5. Cultural Norms Stereotypes DX - RonaldMah

Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist,
Consultant/Trainer/Author
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Mine, Yours, and Ours, Addiction and Compulsivity in Couples and Couple Therapy
Chapter 5: CULTURAL NORMS AND STEREOTYPES AND DIAGNOSIS


Compulsive alcohol use, drug use, and disruptive behavior is often considered more typical of men than women.  And women seen to more typically care for or seek to influence such men.  Gender distinctions are apparent but not consistent in research.  "Women, compared to men, were more likely to attempt to control the health of their partners.  Similarly, Franks and colleagues (2002) found a unidirectional influence.  In their study of smoking cessation among married couples, they found that 'wives' lifestyle choices regarding smoking behavior may have a greater impact on men's lifestyle changes than the reverse' (page 350).  In contrast, others have found that it is the husband's behaviors that influence his wife.  For example, in two separate longitudinal studies of alcohol use in newlyweds (Leonard & Das Eiden, 1999; Leonard & Mudar, 2003), support was found for husbands influencing their wives' drinking over the transition to marriage, but not the reverse.  However, the directionality of this influence pattern later changed.  Although husbands' premarital drinking was predictive of wives' drinking at the couple's first anniversary, wives' drinking at the first anniversary predicted husbands' drinking at the second anniversary (Leonard & Mudar, 2004).  The fact that close personal relationships are dynamic (Blumstein & Kollock, 1988) may explain shifts in partner influence over time" (Leonard and Homish, 2005, page 412).  Leonard and Homish's research at all three periods: initial relationship, first and second anniversary found strong associations between husband and wife marijuana use.  Both husbands and wives who used or did not used had tended to have partners who also used or abstained.  Over time, there was reduction in use with only minor numbers of nonusers starting use later.  On the other hand, wives that used marijuana were more likely to have husbands subsequently start using than the reverse gender situation.  That is, wives did not tend as much to start using even though their husbands were already using.  Women tended to have more influence on men stopping marijuana use than men influence women's use (page 420-21).

Homish and Leonard (page 1436) state that "there was clear evidence of an association between one spouse's views about a married person's heavy drinking behaviors and his/her spouse's heavy drinking and alcohol use related problems… the findings were stronger for wives' views influencing their husbands' heavy drinking.  Only one significant longitudinal relation was identified for a husband's views about a married woman's drinking and his wife's alcohol use.  Women's frequency of intoxication during the first year of marriage was related to husbands' norms about the drinking of married women.  In contrast, women who expected married men to drink less were married to husbands' who reported less frequent heavy drinking, although these associations appeared later in the relationship.  Husbands' drinking during the second year of marriage was related to wives' norms about the drinking of married men.  These findings were significant after controlling for demographic variables, an individual's own alcohol use, and his/her own views about what the drinking habits of married individuals."  The influence of wives on husbands regarding substance use was "influential in the husbands' initiation and cessation of marijuana use through the second marital anniversary" (page 1437).

Well before she became bulimic, Tamlyn and Phillip's relationship was founded on alcohol and drug use from when she was in her early twenties and he was in his early thirties.  They respectively indulged themselves chemically and accepted if not encouraged each other.  Although, Tamlyn came to see her own use as problematic, Phillip did not support her abstinence or reduction of use.  To have done so would have been counter-indicated to his own alcoholism.  In couple therapy, Phillip minimized her drinking as benign while avoiding mention of his consumption.  The therapist should examine each partner's expectations about alcohol or drugs or addictive behaviors before and after the beginning of the relationship.  Have there been changes in the expectations about use or behaviors?  Such examination would have found that Carl drank socially before the marriage with occasional episodes of overindulgence.  However, his drinking got worse as years went by.  Drinking to socialize and for fun became the serious business of drinking to self-medicate for depression and stress in an unhappy marriage where he felt emasculated.  And, it helped him endure his dead-end job at the warehouse and his lost dreams.  Mitchell's recreational drug use became much more problematic after his injuries- as did his online gaming to avoid dealing with Kat.  Samantha's cutting got worse as her relationship with Dyson progressed towards marriage.  Shuman spent more and more time with his twelve-step programs and sponsorees as he and Myanna had more conflict.  Myanna in return spent more on unnecessary purchases and spent more time and energy on their son.  Various social and cultural influences should be explored, including whether they were significantly modeled from the family-of-origin.  The therapist may speculate and investigate about possible gender influenced social/cultural versus psychological reasons for use to explain addiction.  The therapist should see how the partner has previously influenced the individual's addiction.  The partner may be or should be a logical resource for addiction treatment.

The therapist can assess potential and mechanisms to self-medicate based on cultural and societal patterns and pressures.  People from societies where there are often lifelong, enduring, and overwhelming stresses, that cannot be addressed through the individual action may tend to turn to various forms of self-medication.  This characterization may be appropriately considered for many women.  Disempowered by societal and cultural sexism, there may not be many viable options for some individuals.  Impoverished, lower-class or caste strata of society, marginalized, or oppressed communities may have little or no concrete options to gain power and control.  Self-medication for anxiety and depression may be a normal aspect of coping in the community, society, or culture.  The therapist should check for the type of compulsive or addictive behaviors that may be common in a particular social or cultural group, or those that are more prevalent in a social or cultural group.  In addition to traditional social or cultural patterns, the therapist needs to be aware of evolving issues previously unknown in prior generations.  A modern development of great significance, Internet addiction for example, tends to be more problematic for young adults.  It has a typical onset in the late 20s or early 30s.  Mitchell was in this demographic.  Perusing the Internet was another compulsive behavior in addition to his prescription medication, alcohol, and drug use.  "Furthermore… the subjects were in their 30s at the time of interview and reported a 3-year history of problematic use.  Black et al. reported that their subjects were introduced to computers at a mean age of 17 years, and that there was a lag-time of 11 years from initial computer use to problematic computer use.  Because computer use has become so widespread, and even young children are now well versed in computer usage and technology, it is likely that the age at onset of problematic use has dropped" (Shaw and Black, 2008, page 358).  Phillip was not in this demographic since he was in his fifties, however new technology impacted his behavior as well.  The Internet enabled him to compulsively access pornography more readily that what had been available in earlier generations.

WORKAHOLISM
Being dedicated, having a great work ethic, sacrificing for the family, giving 110%, and having high personal standards would be considered part of a positive ethic- in particular an admired and normally rewarded ethic for American men.  However, self-imposed demands, compulsive overworking, poor regulation of work habits, and a hyper-dedication to work can exclude focus and energy for the partner relationship and other life needs.  Couples and family relationships and functioning can break down.  Emotional consequences for the workaholic and his or her partner can include heightened anxiety, anger, depression, and stress.  The individual has and feels more job stress, demands to be perfect, as well as mental and physical health consequences.  Partners of workaholics reported greater marital estrangement and less positive affect towards workaholic partners.  They feel less in control of their lives and more vulnerable to external events and circumstances (Robinson, 2001).  Yet bosses and potential partners covet him or her as a great worker or provider.  In following through on these social and cultural values, many individuals may be clueless about compulsive and addictive aspects despite experiencing negative consequences.  Men in particular may not be able to understand any criticism about their behavior.  They may only be able to see themselves as living up to a personal, family, and societal ideal model as dedicated husband-father-providers.  Daryl was highly successful in the corporate world- an extremely valued dedicated worker.  Working seven days a week up to fourteen or more hours each day was not unusual.  He was near the top of the corporate ladder and a candidate for the senior executive positions.  Carl was also an esteemed hard worker in his more blue-collar workplace.  His supervisors could depend on him for working overtime or an occasional extra shift at the warehouse.  Both men deflected criticism about their lack of adequate involvement emotionally and functionally at home, and highlighted their productivity as workers and providers.

Ironically in identifying workaholism and the interpersonal dynamics, the therapist may upset both partners.  "Family practitioners who work with workaholic couples must be prepared for resistance on both sides.  Over time, family members build a pattern of responses to their loved one's workaholism (Robinson, 1998c).  It has been reported that spouses of workaholics, not unlike spouses of alcoholics, become consumed with trying to convince workaholics to curb their compulsive behaviors and spend more time in family interactions.  In so doing, complaining or being cynical about the workaholic's constant working and family absence often become habitual.  Spouses and children of workaholics report feeling lonely, unloved, isolated, and emotionally and physically abandoned (Robinson, 1998a, 1998b, 1998c).  A common refrain from family members is that even when workaholics are physically present, they are emotionally unavailable and disconnected from the family.  In Japanese families, workaholic men are often referred to as 'seven-eleven husbands,'— a term for marginal fathers who have extricated themselves from family life, work from dawn to dusk, and live on the fringes of their families (Ishiyama & Kitayama, 1994).  In both Japan (Ishiyama & Kitayama, 1994) and the United States (Robinson, 1998a), once family alliances become solidified in the workaholic father's absence, spouses resent violation of their turfs when workaholics do try to become more actively involved in their families.  Older children too often rebuff the workaholic's attempts to reconnect with the family, because parentified roles have often been established and the reentry is regarded as too little, too late (Chase, 1999; Jurkovic, 1997).  Thus, family members sometimes send workaholics mixed signals by complaining about their absences and as movement back into the family system occurs, complaining about their attempts at integration" (page 406).

As often as Marilyn complained about Daryl's affairs, Bethany criticized Carl's lack of motivation, as well as Kat nagged Mitchell about pain medication, and Myanna martyred herself over Shuman spending time at twelve-step meetings instead of with her and the children, they also denigrated how their partners parented or criticized their household decisions and actions.  Their ways of interacting were contradictory to the style established in their absence.  The male workaholic cannot win for trying or not trying.  He is criticized for being away and disconnected.  But when attempting to be more present, it somehow is not what the partner or family wants.  The female partner to the workaholic may complain but simultaneously want to maintain her self-righteous stance.  The therapist that confronts both partners on their respective behaviors does not validate that stance and may incur the wrath of them both.  The female workaholic also compromises her intimacy and availability to partner and family, although stereotypically involved in childcare, school, social, philanthropy, or other culturally sanctioned female activities.  If the therapist challenges her compulsivity, she may feel her stereotypical feminine sense of self criticized.  She would after all, be the "good one" in the relationship according to her personal and cultural self-definition.  Myanna, Tamlyn, Gwyn, Marilyn, and Kat all were arguably overly involved, self-sacrificing, and dedicated caregivers.  The therapist could sense a pride of some sort at their maternal martyrdom.  It is often challenging to gain their acceptance of their complicity in their mutual reciprocal participation in and contribution to their partner's addiction or compulsivity with their co-addictive and enabling choices and behavior

STEREOTYPES AND ADDICTION
There are other potential addiction stereotypes that the therapist may benefit from examining.  While stereotypes can be applied rigidly without careful examination to the detriment of individuals and therapy, they can also suggest important areas of examination that may be relevant based on demographic generalities.  For example, "Ethnicity and the interaction between gender and ethnicity were significant predictors of pathological gambling, after controlling for regular gambling, number of favourite continuous gambling activities, gender, age and occupation.  Males and females were equivalently at high risk in New Zealand European and Maori groups, but not in the Pacific or Asian groups where males were at greater risk" (Clarke, et al., 2006, page 84).  The therapist may consider, for example if gambling is an important addiction that might be relevant to working with Asian or Asian-American clients.  The therapist might also find it useful to know that "As the US data sets show, users (of methamphetamine) are primarily white, but the proportion of Hispanic users is increasing.  Smoking the drug is increasing and is more likely to occur in urban areas, with injection more common in rural areas.  Prevalence is highest in the western states but use is increasing in the eastern part of the country (Maxwell and Rutkowski, 2008, page 229).  In addition, being cognizant of demographic trends may be relevant for assessment.  For example, "In December 2003, a small group of gay male activists publicly declared that use of crystal methamphetamine (crystal), a powerful stimulant, was epidemic among NYC gay men and responsible for an emerging wave of HIV infection" (Braine, et al., 2011, page 368).  During distinct periods of time, in certain vocations, and in identifiable geographic or socio-economic groups, a favored substance of use and abuse or problematic behavior pattern may be relevant to explore for the therapist to investigate with his or her client.  While a demographic similarity is not sufficient for diagnosis of addiction or a particular form of addiction or problematic behavior or disorder, it suggests directions for responsible therapeutic investigation.  Even without the couple presenting it as a concern, the therapist should have been cued by Mitchell's personal history including ADHD, early exposure to stimulant medication (Ritalin), school failures, and athletic sub-culture to explore for addiction or compulsivity issues.  Any one of these issues and specifically, the combination of issues can be indicative of substance or behavioral addiction.

At the same time, the therapist needs to be wary that knowledge of group tendencies does not become clinical stereotyping.  The therapist should be aware of how much he or she has unconsciously integrated mainstream racial, ethnic, gender, or other stereotyping.  Negative social stereotyping of African-Americans as lazy and under-motivated vocationally may cause the therapist to miss poor balance in work and life issues and compulsive work habits.  Neither Daryl's or Mitchell's ethnicity had not been identified.  Daryl was identified as a successful corporate businessperson and Mitchell as a hard-working blue-collar worker dealing with chronic pain.  Had the reader assumed that Daryl was European-American?  What if he were African-American?  Asian-American?  Latino-American?  Native American? A foreign-born immigrant from Europe from this or that country?  From Africa?  From South Africa?  From Ethiopia?  From Somalia?  From Asia?  From Mexico?  From Brazil?  From Haiti?  Would Mitchell be seen differently if he were African-American?  Or, if Mitchell was not in construction but the corporate bigwig?  Or if Daryl was the one in construction?  The therapist's stereotyped perceptions may not be validated by actual experience or research.  "…cultural origin did not moderate the relationship between workaholism and work–life imbalance, and there was no significant mean difference between Caucasian and Black participants on our measure of workaholism" (Aziz, et al., 2010, page 72).

The therapist who does not know this research and holds negative racial or class stereotypes may misdiagnose or minimize a workaholic African-American partner.  Carl who was the warehouse supervisor was African-American, which purposely had not been mentioned previously.  And a workaholic which had been mentioned previously.  It has been found that "stereotypes with regard to alcoholism and alcoholics also have served to influence clinical judgments.  The results of this study clearly indicate that lower socioeconomic status (SES) individuals, whether black or white, were diagnosed correctly for alcoholism more often than were their upper SES counterparts.  Although this prejudice seems to be directed at the poor, the results of this study also imply a need for more accurate diagnoses and treatment for both the poor and the rich" (Luepnitz, et al., 1982, page 666).  In addition, despite evidence of no discernible research difference between black and white drinking patterns, the public believes blacks are more likely to abuse alcohol.  Would Carl as an African-American been more readily diagnosed with alcoholism and his workaholism not identified?  Blacks in their study of lower and upper socioeconomic class were likely to be accurately diagnosed regarding alcoholism, but whites less accurately diagnosed because of these prejudices.  At the same time, bias for both whites and blacks of higher socioeconomic status lowered accurate diagnosis of alcoholism.  Would Daryl who was white and of high socioeconomic class not be recognized as an alcoholic among his other addictions?  Would his infidelity be seen in a different light if he were Latino-American?  Or, Iranian?  Racial bias is not the only bias that the therapist needs to be wary of.  Ethnic, class, gender, and religious bias among others mixed with latent counter-transference can interfere with accurate diagnosis and therefore, treatment.

ADDRESS:
433 Estudillo Ave., #305
San Leandro, CA 94577-4915
Ronald Mah, M.A., Ph.D.
Licensed Marriage & Family Therapist, MFT32136
CONTACT INFORMATION:
office: (510) 582-5788
fax: (510) 889-6553
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