the psychiatric,
psychological and addiction literature and has more recently been used almost
generically to describe a dysfunctional style of relating to others.
1
CO-DEPENDENCY AND FAMILY INTERACTION PATTERN OF THE SPOUSES OF PERSONS WITH ALCOHOL AND
OPIOID DEPENDENCE SYNDROME: A COMPARARTIVE STUDY
Lamichhane et al. (2008) described substance abuse poses problems not only on the
individual user but also on the family and the community. Within the family, it is
often the women who are most affected and it is often they who bear a significant
brunt of the burden. Such burden becomes obvious in developing countries like
Nepal and India, where women are already disadvantaged. Ranganathan (2004)
described that in our societal structure, the family is undergoing a marked transition
and the most noticeable consequence of this transition happens to be a significant
increase in the number of people addicted to alcohol. Alcoholism creates a major
stress on the family members and the family system of the one using or abusing it.
Drinking behavior may interrupt normal family tasks, cause conflict and demand
adjustive and adaptive responses from family members who do not know how to
appropriately respond. Alcoholism creates a series of escalating crises in family
structure and function, which may bring the family to a system crisis.
Mohammadkhani (2009) explained addiction can have adverse effects on morality in

society and consequently because of dependency may destroy morality and cause
crime, hostility and violence directly and indirectly. Addicted family and their first
degree relatives suffer because of these addiction consequences and are victims to
their circumstances. He also conducted a cross – sectional research to determine the
personal–relationship problems of women with addicted husbands as compared to
women having husbands who were not addicted to any substance.
Ranganathan (2004) described in his study that the family members develop
dysfunctional coping behavior called 'Co-dependency'. Therefore, it is imperative to
involve family members in treatment; children of alcoholics are one of the largest,
most explosive and most remedial population who need help. With the number of
women alcoholics on the rise, their addiction leads to neglect of children, and
parenting responsibilities are compromised.
Salehyan et al. (2011) described health and mental disorders in women with
husbands affected by substance dependence disorder are an interactional result of
2
bio-psycho-socio-cultural factors. He attempted to explore the presence of mental
disorders amongst women with husbands affected by substance dependence
disorder using general health questionnaire (GHQ-28) to evaluate the general health
condition of these women. Results showed that there was a significant difference
between the means of psychological disorders in women with husbands affected by
substance dependence disorder. Demographic information showed that, women with
husbands affected by substance dependence disorder suffer from low vocational and
educational level, premature marriage, unemployment, living in insecure rental
houses, low income and family history of substance abuse.
Schäfer (2011) defined that alcohol and drug addiction is a societal problem that is
steadily growing and contributes significantly to the destruction of families and
communities. Research has identified a strong connection between disrupted family
relationships and alcohol as well as other drug addiction. Senthil et al. (2014)
described the impact of alcohol problems on family members of individuals abusing
alcohol is wide-spread; virtually it can penetrate into every area of life, for example
their physical and psychological health, finances, employment, social life and
relationships. Alcoholism and substance dependence problem no longer remains a
source of problem limited only to the dependent person but rather it usually
becomes a continuous source of stress and suffering to all those people who are
closely associated with the alcohol dependent person especially to the alcoholic’s
spouse. It destroys, disturbs and shakes the entire family structure and functions.
Ruchi et al. (2014) found that opioid dependence syndrome has deleterious
consequences not only on the addict but also on the family members especially his
spouse who is most vulnerable to develop significant psychiatric disorder given the
intimate nature of their relationship. It is therefore very important to address these
issues as it will be beneficial for the spouses as they serve to be important source of
moral support and assistance to the substance user’s quest toward abstinence.
3
Mammen et al. (2015) referred that substance use causes drastic harm to the well-
being and health of the individual and more so affects the family as well. Stress of
living with an alcoholic, harmful intimate partner violence and poor marital
satisfaction has contributed to the development of psychiatric morbidities in spouses.
Addressing the mental health issues of spouses of alcoholics can reduce their burden
and improve their quality of life.
Senthil (2016) found that alcoholism is destructive to those closest to the alcoholic
and it affects families in several different ways. Many times, rehabilitating an
alcoholic is only one part of the process of healing at home. Family members may as
well need support and counseling. Families with an alcohol dependent suffer from a
range of problems and their spouses live in constant conflict. s
Sarkar et al. (2016) concluded that substance use disorder not only impacts the
patient himself/herself, but also affects ones family members. In India, familial ties
are stronger between family members and they do play a significant role in the
treatment process. Therefore it is primarily important to understand the inter-
relationship between substance use disorder and the family. Domestic violence and
adverse familial circumstances, both often arise as a consequence of substance use.
Although the spouses of substance users experience greater rates of
psychopathology and distress, children of patients with substance use disorders
demonstrate higher levels of behavioral disturbances.
Dandu et al. (2017) found that described alcohol dependence is on the rise worldwide
over and especially in developing countries such as India. According to the World
Health Organization, about 30% of Indians consume alcohol, out of which 4%–13%
are daily consumers and up to 50% of them, satisfy the category of hazardous
drinking. Another worrying trend in India is that the average age of initiation of
alcohol use has reduced from 28 years during the 1980s to 17 years in 2007. In India,
alcohol abuse also amounts to huge annual losses due to alcohol-related problems in
workplaces.
4
Dowman (2017) the impact of an individual’s drug or alcohol use on one’s family
members has been widely acknowledged. Policy and clinical practice guidelines
advise that drug and alcohol services offer family members practical and therapeutic
support. This area however is limited with regard to focus on the experiences of
children affected by parental drug and alcohol use or how family members can help
improve outcomes for their relatives in treatment for drug and alcohol use. Little is
known about the experiences of affected adult family members in receipt of support
services for themselves.
Need for the Study
Drug addiction is one of the social problems that not only creates psychological and
social problems for the addict, but also creates problems for their families. Drug
addiction is followed by many socio-economical and psychological problems,
therefore identification of effective factors responsible for addiction, especially from
the wives of addicts viewpoint who are the closest members to the affected in
comparison to others in the family is very important. Children and spouses of alcohol-
dependent parents are at higher risk of developing substance abuse, emotional,
behavioral, and mental health disorders at all stages of development leading into
adulthood. Till date there are few studies on the impact of alcohol use as well as
opioid use in children and spouses, especially on co-dependency. The present study
aimed to study empirically the co-dependency and family interaction and its
interrelation to each other.
5
REVIEW OF LITERATURE:
Alcoholism is a disease of the family. Alcoholism is linked to disrupted family role,

violence, impaired family communication and physical and psychological illness.
Several studies have shown that spouses of alcoholics’ present with significant rates
of mental and physical problems, communication problems, low social activity and
poor marital satisfaction. The inconsistent results from previous research clearly
demonstrate the need for more evidence. Ekaterina Raklova (2013) studied co-
dependency and postulated that it is a condition that occurs in family members of
alcoholics or people with other forms of addiction, which is often worse than the
disease itself. Co-dependency can be compared to a symbiosis of an alcoholic and
his/her family members, but this combination has a destructive tendency, not only
for the "donor", but for all family members. Though it was originally formed for and
by humanitarian reasons, such as helping a drinker, but with the development of
alcoholism the mechanism of co-dependency obtained a reverse vector. In the
process, co-dependency poses to be a serious psychological, medical, educational
and social problem. Paul et al. (2018) about30% of Indian population, just less than a
third of the country’s population consume alcohol regularly (as of 2010). The average
Indian consumes about 4.3 L of alcohol per annum. The effects of alcoholism on the
family are profound. As the family become increasingly preoccupied with the family
member’s drinking, there are attempts to recognize and develop various adapting
roles. Co-dependency is types of dysfunctional helping relationship were one person
supports or enables another person’s alcoholic addiction. It affects an individual’s
ability to have a mutually helping relationship also called as relationship addiction.
Arnold (1990) defined co-dependency as a belief that when “someone or something

does not behave the way you want or expect, you feel worse about yourself.” The
idea of “feeling, worse” can include believing that a situation is your fault, and if only
you had tried harder, things would have worked. Co-dependency links personal well-
6
being, self-esteem and substance addiction to the behavior of other people and the
events of the external world.
Bacon et al. (2018) defined co-dependency as a complex and debatable concept,
which has been used over the years by mental health professionals to inform their
practices. Researchers have attempted to identify the main problems associated with
co-dependency; however, their evidence is still inconclusive. Interpretative
Phenomenological Analysis (IPA) has been used to explore the lived experience of co-
dependency from the perspective of self-identified co-dependents.
Hersen et al. (1973) conducted a study to observe the interactional pattern amongst
couples with 4 male alcoholics and their wives (mean age, 44; education, 10 yrs;
married, 26 yrs; husbands' alcoholism duration, 9 yrs) to converse in couples about
the husband's drinking problem and also about topics unrelated to alcoholism. The
interactions were videotaped. It was observed that the wives tended to look at the
husband more during conversation related to his drinking (57-70 sec per 2-min
interval) than during non alcohol-related conversation (23-43 sec per 2-min interval).
Husbands showed a slightly reversed trend. Whether the wife's looking was
associated with positive or negative affect, she paid significantly more attention to
the husband during discussion of his alcoholic behavior.
Mulry (1987) described co-dependency in a family addiction. Co-dependency is a

common and treatable family-system illness that develops in reaction to the stress of
addiction or another "shameful secret" in a family member. This stressful
environment induces emotional changes in each family member and creates a variety
of pathologic family roles. Here research yielded that brief therapy for the co-
dependent family can be noticeably effective when combined with follow-up and
linked with Al-Anon family groups.
Asher and Brissett (1988) in the intensive interviews that were conducted with
women married to alcoholics, it was gathered that co-dependency in the view of an
alcoholic individual’s wife, involves caretaking behavior exists by virtue of their
7
association with an alcoholic. They disagreed widely as to its impact on the self, its
locus as personal or social. Traditionally as well women has always been viewed as
more passive than active but more so there has been a more serious affinity to the
historical view that wives of alcoholics are pathological.
Lyon and Greenberg (1991) studied the evidence of co-dependency in women with an
alcoholic parent, they recruited 48 single, female undergraduates, 24 of whom came
from families with one alcoholic parent and 24 of whom had no alcoholic parent. It
was expected that having learned to obtain approval and self-esteem by conforming
to the demands of an exploitive person, women with alcoholic parents would
continue to seek opportunities to help such people and would be more helpful to an
experimenter portrayed as exploitive than to one portrayed as nurturing. Their
findings strongly supported the existence of co-dependent behavior in women with
alcoholic parents.
O'Brien and Gaborit (1992) examined the relationship between co-dependency,
chemical dependency and depression. They used Beck Depression Inventory and the
Significant Others’ Drug Use Survey (SODS) and the co-dependency Inventory (CDI)
with 115 undergraduate students. The Scores on the co-dependency Inventory (CDI)
and the Significant Others' Drug Use Survey (SODS) were not related significantly. The
finding is consistent with the view that codependency is a unique disorder that,
though at times seems to result from the chemical dependency of significant others,
exists independently of chemical dependency. Being in a relationship with someone
with a chemical dependency is at the root of co-dependency.
Ansara (1995) assessed the relationship between co-dependency, family alcohol
consumption patterns, degree of family dysfunction and gender; using the Spann-
Fischer Co-dependency Assessment Instrument to measure subject’s feelings and
attitudes who were divided into four groups based on their report of family
dysfunction and family alcohol consumption patterns, found that co-dependent
characteristics were more prevalent in subjects from the maximum dysfunction
group compared to those in the minimum dysfunction group regardless of the
8
reported degree of family alcohol consumption pattern and with respect to gender
Females did not score significantly higher than males.
Prest et al. (1998) investigated co-dependency in the clinical and non-clinical families;
they administered the Co-dependency Assessment Inventory (Friel, 1985) and the
Family System Questionnaire with 30 married couples in which 01 member of the
couple was a recovering alcoholic in an aftercare program. The findings suggested
that the etiology and function of co-dependency are different in clinical and non-
clinical families. In the clinical group, there was little difference between alcoholics
and their spouses with respect to dysfunction in their families of origin, current
families, or their co-dependency levels.
Zetterlind and Berglund (1999) studied the co-dependence in substance use disorders
where they used instruments such as the Co-dependence Scale, Coping Behavior
Scale, Hardship Scale, Symptom Checklist (SCL-90), Trait Personality Questionnaire
(TPQ) and The Interview Schedule for Social Interaction (ISSI). They found that 44% of
the relatives met the criteria of co-dependence, 17% were males and 83% were
females. Co-dependence was found to be related to coping Style (fear withdrawal)
and hardship of the relationship but not to the severity of psychopathology or
personality.
Lindley et al. (1999) examined the relationships between co-dependency and age,
gender, self‐confidence, autonomy and succorance,which is the quality of soliciting
emotional support from others, The Spann‐Fischer Co-dependency Scale (Fischer,
etal. 1991), the Adjective Check List (Gough &Heilbrun, 1983) and Co‐Dependents
Anonymous Checklist (Whitfield, 1991) were administered with ninety‐five
undergraduates students. Here researcher found that co-dependency was negatively
related to self‐confidence and positively related to succorance, in addition low
self‐confidence was the strongest predictor of co-dependency.
Martsolfet al. (1999) compared the co-dependency in a group of 77 female and a

group of 72 male helping professionals. The Co-dependency Assessment Tool
9
(CODAT) was used. Findings showed that males had slightly higher co - dependency
than females on the total CODAT.
Bhowmicket al. (2001) examined the relationship between social support, coping
resources and co-dependence in the wives of individuals with drug and alcohol
dependence. For this, thirty male individuals each with drug and alcohol dependence
were assessed for severity of addiction by Addiction Severity Index (ASI). Their wives
were administered Social Support Scale (SSS), Coping Resources Inventory (CRI) and
Co-dependence Assessment Questionnaire (CAQ). Results showed that forty nine
wives were found to be co-dependent. On ASI, the co-dependent group had more
impairment in the financial and legal domains whereas non co-dependent group had
more impairment in the psychological domain. Co-dependent wives were also found
to have lower coping resources and lower social support.
Sabater (2006) conducted a study to investigate the prevalence of co- dependency
and particularly explored its ethno – racial influence of in a population of 156, second
generation, American women, (56 African Americans, 50 Caucasians and 50
Hispanics, ages 18 to 76. He use spann – Fischer Co- dependency Scales, the Alcohol
Attitudes Questionnaire and FACES II to achieve his objective and found that
regardless of ethnic affiliation, when composed to women not married to alcoholics,
wives of alcoholics were more co- dependent, (F (1, 153) = 12.36, p <.05), were
reared in the most dysfunctional families (F (1, 153) = 9.337 , p <.05),and held the
most negative attitudes toward alcohol and alcoholism (r2= .158, F(2,153) = 14.323, p
<.001). Wives of those who used both alcohol and drugs scored highest on co-
dependency (2,152) = 3.26, p <.05, thus a relationship was found between co-
dependency, alcohol and drug abuse in this population.
Ançel andKabakçi (2009)evaluated the psychometric properties of the Co-

dependency Assessment Tool (CODAT) developed by Hughes-Hammer et al. (1998a,
1998b) for Turkish students and investigated the relationship of co-dependency with
attachment styles and family problems. CODAT, Beck Depression Inventory,
Experiences in Close Relationships-Revised, and Family Problems of Young Adulthood
10
Evaluation Scale were administrated to Turkish female nurse students (n = 400). They
found students with higher CODAT scores had more attachment-related anxiety and
reported more family problems after controlling for the effects of depressive
symptoms. They supported the internal consistency and validity of the Turkish
version of CODAT.
Self (2010) explored the relationship between co-dependency and self-reported
history of treatment for substance use disorders among nurses and comparing
nurses' co-dependency scores by gender, race and birth order, having experienced or
witnessed physical violence in the family of origin, having a parent or primary
caregiver with substance use disorder, having a parent or primary caregiver with a
history of mental illness, he found that the nurses co-dependency scores differed
significantly, when compared by history of treatment for substance use disorder.
Nurses who reported treatment for substance use disorder had higher co-
dependency scores than nurses who reported no treatment for substance use
disorder. Those who reported a history of witnessing or experiencing physical
violence in their family of origin had higher co-dependency scores than those who did
not report about those. Another significant finding was that nurses who reported
having a parent or primary caregiver with a history of mental illness had higher co-
dependency scores than those who did not.
James (2012) assessed the co-dependency and depressive symptoms among wives of
alcoholics in selected rural communities of Mysore.He found that on the Co-
dependency scale, 51% of the sample was found to be moderately co-dependent,
49% was found to be highly co-dependent and none of them were completely
independent. About 78% of the samples have got major depression, 22% have mild to
moderate depression and nobody has scored less than 15. Using Karl Pearson
Correlation Coefficient, a positive correlation was found between co-dependency and
depression.
Carruth and Mendenhall (2014) defined co-dependence as “a disease of lost
selfhood. It is any suffering and dysfunction which is associated with or results from
11
focusing on the needs and behavior of others.” Co-dependents become so focused
upon or pre-occupied with important and even less important people in their lives
that they neglect their true self or who they really are. This makes the individual
enter into a state of ‘non-living’ which is progressive.
Rusnáková (2014) studied the process of co-dependency, focusing primarily on the

experience and behavior of co-dependents towards an addicted member of the
family. Participants were the members of a family of an alcoholic person, i.e. the
parents, siblings and partner. One of the outcomes of this study was the creation of a
process model of co-dependency, focusing on the experience and behavior of co-
dependents. This is defined by the phases of co-dependency, namely: denial, anger,
rescuing, sadness, hatred and reconciliation.
Hawkins and Hawkins II (2014) explored the relationship between co-dependence,

gender, positive and negative gender-stereotyped traits, and other measures of
personality and problem drinking on a sample of 208 American undergraduates. Their
study revealed no gender differences on the co-dependence measures. Students
reporting a positive family history of alcohol problems scored significantly higher on
codependence. Co-dependence was negatively correlated with socially desirable
masculinity and femininity traits.
Uzma Zaidi (2015) investigated the impact of family support group on co-dependent
behavior of spouses of drug addicts. They used Co-dependent Scale with 30 female
spouses of drug addict persons, old members of family support group on co-
dependent behavior. Results showed that there is significant difference between new
members and old family support members on variables. Findings can be
implemented to enhance the benefits of self-help groups or group therapies
supported by drug treatment centers to family members.
12
Sarkar et al. (2015) assessed co-dependence in spouses of substance dependent men
in a developing country and to evaluate its relationship with other clinical factors. For
this a total of 100 spouses of alcohol or opioid dependent men seeking treatment at a
de-addiction centre in India were recruited. Using Co-dependence Assessment
Questionnaire, co-dependence was found to be present in 56% of the spouses in the
alcohol dependence group and 64% of the spouses in the opioid dependence group.
Binary logistic regression revealed that codependence was associated with the
younger age of the spouses.
Zaidi (2015) explored the relationship of co-dependency and relationship satisfaction

among spouses of alcohol abusers. It was hypothesized that there would be a
significant relationship between co-dependency and interpersonal satisfactions
among spouses of alcohol abusers. Higher denial, self- esteem, control and
compliance will predict lower interpersonal satisfaction among spouses of alcohol
abusers. Likely so, results show that when Co-dependent scale and relationship
survey was administered with the seventy spouses of alcohol abusers that were taken
from addiction treatment centers of Lahore city using purposive sampling techniques,
correlation and regression analysis shows that there is a significant relationship
between the variables.
Kishor et al. (2013) defined alcohol dependence has adverse health and social consequences;
alcohol related problems primarily occur within the family context and maximum impact is
felt on spouses, given the intimate nature of their relationship. Spouses play an important
role in treatment programs related to alcohol. There is thus a need to study psychiatric
morbidity and marital satisfaction in spouses of alcohol dependent patients in order to
understand and address such issues.
Bortolon et al. (2016) identified the symptoms of co-dependency and health issues
in the co-dependent family members of drug users, they found that drug user’s
mothers and wives who had less than 8 years of education and those who were
unemployed had a greater chance of high co-dependency. They found that a high
13
level of co-dependency imposed a significant burden on the physical and emotional
well-being of those affected, co-dependency has a negative impact on the family
system and on the health of the family members.
Askian et al. (2016) studied a qualitative study to explore the characteristics of co-
dependence among wives of persons with substance use disorder in Iran, a
purposive snowball sampling technique was used to identify 11 Iranian wives of
individuals with substance use disorder. Researchers used in-depth, face to face
interviews, non-participation observation and document analysis to collect their
data and their analysis yielded five main characteristics of co-dependence namely:
denial, enabling behavior, low self-worth, enmeshed self and weak spiritual
relationship with God.
Panaghi et al. (2016) found out the moderating effect of personality traits on the
relationship between living with an addicted man and co-dependency, they selected
140 women (70 wives of addicted men and 70 wives of non-addicted men) as a
sample through convenience sampling method and asked them to complete Spann-
Fischer Co-dependency Scale and NEO-Five Factor Inventory. Findings of this study
showed that co-dependency score was significantly higher among addicted men’s
wives. In addition, for these women, there was a strong positive correlation between
co-dependency and neuroticism as well. Multiple regression analysis confirmed the
significant interaction effects of being an addict’s wife and personality traits of
neuroticism, openness and agreeableness on co-dependency. It was observed that
women with a high level of neuroticism, low level of openness and agreeableness
were more vulnerable to the stress of living with an addict and to co-dependency.
Bortolon et al. (2017) conducted a randomized clinical trial to verify the change in co-
dependent behavior after intervention with 6 months of follow-up. The intervention
that was used was the Tele-intervention Model and Monitoring of Families of Drug
Users (TMMFDU), which was based on motivational interviewing and stages of
change, that aims to encourage the family to change the co-dependents' behaviors. It
14
included three hundred and twenty-five families with high or low co-dependency
scores who were randomized into the intervention group (n = 163) or the usual
treatment (UT) (n = 162). After 6 months of follow-up, the family members of the
TMMFDU group were twice as likely to modify their co-dependency behavior when
compared to the usual treatment group (OR 2.08 CI 95% 1.18–3.65). Results show
that the TMMFDU proved to be effective in changing co-dependent behaviors among
compliant family members of drug users.
Bacon et al. (2018) recruited eight participants from local support groups for co-
dependency in the UK. They offered in-depth information about their subjective
experiences and embedded in their life world. The data was gathered through
interviews and a visual method. The shared experience of co-dependency was
portrayed by the participants as a complex but tangible multidimensional
psychosocial problem in their lives. They incorporated three interlinked experiences,
a lack of clear sense of self, an enduring pattern of extreme, emotional, relational and
occupational imbalance, and an attribution of current problems in terms of parental
abandonment and control in childhood.
Paul et al. (2018) aimed to assess the co-dependency and quality of marital life
among spouses of patients with alcohol dependence syndrome (ADS). They used
socio - personal proforma, Span Fischer Co-dependency Scale and Quality of Marital
Life Scale with 80 spouses of patients with alcohol dependence syndrome. The
results showed that the majorities (48.75%) of the subjects weremoderately co-
dependent and 41.25% of subjects were severely co- dependent. The mean level of
quality of marital life was found to be 36.75 with standard deviation of 19.54. The
study also identified a moderate negative correlation between co-dependency and
quality of marital life (r=0.302, p=0.006).Significant (p=0.017) association were found
between co-dependency with gender (p=0.0012), education (p=0.017), duration of
marital life (0.00002) and previous history of abstinence (0.0138).
15
Family Interaction Pattern
Gorad (1971) conducted a study to explore communication styles and interaction of

alcoholics and their wives. Derived from an interpersonal-interactional theory of
alcoholism, it was hypothesized that the alcoholic would use a style of
communication characterized by responsibility avoidance, when interacting with his
wife. Another hypothesis was that the wife of an alcoholic would use a more direct,
responsibility‐accepting style of communication than her husband, when interacting
with him. Lastly, the interaction between an alcoholic and his wife would be marked
by (a) an inability to function as a unit for mutual benefit, and (b) rigidity of
complementarily and/or escalation of symmetry. Gorad tested these hypotheses by
placing twenty married couples with alcoholic husbands and twenty normal control
couples in an interactional game play situation. All the hypotheses that were stated
above were confirmed. It was also found that alcoholic couples use the escalation of
symmetry pattern.
Hersen et al. (1973) conducted a study to observe the interactional pattern amongst
couples with 4 male alcoholics and their wives (mean age, 44; education, 10 yrs;
married, 26 yrs; husbands' alcoholism duration, 9 yrs) to converse in couples about
the husband's drinking problem and also about topics unrelated to alcoholism. The
interactions were videotaped. It was observed that the wives tended to look at the
husband more during conversation related to his drinking (57-70 sec per 2-min
interval) than during non –alcohol - related conversation (23-43 sec per 2-min
interval). Husbands showed a slightly reversed trend. Whether the wife's looking was
associated with positive or negative affect, she paid significantly more attention to
the husband during discussion of his alcoholic behavior.
Becker and Miller (1976) indicated a 24 minute videotape to compare the verbal and
non-verbal marital interaction patterns of 6 wives and their alcoholic husbands and 6
16
wives and their non-alcoholic husbands at Virginia Alcohol(VA) alcoholism center.
Two independent raters evaluated the 2 phases of videotaped behavior--discussions
of alcohol-related (A) and non-alcoholic-related (NA) topics. Subjects were observed
on the domains of the subject’s duration of looking, duration of speech, number of
positive statements, number of negative statements, number of interruptions,
touching and requests for new behavior. It was revealed that a significant main effect
of Sex and a significant Sex by Topic interaction: husbands talked more during A than
NA periods; wives talked more during NA periods; husbands talked as much as wives
during A periods; and husbands talked less during NA periods. Alcoholic husbands
and their wives interrupted each other more frequently than did the non-alcoholic
group.
Gantman. (1978) evaluated family interaction patterns and the symptomatology of

the individual family member. Thirty families were recruited in this study and
divided them in the three groups of families. Evaluated in a one-hour therapeutic
interview while three observers behind a one-way mirror rated verbal behavior and
the quality of interaction between father, mother, and adolescent. In addition, the
quality of the family's interaction was assessed at four different times during the
interview. The results showed the normal group was significantly different from the
other two groups in frequency of scapegoating of the adolescent and displayed
clearer communication, more freedom of expression, more cooperation, and
greater sensitivity among members in the comparison to the two disturbed groups.
Steinglass (1981) studied ‘the alcoholic family at home: Patterns of interaction in dry,
wet, and transitional stages of alcoholism. He observed thirty-one alcoholic families
in their homes on nine separate occasions over a six-month period. During each
occasion, systematic recordings of interactional behavior using the Home
Observation Assessment Method was made by the researcher which concentrated on
family's style of regulating its home environment. Three distinct patterns of home
behavior could be identified using univariate and multivariate statistical analyses.
17
Each pattern was associated with one of three "family alcohol phases": a stable wet,
stable dry or transitional phase. These families manifested characteristic family-level
patterns of behavior in their homes at different stages in the course of chronic
alcoholism. The critical issue was the relative rigidity versus flexibility of behavior.
Families in either stable wet and transitional phases proved to have rigid patterns of
behavior; nevertheless those in the stable dry phase had flexible patterns.
Jacob et al. (1981)conducted a cross - sectional study to evaluate communication

styles of 8 alcoholic and 8 non- alcoholic couples, they found that the alcoholic
couples had more negative interaction with their couple (hostility, blame, criticism)
during the drinking period than the non-drinking period.
Dhanasekara and Ranganathan et al. (2017) stated in their study that as much as
Alcohol Dependence Syndrome (ADS) affects the family as a whole unit, alcohol
dependence succumbs the family to go through a process of adaptation to their new
environment and often this results in failure leading to dysfunction in coping and
maintaining cordial relationships and problem solving as well.
Dhanasekara et al. (2017) aimed to describe family interaction patterns of persons

with alcohol dependence in India. For this, ninety participants and their care -givers
were interviewed belonging to 3 different groups. The first two groups of patients
included respondents who had been seeking treatment and had either been
abstinent or relapsed and the third group of respondents comprised of a control
group. Findings showed that the relapse group had a higher level of dysfunction
when compared to the abstinent group of patients in terms of their role,
communication, cohesiveness, leadership and overall family interactions. The results
indicate that families who have a member who is dependent on alcohol have poor
family interaction patterns that are known to cause family dysfunction.
18
Frankenstein et al., (1985) evaluatedthe marital communication and problem solving
of alcoholic and non - alcoholic couples, Couple were engaged in 10 - minutes conflict
-resolution discussions of varying intensity counter – balanced for alcohol and non -
alcohol sessions. Couples expressed significantly more positive verbalization in the
alcohol session than in the non –alcohol sessions. The finding revealed that the non
alcoholic spouses, who doubled their rate of positive verbal behavior when
interacting with an intoxicated partner. Alcoholic spoke more and tended to make
more problem describing statements while intoxicated than while sober. The
alcoholic made a greater number of problems – solving statement than did their
spouses. Marital satisfaction reflected that alcoholic were significantly more
dysfunctional than non -alcoholics.
Jacob and Krahn (1988) observed the marital interactions of 107 couples were
observed as they engaged in discussions of personally relevant problems. Amongst 38
couples, the husband was alcoholic, for 35 couples the husband was depressed, and
for 34 couples neither spouse had a diagnosed psychopathology. Observations were
conducted during sessions when alcohol was consumed by spouses and during non-
drinking sessions. Alcoholic couples tended to be more negative (more critical and
disagreeable) than depressed and non - distressed couples “when drinking” but were
indistinguishable from other couples“when not drinking”. The consumption of
alcohol led to the increased expression of affective behavior, both positive and
negative. Unanticipated three-way interaction effects also differentiated the
alcoholic couples and are considered in terms of sex of the participating child and
pattern of drinking manifested by the husband (episodic versus steady).
Tislenko and Steinglass (1988) explored the relationship between sex of the identified
alcoholic and patterns of interaction in the home. Twenty-three families with a male
alcoholic member were compared to eight families with a female alcoholic member
along a series of factors representing basic dimensions of interactional behavior. A
19
direct observation was made of families in their homes, using the Home Observation
Assessment Method (HOAM). Findings indicate that overall patterns of family home
behavior were remarkably similar when sex of the alcoholic member was the only
variable used to distinguish comparison groups. Thus no direct impact of sex of the
alcoholic family member on family behavior could be demonstrated in this
naturalistic observation study.
Zweben et al. (1988) conducted the Marital Systems Study (MSS) to compare the
effectiveness of a short‐term systems‐based outpatient treatment consisting of eight
sessions of Conjoint Therapy with a single session of Advice Counseling which also
involved the spouse. They recruited 218 alcoholic couples for Conjoint Therapy and
Advice Counseling. From this sample, 102 couples dropped out of treatment process.
Result showed significant improvement on all marital adjustment and
drinking‐related outcome measures, the drinking and family functioning are strongly
and reciprocally linked.
Jacob and Leonard (1988) assessed the impact of alcoholism subtype on marital
interaction and drinking style with differential levels of marital satisfaction and
stability. In this effort, observations of 49 alcoholics and their wives were conducted
during sessions when alcohol was consumed and during non - drinking sessions.
Different patterns of interactions emerged for episodic and steady alcoholics. On the
drink nights, episodic alcoholic couples evidenced less problem solving than did the
steady alcoholic couples. Among the episodic couples, the husbands were more
negative on the drink nights than were the wives, whereas among steady couples,
wives were more negative than were the alcoholic husbands. The interaction
displayed by the episodic alcoholics and their spouses was suggestive of a coercive
control pattern. The steady alcoholic and his spouse displayed a pattern suggestive
of high levels of problem solving.
20
Velleman et al. (1993) described the relatives of problem drug users in four centers of
the south-west of England. They interviewed 50 close relatives of identified problem
drug users, with the identification occurring through clinics and self-help groups; they
suggested seven key aspects of family life that could be adversely affected by prolong
alcoholism, such as: roles, rituals, routines, social life, finances, communication and
conflict. Drinking problems may negatively alter the marital and family functioning by
inadequate fulfillment of needs and expectations of spouse and other family
members by the alcohol dependence person as well as disposing off the
responsibilities to other members.
Barry and Fleming (1990) conducted a study to examine family cohesion,

expressiveness and conflict in alcoholic families. They used the NIMH Diagnostic
Interview Schedule alcohol subscale, based on DSM–III criteria, and a family
environment scale. Results show that alcoholics with a family history of alcoholism
reported significantly less cohesion and expressiveness, and more conflict in their
present families than did either non–alcoholics with a family history of alcoholism or
non–alcoholics with no family history of alcoholism. Non‐alcoholics who grew up in
alcoholic families reported present family relationships similar to non–alcoholics with
no family history of alcoholism. Findings in this study supports the general perception
that individuals who grew up in alcoholic families experience more family dysfunction
in adulthood. The presence of family history and alcohol problems in the subject
produced the perception of family dysfunction and disturbed family relationships.
Sergin and Meness (1996) conducted a study to examine the relationship between
parent’s alcoholic and their young adult children’s social skill. It was hypothesizes that
parental alcoholism would be negatively related to children’s social skills and this
relationship would be moderated by family communication styles and young adults’
coping styles. For this, 143 students completed self –report measures of parental
alcoholism, social skills, family communication and coping styles. Subject also had
sibling complete measures of parental alcoholism and family communication. Results
21
showed that there are no significances in young adult children’s social skills s a
function of parental alcoholism. Family communication and young adults ‘coping
styles did not appear to moderate this relationship and children may exhibit
undistributed psychological functioning despite having an alcoholic parent.
Murphy and O’Farrell (1997) conducted a study to examine the associations between
communication problems and marital violence in couples with a male alcoholic and
also an attempt was made to determine whether the communication correlates of
marital violence found in non-alcoholic community samples also characterize male
alcoholics' relationships. Results showed that the base-rate percentage of aversive-
defensive communication was significantly higher for couples with a physically
aggressive husband than for couples with a non-aggressive husband. Facilitative-
enhancing communication did not differ significantly between groups. In sequential
analyses, physically aggressive husbands, but not their wives, displayed more
negative reciprocity than their non - aggressive counterparts. Alcoholic husbands in
general displayed lower rates of facilitative-enhancing communication than did their
wives. The maritially aggressive alcoholics were high in negative responses contingent
upon their wives' prior negative behavior and were unlikely to terminate aversive
interchanges.
Fals-Stewart et al. (1999) made an attempt to study the dyadic adjustment and
substance use of couples. They examined a drug-abusing husband (n = 94), couples
with a drug-abusing wife (n = 36), couples in which both partners abused drugs (n =
87), and non-substance-abusing conflicted couples (n = 70). Results showed that a
higher percentage of days abstinent during the year before treatment for drug
abuse were associated with a higher level of relationship satisfaction. When both
partners abused drugs, the relationship between percentage of days abstinent and
relationship satisfaction became stronger and more negative as the time partners
spent together using drugs increased. A higher percentage of days abstinent were
22
associated with relationship stability for couples with 1 drug-abusing partner during
and 1 year after treatment; for couples in which both partners abused drugs, a higher
percentage of days abstinent was associated with relationship instability.
Bell (2000) conducted a study that investigated emotional cutoff in women who
abuse substances and who entered a treatment program for the same. Based upon
the Bowen Family Systems theory, three questions were explored here. First, the
degree of emotional cutoff in this sample was compared to a non-clinical sample of
women. Secondly, the relationship was explored between the variable of emotional
cutoff and the following variables: substance abuse variables, individual psychological
functioning variables, and marital and family relationship variables. Finally, the
relationship was explored between dropout from substance abuse treatment and
emotional cutoff. Results showed that the degree of emotional cutoff was
significantly higher in the clinical sample of women who abused substances than in
the other two comparison samples that included a sample of women balancing
multiple roles or responsibilities and one that is a mixed sample of divorced men and
women. Emotional cutoff was also found to have a significant positive relationship
with the following variables: behaviors characteristic of substance abusers, behaviors
of a highly defensive person, symptoms of depression, anxiety, hostility,
psychoticism, somatization, obsessive compulsive disorder, interpersonal sensitivity,
and a global psychological dysfunction. A significant negative relationship was found
between emotional cutoff and denial of substance abuse. There was however no
significant relationship between emotional cutoff and marital satisfaction, health or
distress in family functioning, dropout from treatment, severity of substance abuse
and symptoms of paranoia or phobia.
Stuart et al. (2003) investigated extensive theoretical and empirical evidence linking
substance abuse and marital violence in batterer populations, and compared
hazardous and non-hazardous drinkers' substance use characteristics, marital
23
aggression, extra-marital violence (i.e., general violence), depressive
symptomatology, marital satisfaction and other relevant variables. The researchers
recruited 150 men who were arrested for violence and were court referred to
batterer intervention programs. Multiple measures of substance use and abuse were
administered on them and assessments were also made on the batterers' marital
aggression, relationship satisfaction, depressive symptomatology, use of general
violence, and their relationship partners' substance use. The sample was divided into
groups of Hazardous Drinkers (HD) and Non-hazardous Drinkers (NHD). It was
gathered from this investigation that across the entire sample, half of the batterers
had an alcohol-related diagnosis and approximately one third reported symptoms
consistent with a drug-related diagnosis. Over one third of the total sample reported
that their relationship partners were hazardous drinkers. Relative to the Non
Hazardous Drinkers group, the Hazardous Drinkers group scored significantly higher
on measures of general violence, depressive symptomatology, alcohol use, alcohol
problems and drug related problems. The Hazardous Drinkers group also reported
significantly higher partner alcohol and drug use and abuse scores, relative to the
Non -Hazardous Drinkers group.
Kline and Stafford (2004) compared the contributing role of two aspects of social
interaction to the quality of marital relationships, the frequency of casual interaction
between marital partners versus the quality of social interaction as exhibited by
partners’ reliance on universal rules of social interaction. It was indicated that
although each of these features are associated with trust, liking, satisfaction, and
commitment, reliance on basic interaction rules plays the more important role,
showing 51% of the variance is in the composite marital quality index.
Lipsky et al. (2005) carried out a study to explore the psychosocial and substance use
risk factors for intimate partner violence (IPV). They described the relationship
between family violence and subsequent intimate partner violence (IPV) and even
24
accounted for partner alcohol use in IPV victimization. In light of this, a case-control
study was carried out in which cases that is women identified as having IPV concerns
and an IPV history and controls who were women without IPV were frequency-
matched by age group and race/ethnicity. The sample included 182 cases and 147
controls. Logistic regression was performed to calculate adjusted odds ratios (AOR)
for any IPV, physical IPV, and sexual IPV. Findings show that living with a partner (not
married) and witnessing parental violence were independent risk factors for any IPV.
Partner's alcohol use and heavier drinking were also significant risk factors. It was
also observed that the pattern of risk factors varied only slightly for physical IPV and
sexual IPV, there was a substantial relationship between partner alcohol use and IPV
among women beyond the woman's substance-use.
Floyd et al. (2006) examined problem-solving marital interactions of alcoholic and

non-alcoholic couples (N = 132). Four alcoholic groups that included alcoholic
husband with an antisocial personality disorder or not, paired with alcoholic or non-
alcoholic wives. Comparison was made with each other and with a group where both
spouses were non-alcoholics. Researchers found that couples with an antisocial
alcoholic husband had higher levels of hostile behavior regardless of wives’
alcoholism status. Rates of positive behaviors and the ratio of positive to negative
behaviors were greatest among couples in which either both or neither of the
spouses had alcoholic diagnoses and was lowest among alcoholic husbands with non-
alcoholic wives.
Rangarajan and Kelly (2006) attempted to explore family communication patterns,

family environment and the impact of parental alcoholism on offspring self-
esteem. This required participant a total of 227,to complete self-reports of parental
alcoholism, family environment, and family communication patterns (FCP) and self-
esteem. Results indicated a negative relationship between the seriousness of both
maternal and paternal alcoholism and self-esteem. Paternal and maternal alcoholism
were related to the two dimensions of family environment that is family stressors
25
and parental disregard, although the effect for paternal alcoholism was larger. The
relationship between maternal alcoholism and offspring self-esteem was partially
mediated by parental disregard, whereas the relationship between paternal
alcoholism and self-esteem was mediated by parental disregard and perceptions of a
conversation-orientation family communication patterns.
Gruber and Taylor (2006) conducted a research and provided treatment to increase
the recognition of the role that family, family functioning and family interaction
pattern has for understanding the incidence and impact of substance abuse.
Substance abuse is identified as a family problem and its occurrence was explored
within families as well as its impact on marital relationship, family violence, child
abuse and neglect and its effects on children at various developmental stages. The
impact of substance abuse on the roles of spouses and parents were examined. It
was observed that the family has an important role as a participant in active
substance abuse as well as a valuable treatment resource. This suggested that focus
should increase on the family as part of research in substance abuse.
Saatcioglu et al. (2006) found that substance abuse is a family disease, which requires
joint treatment of family members. Family is an important part of the diagnosis and
treatment chain of alcohol and substance abuse. Abuse of alcohol and substance is a
response to fluctuations in the family system. In consideration of interactions within
the family system, it seems an important requirement that the clinician involves
andmaintains the presence of, the family in its entirety in the treatment process. A
family often needs as much treatment as the family member who is the abuser of
alcohol or a substance. Participation of the family in the treatment process as group
members and by assuming a supportive role are assets in terms of preventing relapse
and extending clean time and also very important for solving conflicts,
communication and role transition that give rise to abuse of alcohol or substances.
26
Shyangwa et al. (2008) conducted a cross-sectional study in De-Addiction centre
under department of psychiatry, AIIMS, New Delhi, India. They administered
Addiction Severity Index scale with patients, Family Burden Interview Schedule (FBIS)
with their wives. Hence it was found that opioid dependent subjects cause
considerable amount of distress to their care providers, family burden was perceived
as "severe" by subjects' spouses.
Lamichhane et al. (2008) explored family burden in substance dependence syndrome.
About 60 subjects and their primary care takers (PCTs) were included for the study,
30 of them with alcohol dependence and 30 with injecting drug use and ICD-10
criteria was used for the diagnosis. Family burden interview schedule was used to
assess the family burden. Results on this study showed that the overall burden was
higher on the group with injecting drug use (IDU) than the group with alcohol
dependence (ADS), 66.7% and 46.7% respectively. The spouses were found to be
generally more tolerant than the other caregivers as primary care takers in terms of
total burden perceived.
Schäfer (2008) conducted a Multiple Family Group (MFG) treatment in an 18-week

residential therapeutic program for people with a severe substance disorder. He
undertook individual in-depth interviews with nine residents and three ex-residents
of European descent and then these interviews were analyzed using a descriptive
thematic analysis. It was indicated that, prior to taking part in the program, patient’s
relationships with their families were seriously damaged and their situations often
appeared complex and hopeless. After attending the MFGs all of the participants of
this study experienced a number of positive changes in their relationships with their
family members and partners. They had gained more awareness about their
interactions, better communications skills and were able to integrate these skills into
their relationships with their families and partners.
27
Karowet al. (2008) carried out an investigation to find out the association between
the current status and longitudinal changes in different clinical and social variables
with quality of life (QOL) in opiate addiction. It was hypothesized that drug use, co-
morbid personality disorders and social problems are associated with worse quality
of life (QOL). About 107 participants with long-term opiate addiction were included
and were interviewed using Europ-ASI and PDQ-R. QOL (SF-36) and changes in
different domains of the Europ-ASI were assessed after 2 years. It was found that
personality disorders, interpersonal conflicts with the family or partner and ongoing
need for somatic and psychiatric treatment were significantly associated with worse
subjective quality of life (QOL), whereas changes in drug and alcohol use, the
economic situation, legal problems and social problems with persons outside of the
family showed no relevant association with quality of life (QOL). Such findings suggest
that emphasis should be made on helping clients to reduce intra and interpersonal
conflicts according to co-morbid conditions and among family members and
partnerships. In addition, much support is needed for extended interventions in long-
term opiate addiction.
Singh et al. (2009) assessed the interaction patterns with alcohol dependent person
in the families, they administered family interaction pattern scale and general health
questionnaire -12in 30 spouses of alcohol dependent persons, results showed that
poorer pattern of interaction was found in the domain of reinforcement, social
support, role, communication, leadership and the family interaction scale total score
in spouses of patients with alcohol dependence compared to non- alcohol
dependence.
Jones et al. (2011) developed a treatment to reduce a male partner's drug use in
order to improve pregnant patient's treatment outcomes. Motivational Enhancement
Therapy was used to encourage treatment participation. This was a novel
intervention package for engaging male partners in drug treatment called HOPE
(Helping Other Partners Excel). This involved six sessions which was followed by a
28
drug-abstinent contingency-based voucher incentive program to help maintain drug
abstinence, male partners had rapid facilitation into either opioid detoxification with
aftercare or methadone maintenance. Interwoven into treatment were both couple's
counseling and a men's group educational program designed to strengthen the
support provided by the men to their partners during pregnancy and post-delivery.
Results showed that as compared to the men in the control condition who received
only weekly support and referrals for treatment, men in the HOPE group showed
increased treatment retention, transient decreases in heroin use, increased
involvement in recreational activities, less reliance on public assistance and increased
social support for their pregnant partners.
Schäfer (2011) conducted in - depth interviews with 12 participants who were

residents and ex-residents in the Higher Ground Alcohol and Drug Rehabilitation
Trust, Auckland, New Zealand. These interviews were further analyzed using a
qualitative framework. Results showed that the majority of participants had
experienced painful and traumatic childhoods in their families of origin, which
contributed to their subsequent addictive behavior and which they felt had affected
their current familial relationships. All participants and their families had suffered
from various forms of family disruption, such as loss of custody of their children, loss
of employment, marital breakdown, physical and psychological abuse, depression
and ill health. Some participants had also committed drug-related crimes and
experienced accidents as a result of their addictions, which also affected their
relationships with their families.
Malik et al. (2012) assessed the impact of substance dependence on primarycare-

takers in rural area of Punjab, a Family Burden Interview Schedule was administered
on them and findings showed that a majority of primary care - takers were found to
have a moderate burden especially in financial areas, disruption of routine activities,
family leisure and family interaction. Higher proportion of burden was seen amongst
29
primary care - takers of illiterate patients of reproductive age group, of lower socio -
economic status, having multiple and longer duration of substance dependence and
those who had several relapse.
Chavan et al. (2011) conducted cross-sectional study in both urban and rural parts of
the city of Chandigarh. To evaluate the coping strategies employed by caregivers of
patients with substance dependence, they used Tri-Dimensional Coping
Questionnaire for Substance Dependence (TCQSD) with their care - givers, findings
revealed that the family members try to cope by making attempts to work along with,
rather than against, the individual. The families and community are supportive and
accepting rather than rejecting, antagonistic and critical.
Stanley (2012) conducted a study to examine the differences in the interpersonal

dynamics of couples living in alcohol-complicated and alcohol-free marital
relationships in India. An ex-post facto cross-sectional design was used to compare
150 wives of alcoholics with an equal number of wives of non - alcoholics, who were
administered, standardized instruments to assess marital adjustment and family
interaction pattern. Analyses showed that wives of alcoholics have lower levels of
marital adjustment and a poorer family interaction pattern across various domains.
Co-variates that were analyzed here included four variables such as type of family,
type of marriage, consanguinity, and wife's occupational status. It was also implicated
in this study that de - addiction programs are required in India and that there is an
urgent need for couple/family based therapy.
Nebhinani et al.(2013)conducted a cross-sectional study with Injecting Drug User

(IDU) and Non - injecting Drug User (NIDU), there were 40 participants in each group
along with their family care - givers that were attending a de-addiction centre at a
multi - specialty teaching hospital in North India, with ICD-10 diagnosed opioid
dependent criteria. Family Burden interview schedule was used to assess the pattern
of burden borne by the family care - givers. The result showed that The IDU group
30
was characterized by older age, longer duration of substance dependence, greater
subjective and objective family burden in all the areas compared to NIDU group, and
single status and unemployment were associated with severe objective burden.
Kishor et al. (2013) assessed the pattern of psychiatric morbidity, marital satisfaction
in spouses of men with alcohol dependence syndrome. They used marital satisfaction
scale with 60 spouses of men with alcohol dependence syndrome. They found that
more than half of the spouses (65%) had a psychiatric disorder. primarily mood and
anxiety disorder were present. major depressive disorder was present in 43%.
psychiatric morbidity, marital dissatisfaction in spouses and higher adverse
consequences of alcohol dependence in their husbands were significantly correlated
with each other and their association was robust particularly when problems in the
physical, interpersonal and intrapersonal domains were high.
Dsouza et al. (2015) studied the cognitive dysfunctions in the spouses of patients with
alcohol dependence syndrome (ADS). They used Standardized Mini Mental State
Examination (SMMSE), Trail Making Test B (TMT-B), Digit Symbol Substitution Test
(DSST) 30 spouses of patients. It was found that 26.6% of the spouses were
cognitively impaired.
Senthil (2016) carried out a study to compare the family interaction and
codependency in spouses of alcohol dependence and spouses of normal control.
Using a sample of 30 spouses in each group that included the patients himself in each
group, Alcohol Dependence Questionnaire was administered on the patients and
General Health Questionnaire was administered on spouses for screening purpose.
Family Interaction Pattern scale and Co-dependency Scale were administered on the
spouses of both groups. Findings showed that spouses of individuals with alcohol
dependence syndrome had significantly higher scores in Family Interaction Pattern
Scale; especially in the domains of reinforcement and role as compared to spouses of
normal individuals. The level of co-dependency was significantly higher in the spouses
31
of individuals with alcohol dependence syndrome as compared to spouses of normal
individuals.
Singha and Raychaudhuri (2016) made an attempt to assess the relationship between
family interaction pattern, family burden and quality of life among caregivers of
individuals with alcohol dependence. A sample of 60 care - givers of alcohol
dependence, those who were willing and those who satisfied the inclusion and
exclusion criteria were included in the study. Family Interaction Pattern Scale, Family
Burden Interview Schedule and WHO Quality of Life Scale were applied on the care -
givers of individuals with alcohol dependence. Overall findings indicated that a
significant positive correlation exist between family interaction patterns, family
burden and quality of life among care - givers of individuals with alcohol dependence.
Lingeswaran (2016) in an effort to examine the general health of the wife, children
and adolescents of a family with paternal alcohol use and to assess the personal,
family, social, occupational and educational environment of families with paternal
alcohol use. International Classification of Diseases (ICD-10) diagnosis was used to
diagnose alcohol dependence in the father. Socio - demographic proforma, General
Health Questionnaire (GHQ), World Health Organization Quality of Life-Bref
(WHOQOL-BREF) version were used to collect clinical data of the children and
spouses. Results on SPSS indicated that mean GHQ scores were highest in spouses
(32.92) as compared to children between 12 – 15 years (20.34) and children between
16–20 years (25.01) age group. QOL scores were low among spouses and children
across all age groups. Physical, psychological health, well-being and QOL are
significantly impacted in families where the father is alcohol dependent. Spouses
were found to be more severely affected than children.
Vaishnavi et al. (2017) conducted a cross-sectional descriptive study with 200

patients with alcohol dependence and their care - givers to assess the pattern of
burden on the care - givers of alcohol dependent patients and relationship between
32
the severity of dependence and the burden on care - givers. The results
demonstrated that care - givers of alcohol dependent patients reported significant
objective burden and subjective burden and the severity of alcohol dependence and
the domains of burden such as financial burden, disruption of family interaction, and
disruption of family routine activities were positively correlated with high level of
significance.
Senthil et al. (2014) examined the difference in the perception of family interaction
pattern, family environment and co - dependency between the spouses of alcohol
dependent persons and spouses of normal individuals. This consisted of 60 samples,
among which 30 participants were spouses of individuals with alcohol dependence
and 30 participants were spouses of normal individuals. Results of statistical analysis
performed showed that the spouses of patients with substance dependence have
significant poor score on family interaction pattern and family environment than
spouses of normal controls. This shows that the spouses of patients with substance
dependence have poor perception of family interaction pattern and that of family
environment as well than spouses of normal controls.
Pourmovahed et al. (2013) conducted a descriptive cross-sectional study, they used a

special questionnaire and it included 261 spouses of addicts who were selected
randomly and whose husbands were referred to the detoxification centers of Yazd
city. Results of this study show that, from the viewpoints of the wives of the addicts,
easy access to drugs was the most important factor responsible for addiction (Mean
score of 4.42 +/-0.83 from a total score of 5). The other important factors were that
of having addicted friends and inability of the person to refuse when invited to use
drugs by acquaintances (Mean scores of 4.41 +/- 0.84 and 4.35+/- 0.92, respectively).
In this perspective, to effectively control addiction in young population, increase in
self-esteem is primarily important.
33
Mattoo et al. (2013) conducted a cross-sectional study with ICD-10 diagnosed
substance dependence subjects and their family. Family burden interview schedule
was used to assess the pattern of burden of the family care - givers of 120 men with
alcohol and opioid dependence. They found that opioid and alcohol+opioid
dependence groups, more often the alcohol dependence group was older, married,
currently working, having a higher income and with the wife as a care - giver. Family
burden was moderate or severe in 95-100 per cent cases in all three groups and more
for disruption of family routine, financial burden, disruption of family interactions,
disruption of family leisure and family burden was associated with low income and
rural location. Almost all (95-100%) care - givers reported a moderate or severe
burden, which indicates the gravity of the situation and the need for further work in
this area.
Bhattacharjee et al. (2013)assessed the perceived family environment in spouses of

alcohol-dependent patients, they took a sample of 30 spouses of patients diagnosed
with alcohol dependence syndrome (ICD-10 DCR) and 30 spouses of normal controls
(GHQ-12 score <3). The hindi version of the Family Environment Scale was
administered to all the participants. Results showed that spouses of alcohol-
dependent patients scored significantly lower on cohesion (p < 0.0001, Cohen’s d =
1.47), expressiveness (p < 0.0001, Cohen’s d = 1.49), independence (p = 0.0002,
Cohen’s d = 1.04), achievement orientation (p < 0.0001, Cohen’s d = 1.67), intellectual
cultural orientation (p = 0.0002, Cohen’s d = 1.06), active recreational orientation (p <
0.0001, Cohen’s d = 1.15), moral religious emphasis (p < 0.0001,Cohen’s d = 1.33) and
organization (p = 0.0009, Cohen’s d = 0.92) than the control group. However, there
was no difference in control and conflict domains between the two groups.
Lander et al. (2013) postulated in their article that the effects of substance use
disorder (SUD) are felt by the whole family. The family context holds information
about how such a disorder develop, how it is maintained, and what can positively or
negatively influence the treatment of the disorder. Family systems theory and
34
attachment do provide a framework for understanding how substance use disorders
affect the family. In addition, understanding the current developmental stage of a
family helps to gather information about impairment and determination of
appropriate interventions. Substance use disorders also negatively affects emotional
and behavioral patterns from the inception of the family; this is seen in poor
outcomes for the children and adults with substance use disorders.
Bratek et al. (2013) analyzed the impact of family structure and relations between its
members in the development of alcohol addiction in children growing up in these
families. Researchers used anonymous questionnaire which included questions
referring to family structure, parents’ divorce, prevalence of alcoholism in the family,
parents’ attitude towards alcohol and parent-child relationships. The study group
consisted of 125 people, 83 men and 42 women, aged from 22 to 68 participating in
treatment programs for alcohol addiction. The control group consisted of 231 people,
136 men and 95 women, age from 17 to 65, with no history of alcoholism. Findings
showed that the study group participants stated less frequently that they had been
raised by both parents (78% vs 87%, p<0.05). The participants also claimed to be
more often punished for their failures, abused physically/verbally and could less
often depend on their parents. It was concluded that patients addicted to alcohol
were more often raised by a single parent, they were more likely to have alcohol-
dependent parents and relationships with their parents were more often impaired.
Ruchi et al. (2014) evaluated the psychiatric morbidity of 100 spouses of men with
opioid dependence syndrome. Severity of opioid dependence in the husbands was
assessed using Severity of Opioid Dependence Questionnaire (SODQ). Quality of life
and marital satisfaction was assessed using Short Form Health Survey 36 (SF 36) and
Marital Satisfaction Scale (MSS) respectively. Data analysis reveals that 33% of
spouses had a psychiatric disorder. Primarily mood and anxiety disorder was present
in 22% and 9% of subjects respectively. Highly significant difference existed between
35
cases and controls in terms of marital satisfaction (p = 0.0001) and quality of life
(p≤0.05) indicating low marital satisfaction and poor quality of life in spouses of
opioid dependent individuals. Psychological distress and psychiatric morbidity in
spouses of opioid dependent men is high, with poor quality of marital life and marital
satisfaction being low.
Gupta et al. (2014) carried out a study to ascertain the psychiatric morbidity in wives
of substance dependent men and also to assess their social support and coping as its
correlates. They recruited two groups of substance dependent men (alcohol and
opioid) and their wives with 50 members in each group. The subjects were assessed
for dependence severity, psychiatric morbidity (GHQ 12 and MINI were used), coping,
and social support. Findings showed that patients and spouses in the opioid
dependent group were of younger age and had a lesser duration of marriage than
those of alcohol dependent group. In both groups, more than 70 percent of the
spouses had scores above the cutoff level in the GHQ 12. The psychiatric diagnosis
was present in 16 percent and 20 percent of the wives in alcohol and opioid
dependence groups, respectively, depression and dysthymia being the commonly
encountered diagnoses. The most common coping mechanisms utilized were those of
denial and internalization. On multivariate logistic regression, GHQ-12 scores were
found to be the predictors of MINI diagnosis. It is implicated that psychological
morbidity is common in wives of patients with substance use disorders therefore
attention to their mental health issues can relieve the distress in this vulnerable
population.
Santos et al. (2015) carried out a study to verify the marital interactions in marital
pair and mental health, and also to investigate the evidence for the validity of the
Checklist for Interpersonal Transactions (CLOTT-II). A sample of participants of 169
couples were taken from the southeast of Brazil and they were required to respond
to a General Health Questionnaire (GHQ) and CLOIT-II. It was observed that on the
36
GHQ, participants with low mental health problem tended to occupy interpersonal
positions in the range between Deference/Trust and Affective warmth/Friendliness.
While in the group with high scores on mental health (symptomatic participants),
interactions were defined by Coldness/Hostility. Mental health problems were
positively correlated with mistrust, coldness and the validity of the CLOIT-II indicated
that the study of interpersonal relationships is relevant for the understanding of
mental health.
Fatima et al. (2015) compared the marital adjustment and life satisfaction among
spouses of patients with alcohol dependence and normal healthy control at Ranchi
Institute of Neuro-Psychiatry and Allied Sciences, Ranchi.They recruited thirty
patients with alcohol dependence syndrome with their spouses and their ages were
30 age and socio-economic status matched healthy control with their spouses. Life
Satisfaction Scale and Marital Adjustment Questioner were administered
respectively. Results showed that a significant difference in respect to life satisfaction
among the spouses of individual with alcohol dependence syndrome and normal
healthy control. Life satisfaction as well as marital adjustment was better in spouses
of normal healthy control as compared to spouses of patients of alcohol dependence.
Maheswari and Kanagajothi (2015) assessed the marital adjustment among the
alcoholics, who are treated at SOCSEAD de - addiction center, Tiruchirappalli, during
April to June 2014. Marital adjustment scale was administered with 90 spouses of
alcoholics. It revealed that a little more than half (51.1 percentage) of the
respondents had low level of marital adjustment. Remaining 48.9 percent of the
respondents had high level of marital adjustment. The marital adjustment among the
respondents who are frequently consuming alcohol is very poor.
Dowman (2017) carried out a research to explore the impact that having a relative
who uses drugs or alcohol had on family members’ lives as well as affected family
37
members’ experiences of seeking help for themselves. He carried out semi -
structured interviews with eleven adults affected by a family member’s drug and/or
alcohol use and were receiving support from a family, partners and friends service in
London. Using thematic analysis that involved six phases of analysis, five main themes
were produced across the data. Each indicated important factors in the journey of
having a relative who uses drugs or alcohol. The themes were: family members’
distress, ruptures in relationships, responsibility, routes to receiving help and
relieving the pressure.
Babalola et al. (2017) carried out a research to determine the psycho-social correlates
of hazardous alcohol use among secondary school teachers in Southwestern Nigeria.
For this a multi - stage sampling technique was used to select 288 secondary school
teachers in Ogun State of Nigeria. The 10 item Alcohol Use Disorders Identification
Test (AUDIT) was utilized in assessing alcohol use, while psychological wellbeing was
measured using General Health Questionnaire 12 (GHQ-12). Findings show that
30.9% of respondents met the criteria for hazardous alcohol use. Alcohol related
injuries were reported by 10.4% while heavy episodic drinking occurred in 26.7% of
the teachers. Male teachers were 6 times more likely to engage in hazardous alcohol
consumption and 16.7% of teachers had psychological distress (GHQ 12 score of ≥3).
It was also found that alcohol related injury was significantly associated with
psychological distress (χ 2 =86.80, p=0.001) and respondents with a history of alcohol
related injury were 30 times more likely to have psychological distress (OR=30.62,
CI=11.95-78.49).
Deepaet al. (2017) evaluated the Marital Quality and Social Functioning in spouses of
individuals with and without alcohol dependence of sixty participants, who fulfilled
the criteria of ICD-10-DCR, the 30 participants were the spouses of alcohol dependent
(AD) and 30 participants were from normal population. However the research found
that Spouses of alcohol addicted individuals perceived significantly lesser marital
quality and social functioning than the spouses of non-alcoholic individuals. There is
38
positive relation between marital quality of life and social functioning of spouses of
alcohol dependent individuals. Alcohol addiction causes marital disharmony and
instances of family violence leading to an unhealthy ambience in the family
environment.
Mammen et al. (2015) conducted a study to assess the pattern of psychiatric
morbidities in spouses of male patients with alcohol dependence syndrome. An
attempt was also made to determine the most common type of psychiatric disorder
among these women, to identify the factors influencing psychiatric morbidity and to
explore the association between psychiatric morbidity in them and severity of alcohol
dependence in the male patients. Spouses of 100 male patients were recruited to this
study which was observational and cross - sectional in nature. MINI PLUS and SADQ
were used to measure psychiatric morbidities. Results showed that 36 % of the
spouses had psychiatric morbidity, out of which mood disorders comprised 50 % and
anxiety and stress related disorders comprised about 36% of the total morbidity.
There was significant association between psychiatric morbidity in the wives and
severity of alcohol dependence. It was evident that a major proportion of wives are
having psychological morbidities which have clear links to the severity of alcohol use
pattern in their husbands.
Aminolroayae (2015) conducted a comparative study comparing violence against
women with and without an addicted spouse. The study was conducted on 200
married women in Kashan, Iran with 100 cases in each group. The data was collected
using Haj-Yahia Violence Questionnaire. Results on Chi-Square, Mann-Whitney U, and
Kruskal-Wallis Tests, Odds Ratio (OR) and Kendall's Correlation Coefficient show that
the overall mean score of violence was 69.29 ± 14.84 for the women with addicted
husbands and 40.02 ± 9.26 in women with non-addicted spouses (p < 0.001). The
mean score of psychological violence was 39.03 ± 7.60 in women with addicted
spouses and 21.86 ± 6.11 in those with non-addicted husbands (p < 0.001).
Furthermore, the mean score of physical violence was 20.98 ± 6.50 in women with
addicted spouses and 12.2 ± 2.55 in those with non-addicted husbands (p < 0.001).
39
Moreover, the mean scores of sexual violence were 4.52 ± 2.21 and 3.28 ± 0.75 in
women with and without addicted spouses, respectively (p < 0.001). Such findings
suggest that the overall rate of violence was significantly higher among women with
addicted spouse and especially if the spouses abused more than one type of
substances.
Kumar (2016) examined the nature of family interaction patterns in alcoholic families
in India, and whether these interaction patterns were significantly different from
those of non-alcoholic families. About 40 alcoholic families (AFs) and 10 non-alcoholic
families (NAFs), comparable in age and duration of marriage, were assessed using the
Indian modification of the Family Interaction Scales. Results revealed significant
differences between alcoholic families (AFs) and non – alcoholic families
(NAFs).Alcoholic families (AFs) were characterized by poor communication patterns,
lack of mutual warmth and support, spouse abuse and poor role functioning. Spouses
of alcoholics expressed greater dissatisfaction in all the areas of family functioning,
than alcoholics themselves. Non – alcoholic families (NAFs) were characterized by
free and open communication, mutual warmth and satisfaction and sharing
responsibilities.
Dandu et al. (2017) conducted a cross-sectional study at the Department of Psychiatry,
Sri Venkateswara Ramnaraian Ruia Government General Hospital (SVRRGGH), Tirupati,
Andhra Pradesh, researchers attempted to determine the frequency and nature of
psychiatric morbidity in spouses of patients with Alcohol-Related Disorders (ARDs). The
age of the alcohol-dependent men and spouses of men with ADS ranged from 23 to 67
years and 21 to 60 years respectively. Among the study population, 36.6% of alcohol-
dependent men were in the age group of 31–40 years and 43.6% of wives were in
between 31 and 40 years. Findings in this study showed that there is an association
between the duration of alcohol abuse by husband, marital life satisfaction, poor family
support, and low socio- economic status with psychological morbidities in spouses of
men of alcohol related disorder. But community studies with adequate sample size are
required to estimate the effect of these key determinants.
40
Sarkar et al. (2016) studied on the co - dependence often develops in the familial
relationship, which perpetuates the disorder. Substance use places quite a burden on
the family, both psychologically as well as in terms of resources. As stated before,
treatment to family members is equivalently important as they can provide
motivation, emotional support, and practical help during the treatment of substance
use disorders and hence need to be engaged in the therapeutic process. With the
changing family structure and family dynamics in Indian culture, these might
umbrella and change the effects substance use disorder has on the family.
Bortolon et al. (2016) conducted a cross-sectional study to identify the symptoms of

co - dependency and health issues in the co - dependent family members of drug
users; they recruited 505 family members in toll-free telephone counseling service.
Drug users’ mothers and wives who had less than 8 years of education and those who
were unemployed had a greater chance of high co - dependency. High level of co -
dependency imposed a significant burden on the physical and emotional well-being
of those affected, resulting in poor health, reactivity, self-neglect and additional
responsibilities. They concluded that co - dependency has a negative impact on the
family system and on the health of the family members of drug users.
Mallick et al. (2016) conducted a study to assess the burden and coping of the family
members and caregivers of men with alcohol and opioid dependence as well as
Schizophrenia, there were 30 samples of each group involved in it, information were
collected from key relatives regarding the burden and coping styles. To compare the
socio-demographic parameters, both in families of men with alcohol and opioid
dependence, as well as in families of men with schizophrenia, the burden on care -
givers and coping strategies. Results revealed that Age difference is significant
(p=0.02) and majority of care - givers are women (n=75; 83.3%). Most care - givers
were married (n=88; 97.8%). There was association of negative symptoms scale score
with 'distancing' coping strategy. Researchers concluded that the social support of
41
substance dependence groups is more than that of schizophrenia. Marital status of
the patient again demonstrated significant associations with care - giver coping.
Kıvanç. (2017) identified the relationship between marital adjustment and gender
roles in wives of the patients with alcohol dependence disorder. A sample was taken
which included 33 wives of patients who fulfilled the DSM – IV TR criteria for Alcohol
dependence disorder. For this, Marital Adjustment Scale (MAS), Maslach Burnout
Inventory (MBI), Bem Sex Role Inventory-Short Form (BSRI), and Beck Depression
Inventory (BDI) were applied to these wives and the results of correlation analysis, t
test and logistic regression analysis showed a negative correlation with “emotional
exhaustion”, “depersonalization” and BDI scores. There was a negative correlation
between depression scores and “personal accomplishment” while depression scores
were positively correlated with “emotional exhaustion” and “depersonalization”
scores. While emotional exhaustion and marriages longer than ten years was
negatively correlated with marital adjustment, masculinity was associated positively
with marital adjustment.
Saroopachary et al. (2019) conducted cross-sectional hospital-based study,to

compare the amount of burden among the caregivers with the severity of alcohol
dependence in patients. The study sample was collected from patients admitted for
alcohol dependence syndrome and their care – givers from November 1, 2016 to
April 30, 2017. They administered Severity of Alcohol Dependence Questionnaire and
Family Burden Interview Schedule. The resulted showed severe ‘burden is more seen
in females, unemployed, in families where domestic violence is present.
42
AIM, OBJECTIVES & HYPOTHESES
Aim of the study
Aim of the present study was to examine the co-dependency and family interaction
pattern of spouses of persons with alcohol and opioid dependence syndrome.
Objectives
The objectives of the study were as follows:
 To assess and compare co–dependency and family interaction pattern in spouses of

patients with alcohol dependence syndrome and opioid dependence syndrome.
 To find out the relationship between the co–dependency and family interaction
pattern of spouses of patients with alcohol dependence syndrome and opioid
dependence syndrome.
Hypotheses
The hypotheses of the study were as follows:
 There would be no significant difference in co-dependence and family interaction

pattern between the patients with alcohol dependence syndrome and opioid
 There would be no significant relation among co-dependency and family interaction

pattern of spouse of patients with alcohol dependence syndrome and opioid
43
METHODOLOGY
Venue:
S.S. Raju Centre for Addiction Psychiatry, Central Institute of Psychiatry,
Ranchi.
Study Design:
The present study was a hospital based cross - sectional study.
Sampling Technique:
Criteria based purposive sampling technique was used.
Sample Size:
The total sample size consisted of sixty (60) married male patients of alcohol
dependence and opioid dependence. Further divided into thirty (30) patients with alcohol
dependence syndrome and thirty (30) patients with opioid dependence syndrome as per
ICD-10-DCR and their spouses for the present study.
Inclusion Criteria for Patients
 Diagnosed Patients with alcohol dependence syndrome as per ICD-10 DCR
(WHO, 1993).
 Diagnosed Patients with opioid dependence syndrome as per ICD-10 DCR
(WHO, 1993).
 Age range of the patients between 25 - 50 years.
 Only married male patients presently living with their wives selected.
 Must be living with the wives in the same house.
 Those who gave written informed consent for the study.
44
Inclusion Criteria for Spouse:
 Must be living with the patients in the same household.
 Age range of the spouse must be between 20 - 50 years.
 Those who gave written informed consent for the study.
Exclusion Criteria for the Patients:
 Age range less than 25 year and above 50 years.
 Having co-morbid psychiatric illness.
 Having significant co-morbid physical illness and/or disability and/or intellectual

sub-normality.
 Not willing to participate in the study.
Exclusion Criteria for the Spouses:
 Those who are not living with the patients in the same household.
 Having psychiatric and physical illness, intellectual sub-normality or disability.
 Not willing to participate in the study.
TOOLS TO BE USED IN THE COLLECTION OF DATA
1. Socio - Demographic and Clinical Data Sheet:-
Semi - structured Performa, which include various socio-demographic variables like

age in years, education, qualification, occupation, marital status religion,ethnicity,
family set up, domicile and relationship with the patient, type and onset of taking of
alcohol and opioid, maximum and average amount spent on alcohol and opioid,
maximum and average amount consumed in a day etc.
45
2. Addiction Severity Index (ASI) (McClellan et al., 1980):
The Addiction Severity Index (ASI) is a clinical/research instrument which has
been in wide use to assess the treatment problems found in alcohol- and
drug-abusing patients. The ASI is a semi-structured interview designed to
address seven potential problem areas in substance-abusing patients: medical
status, employment and support, drug use, alcohol use, legal status,
family/social status, and psychiatric status. The ASI can be used effectively to
explore problems within any adult group of individuals who report substance
abuse as their major problem. In the present study ASI will be applied to
assess the severity of addictive behavior of the selected patients.
3. Family Interaction Patterns Scale (FIPS) (Bhatti et al., 1986):
Family Interaction Patterns Scale (FIPS) has been developed by Bhatti and his
colleagues in 1986 to measure the quality of family functioning. The scale has
106 items under 6 domains. Reinforcement, social support system, role,
communication, cohesion and leadership on 0-4 pointlikert scale. Higher score
shows dysfunction in that sub domain. Studies of Bhatti and his colleagues
(1986) have shown the ability of scale to measure the dysfunction in the
families of alcoholics and opioid, hysterical and depressive and thus
established its validity, inter rate reliability and test retest reliability.
4. Co-Dependency Assessment Tool (CODAT)(Hughes-Hammer et al., 1998):
This constitutes25 items based on co-dependency, a significant health risk,

particularly for women because co- dependent women are often involved in
abusive and potentially harmful relationship. It is a multivariate tool that
conceptualizes co-dependency as a construct comprising five factors, these are
other focus /self-neglect, low self-worth, hiding self, medical problem, family
of origin issues. the 25 statement of this tool can be measured by the 1-5
tools, like 5- most of the time , 4- usually , 3 - often , 2- occasionally , 1- rarely.
Higher score indicates greater dependency.
46
PROCEDURE:
The present study conducted on inpatients those admitted at the S.S Raju Centre for
Addiction Psychiatry of Central Institute of Psychiatry, Ranchi was interviewed for
sample. Thirty (30) male married person with alcohol dependence and thirty (30)
male married person with opioid dependence patients were selected as per the
inclusion and exclusion criteria of the study. Subsequently spouses of these patients
were approached to participate as per the inclusion and exclusion criteria of the
study. At last total sixty (60) married male patients of alcohol dependence and opioid
dependence patients and their spouses were selected after that the aims and
objectives of the study explained and written informed consents were taken.
Necessary socio-demographicand clinical information were collected by using
structured socio-demographicsheet. For measuring the degree of addiction, the
Addiction Severity Index (ASI) was administered to both the group of patients. Both
the scales Family Interaction Patterns (FIPS) and Co-dependency assessment (CODAT)
were administered to both the group of the spouses.
Statistical Analysis
Data were analyzed with the help of Statistical Packages for Social Science (SPSS-
25.0). Descriptive statistics (percentage, mean and standard deviation) were used to
describe various sample characteristics. Chi square test was used for describing and
comparing categorical data. “t” test was used for group comparison on continuous
data. Mann Whitney U was used for comparison of both group. Pearson r (two-tailed
correlation coefficient) was used for correlation analysis.
47
RESULTS
Table - 1: Socio-Demographic Profile of the Patients with Alcohol dependence and

Opioid dependence.
Variables Sub- Group(n=60) χ2/

classificat
ion df Fisher’s p
exact
Alcohol Opioid
Group (n=30) test
n (%) Group(n=30)
n (%)
Domicile Rural 16 (26.7%) 17(28.3%)
1 0.067 0.795
Urban 14 (23.3%) 13(21.7%)
Occupation Employed 25(41.7%) 21(35.0%)
1 1.491 0.222
Unemploy 5 (8.3%) 9 (15.0%)
ed
Religion Hindu 23 (38.3%) 14(23.3%)
1 5.711 0.017*
Others 7 (11.7%) 16(26.7%)
Low 9 (15.0%) 17 (28.3%)

Socio
economic 2 5.126 0.077*
status Middle 13 (21.7%) 10 (16.7%)
48
Upper 8 (13.3%) 3 (5.0%)
Nuclear 13(21.7%) 9 (15.0%)
Family type 1 1.148 0.422

Joint 17 (28.3%) 21 (35.0%)
General 9 (15.0%) 17(28.3%)
Category 1 4.344 0.067*

Others 21 (35.0%) 13(21.7%)
External 23(38.3%) 18(30.0%)
Locus of
1 1.926 0.165
control Internal 7(11.7%) 12(20.0%)
0-5 times 30 (50.0%) 28 (46.7%)

Total
number of 1 2.069 0.492

hospitalizati > 5 times 0 (0.0%) 2 (3.3%)
on
Frequency 1-5 times 27 (45.0%) 16 (26.7%)
2 10.064 0.003**
>5 times 3 (5.0%) 13 (21.7%)
p≤0.01** at significant, p≤0.05* at significant, p≤0.001*** at significant level (two-tailed)
49
Table – (1) showing the socio-demographic variables of the patients with alcohol
dependence and opioid dependence. In the present study socio-demographic
variables revealed that majority of the patients domicile were from rural background
in (26.7%) alcohol dependence and (28.3%) in opioid dependence, whereas (23.3%)
and (21.7%) were from urban background respectively.
In occupation of the patients most of them (41.7%) and (35.0%) were employed in
both groups while (8.3%) and (15.0%) were unemployed in alcohol and opioid
dependence respectively.
In religion of patients majority of them belongs to (38.3%) Hindus in alcohol

dependence and (26.7%) other religion were found in opioid dependence. Whereas
other religion was (11.7%) in alcohol dependence and (23.3%) Hindus were found in
opioid dependence.
Considering socio economic status of the patients most of them belongs to middle
economic status in alcohol dependence (21.7%) and (28.3%) low economic status in
opioid dependence, whereas patients with low economic status is (15%) and high
economic status is (13.3%) in alcohol dependence. About (16.7%) in middle economic
status and (5%) in high economic status was found in opioid dependence.
In both groups of patient’s family type, majority of them belongs to joint family
(28.3%) and (35.0%) respectively. Patients belongs to nuclear family were (21.7%)
and (15.0%) in both the groups respectively.
Considering patients category most of them belong to (35.0%) other (caste)s in

alcohol group and (28.3%) in opioid dependence, whereas (15%) general category in
alcohol group and (21.7 %) were in opioid dependence respectively.
In the both group of patients majority of them showed external locus of control i.e.
(38.3%) and (30%) in alcohol and opioid dependence respectively, whereas patients
with internal locus of control is (11.7%) and (20%)in alcohol and opioid dependence
respectively.
50
Total number of hospitalization of patients with alcohol dependence (50%) and
(46.7%) opioid dependence between 0-5 times hospitalization were found, while
number of hospitalizations more than five (> 5) times’ patients with alcohol
dependence were not found, but (3.3%) patients more than five (> 5) times’
hospitalization were found in opioid dependence.
Frequency of in-take of substance between 1-5 times is (45%) with alcohol

dependence and (26.7%) with opioid dependence. While more than five (>5) times’
(5%) and (21.7%) was observed in patients with alcohol and opioid dependence
respectively.
Table - 2: Clinical Variables of Patients with Alcohol Dependence and Opioid Dependence.
Alcohol group Opioid group

Mann
Variables df Whitney p
Mean (Mean ± Mean U
(Mean± S.D)
Rank S.D) Rank
Age 39.53± 7.31 33.33±6.23 58 3.532 0.001**
Years of
9.93 ± 3.98 9.80 ± 3.88 58 0.131 0.896
Education
Age of onset 28.47 ±7.10 27.17 ±5.61 58 0.786 0.435
Duration of illness 6.00±5.43 32.5 5.03±4.03 28.5 58 390.00 0.370
Maximum 2105.33±1244.22 45.50 6.00 ±18.45 15.50 58 0.000 0.000***

amount intake
Minimum 983.33±1426.00 45.43 4.25±14.64 15.58 58 2.000 0.000***
amountintake
51
Table (2) showing the clinical variables of patients with alcohol dependence
and opioid dependence. The mean age of patients with alcohol dependence (39.53±
7.31) and (33.33±6.24) was found in opioid dependence. There was significant
difference found in age of patients at 0.01 level.
Age of onset was (28.48 ±7.10) in alcohol dependence and (27.17±5.61) in

opioid dependence. Duration of illness was observed (6.00±5.44; 32.5) and
(5.03±4.04; 28.50) in patients with alcohol and opioid dependence respectively.
There was no significant difference found in age of onset and duration of illness.
Maximum amount of in-take was (2105.33±1244.22; 45.50) in alcohol

dependence and (5.99±18.47; 15.50) in opioid dependence, while minimum amount
of in-take was (983.33±1426.00; 45.43) in alcohol dependence and (4.25±14.64;
15.58) in opioid dependence. There was significant difference found in both the
maximum amount of in-take and minimum amount of in-take at 0.001 level.
Years of Education was found (9.93 ± 3.98) in patients with alcohol

dependence and (9.80 ± 3.88) in patients with opioid dependence. There was no
significant difference found.
52
Table – 3: Comparison of the Family Interaction Pattern among Patients with Alcohol
Dependence and Opioid Dependence.
Family Interaction Alcohol group Opioid group t df p

Pattern Domains
(Mean ± S.D) (Mean ± S.D)
Reinforcement 20.03± 4.34 22.23 ± 4.34 1.962 58 0.055
Social support system 23.57± 3.91 26.87± 4.43 3.052 58 0.003**
Role 54.16± 7.71 57.20 ± 7.57 1.537 58 0.130
communication 54.80± 7.10 54.97 ± 4.70 0.107 58 0.915
Cohesiveness 32.33± 5.62 33.27± 3.99 0.742 58 0.461
Leadership 34.33± 3.80 37.33 ± 4.55 2.772 58 0.007**
Table (3) showing the comparison of Family Interaction Pattern among

patients with alcohol dependence and opioid dependence. There was significant
difference found in social support (23.57± 3.91;26.87± 4.43912) and leadership
(34.33 ± 3.80;37.33± 4.55) significant at 0.01 level. No significant difference found in
other domains of role, communication and cohesiveness of family interaction pattern
scale.
53
Table – 4: Comparison of the Codependency Assessment among Patients with Alcohol Dependence
and Opioid Dependence.
Codependency Alcohol group Opioid group t df p

Assessment(CODAT)
Domains (Mean ± S.D) (Mean ± S.D)
Self-neglect 10.63± 3.15 10.00± 2.62 0.845 58 0.402
Self-worth 10.23 ± 2.71 11.80± 3.24 2.030 58 0.047*
Hiding self 10.23± 3.25 11.16± 3.60 1.053 58 0.297
Medical problem 10.00 ± 2.70 9.40± 2.88 0.833 58 0.408
Family of origin issues 10.43± 3.11 10.63± 2.98 0.254 58 0.800
Table (4) showing comparison of the codependency assessment among patients with
an alcohol dependence and opioid dependence. Co-dependency assessment domain
self-worth (10.23±2.71; 11.80 ± 3.24) was found significant at 0.05 level. There was
no significant difference found in other domains like self-neglect, hiding self, medical
problem and family origin issues.
54
Table –5: Comparison of the Addiction Severity Index among Patientswith Alcohol dependence and
Opioid dependence
Addiction Severity Index Alcohol group Opioid group Man p

Whitney
Domains
U
(Mean ± S.D) Mean (Mean ± S.D) Mean
Rank Rank
Medical 0.94 ± 1.059 36.95 0.70 ± 1.02 24.05 256.500 0.004**
Employment 5.60± 17.85 28.45 14.14 ± 44.10 32.55 388.5000 0.363
Legal 0.03±0.10 28.33 1.00± 3.90 32.68 385.000 0.169
Family 2.77 ±9.18 37.12 1.14±4.57 23.90 251.500 0.003**
Psychiatric 7.22± 23.70 28.33 1.29 ± 2.05 32.79 382.000 0.351

Table (5) showing comparison of the Addiction Severity among patients with
alcohol and opioid dependence.
In the addiction severity both the domains medical (0.94 ± 1.059&0.70 ± 1.02;
36.95&24.05) and Family status (2.77 ± 9.18 &1.14 ±4.57; 37.12 & 23.90) were found
significant at 0.01 level.

There were no significant differences found between two groups in other
domains like employment, legal, and psychiatric of addiction severity index scale.
55
Table – 6: Correlation among the Co-dependency and Family Interaction Pattern of Patients with Opioid
Dependence.
Co-dependency Family Interaction Pattern
Assessment Reinforcement Social Role Communication Cohesiveness Leadership FIPS-

support Total
Self
0.502** 0.213 0.189 0.053 - 0.148 0.173 0.245
neglect
Self-worth 0 .417* 0.276 0.251 - 0.147 - 0.129 - 0.009 0.181
Hiding self 0.689** 0.137 0.265 - 0.144 - 0.272 - 0.109 0.162
Medical -
0.434* 0.026 0.099 - 0.287 - 0.338 - 0.074
problem 0.016
Family of 0 .124
0.041 0.215 - 0.050 0.166 - 0.039 0.124
origin issues
CODAT- Total 0.514** 0.084 0.176 -0.215 -0.232 -0.113 0.070
Table (6) showing correlation among the co-dependency and family

interaction pattern of patients with opioid dependence. In co-dependency both the
domains self-neglect and hiding self was positively correlated with reinforcement
significance at0.01 level. Also, domains self-worth and medical problem were
positively correlated with reinforcement at significance 0.05 level in family
interaction pattern scale.
56
Table – 7: Correlation among the Codependency and Family Interaction Pattern of patient
with Alcohol Dependence.
Family Interaction Pattern Co-dependency domains
domains
Self Self- Hiding Medical Family of CODAT
neglect worth Self problem origin TOTAL
issue
Reinforcement 0.003 0.032 - 0.081 - 0.009 0.109 0.015
Social support system - 0.102 0.159 - 0.159 - 0.052 0.089 - 0.025
Role - 0.077 0.008 - 0.121 0.233 0.335 0.094
communication - 0.030 - 0.076 - 0.356 0.088 0.191 - 0.057
Cohesiveness - 0.053 0.180 - 0.001 0.309 0.153 0.144
Leadership - 0.157 0.136 - 0.202 0.202 0.148 0.017
FIPS – Total - 0.161 0.052 - 0.210 0.252 0.243 0.033
Table (7) showing correlation among the Co-dependency and Family Interaction
Pattern of Patients with alcohol dependence. There is no statistically significant
correlation found among the Co-dependency and Family Interaction Pattern of
patients with alcohol dependence.
57
DISCUSSION
The present study was conducted with an aim to compare and correlate role
of the co-dependency and family interaction pattern of spouses of Patients with
alcohol dependence and opioid dependence syndrome.
Discussion of Methodology
The impact of addiction on family members varies in degree depending on the

role they play in the family and the responsibilities they carry. Until now addiction
touches all their lives. Mostly, the spouses of addicts face the troubles from all
directions in the family. The main reason is that the family struggles to maintain its
stability with a sequence of adjustments. All the time spouses look dilemma and
exhibit emotionally pathogenic attitude toward her husband. Finally, she herself
become co-dependent by adopting the behavioral and emotional imbalance of their
partner such as remain devoted to the care and support of their spouse. Families of
person with substance dependence often encounter problems pertaining to family
interaction among members, deficit of families in several essential areas like
providing care and nurture to all members, fulfillment of emotional and attachment
related needs of members, economic hardship and interaction with community.
Abuse of substance like alcohol or opioid is a response to fluctuations in the
family system. In consideration of interactions within the system, it seems an
important requirement that the family often needs as much treatment as the family
member who is the abuser of alcohol or a substance. The multiplicity of factors
associated with drug abuse and their inter-relatedness makes the problem a complex
one (Ray, 2007).
This study was conducted at the Central Institute of Psychiatry, Ranchi. It was
a cross sectional study. The aim of the study was to investigate the impact of family
co-dependency and family interaction pattern of spouses of patients with alcohol
58
dependence and opioid dependence syndromes. Also, the present study is planned to
assess the severity of addictive behavior of the selected patients.
According to the International Classification of Diseases (ICD-10) the

“dependence syndrome” is defined as: “a cluster of behavioral, cognitive, and
physiological phenomena that develop after repeated substance use and that
typically include a strong desire to take the drug, difficulties in controlling its use,
persisting in its use despite harmful consequences, a higher priority given to drug use
than to other activities and obligations, increased tolerance, and sometimes a
physical withdrawal state.”
In the present study measuring the patients’ severity of addictive behavior

McClellan et al., (1980) the Addiction Severity Index (ASI) was used. This scale is in
spacious to assess the treatment problems found in alcohol and drug abusing
patients in clinical or research setup. This scale was designed to address seven
potential problem areas in substance-abusing patients: medical status, employment
and support, drug use, alcohol use, legal status, family or social status, and
psychiatric status. The Addiction Severity Index tool was used efficiently to explore
problems within any adult group of persons with substance abuse as major problem.
The main objective of this study was to compare the level co-dependency of
spouses of persons with alcohol dependence and opioid dependence syndrome.
Families with substance dependents suffer from a range of problems. Spouses can
live in constant conflict. Co-dependency is an emotional and behavioral condition
that affects a persons’ ability to have healthy and mutually satisfying relationships.
According to Goff and Goff, (1988) Co-dependency is a learned behavior, expressed

by dependencies on people and things outside of the self, which neglect and diminish
one's own identity. It is a significant health problem (Goff & Goff, 1988).
59
The major advantages of the CODAT for assessing co-dependency are its
comprehensiveness and its grounding in the Wegscheider-Cruse and Cruse (1990)
theoretical model. The original model developed by Wegscheider-Cruse and Cruse
(1990) conceptualized the core symptoms to be denial, repression, and compulsion.
In his study, the results of the factor analysis indicate that other focus/self-neglect
(control and boundary issues) constitutes the core symptom; the compulsion
symptom was incorporated in the core symptom of other focus/self-neglect in the
revised model. Wegscheider-Cruse and Cruse (1990) conceptualized the secondary
symptoms of co-dependency to be low self-worth, relationship problems, and
medical problems.
In the revised model, secondary symptoms that emerged from the factor
analysis were low self-worth, hiding self (repression and denial), medical problems,
and family of origin issues.
The core symptom of co-dependency (other focus/self-neglect) suggests that

the co-dependent individual neglects the self and focuses on others; as a result, the
individual develops a host of secondary symptoms. The individual suffers from low
self-esteem as a result of lack of identity formation and unresolved family of origin
issues. The family of origin issues contributes to a learned behavior of repression and
denial of feelings. The person's focus on the need to care for, and control, others
results in neglect of the self, which eventually can lead to the onset of a variety of
medical problems.
For measuring the co-dependency of spouses Hughes-Hammer et al (1998) Co-

Dependency Assessment Tool (CODAT) was used. This scale comprised of 25 items
based on co-dependency, a significant health risk, particularly for women because co-
dependent women are often involved in abusive and potentially harmful relationship.
It is a multi-variate tool that conceptualizes co-dependency as a construct comprising
five factors, these are other focus /self-neglect, low self-worth, hiding self, medical
60
problem, family of origin issues. This scale was widely using and a valid and reliable
tool for measuring the co-dependency of spouses with drug dependents.
Consequences of co-dependency family are important functioning like

interpersonal relationship; general family atmosphere may become pathological
because of this problem. Evidence from studies suggest that the experience of
affected family members in coping with substance misusing relatives can be
devastating for the physical, financial, interpersonal and social aspects of the family
functioning (Copelloet al., 2009a, 2010; Templeton & Coppello, 2012;
Velleman&Templeton,2003).
Therefore, another parameter family interaction pattern of spouseswas added

to compare persons with alcohol dependence and opioid dependence syndrome. For
measuring family interactions of spouses Bhatti et al. (1986) Family Interaction
Patterns Scale (FIPS) was used. This scale was developed to measure the quality of
family interactions among family members. Such as reinforcement, social support
system, role, communication, cohesion and leadership. Already Bhatti and his
colleagues (1986) have shown the ability of scale to measure the dysfunction in the
families of alcoholics, hysterical and depressives and established its validity, inter rate
reliability and test retest reliability.
Previous studies also highlighted Vellemanetal (1993) suggested that there

were seven key aspects of family life that could be adversely affected by prolong
alcohol and opioid dependence, such as: roles, rituals, routines, social life, finances,
communication and conflict.
This study was planned further to find out the relationship among the co-
dependency and family interaction pattern of spouses of persons with alcohol and
opioid dependence syndrome.
61
Discussion of Results
In India, the increase in drug abuse in various segments of society during the
past decade has led to an alarming increase in constant worry (Singh, 1992).
However, the most commonly used legal substances are nicotine, alcohol. Traditional
drugs such as bhang, ganja, opium and charas were used for recreation or as part of
religious rituals by certain sections of societies. Past few decades, the drug scenario
in the country has changed rapidly. The changes are seen in terms of availability,
choice of psycho-active drug, users, and their socio-demographic characteristics
(Sharma, 2005).
The aim of the present study was to compare and correlate role of the co-
dependency and family interaction pattern of spouses of persons with alcohol
dependence and opioid dependence syndromes.
In the present study different socio-demographic and clinical variables table

(1&2) revealed that the persons with alcohol dependence mean age (table-2) was
(39.53± 7.31) and (33.33±6.24) was found in persons with opioid dependence. There
was significant difference found in the age of patients at 0.01 level. Other socio-
demographic variables table (1) that majority of participants in our study were from
rural background (26.7%) in alcohol and (28.3%) in opioid dependence.
In occupation of the patients most of them (41.7%) and (35.0%) were employed in
both groups while (8.3%) and (15.0%) were unemployed in alcohol and opioid
dependence respectively.
Similar results were reported by Ziaddiniet al. (2010) in their study that 67.9%
of their subjects were employed, and 52% were unmarried and parallel other study
Nigam et al. (1993) reported that 91.7% of the subjects were employed, and 86.1%
had education below 10 years like the present study.
In previous Indian studies similar finding were found in a community-based

study at Bangalore Gururaj et al. (2006) almost two-third of patients was in 26-45
62
years age group and majority had low education level. Most of the patients were
unskilled worker in their study.
Another hospital-based study by Pradeep et al. (2010) most of the patients

were in third decade of life found in the study.
Considering patient’s family type in both groups majority of them belong to

joint family (28.3%) and (35.0%), also in category most of them belong to other
(caste)s (35.0%) and (28.3%) in alcohol and opioid dependence were found
respectively.
In the religion majority of them belong to Hindus (38.3%) in alcohol and

(26.7%) other religions in opioid dependence; as well as most of them belong to
middle (21.7%) and (28.3%) low economic status in alcohol and opioid dependence
respectively.
Previously as above discussed few socio demographic variables reported by

previous Indian studies similar finding were found in a community-based study at
Bangalore Gururaj et al. (2006) almost two-third of patients was in 26-45 years age
group and majority had low education level. Most of the patients were unskilled
worker in their study. Other study Nigam et al. (1993) reported that 86.1% had
education below 10 years like the present study.
Above study finding supporting to present study findings such as parsons with
unskilled worker (Gururaj et al. (2006)) and had education below 10 years like (Nigam
et al.(1993)) psychosocial issues leads to vulnerability in community, such as paid
low wages to them it became low economic status in the community.
Similar results were reported by recent epidemiological studies that have

examined determinants of transitions across different stages of substance use have
demonstrated that commonly reported associations in aggregate analyses, such as
those observed for gender and ethnicity, may have highly different or even opposite
63
effects, depending on stage of use examined (Swendsen et al., 2008; O’Brien &
Anthony et al.,2005).
Other specific variables most frequent socio-demographic characteristics

analyzed in present study such as external and internal locus of control, frequency of
in-take of substance and number of total hospitalizations.
in present study, majority of participants were showed frequency of in-take of
substance is between 1-5 times both groups while more than five (>5) times was
observed less in alcohol dependence whereas it was more or less same in (21.7%)
opioid dependence.
Number of total hospitalizations between 0-5 times (50%) in alcohol
dependence and (46.7%) in opioid dependence. While number of hospitalizations
more than five (> 5) times were found in patients with opioid dependence than in
alcohol dependence.
About locus of control most of them both groups external locus of control
(38.3%) and (30%) were observed in alcohol and opioid dependence respectively.
Previous past decade studies by John et al. (2009) in southern rural India
confirmed that 14.2% of the population surveyed had hazardous alcohol use. A
similar study by Sampath et al. (2007) showed that 17.6% admitted patients had
hazardous alcohol use in the tertiary hospital. A study of urban of child laborers in
slums of Surat by Bansal and Banerjee (1993) perceived that 45% used different
substances. The substances used were snuff, cannabis and opioids, smoking tobacco,
followed by chewable tobacco. Tripathi and Lal (1999) found that the injecting drug
use is also becoming apparent among street children.
Previous literature shown that in the study of Sachdev et al. (2002) observed
that there is a downward trend in use of opium, and the use of poppy husk (bhukki)
has almost doubled. A recent study conducted by Kalra and Bansal (2012) in de-
addiction centre of Punjab has shown that (n=178) of the patients reporting to a de-
64
addiction centre were abusing bhukki and more than two (2) kg of bhukki was
consumed per month by the patients. These figures are much similar to our study.
In the present study table (2) shows the clinical variables of the patients with
alcohol dependence and opioid dependence. The persons with alcohol dependence
mean age was (39.53 ± 7.31) and (33.33 ± 6.24) mean age was found in patients with
opioid dependence. There was significant difference found in age of patients at 0.01
level patients with alcohol and opioid dependence. Already discussed about mean
age of patients with alcohol and opioid dependence.
Minimum amount of in-take of alcohol (983.33 ± 1425.99; 45.50) and (4.25 ±

14.64; 15.50) opioid was found while maximum amount of in-take alcohol (2105.33 ±
1244.22; 45.43) and (5.99 ± 18.47; 15.57) opioid was found in patients with alcohol
and opioid dependence respectively. There was significant difference found in both
the maximum amount of in-take and minimum amount of in-take at 0.001 level in
both groups.
However, in the age of onset, duration of illness and years of education was
not found significant difference patients with alcohol and opioid dependence.
In the present study clinical variables from the above findings, it can be
concluded that there is a trend towards abuse/intake of both, alcohol and drugs.
Studies done in past decade, Vasvani (1998) had reported increasing trend in abuse
of benzodiazepines and other over the counter available drugs. Sachdev et al. (1986)
has also reported a significant increase in abuse of drugs available over the counter
like that of dextropropoxyphene, diphenoxylate, codeine phosphate etc.
The current Indian study at New Delhi WHO Biennium Project Report Drug
Abuse Monitoring System (DAMS) conducted by National Drug Dependence
Treatment Centre, (2006-2007) data emphasized that opium and its derivatives
(heroin, other opioid) emerged as second preferred drug category as 40% men
65
reported its use (14% each for opium and heroin and 12% for other opoidmainly
spasmoproxyvan, Fortwin and norphine etc.).
Whereas examining about the alcohol, there has been a steady increase in the
per capita consumption of alcohol in most parts of the world and it is projected to
rise in the coming years. There has been an increase in alcohol availability, and an
associated increase in alcohol consumption and alcohol-related disorders (Obot,
2006; Prasad, 2009) in Low- and Middle-Income Countries (LMIC); led by countries
such as India and China, possibly due to rising incomes and aggressive marketing by
the alcohol industry (World Health Organization, 2014).
In the community surveys, rates of both alcohol and drug dependence

disorders are found to increase as a function of male sex, younger age, lower
education, unmarried status, low income and other variables indicative of social
disadvantage that often concentrate together within population subgroups (Anthony
et al 1994., Warner et al.,1995).
According to Kulis et al. (2003); and Williams and Ricciardelli (1999) noticed
that normative peer behavior or social values also encourage substance use
differently by gender. In the same way, numerous individual and environmental risk
factors may interact to determine the final expression of substance use patterns
observed in descriptive epidemiology.
In the present study different socio-demographic and clinical variables table

(1&2) exposed that it is a well-established fact that the rates of both alcohol and drug
dependence disorders are found typically increasing in our society.
3. Comparison of Family Interaction Pattern among Patients with Alcohol

66
In the present study comparison of Family Interaction Pattern table (3) among
persons with alcohol and opioid dependence revealed that reinforcement was found
(20.03± 4.34; 22.23 ± 4.34) significant at 0.05 level. Also, both the domains social
support (23.57 ± 3.91; 26.87 ± 4.44) and leadership (34.33 ± 3.79; 37.33 ± 4.56) were
found significant at 0.01 level.
Present study perceived that family interaction patterns of the persons with
opioid dependence more dysfunctions in reinforcement, social support and
leadership domains than persons with alcohol dependence.
The role of family relationships in the creation and maintenance of alcohol

and other drug-related problems have identified a strong connection between
disrupted family relationships and alcohol and another drug addiction (Stanton et al.
,1984; Stanton and Shadish , 1997; Velleman, 1992).
In the present study family interaction variables from the above findings
similar to past studies. Previous literature shown that in the study of Lederer (1991)
suggested some markers that distinguish alcoholic families from other families,
including reciprocal extremes of behavior between family members, lack of a model
of normalcy, and power imbalances in family organization. Another study Velleman
(1992) also writes about the impact of drinking on family roles, communication, social
life and finances; for example, finances that are limited through expenditure on
alcohol/other drugs, family gatherings that are spoiled because of drunken behaviors,
and roles that have to be allocated because the addicted family member is unable to
carry out daily tasks.
A previous study Bhowmick et al. (2001) which had shown that co-dependent
spouses had significantly poorer social support (student t = 3.66, p < 0.01). Lower
perceived social support may be a proxy marker of introversion, which translates into
overall less social interaction.
Jacob et al. (1983) studied alcohol dependents and compared them to normal
families. Interaction between the alcohol dependent persons and his spouses
67
revealed more negative affect than in the normal family couples. The presence of
alcohol increased this type of interaction. Alcohol dependent fathers showed less
leadership, assertiveness, and problem-solving behavior with the spouses and
children.
Rychtariket et al. (1989) had found that married males with dependence to
alcohol tended to present their marriage in an unrealistically favorable manner and
report that drinking has not caused impairment in their marriages, whereas their
spouses would report significant marital discord as well as faulty interaction between
them and their alcohol dependent husbands. The poor family interaction and family
support can have deep rooted impact on the prognosis of alcohol dependence
syndrome which was seen by previous researchers (Jacob & Seilhamer, 1989; Akhito
et al., 2003).
4. Comparison of the Codependency Assessment among Patient with Alcohol

In the present study comparison on Co-dependency Assessment Scale table

(4) illustrated that self-worth (10.23±2.71; 11.80±3.24) was found significant at 0.05
level among spouses of persons with alcohol and opioid dependence.
This showed that the spouses of persons with opioid dependence more Co-
dependent in domain of self-worth than spouses of persons with were alcohol
dependence.
Previous literature shown co-dependency includes thoughts of self-criticism
and self-hatred and feelings of shame, self- blame and humiliation. Fossum and
Mason (1986) indicate that the shame evolves in individuals as a result of being
raised in shame bound families.
Hinkin and Kahn (1995) showed in a study of 97 wives of either alcoholic
(n=31), psychiatric (n=35), or dental (n=31) patients at a Veterans Administration
inpatient unit and outpatient clinic, that the subjects who had a positive family
68
history of alcoholism had significantly lower self-esteem scores when compared with
those with negative family histories.
Dear (2009) label co-dependency as a kind of addiction. Dysfunction within

the family of an addict was found to be the leading cause of addiction and relapse.
Co-dependency is considered or well thought out as an unhealthy pattern of coping.
Consequences of co-dependency denial, self-esteem, compliance and control are
known as crucial factors of co-dependency. These factors are shared by addicts and
their spouse as well. This leads to mental health issues, such as anxiety or depression,
may stem directly from the effect of denial on the family and moreover spoil the self-
worth that destroy the second major factor of co-dependency known as self-esteem.
Having low self-esteem spouses of drug addict comply the demand instead their own
need and they suppressed their own wishes. (Allcorn, 1992).
5. Comparison of the Addiction Severity among Patients with Alcohol and Opioid
Dependence.
In the present study comparison on Addiction Severity scale table (5)

illustrated that in the addiction severity scale both the domains medical (0.94 ± 1.059
&0.70 ± 1.02; 28.45 & 32.55) and family status (2.77 ± 9.18 &1.14 ± 4.57; 37.12
&23.89) were found significant at 0.01 level. There were no significant differences
found between two groups in other domains like employment, legal, and psychiatric
of addiction severity index scale.
Present study showed that the person with alcohol dependence consuming
pattern is higher than persons with opioid dependence.
Previous studies also supporting present results that Harpham (1994)
highlighted that various factors which lead to an increasing number of drug addicts
are absence of parental love and care in modern families where both parents are
working, disintegration of the old family system, and a decline of moral values in the
young generation.
69
In the study Bierut et al. (2002) found that familial transmission of substance
dependence is considered a potential risk factor, and considerable evidence supports
the causal role of familiarity in substance abuse.
Another study from India Sahoo (2007) revealed nicotine and alcohol as the
most common initiating drugs of abuse. Exposure of young minds to promotional
advertisement of tobacco products and to films that have smoking scenes have been
directly associated with the initiation of smoking in adolescents.
According to the WHO-SEARO (2007) report National Household Survey of
Alcohol and Drug Abuse (2003) 21.4% were reported to be current users of alcohol
(used in last 30 days). Health problems for which alcohol is responsible are only part
of the social damage, which includes family disorganization, crime, and loss of
productivity (Park2011).
A survey from Government of India & World Health Organization

Collaborative Program (2011) on substance use male drinkers self-reported found that
their drinking had caused problems with their finances, physical health and social life.
One of four said it had affected their carrying out household responsibilities and
personal relationships. A considerable pro-portion of women users also reported
adverse consequences of their drinking – with more than 20% reporting problems with
finances, social life and physical health, and 10% or more reporting problems in their
house work, marriage and relationships.
Alcohol use is associated with greater morbidity. Alcohol users had greater
sleep problems, presumptive heart problems and injuries than non-users. They also
reported significantly greater rates of skin problems, jaundice, burning pain in the
stomach and other gastro-intestinal problems, joint pains, chronic cough and fever
suggestive of tuberculosis or chronic lung infections. One must guard against making
any claim for causative links between alcohol and specific disease conditions from this
above study. But it certainly does appear that alcohol users had higher rates of illness
than non-users. Heavy users had a greater prevalence of these problems than light
users.
70
6. Correlation among the Codependency and Family Interaction Pattern of Patients
with Opioid Dependence.
In the present study correlation (table-6) among the Co-dependency and
Family Interaction Patterns revealed that both the domains self-neglect and hiding
self positively correlated with domain reinforcement significantly at 0.01 levelwere
found in family interaction pattern scale. Furthermore, both the domains self-worth
and medical problem positively correlated with domain reinforcement significantly at
0.05 level.
In present study, co-dependency positively correlated with reinforcement in

family interaction patterns. It means opioid dependence spouses were high level on
co-dependence in the family and very poor adaptation of reinforcement among
family members. This leads to negative impact on family functioning. Reinforcement
defines that processes adopted by the family to enable the members to imbibe
socially approved behavior.
Previous literature reported that the barrier of codependence is part of the

notion of family interdependence, and the idea that one member’s problem(s)
represent a problem in the total family system (Nugent, 1994). When substance use
moves to levels of abuse and addiction, families lose their balance (homeostasis) that
increases demands on family members’ to assume responsibilities for the abusive or
addicted family members.
Wegscheider-Cruse (1985) described codependence is an addition to a

relationship that stifles self-growth and self-expression and which closely resembles a
person's addiction to alcohol or drugs. That ultimately becomes a dysfunctional
relationship and impacts upon all other close relationships. In a co-dependent family,
members have not developed their own independence and, consequently, believe that
they cannot express their own needs, wants, and feelings (Nugent, 1994).
71
Hence, the recognition of co-dependence may help in negating its harmful
effects. Among the close relatives, spouses who live with the substance user are at
the greatest risk of developing or having codependence. They are affected in many
ways due to substance behavior and experience stress of living with a substance user
(Mudar et al. 2001). Reinforcement had relevance to existence of reinforcement, non
- existence of reinforcement, balanced reinforcement and faulty reinforcement.
The family unit can be conceptualized as systems with interdependencies

among its members. An implication of this perspective is that when one part of the
system changes or is “damaged” it impacts other parts of the system. Implication of a
systemic perspective is the potential for reciprocal impact of substance use and
abuse and other family member behavior.
Another implication is that Stevens-Smith (1998) considered as a system the

family may adapt to protect and accommodate the substance user resulting in
accommodating dysfunctional family relationships. This adaptation often includes
denial and dishonesty to avoid addressing the issue, and the implementation of
family rules and behaviors that mask family members’ dependency behavior.
This finding was confirmed by aforementioned studies showing that absence

of a goal, hopelessness, low self-esteem, failure to achieve goals, lack of confidence
in the future, poor character development, and a life brimming with frustration,
anxiety, depression, panic, aggression, lack of security and unpredictable
environment that are caused by unpleasant conditions of living with an addict lead
addicts’ wife to score high in co-dependency.
According to Hughes-Hammer and colleges (1998) symptoms associated with

co-dependency are hiding oneself, medical problems and low self-worth. Low self-
worth includes self-criticism, self-blame and shame.
Problematic substance abuse usually is traumatic to a family system (Hawkins,

1998), which then drives a process of short and long-term adjustment as a defense
72
mechanism by substance abusers and codependent family members, if use progresses
to abuse and to addiction (Steinglass et al. 1987).
Malpique et al. (1998) report that families who are chemically dependent spend
at least part of their lives in a confused and chaotic atmosphere, resulting in role
distortion, imbalance, and weak emotional support. There is considerable value, in
assessing family systems which experience trauma in terms of their assumption of
major roles.
7. Correlation among the Codependency and Family Interaction Pattern of Patients

with Alcohol Dependence.
In the present study correlation (table-7) among the Co-

dependency and Family Interaction Patterns revealed that though correlations exist
between co-dependency and family interaction pattern among patients with alcohol
dependence but were not statistically significant. previous studies Singh and
Bhattacharjee et al. (2009) assessed the interaction pattern with alcohol dependent
persons in the families, they administered with family interaction pattern scale and
general health questionnaire -12 with 30 spouses of alcohol dependent persons,
results showed that poorer pattern of interaction was found in the domains of
reinforcement, social support, role, communication, leadership and family
interaction scale total score in spouses of patients with alcohol dependence
compared to people with no alcohol dependence. Contradictory to general finding of
other studies, present study did not find any significant relationship among co-
dependency and family interaction pattern of the Patients with alcohol dependence.
Earlier study Gorad (1971) examined areas like marital

interactional dynamics, roles, expectations and patterns, especially in relation to
alcohol dependence of married males, showed a high degree of blaming, competition
for dominance, responsibility avoidance by those addicted persons and presence of
73
negative emotion and affect in the interactional and communicational pattern
between couples with alcohol dependent.
The acknowledgment that the use of a substance by a relative is a real

problem might lead to family members feeling highly marginalized in terms of being
the cause of the problem, or possible feelings of shame that the problem may bring
to the family in general. Cultural barriers that impose difficulties for families to
understand and accept the gravity that substance misuse can cause family members
should therefore be considered when developing interventions.
74
SUMMARY AND CONCLUSION
The study was conducted at the Central Institute of Psychiatry; Ranchi with the aim
to find out the co-dependency and family interaction pattern of spouses of person with
alcohol and opioid dependence syndrome and its relation to each other. The total sample
size was 60, 30 married patients of alcohol and their spouses and 30 married patients of
opioid dependence and their spouses. The tools were used Socio-demographic and clinical
sheet, Addiction Severity Index (ASI); Family Interaction Patterns Scale (FIPS) and Co-
dependency Assessment Tool (CODAT). The data was analyzed with the help of Statistical
Packages for Social Sciences (SPSS- 25.0) by applying the appropriate test.
The findings can be summarized as:
1. Present study revealed poor family interaction pattern in the domains of

“Reinforcement” “Social Support” and “Leadership” in the spouse with opioid
dependent in comparison to the spouse with alcohol dependent.
2. Results also indicated significant difference in codependency between the

spouse with alcohol dependent and spouse with opioid dependent. The
spouse with opioid dependent scored significantly high in domain of self-
worth in comparison to spouse with alcohol dependent.
3. Findings are suggestive of positive association between all domains of

codependency assessment and reinforcement pattern of the spouse with
opioid dependent.
CONCLUSION
The present study revealed that spouses of patient with opioid dependence were
having more codependent as well as dysfunctional family interaction patterns found in
compare to spouses of patient with alcohol dependent.
75
LIMITATION
 There was no specific gender separation in study as female patients
are not admitted specifically for substance abuse problems.
 Majority of sample were taken from urban region and joint families,
therefore, adequate proportional representation of all areas could not
be included in present study.
 Other psychosocial factors influencing family interaction pattern and

codependency (as stigma, express emotions etc.) were not assessed.
FUTURE DIRECTIONS
The present study assessed the family interaction pattern and codependency
in spouse with alcohol dependent and opioid dependence and its relation to each
other.
On basis of findings extracted out of present study, this study proposes

following future directions for further study.
 Inclusion of patients of both genders.
 Family pattern variables related to substance can be assessed in

various types of families (joints, nuclear, extended etc.) and various
regions (urban, rural, semi urban etc.)
 The quality of family pattern and codependency variables can be

assessed in longitudinal study also.
 The codependency experience can be well shared through case studies

as well in the future.
76
IMPLICATION
Present study findings suggested that spouses of patients with opioid dependence
were more co-dependents and also had more dysfunctions in family interaction
patterns than persons with alcohol dependence. Consequences of co-dependency
reported significant family disorganization as well as health and mental health
problems within the entire family system.
Present study findings suggested that it is very important for the mental health
professionals to identify the needs of the families. Finding out areas need attention
and strategies to restore the wellbeing of an individual with substance dependence
and their family. It requires clinicians’ knowledge and skill based comprehensive
assessment. Substance dependence issues need multidimensional approaches to
bring fruitful outcomes. Engagement and implementation strategies, as well as the
interventions themselves, must be tailored to local and cultural characteristics.
Potential short-term interventions can be provided at the time of hospitalization for
families of patients with substance dependence on aspects appropriate to areas of
family functioning. Such as psycho-education and short- term family therapies, which
ensures improvement in the quality of life and better recovery of patients and
families.
77
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APPENDIX
GOVERNMENT OF INDIA
KANKE, RANCHI, JHARKHAND
CONSENT FORM
I, hereby give consent for the study on “CO-DEPENDENCY AND FAMILY
INTERACTION PATTERN OF THE SPOUSES OF PERSONS WITH ALCOHOL
AND OPIOID DEPENDENCE SYNDROME: A COMPARARTIVE STUDY” to be
done at CENTRAL INSTITUTE OF PSYCHIATRY (CIP) KANKE, RANCHI. I
have been fully explained about the procedure and I understand that it is a completely
academic exercise.
Name :
Signature :
Date :
मैअपनीमर्जीसे“CO-DEPENDENCY AND FAMILY INTERACTION PATTERN OF
THE SPOUSES OF PERSONS WITH ALCOHOL ANDOPIOID DEPENDENCE

SYNDROME: A COMPARARTIVE
STUDY”नामकअभ्यासमेशाममलहोनाचाहता/चाहतीहूँ।यहअभ्यासएकअध्ययनहै औरइसविष
यकीर्जानकारीमुझमे मलगयीहै ।
नाम:
हस्ताक्षर :
तारीख:
97
GOVERNMENT OF INDIA
KANKE, RANCHI, JHARKHAND
CO-DEPENDENCY AND FAMILY INTERACTION PATTERN OF THE SPOUSES

OF PERSONS WITH ALCOHOL ANDOPIOID DEPENDENCE SYNDROME: A
COMPARARTIVE STUDY
SOCIO-DEMOGRAPHIC AND CLINICAL DATA SHEET OF THE PATIENT
S. L. No Date of Data Collection
CRF NO.
Name of the
1
patient
2 Age
(1) Male
3 Gender
Year of
4
education
5 Occupation (1) Employe

(2) Unemployed
d
Monthly Income
6
(in rupees)
Socio-economic
status(Kuppuswa
7 my's Socio- (1) Low (2) Middle (3) Upper
Economic Status
Scale 2018
(2) Joint
8 Family Type (1) Nuclear
98
9
Domicile (1) Rural (2) Urban
Religion (1) Hindu (2) Other

10
11 Category (2) Others

(1) General
12 Marital Status (1) Unmarri (2) Married

ed
Age of Onset
Taking alcohol /
13 opioid
(in years)
Locus of Control
14 (Rotter’s locus of (1) External (2) Internal
control scale)
15 Duration of
Illness
Total No. Of
16 Psychiatric
Hospitalizations
 Frequency of use:
 Last Intake:
 Maximum Amount of expenditure on alcohol/opioid (P.M.)
 Average Amount of expenditure on alcohol/opioid (P.M.)
 Maximum Amount of alcohol/opioid consumed in a day
 Average amount of alcohol/opioid consumed in a day
99
SOCIO-DEMOGRAPHIC DATA (INFORMANTS):
Name:
Age:
Sex: (a) Female
Marital Status: (a) Married
Education:
Occupation: (a) Employed (b) Unemployed
Family Income:
Informant with living of the patient:
100
FAMILY INTERACTION PATTERN SCALE (FIPS) (Bhatti et al., 1986)
;gk¡ ikfjokfjd thou ds ckjs esadqNlokygSAgjloky dk tokcfn, x, pkj ¼4½ mRrjksa es ls dksÃ
,d gksldrkgSa&ges'kk] dHkh&dHkh] ,dknckj] dHkhugha&vki bls /;ku ls i<+s] lkspv
sa kSjvkids ifjokj ds ckjs
esatksBhdgks ml ijlgh dk fu'kku yxk;s@a crk;saA
1- lkekU; crkZo ds fy, ifjokj ds yksxks ls ;g mEehn dh tkrhgSfdos ifjokj ds fu;eksa dk ikyudjsaA
ges'kk dHkh&dHkh ,dknckn dHkhughaA
2- gekjs ifjokj esl

a gh&xyr] vPN&cqjk ;kmfpr&vuqfpr bl ckrijcgqrtksjfn;ktkrkGsa
ges'kk dHkh&dHkh ,dknckn dHkhugha A
3- Ikfjokfjd fu;eksa ds rksMt

+s kusij ?kj ds yksxksd
a ksMk¡VktkrkgSA
4- ifjokj ds gj ,dlnL; dksmldsdke ds vuqlkjvk¡dk ¼ekik½ tkrkgSA
5- ifjokfjdfu;eksa ds rksMt
+s kusij buke jksdfn;ktkrkgSA
6- bl ckr ls dksÃ [kklQdZughaiM+rkfd ?kj ds yksxvkilesfa dlrjg dk crkZodjrsgaSA
7- vkerkSj ls ifjokj ds lnL;ksa dk cqjkcrkZoutjUnktdjfn;ktkrkgSA
8- Ikfjokfjd fu;eksa ds rksMt

+s kusij ?kj ds yksxksa dk VksdkatkrkgSA
9- EkkewyhlQyrkijHkh ?kj ds yksxksa dh rkjhQ dh tkrhgSA
101
10- EkkewyhvlQyrkijHkh ?kj ds yksxksd
a ksNksVkfn[kk;ktkrkgSA
11- gekjs ifjokj esv

a ko';deqnn~kisa j [kkl /;kufn;ktkrkgSA
12- gekjs ifjokj esv

a ko';deqnn~kisa j [kkl /;kuughafn;ktkrkgSA
13- ijs'kkuh ds eqnn~ksaijgekjs ?kj ds yksx fey djckrsdjrsgSA
14- ijs'kkuh ds oDr ?kj ds lnL; dksviusvkigy<w<+us ds fy, NksM+ fn;ktkrkGsa
15- ijs'kkuh ds le; esga esnksLrks]a iM+ksfl;ksavksjfj'rsnkjksa ls mruhghennfeyrhgS] ftruhfd ifjokj ds lnL;ksalsA
16- Tk:jr ds le; esa ifjokj ds lnL;ksa ls enn u feyus ds

dkj.kgesea tcwjuiM+ksfl;ksavkSjnksLrksaijfuHkZjgksukiM+rkgSA
17- ijs'kkfu;ksa ds oDr ifjokj ds eqdkcysnksLrksavksjiM+ksfl;ksa ls T;knkennfeyrhgSA
18- gekjhsifj'kkfu;ksa es nksLrksavksjiM+ksfl;ksa ls enn u feyus ds dkj.kgesLa o;alsohvkSjljdkjhlaLFkkvksa ls

ennysuhiM+rhgSA
19- gekjscjq sgkykresea nnek¡xus ds fy, Lo;alsohlaxBu] ljdkjh ;k /kkfeZdlaLFkkughgSA
20- Ckqjos Dresca kgjhlaLFkk, gekjhijokgughadjrhA
102
21- eqlhcr ds le; ifjokj ds yksx le>ughaikrsfdosD;kdjsvkSjdgk¡ tk,aA
22- gekjs ifjokj esga j ,ddksfo'ks"kdkefn;ktkrkgSA
23- lnL;ksadksdkedjus dk rjhdkcrk;ktkrkgSA
24- lHkhlnL; tkursga SafdmUgsDa ;kdkedjukpkfg,A
25- LknL;ksa ls ;g mEehngSfdosviuhftEesnkfj;k¡ crk, x;srfjds ds eqrkfcdfuHkk,¡A
26- lnL; fn;sx;sdkeksa ds vkykoknwljsvkSjdkeHkhdjrsgSaA
27- lnL;ksa ls ;g mEehn dh tkrhgSfdosfn, x, dkeksa ds vykokvkSjdkeHkhdjsAa
28- lnL; gk¡ dgus ds ckotwnHkhvfrfjDrdkeughadjrsA
29- Ifjokj ds fdlhHkhlnL; dks [kkl@fo'ks"kdkeughafn;ktkrkA
30- lnL; dksviukdke [kqndjus dh NwVgSA
31- lnL;ksadks ;g ekyweughagSafdosdkSulkdkedSlsdjsaA
103
32- lnL; ,dnwljsdksdkedjuseesa nnnsrgas SaA
33- lnL; viukdkedjusensa wljs dh ennysukeqf'dy le>rsgSaA
34- lnL; viusdkeksa ds vykoknwljksa ds dkeHkhtkursga SaA
35- ifjokj esadksÃHkhfdlh ds dkeksd

a ksvPNhrjgughatkurkgSA
36- ifjokj esadkSu] D;kvkSjfdrukdjsa bl ckrij>xM+kgkstkrkgSA
37- ifjokj esa ,dghdkedks ,d lkFkdÃyksxdjrsga SaA
38- gekjs ifjokj ds lnL; viukdke u djdsnwljksa dk dkedjukilandjrsga SaA
39- ifjokj esalnL; ,dnwljs ds dkeesaVksdk&Vkdhdjrsga SaA
40- gekjs ifjokj esfa dlhlnL; ds dke u djusdksutjUnktughafd;ktkrkgSA
41- ifjokj esa [kkldkeksd

a ksdkSudSld
s jsxk ;g r; gSA
42- gekjs ifjokj esga j ,ddksviuhÃPNk ds vuqlkjdkedjus dh vktknhgSA
104
43- Ikfjokjesga j ,ddksviusrjhds ls dkedjus dh NwVgSA
44- Ikfjokjesfa n;s x, dkeksa ds vfrfjDrdkedjuset

sa kseqf'dygksrhgSlnL; mlscrkldrsagSaA
45- lnL;ksadksviukdkedjused
sa ksÃeqf'dyughagksrhgSA
46- lnL; viukdkevklkuhvkSjdq'kyrk @ c[kwch ls djldrsgSA
47- dkegqvk ;kughabldhfdlhdksHkhdksÃijokgughaA
48- ifjokj esa ,dnwljs dh ckr le>ukvklkugSA
49- ifjokj esa ,dnwljsdksdgus ds fy, cgqrdqNgksrkgSA
50- lnL; viust:jr ds fy, ftllsHkhenn pkgs] vklkuh ls dg ldrsgSA
51- TkclnL; ckrdjrsgaSrksnwljsoghvFkZfudkyrsgSa ;keryc@le>rsgSaA
52- vkil dh ckr&fpresd

a qNlnL; de T;knkcksyrsga SA
53- lnL; ,dnwljs ls ckrdjusev

sa klkuhvkSjvktknheglwldjrsga SaA
54- ifjokj esatcHkhdksÃfdlh ls ckrdjrkgSrksmlsvulqukdj] nqljsviuk&viukdkedjrsja grsga SA
105
55- ifjokj est

a :jrgksusijghyksxvkilesca krdjrsga SaA
56- Ifjokj esv

a kerkSj ls brukdqNckrdjusdksgksrkgS] fddgk¡ ls vkSjfdlrjgckr 'kq: dh tk;] ;g
le>ukeqf'dygksrkgSA
57- lnL; vius&vkinwljs ds f[kykQckrdjrsga Sagkykfd bls vPNkugha le>k tkrkA
58- Cksdkj dh ckrksea sa my>us ds ctk; gepqijgukilUndjrsga SaA
59- ifjokj esadkSu] fdlls] fdrukckrdjsablds ckjs esfa u;egSA
60- fdlh ,ddkedksdjus ds fy, lnL; nksfojks/khrjhdksd

a kscrkusey
sa xsjgrsgSA
61- ifjokj esa ,d le; ijdÃelys ,d lkFkmBk;stkrsagSaA
62- ifjokj esatceqn~nksaijckr dh tkrhgSrksmls le>ukeqf'dygksrkgSA
63- tcHkh ifjokj esafdlh ,d [kklfo"k; ijckrgksrhgSrksnl

w jschpesaughavkrsga SaA
64- TkcdqNeqn~nksaij ifjokj esca krgksrhgSrkslnL; mllsgVdjnwljhckrsdjrsagSaA
106
65- tcHkh [kkleqnn~ ksia jckrfprgksrhgSrkscPpksadksnwjj[kk tkrkgSA
66- lnL; [kkleqn~nksijckr&phrdjrsoDrnwljksa ls lykge'kfojkysukcqjkughaekursaA
67- gekjs ifjokj es lHkht:jrsa ,d ghlnL; ds tfj;sdgh@crk;htkrhgSA
68- dÃgkykrdksysdjgekjs ?kjesl

a nL; iwjhvktknh ls viuhHkkouk,¡ dg ldrsagSaA
69- Tkc ?kj ds nwljsyksxlykge'kfojkdjrsgSrkslnL; mlsilUnughadjrsAa
70- ifjokj esadÃ ,slsHkh le; vkrsgStcgekjsiklckrdjus ds fy, dqNughagksrkA
71- ifjokj esalnL; viuhHkkouk,¡ [kqydjfn[kk ughaldrsagSaA
72- ge ,dnwljs ls dqNHkhdgrsgSa /;ku ls dgrsagSaA
73- ifjokj esarjg&rjg ds gkykresl

a nL; viuhHkkoukviusrdghj[kukilUndjrsga SaA
74- gevius ifjokj esa ,dlkFkfeytqydjjgukilUndjrsga SaA
75- ifjokj esalnL; dÃphts@

a dkelkFk&lkFkdjukilUndjrsga SaA
107
76- ifjokj esaeuksjatudk;ZØefeytqydjcuk;ktkrkgSA
77- Ikfjokj ds lnL; vius&viusdkedjukilUndjrsga SaA
78- ifjokj ds lnL; feytqydjiwjs ifjokj ds fy, dkedjukilUndjrsagSaA
79- ifjokj esa ,d nwljsds :fp@dk;ZØe dh fdlhdksijokgughaA
ifjokj ds lnL;ksadks ;g dksÃ t:jh ughagSfdogfeytqydjjgsaA
80-
81- ifjokj ds lHkhlnL; de ls de fnueas ,dckjlkFkjgus dh bPNk j[krsagSaA
82- ifjokj ds lnL; viusdqNdk;ZØeviusrdgh j[krsga SaA
83- ;g t:jh gSfd ifjokj esl

a HkhlnL; fnuesa de ls de ,d ckj ,d lkFkfeysAa
84- Tkciwjkifjokj ,dlkFkgksrkgSrks ikfjokfjd mRlo@R;ksgkj [kq'kh ds ekSdsgksrgsa SaA
85- ifjokj ds lnL; feytqydj ?kj ls ckgj /kweus&fQjus dh ;kstukughacukrsaA
86- vko';dckrksaijHkh ifjokj ds lnL; tkucw>djHkkx ugh ysr@

sa ijokg ugh djrsAa
108
87- ifjokj esalnL; ,dnwljsdksuhpkfn[kkrsagSaA
88- ifjokj ds lHkhlnL; ,dnwljs dh ijokgdjrsga SaA
89- tc ifjokj ds lnL;ksa ds ikldqN [kkldjusdksughagksrkrcos ,d lkFk o[r fcrkukilUndjrags SA
90- ifjokj esa ,dlnL; dksigpkudjuk;d@yhMj@usrkekukx;kgSA
91- ijs'kkuhesl
a Hkhusrk@yhMj@uk;d dh lykgysrgsa SaA
92- ifjokj ds jkstejkZ ds dkeksa dh ns[kHkky ifjokj dk yhMjdjrkgSA
93- ifjokj esa ,dusrk@yhMj@uk;d dk gksukmruk t:jh ughagSA
94- ifjokj ds lnL;ksa ls lykge'kfojkfd;sfcukghusrk@yhMjlcrjg ds QSlysysrkgSA
95- usrk@yhMjlHkhlnL;ksa ls lykge'kfojkdjdsQSlysy

a srkgSA
96- ifjokj ls tqM+hckrksia jgj ,dvius&viusQSlysysrkgSA
97- usrk@yhMj ds QSlyksa dh ifjokj ds vU; lnL; ijokgughadjrsA
109
98- TkclnL; ijs'kkfu;ksa dk lkeukdjrsgaSrcogusrk@yhMj dh t:jr eglwldjrsga SaA
99- Ikfjokj ds lnL;ksa dh iwjhlgefr u gksusijHkhusrk@yhMjeqn~nksaijviukQSlykysysrkgSA
100- lHkhdksvius ckjs esQ

a Slysysus dh dkQhvktknhgSA
101- ,dckjQSlykysus ds cknmlscnyukeqf'dygSA
102- QSlys r; gkstkusijmUgsaykxwdjfn;ktkrkgSA
103- lnL;ksadks ifjokj ds vgeeqn~nksaijQSlysysus dh iwjhvktknhnhtkrhgSA
104- lHkhlnL;ksa ds futhekeyksa ds QSlysusrk@yhMjysrkgSA
105- ftudksQSlysdjusgSogt:jriM+usijghQSlysdjrsga SaA
106- Ikfjokjesoa kLroesfa dlhdksHkhusrk@yhMjughadgktkldrkA
Reference:
Bhatti, R.S, Krishna, D.S., & Ageira, B.L., (1986). Validation of family interaction
patterns scale. Indian Journal of Psychiatry, 28(3), 211.
110
Co-dependency Assessment Tool. (CODAT)(Hughes-Hammer et al., 1998)
This tool can be measured by the 1-5 tools, like
5- Most of the time.
4- Usually.
3 - Often.
2- Occasionally.
1- Rarely.
Self-neglect
1. I feel compelled or forced to help other people solve their problems.

2. I try to control events and how other people should behave.
3. I become afraid to let other people be who they are and allow events to happen
naturally.
4. I try to control events and people through helplessness, guilt, coercion, threats,
advice-giving, manipulation, or domination.
5. I feel compelled or forced to help people solve their problems (ie, offering
advice).
Self-worth
6. I feel ashamed of who I am.

7. I pick on myself for everything, including the way I think, feel, look, act, and
behave.
8. I blame myself for everything too much.
9. I feel humiliated or embarrassed.
10. I hate myself.
Hiding self
11. I put on a happy face when I am really sad or angry.

12. I keep my feelings to myself up a good front.
13. I hide myself so that no one really knows me.
14. I keep my emotions under tight control.
15. I push painful thoughts and feelings out of my awareness.
Medical problems
111
16. I worry about having stomach, liver, bowel, or bladder problems.
17. I am preoccupied with the idea that my body is failing me.
18. I feel that my general health is poor compared with my family and friends.
19. I feel ill and run down.
20. I have stomach, bladder, or bowel trouble.
Family of origin issues
21. When I was growing up, my family didn’t talk openly about problems.
22. I grew up in a family that was troubled, unfeeling, chemically dependent, or
overwrought with problem.
23. My family expressed feelings and affection openly when I was growing up.
24. I am unhappy now about the way my family coped with problems when I was
growing up
25. . I am unhappy about the way my family communicated when I was growing
up.
Reference:
Hughes-Hammer, C. Martsolf, D.S. Zeller, R.A. (1998 Oct 1) .Development and testing
of the Co-dependency Assessment tool. Archives of Psychiatric Nursing, 12(5),
264-72.
112
113
{Module Name} Module
Addiction Severity Index - 5th Edition
Clinical/Training Version
A. Thomas McLellan, Ph.D. HOLLINGSHEAD CATEGORIES:

Deni Carise, Ph.D. 1. Higher execs, major professionals, owners of large businesses.
Thomas H. Coyne, MSW 2. Business managers if medium sized businesses, lesser professions, i.e.,
nurses, opticians, pharmacists, social workers, teachers.
T. Ron Jackson, MSW
3. Administrative personnel, managers, minor professionals, owners/
Remember: This is an interview, not a test proprietors of small businesses, i.e., bakery, car dealership, engraving
business, plumbing business, florist, decorator, actor, reporter, travel
Item numbers circled are to be asked at follow-up. agent.
Items with an asterisk * are cumulative and should be rephrased at 4. Clerical and sales, technicians, small businesses (bank teller,
bookkeeper, clerk, draftsperson, timekeeper, secretary).
5. Skilled manual - usually having had training (baker, barber, brake
INTRODUCING THE ASI: Introduce and explain the seven potential person, chef, electrician, fireman, machinist, mechanic,
problem areas: Medical, Employment/Support Status, Alcohol, Drug, paperhanger, painter, repairperson, tailor, welder, police, plumber).
Legal, Family/Social, and Psychiatric. All clients receive this same 6. Semi-skilled (hospital aide, painter, bartender, bus driver, cutter, cook,
standard interview. All information gathered is confidential; explain what drill press, garage guard, checker, waiter, spot welder, machine
that means in your facility; who has access to the information and the operator).
process for the release of information. 7. Unskilled (attendant, janitor, construction helper, unspecified labor,
There are two time periods we will discuss: porter, including unemployed).
1. The past 30days
2. Lifetime
LIST OF COMMONLY USED DRUGS:
Patient Rating Scale: Patient input is important. For each area, I will ask Alcohol: Beer, wine, liquor
you to use this scale to let me know how bothered you have been by any Methadone: Dolophine,LAAM
problems in each section. I will also ask you how important treatment is Opiates: Pain killers = Morphine, Diluaudid, Demerol,
for you for the area being discussed. Percocet, Darvon, Talwin, Codeine, Tylenol 2,3,4,
Thescaleis: 0 - Not at all Robitussin,Fentanyl
1 -Slightly Barbiturates: Nembutal, Seconal, Tuinol, Amytal,Pentobarbital,
2 -Moderately Secobarbital, Phenobarbital, Fiorinol
3 -Considerably Sed/Hyp/Tranq: Benzodiazepines = Valium, Librium, Ativan,Serax
Tranxene, Xanax, Miltown,
4 -Extremely Other = Chloral Hydrate (Noctex),
Inform the client that he/she has the right to refuse to answer any question. Quaaludes Dalmane, Halcion
If the client is uncomfortable or feels it is too personal or painful to give an Cocaine: Cocaine Crystal, Free-Base Cocaine or “Crack,” and
answer, instruct the client not to answer. Explain the benefits and “Rock Cocaine”
advantages of answering as many questions as possible in terms of Amphetamines: Monster, Crank, Benzedrine, Dexedrine, Ritalin,
developing a comprehensive and effective treatment plan to help them. Preludin, Methamphetamine, Speed, Ice, Crystal
Cannabis: Marijuana, Hashish
Hallucinogens: LSD (Acid), Mescaline, Mushrooms (Psilocybin),Peyote,
Please try not give inaccurate information! Green, PCP (Phencyclidine), Angel Dust,Ecstacy
Inhalants: Nitrous Oxide, Amyl Nitrate (Whippits,Poppers),
Glue, Solvents, Gasoline, Toluene, Etc.
INTERVIEWER INSTRUCTIONS:
1. Leave no blanks. Just note if these reused: Antidepressants,
2. Make plenty of Comments (if another person reads this ASI, they Ulcer Meds = Zantac, Tagamet
Asthma Meds = Vento line Inhaler,
should have a relatively complete picture of the client's perceptions of Theodur Other Meds = Antipsychotics,
his/her problems). Lithium
3. -9 = Question not answered.
-8 = Question not applicable. ALCOHOL/DRUG USE INSTRUCTIONS:
4. Terminate interview if client misrepresents two or more sections. The following questions refer to two time periods: the past 30 days and lifetime.
5. When noting comments, please write the question number. Lifetime refers to the time prior to the last 30 days.
 30 day questions only require the number of days used.
HALFTIMERULE: If a question asks the number of months,  Lifetime use is asked to determine extended periods of use.
round up periods of 14 days or more to 1  Regular use = 3+ times per week, binges, or problematic irregular
month. Round up 6 months or more to 1 use in which normal activities are compromised.
year.  Alcohol to intoxication does not necessarily mean "drunk", use the
words “to feel or felt the effects", “got a buzz”, “high”, etc.
Instead of intoxication. As a rule of thumb, 3+ drinks in one
CONFIDENCE RATINGS: Last two items in each section. sitting, or 5+ drinks in one day defines “intoxication".
Do not over-interpret.  How to ask these questions:
Denial does not warrant  “How many days in the past 30 haveyouused ..... ?”
misrepresentation. “How many years in your life have youregularlyused. ...... ?”
Misrepresentation = overt contradiction in
information.
Probe, cross-check and make plenty of comments!

{Module Name} Module
Addiction Severity Index - 5th Edition
Clinical/Training Version
AgencyName: SiteName:
ID#: Date: / /
GENERAL INFORMATION
G1. ID Number GENERAL INFORMATION COMMENTS
G4. Date of Admission / / (Include the question number with your notes)
mm/dd/yyyy
G5. Date of Interview / /

mm/dd/yyyy
G6. Time Begun :

Use 24 hr clock; code hours: minutes
G7. Time Ended :

Use 24 hr clock;codehours:minutes HRS MINS
G8. Class
1- Intake 2 - Follow-up
G9. Contact Code
1 -In person 2 - Telephone (Intake ASI must be in person)
G10. Gender
1- Male 2 -Female
G99. Treatment Episode Number
G11. Interviewer Code Number
G12.Special
1 - Patient terminated
2 - Patient refused
3 - Patient unable to respond
G14. How long have you lived at your current /

address? YRS MOS
G15. Is this residence owned by you or your family?
0 -No 1 - Yes
G16. Date of birth / /

mm/dd/yyyy
G17 Of what race do you consider yourself?
1 - White(notHisp) 5 - Asian/Pacific
2 - Black(not Hisp) 6 - Hispanic-Mexican
3 -American Indian 7 - Hispanic-Puerto Rican
4 -Alaskan Native 8 -Hispanic-Cuban
9 -Unknown
G18. Do you have a religious preference?
1 -Protestant 4 - Islamic
2 -Catholic 5 -Other
3 -Jewish 6 -None
G19. Have you been in a controlled environment in
the past 30days?
1 -No 4 - Medicaltx
2 -Jail/prison 5 - Psychiatric tx
3 - Alcohol ordrugtx 6 -Other
A place, theoretically, without access to drugs/alcohol.
G20. How manydays?
If G19 is No, code -8.
Refers to total number of days detained in the past 30 days.
MEDICAL STATUS
M1. * How many times in your life have you been MEDICAL COMMENTS
hospitalized for medical problems? (Include the question number with your notes)
Include O.D.’s and D.T.’s. Exclude detox, alcohol/drug, psychiatric treatment
and childbirth (if no complications). Enter the number of overnight
hospitalizations for medical problems.
M2. How long ago was your last hospitalization for /
physical problem? YRS MOS
If no hospitalizations in Question M1, then code -8 / -8.
M3. Do you have any chronic medical problems which

continue to interfere with your life?
0-No 1 - Yes
If Yes, specify in comments.
A chronic medical condition is a serious physical condition that requires regular
care (i.e., medication, dietary restriction) preventing full advantage of their
abilities.
M4. Are you taking any prescribed medication on a

regular basis for a physical problem?
0-No 1 - Yes
Medication prescribed by a MD for medical conditions; not psychiatric
medicines. Include medicines prescribed whether or not the patient is currently
taking them. The intent is to verify chronic medical problems.
M5. Do you receive a pension for a physical disability?

0-No 1 - Yes
Include Workers’ compensation, exclude psychiatric disability.
M6. How many days have you experienced medical

problems in the past 30days?
Include flu, colds, etc. Include serious ailments related to drugs/alcohol, which
would continue even if the patient were abstinent (e.g., cirrhosis of liver,
abscesses from needles, etc.).
For Questions M7 & M8, ask patient to use the Patient Rating Scale
M7. How troubled or bothered have you been by these
medical problems in the past 30days?
Restrict response to problem days in Question M6.
M8. How important to you now is treatment for these medical

problems?
If client is currently receiving medical treatment, refer to the need for
additionalmedical treatment by the patient.
INTERVIEWER SEVERITY RATING

M9. How would you rate the patient’s need for medical
treatment?
Refers to the patient’s need for additional medical treatment.
CONFIDENCE RATINGS
Is the above information significantly distorted by:
M10. Patient’s misrepresentation?
0-No 1 - Yes
M11. Patient’s inability to understand?
0-No 1 - Yes
EMPLOYMENT/SUPPORT STATUS
E1. *Education completed / EMPLOYMENT/SUPPORT COMMENTS
GED = 12 years, (Include the question number with your notes)
note incomments. YRS MOS
Include formal educationonly.
E2. * Training or technical education completed

Formal,
organized training only. For militarytraining,only MOS
include training that can be used in civilian life (i.e., electronics,
computers).
E3. Do you have a profession, trade, or skill?

0-No 1 - Yes
Employable, transferable skill acquired through training.
If Yes, specify:
E4. Do you have a valid driver’s license?

0-No 1 - Yes
Valid license; not suspended/revoked.
E5. Do you have an automobile available for use?

0-No 1 - Yes
If answer to E4 is No, then E5 must be No.
Does not require ownership, only requires availability on a regular basis.
E6. How long was your longest full-time job? /

Full-time = 35+
hours weekly; does not necessarilymean YRS MOS
most recent job.
E7. * Usual (or last)occupation

Specify
Use Hollingshead Categories Reference Sheet
E8. Does someone contribute to your support in anyway?

0-No 1 - Yes
Is patient receiving any regular support (i.e., cash, food, housing) from family/
friend. Include spouse’s contribution; exclude support by an institution.
E9. Does this support constitute the majority of your
support?
0-No 1 - Yes
If E8 is No, then E9 is -8.
E10. Usual employment pattern, past 3years?

1 - Full time(35+hours) 5 - Military service
2 - Part time(regular hours) 6 - Retired/disability
3 - Part time(irregular hours) 7 -Unemployed
4- Student 8 - In controlled environment
Answer should represent the majority of the last 3 years, not just the most
recent selection. If there are equal times for more than one category, select
that which best represents the current situation.
E11. How many days were you paid for working in the
past 30days?
Include “under-the-table” work, paid sick days and vacation.
EMPLOYMENT/SUPPORT STATUS (cont)
For questions E12-E17: EMPLOYMENT/SUPPORT COMMENTS
How much money did you receive from the following sources in
(Include the question number with your notes)
the past 30 days?
E12. Employment $ ,
Net or “take home” pay, include any “under the
table” money.
E13. Unemployment compensation $ ,

E14. Welfare $ ,
Include food stamps, transportation money
provided by an agency to go to and from treatment.
E15. Pension, benefits or social security $ ,

Include disability, pensions, retirement, veteran’s
benefits, SSI & workers’ compensation.
E16. Mate, family or friends $ ,

Money for personal expenses (i.e., clothing);
include unreliable sources of income.
Record cash payments only, include windfalls
(unexpected), money from loans, legal gambling,
inheritance, tax returns, etc.
E17. Illegal $ ,
Cash obtained from drug dealing, stealing, fencing
stolen goods, illegal gambling, prostitution, etc.
Do not attempt to convert drugs exchanged to a
dollar value.
E18. How many people depend on you for the majority

of their food, shelter,etc.?
Must be regularly depending on patient; do include alimony/child support, do not
include the patient or self-supporting spouse, etc.
E19. How many days have you experienced employment

problems in the past30?
Include inability to find work, if they are actively looking for work, or problems
with present job in which that job is jeopardized.
For Questions E20 & E21, ask patient to use the Patient Rating Scale
E20. How troubled or bothered have you been by these
employment problems in the past 30days?
If the patient has been incarcerated or detained during the past
30 days, they cannot have employment problems. In that case,
code -8.
E21. How important to you now is counseling for these

employment problems?
Stress help in finding or preparing a job, not giving them a job.

E22. How would you rate the patient’sneed for
employment counseling?
CONFIDENCE RATINGS
E23. Client’s misrepresentation?
0-No 1 - Yes
E24. Client’s inability to understand?
0-No 1 - Yes
ALCOHOL/DRUGS
Route of Administration Types:
1-Oral 2-Nasal 3-Smoking 4 -Non-Injection 5 -IV
Note the usual or most recent route. For more than one route, choose the most
severe. The routes are listed from least severe to most severe.
A. B. C. ALCOHOL/DRUGS COMMENTS
Past 30 Lifetime Route of (Include the question number with your notes)
Days (Years) Admin
D1. Alcohol (any use at all)
D2. Alcohol (to intoxication)
D3. Heroin
D4. Methadone
D5. Other Opiates/Analgesics
D6. Barbiturates
D7. Other Sedatives/Hypnotics/

Tranquilizers
D8. Cocaine
D9. Amphetamines
D10. Cannabis
D11. Hallucinogens
D12. Inhalants
D13. More than one substance per day

Including alcohol
D14. According to the interviewer, which substance is/are

the major problem?
Interviewer should determine the major drug or drugs of abuse.
Code the number next to the drug in questions D1-D12, or:
00 = no problem
15 = alcohol & one or more drugs
16 = more than one drugs but no alcohol.
Ask patient when not clear.
D15. How long was your last periodofvoluntary

abstinence from thismajorsubstance? MOS
Last attempt of at least one month, not necessarily the longest. Periods of
hospitalization/incarceration do not count. Periods of ant abuse, methadone,
or naltrexone use during abstinence do count.
00 = never abstinent
D16. How many months ago did this abstinence end?
If D15 = 0, then D16 = -8, 00 =Still abstinent MOS
ALCOHOL/DRUGS (cont)
D17.* How many times have you had Alcohol D.T.’s? ALCOHOL/DRUGCOMMENTS
Delirium Tremens(DTs):Occur24-48hoursafterlastdrink, (Include the question number with your notes)
or significant decrease in alcohol intake, shaking, severe
disorientation, fever, hallucinations, they usually require
medical attention.
D18.* How many times have you overdosed on drugs?

Overdoses (OD): Require requires intervention by someone
to recover, not simply sleeping it off, include suicide attempts
by OD.
How many times in your life have you been treated for:
D19.* Alcohol abuse?
D20.* Drug abuse?

Include detoxification, halfway houses, in/outpatient counseling,
and AA or NA (if 3+ meetings within one month period).
How many of these were detox only?
D21.* Alcohol?
If D19 = 0, then D21 = -8
D22.* Drugs?
If D20 = 0, then D22 = -8
How much money would you say you spent during the past 30
days on:
D23. Alcohol? $ ,
D24. Drugs? $ ,
Only count actual money spent. What is the financial burden caused by
drugs/alcohol?
D25. How many days have you been treated in an

outpatient setting for alcohol or drugs in the past
30 days?
Include AA/NA
How many days in the past 30 have you experienced:

D26. Alcohol problems?
D27. Drug problems?
Include craving, withdrawal symptoms, disturbing effects of use, or wanting to
stop and being unable to.
For Questions D28 - D31, ask patient to use the Patient Rating Scale
How troubled or bothered have you been in the past 30 days by
these:
D28. Alcohol problems
D29. Drug problems
How important to you now is treatment for these:
D31. Drug problems
How would you rate the patient’s need for treatment for:
D33. Drug problems
CONFIDENCE RATINGS
D34. Client’s misrepresentation?
0-No 1 -Yes
D35. Client’s inability to understand?
0-No 1 -Yes
LEGAL STATUS
L1. Was this admission prompted or suggested by the LEGAL COMMENTS
criminal justice system? (Include the question number with your notes)
0-No 1 - Yes
Judge, probation/parole officer, etc.
L2. Are you on probation or parole?

0-No 1 - Yes
Note duration and level in comments.
How many times in your life have you been arrested and
charged with the following?
L3. * Shoplifting/Vandalism
L4. * Parole/Probation Violations
L5. * Drug Charges
L6. * Forgery
L7. * Weapons Offense
L8. * Burglary/Larceny/Breaking &Entering
L9. * Robbery
L10.* Assault
L11.* Arson
L12.* Rape
L13.* Homicide/Manslaughter
L14.* Prostitution
L15.* Contempt of Court
L16.* Other:
Include total number of counts, not just convictions.
Do not include juvenile (pre-age 18) crimes, unless they were tried as an adult.
Include formal charges only.
L17.* How many of these charges resulted in convictions?

If L3-16 = 00, then Question L17 = -8.
Do not include misdemeanor offenses from questions L18-20 below.
Convictions include fines, probation, incarcerations, suspended sentences,
guilty please, and plea bargaining.
How many times in your life have you been charged with the
following:
L18.* Disorderly conduct, vagrancy,publicintoxication
L19.* Driving while intoxicated
L20.* Major driving violations
Moving violations: speeding, reckless driving, no license, etc.
L21.* How many months were you incarcerated in your

life?
If incarcerated 2 weeks or more, round this up to1month. MOS
List total number of months incarcerated.
L22. How long was your last incarceration?

Of 2 weeks or more. Code -8 ifneverincarcerated. MOS
L23. What was it for?

Use codes 03–16, 18–20
If multiple charges, code most severe. Code -8 if
never incarcerated.
L24. Are you presently awaiting charges, trial, or sentence?

0-No 1 -Yes
L25. What for?
Refers to Question L24. Use the number of the type of crime
committed: 03-16 and 18-20. If multiple charges, code most severe.
LEGAL STATUS (cont)
L26. How many days in the past 30 were youdetainedor LEGAL COMMENTS
incarcerated?
Include being arrested and released on the same day.
L27. How many days in the past 30 have youengagedin

illegal activities forprofit?
Exclude simple drug possession. Include drug dealing,
prostitution, selling stolen goods, etc. May be cross-checked
with E17 under Employment section.
For Questions L28 & L29, ask patient to use the Patient Rating Scale
L28. How serious do you feel your present legal problems
are?
Exclude civil problems.
L29. How important to you now is counseling or referral

for these legal problems?
Patient is rating a need for additional referral to legal counsel for
defense against criminal charges.

L30. How would you rate the patient’s needforlegal
services orcounseling?
CONFIDENCE RATINGS
L31. Client’s misrepresentation?
0-No 1 - Yes
L32. Client’s inability to understand?
0-No 1 - Yes
FAMILY HISTORY
Have any of your blood-related relatives had what you would call a significant drinking, drug use or psychiatric problem?
Specifically, was there a problem that did or should have led to treatment?
0 - Clearly NO for all relatives in the category
1 - Clearly YES for any relative within category
-9 - Uncertain or don’t know
-8 - Never was a relative
In cases where there is more than one person for a category, record the occurrence of problems for any in that group.
Accept the patient’s judgment on these questions.
Mother’s Side Alc Drug Psych Father’s Side Alc Drug Psych Siblings Alc Drug Psych
H1. Grandmother H6. Grandmother H11. Brother
H2. Grandfather H7. Grandfather H12. Sister
H3. Mother H8. Father
H4. Aunt H9. Aunt
H5. Uncle H10. Uncle
FAMILY HISTORYCOMMENTS
FAMILY/SOCIAL RELATIONSHIPS
F1. Marital Status FAMILY/SOCIALCOMMENTS
1 -Married 4 -Separated (Include the question number with yournotes)
2 -Remarried 5 -Divorced
3 -Widowed 6 - Never married
Common-law marriage = 1. Specify in comments.
F2. How long have you been in thismaritalstatus? /

Refers to F1. If never married, then sinceage18. YRS MOS
F3. Are you satisfied with thissituation?
0-No 1-Indifferent 2 -Yes
Satisfied=client generally liking the situation.
Refers to F1 and F2.
F4. * Usual living arrangements (past 3 years)

1 - With sexual partner children 6 - With friends
2 - With sexualpartneralone 7 -Alone
3 - With children alone 8 - Controlled environment
4 -With parents 9 - No stable arrangement
5 - With family
Choose arrangements most representative of the past 3 years. If there is an
even split in time between these arrangements, choose the most recent
arrangement.
F5. How long have you lived inthesearrangements? /

If with parents
or family, sinceage18. YRS MOS
Code years and months living in arrangements fromF4.
F6. Are you satisfied with these arrangements?

0-No 1-Indifferent 2 - Yes
Do you live with anyone who:
F7. Has a currentalcoholproblem? 0-No 1 -Yes
F8. Usesnon-prescribeddrugs? 0-No 1 -Yes
Or abuses prescribed drugs
F9. With whom do you spend most of your free time?

1- Family 2-Friends 3 -Alone
If a girlfriend/boyfriend is considered as family by patient, then they must refer
to them as family throughout this section, not a friend.
F10. Are you satisfied with spending your free time this
way?
0-No 1-Indifferent 2 - Yes
A satisfied response must indicate that the person generally likes the situation.
Refers to F9.
F11. How many close friends do you have?

Stress that you mean close.
Exclude family members.
These are “reciprocal” relationships or mutually supportive
relationships.
Would you say you have had a close reciprocal relationship

with any of the following people:
F12. Mother
F13. Father
F14. Brothers/Sisters
F15. Sexual Partner/Spouse
F16. Children
F17. Friends
0 - Clearly NO for all in class -9 - Uncertain or “I don’t know”
1 - Clearly YES for any in class -8 - Never was arelative
By reciprocal, you mean “that you would do anything you could to help them
out and vice versa.”
FAMILY/SOCIAL RELATIONSHIPS (cont)
Have you had significant periods in which you have experienced FAMILY/SOCIALCOMMENTS
serious problems getting along with: (Include the question number with your notes)
0-No 1- Yes Past30Days In Your Life
F18. Mother
F19. Father
F20. Brothers/Sisters
F21. Sexual Partner/Spouse
F22. Children
F23. Other significant family
Specify:
F24. Close Friends
F25. Neighbors
F26. Co-Workers
“Serious problems” mean those that endangered the relationship.
A “problem” requires contact of some sort, either by telephone or in person.
If no contact, code -8.
Has anyone ever abused you?

0-No 1- Yes Past30Days In Your Life
F27. Emotionally?
Make you feel bad through harsh words
F28. Physically?
Caused you physical harm
F29. Sexually?
Force sexual advances/acts
How many days in the past 30 have you had serious conflicts:
F30. With your family?
F31. With other people? (excluding family)
For Questions F32 - F35, ask patient to use the Patient Rating Scale
How troubled or bothered have you been in the past 30 days by:
F32. Family problems
F33. Social problems
How important to you now is treatment or counseling for these:
F34. Family problems
Patients ratinghis/herneedforcounselingforfamilyproblems,
not whether they would be willing to attend.
F35. Social problems

Include patient’s need to seek treatment for suchsocialproblems
as loneliness, inability to socialize, and dissatisfaction with friends.
Patient rating should refer to dissatisfaction, conflicts, or other
serious problems.

F36. How would you rate the patient’s need forfamilyand/
or social counseling?
CONFIDENCE RATINGS
F37. Client’s misrepresentation?
0-No 1 - Yes
F38. Client’s inability to understand?
0-No 1 - Yes
PSYCHIATRIC STATUS
How many times have you been treated for any psychological or PSYCHIATRIC STATUS COMMENTS
emotional problems: (Include the question number with your notes)
P1. * In a hospital or inpatient setting?
P2. * Outpatient/private patient?
Do not include substance abuse, employment, or family counseling. Treatment
episode = a series of more or less continuous visits or treatment days, not the
number of visits or treatment days.
Enter diagnosis in comments if known.
P3. Doyoureceiveapensionforapsychiatricdisability?
0-No 1 - Yes
Have you had a significant period of time (that was not a direct
result of drug/alcohol use) in which you have:
0-No 1- Yes Past 30 Days In Your Life
P4. Experienced serious depression
Sadness, hopelessness, lossofinterest,
difficulty with daily functioning
P5. Experienced serious anxiety or
tensionUptight, unreasonably worried,
inability to feel relaxed
P6. Experienced hallucinations
Saw things/heard voices that others didn’t
see/hear
P7. Experienced trouble understanding,
concentrating or remembering
P8. Experienced trouble controlling violent
behavior including episodes or rage or
violence
Patient can be under the influence of alcohol/drugs.
P9. Experienced serious thoughts of suicide
Patient seriously considered a plan for taking his/
her life.
Patient can be under the influence of alcohol/drugs.
P10. Attempted suicide
Include actual suicidal gestures or attempts.
Patient can be under the influence of alcohol /
drugs.
P11. Been prescribed medication for any
psychological or emotional problems
Prescribed for the patient by a physician. Record
“Yes” if a medication was prescribed even if the
patient is not taking it.
P12. How many days in the past 30 haveyouexperienced

these psychological or emotional problems?
Refers to problems noted in Questions P4-P10.
For Questions P13 &P14, ask the patient to use the Patient Rating Scale
P13. How much have you been troubled or bothered by
these psychological or emotional problemsinthe
past 30days?
Patient should be rating the problem days from Question P12.
P14. How important to you now is treatmentforthese

psychological problems?
PSYCHIATRIC STATUS (cont)
The following items are to be completed by the interviewer: PSYCHIATRIC STATUS COMMENTS
At the time of the interview, thepatientwas: 0-No 1 -Yes (Include the question number with your notes)
P15. Obviously depressed/withdrawn
P16. Obviouslyhostile
P17. Obviously anxious/nervous
P18. Having trouble with reality testing, thought disorders,

paranoid thinking
P19. Having trouble comprehending, concentrating,

remembering
P20. Having suicidal thoughts

P21. How would you rate the patient’s needforpsychiatric/
psychological treatment?
CONFIDENCE RATINGS
P22. Client’s misrepresentation?
0-No 1 - Yes
P23. Client’s inability to understand?
0-No 1 - Yes
SEVERITY PROFILE
Problems 0 1 2 3 4 5 6 7 8 9
MEDICAL
EMPL/SUP
ALCOHOL
DRUG
LEGAL
FAM/SOC
PSYCH
Reference:
McLellan, A.T. Kushner,H. Metzger, D. Peters ,R. Smith, I. Grissom,G. Pettinati, H. Argeriou, M.
(1992 Jun 1) The fifth edition of the Addiction Severity Index. Journal of substance abuse
treatment. 9(3), 199-213.

Co-dependency and Family Interaction in Spouses of Persons with Alcohol and Opioid Dependence

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Co-dependency and Family Interaction in Spouses of Persons with Alcohol and Opioid Dependence

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CO-DEPENDENCY AND FAMILY INTERACTION PATTERN OF THE SPOUSES OF

PERSONS WITH ALCOHOL AND OPIOID DEPENDENCE SYNDROME:

Under the Joint Guidance of

Prof. (Dr.) Basudeb Das, M.D.

Professor, Department of Psychiatry

Asst. Professor, Department of Psychiatric Social Work,

SUBMITTED TO RANCHI UNIVERSITY IN PARTIAL FULFILMENT OF THE

Interaction Pattern Of The Spouses Of Persons With Alcohol And Opioid

dependence Syndrome: A Comparartive Study" has been carried out by me, at

Assistant professor of Psychiatric Social Work, Central Institute of Psychiatry,

of Psychiatry, Ranchi, pursuing the course of Master of Philosophy in Psychiatric

Social Work of Ranchi University for the session 2017-2019.

The study titled “Co-Dependency And Family Interaction Pattern Of The

Spouses Of Persons With Alcohol And Opioid Dependence Syndrome: A

approved for submission to Ranchi University in partial fulfillment of Master of

Philosophy in Psychiatric Social Work.

“My teachers are my shepherd”

I owe to my teacher Prof (Dr.) D. Ram, Director for giving me an opportunity to

S.L. No TITLE Pages

3 AIM,OBJECTIVE & HYPOTHESES 43

7 SUMMARY AND CONCLUSION 75

8 LIMITATION & FUTURE DIRECTION 76

Cermak (1984) defined codependence as "people whose lives had become

Mohammadkhani (2009) explained addiction can have adverse effects on morality in

Need for the Study

Alcoholism is a disease of the family. Alcoholism is linked to disrupted family role,

Arnold (1990) defined co-dependency as a belief that when “someone or something

Mulry (1987) described co-dependency in a family addiction. Co-dependency is a

Martsolfet al. (1999) compared the co-dependency in a group of 77 female and a

Ançel andKabakçi (2009)evaluated the psychometric properties of the Co-

Rusnáková (2014) studied the process of co-dependency, focusing primarily on the

Hawkins and Hawkins II (2014) explored the relationship between co-dependence,

Zaidi (2015) explored the relationship of co-dependency and relationship satisfaction

Gorad (1971) conducted a study to explore communication styles and interaction of

Gantman. (1978) evaluated family interaction patterns and the symptomatology of

Jacob et al. (1981)conducted a cross - sectional study to evaluate communication

Dhanasekara et al. (2017) aimed to describe family interaction patterns of persons

Barry and Fleming (1990) conducted a study to examine family cohesion,

Floyd et al. (2006) examined problem-solving marital interactions of alcoholic and

Rangarajan and Kelly (2006) attempted to explore family communication patterns,

Schäfer (2008) conducted a Multiple Family Group (MFG) treatment in an 18-week

Schäfer (2011) conducted in - depth interviews with 12 participants who were

Malik et al. (2012) assessed the impact of substance dependence on primarycare-

Stanley (2012) conducted a study to examine the differences in the interpersonal

Nebhinani et al.(2013)conducted a cross-sectional study with Injecting Drug User

Vaishnavi et al. (2017) conducted a cross-sectional descriptive study with 200

Pourmovahed et al. (2013) conducted a descriptive cross-sectional study, they used a

Bhattacharjee et al. (2013)assessed the perceived family environment in spouses of

Bortolon et al. (2016) conducted a cross-sectional study to identify the symptoms of

Saroopachary et al. (2019) conducted cross-sectional hospital-based study,to

Aim of the study

The objectives of the study were as follows:

 To assess and compare co–dependency and family interaction pattern in spouses of

The hypotheses of the study were as follows:

 There would be no significant difference in co-dependence and family interaction

 There would be no significant relation among co-dependency and family interaction

Inclusion Criteria for Patients

 Diagnosed Patients with alcohol dependence syndrome as per ICD-10 DCR

 Diagnosed Patients with opioid dependence syndrome as per ICD-10 DCR

 Age range of the patients between 25 - 50 years.

 Must be living with the wives in the same house.

 Those who gave written informed consent for the study.

 Must be living with the patients in the same household.