What role do personal relationships play in the aetiology and maintenance of addiction? In the alcohol and other drug (AOD) field, there is a concern that negative experiences in early relationships predispose, if not cause, problems in later life. This suspicion is often complemented by a concern for the effects of current relationships. For example, it is often thought that continued associations with substance-using peers is correlated with relapse. More theoretically, a suspicion regarding current relationships is associated with powerful motifs such as co-dependence and collusion. There is a tendency for families to be viewed negatively. For example, Matthew, Regmi & Lama (2018: 65) report that there are ‘various factors and forces associated with family in the initiation, maintenance and recovery of addictive disorders.’
Animated by the social determinates of health research (Wilkenson & Marmott, 2003; Wilkinson & Pickett, 2009), and informed by cross-cultural (Tropenaars & Hampden-Turner, 2002) and feminist scholarship (Davies et al., 2006), an alternative starting point emphasises the importance of both familial and non-familial relationships. These knowledge streams make the case that well-being – psycho-social health – relies on each person having a ‘good enough’ quality in their personal connections. This argument has a broad remit as it is relevant to the general population whilst having, perhaps significant, purchase for those who present for treatment.
Consistent with this orientation, Price-Robertson, Obradovic & Morgan (2016) make the case that recovering from serious mental illness is contingent on ‘relational’ dimensions of the recovery process. In relation to the AOD field, Best (2017), Best & Laudet (2010) and Best et al. (2011) emphasise the importance of peer networks and suggest that engagement with others in recovery supports positive change while Anderson (2018) summarises how socio-grams can be used to explore the growth of a person’s ‘recovery capital’. It seems peers can have positive, as well as negative effects. Another attitude to relationships might acknowledge that addiction-related behaviours will tend to have a negative effect on relationships rather than default to blaming families for their purported role in initiating and maintaining addiction.
In order to further this positive line of approach, this report presents a program initiative based on the premise that the overall relational capacity of the client can be developed in a focused, incremental manner. If viewed in this way, relationship capacity becomes a particular and innovative focus for rehabilitative intervention. Such a focus seems to be unusual, if not positively unique—we were not able to locate accessible program material that aimed to measure a client’s capacity to initiate and sustain personal relationships.
Given there was a gap, the authors set out to design, test and implement a purpose-built program component to serve this purpose. As the site of the project was a modestly scaled and funded AOD residential service, the decision was made to construct a low-tech, accessible, self-report instrument that program participants and staff could use to focus attention on the importance of, and to articulate opportunities to improve, the capacity to ‘relate well’. As will be examined shortly, this component has several functions and is therefore not straightforward to categorise. Given that different functions could be served – part assessment instrument / part pedagogical program – we came to think of this component as a self-assessment tool whose subject was ‘relating well.’ In the spirit of the original conception of action research, this component was developed though ‘a spiral of steps, each of which (was) composed of a circle of planning, action and fact-finding about the result of the action’ (Lewin, 1946: 34). Such a tool also appealed as it aligned with the peer-support / community-building ethos of the SHARC program. This process did not seek to approximate objectivity – issues of validity and reliability were not the priority. Less a traditional assessment device than a therapeutic aide, the vision was to build a multi-purpose ‘widget’ – an inter-subjective document that could be an intervention (by setting the terms of attention) and also be a baseline in relation to which goal attainment could be judged, goals reviewed and modified and, more generally, progress (at individual and program level) monitored. As a self-assessment tool, the idea was to consciousness-raise and empower more than monitor and investigate.
What follows presents a linear rather than a process account. Essentially a third-person summary, this account cannot articulate the iterative and recursive nature of the exercise but has advantages in terms of clarity and accessibility.
After engaging with Building the client’s relational base: A multi-disciplinary handbook (Furlong, 2013) the first author contacted the second author. This contact stimulated a series of intense and evolving discussions identifying commonalities, differences and assumptions with respect to the subject – ‘relating well.’
A key outcome of these early discussions was the recognition that the subject of the proposed program initiative is inevitably indeterminate – that personal relationships are necessarily uncertain, even, to a degree, mysterious. It follows, there can be no academic, inter-cultural or public consensus concerning the characteristics of a ‘good relationship.’ More, there is no ‘gold standard’ when it comes to conceptualising and evaluating family, couple, group or peer relationships. Similarly, there is no established conclusion as to what can, or should be, the focus for educational and therapeutic programs which aim to improve the capacity for healthy relationships. Worthy badges may be available, for example – ‘respectful relationships’ (Flood, Fergus & Heenan, 2009), but, the programmatic content that is available remains contested and is, in the main, untested.
What seemed solid in this pool of uncertainty, was our collective belief that it was timely and important to inject a greater emphasis on relational well-being into the local service. We knew what would be developed would be not be final, but we thought it would be likely to be a step in the right direction. How was this intention to be put into action?
The agency was modestly resourced, so it was not tenable to initiate a ‘pure research’ project. Rather than regard this as a limit to what might be achieved, in the spirit of innovative action research, a different approach began to be envisaged – let’s not try and isolate a dependent and independent variable. More broadly, what could be developed that would assist clients in a program that encourages self-reflection and individual recovery planning that would serve multiple purposes?
A multi-purpose vehicle
Over a relatively short period, it was resolved to make a virtue out of necessity by setting out to develop a single tool that could service several levels of purpose. Broadly, we envisaged a dynamic kind of questionnaire; not the standard variety that seeks to gather information, but one that might act as a change-agent and pedagogical content-carrier.
The primary purpose 1: Setting the terms
The aim of the project was to focus attention onto the relational. We envisaged a dynamic and accessible document, a kind of reflective tool that would focus attention onto the relational across the course of the resident’s progress within the program. This evolving document would be an active site and the focus of ongoing follow-up.
We explicitly intended to be interventive. Put another way, the intention was pedagogical as the aim was to insert a change agent, a particular content carrier, into the program that prompted learning to ‘relate well’. Whilst such a discovery process is inevitably personal, the field of action is not neutral as the questions that structure attention, to an extent, lead the individual by setting the terms for thinking and response. Similarly, if certain themes are embedded (in texts or in dialogues) this will tend to delimit the field of attention. Consideration within this field will therefore tend towards prescribed categories of thinking. This might be described in terms of sensitising or consciousness-raising. More accurately, it is a deliberate exercise in utilising ‘social influence’ (Pentony, 1981).
We imagined a vehicle that would carry content and intention. Rather than the usual ‘let’s objectively gather the facts’ questionnaire, we wished to have an instrument that would structure attention and provide a language for articulating a dimension of life – our relationships – that is often opaque. For many, relationships are powerful, but cannot be seen or quantified. They have no voice but are both dangerous and vital. At a second level of uncertainty, it is impossible to have an objective knowledge of the part one plays in one’s many relationships (Furlong, 2014). With this background, it was thought useful to promote a greater attention to, and to prompt residents to engage more fully with, the relational. If the residents could better understand and communicate their experience of relationships, we believed this would be, in and of itself, interventive.
Goal setting was envisaged to have a key agency in this work. The same instrument could be used by residents and associated program-staff to set and review relationship-oriented goals. The contention was that embedding a concern for the relational would be accentuated when goals are formally established and reviewed. At a symbolic level, the articulation of relationships – their importance, their malleability and the conditions that make them facilitative or antagonistic – becomes, not only a focus of attention, but an abiding program companion. This attention adds a distinctive dimension to the detail that is commissioned in routine treatment and recovery documentation.
The premise was to find a ‘good-enough’ set of questions and categories that could be arranged to embed appropriate ideas, attitudes and themes. By focusing attention and establishing the terms of a discussion, an organising principle, if not a formal framework, might be established. At the least, we imagined a vehicle could be developed that would project the relational – its importance, possibilities and difficulties – into conversations and reflections that regularly occurred in the program. We hoped that the vehicle, however it was eventually named and whatever it ended up looking like, could function as an externalised focus point for residents and staff alike. What was wanted was not a neutral instrument but a cart-wheeling intervention.
Supplementary purpose 1: Data for program evaluation
Funders demand outcome evaluation at the program level. Depending on the funding agreement, this demand may not be satisfied by ‘activity reporting’ – how many assessment interviews, how many client contacts and average length-of-stay? – and may require data that is appropriately conceptualised and measured. In addition to meeting accountability requirements, quality data would also support internal program reviews.
If individuals could map their relationships, set goals and review their progress with these goals, could this data be used for program evaluation? This was a key concern mindful, as mentioned earlier, there were severe research-related resource limits and the implementation of the relationship-centred aspects of the program was, itself, a work-in-progress. Clearly, it was not possible to use a classic design based on the measurement of outputs and outcomes against baseline scores of, say, attitudes or behaviour. It was, however, possible to set out to aggregate over-time self-report data from one or more generations of residents. Such a dataset would have the potential to be useful in program evaluation. In the working-up of the questionnaire, this level of action consolidated as a second level of purpose.
An example might concretise this idea. The Basis 32 self-assessment instrument used in many mental health services, asks clients about their ‘isolation and feelings of loneliness’ at key points during treatment. If SHARC residents were routinely asked this question on admission and discharge from the service; the aggregate data from this enquiry would speak to the aspiration of the current project and become a metric that could be constructively used as one indicator in the evaluation of the program.
Supplementary purpose 2: A component of the pre-admission assessment process
A second supplementary purpose concerned the use of the questionnaire as a component in the initial screening of program applicants. Mindful no empirical rationale has been established; it is logical to expect that possible categories-of-concern in the proposed instrument would have some value in guiding staff to be aware of the relational sensitivities of program applicants. For example, it might identify issues relevant for a new resident in a group-work based program. The interaction generated in an applicant being asked to engage with the tool would play a role in assisting the induction process. Ideas and themes would be introduced, and information might be generated which could brief staff about attitudes and behaviours new residents might arrive with that could challenge and/or be disruptive to their engagement in the program.
That three purposes might be served by the one ‘widget’ consolidated as a conclusion early in the life of the project. The next step was to begin a process to build such an instrument mindful the task represented an ambitious initiative. As noted earlier, an iterative process developed the initial draft. This process cannot be duplicated in what follows. Rather, a linear account of the process is described in terms of two successive steps:
(i) The identification of proposed domains and their constituent dimensions.
(ii) The consultation process undertaken with service users and other stakeholders.
Stage 1: Developing an initial draft
Might there be a multi-purpose aide that speaks to the same, or similar, ends to those we wished to realise? The first step in the developmental process was to review the material that is currently available. The results of this enquiry are set out below.
What is currently available?
Employing a mix of observational and self-report measures, an extensive number of instruments were found to assess family functioning, e.g. the Circumflex model; BIAS; etc. In terms of the individual, there are a great number of instruments that focus on diagnosis, for example depression (Beck; Hamilton, etc.), Activities of Daily Living (Waisman; Katz, etc.) and on individual functioning and wellbeing (GAF; the Pro-Change Functional Well-Being Scale; etc.). This material has minimal value for the current purpose.
Within measurement tools, there is often a category of record concerned with personal relationships. For example, ‘Family and relationships’ is one of ten areas in The Drug and Alcohol Star version of Outcomes Star™. Similarly, ‘Family and friends’ is one of eight areas in the Well-being Star for people living with long term health conditions. Additionally, there is some attention given to similar categories in a range of protocols used for intake and data gathering purposes. For example, in our local jurisdiction, state authorities prescribe that the Victorian Alcohol and Other Drugs Comprehensive Assessment Tool (2017) be administered for each entry to an AOD service. This tool includes several non-primary categories that, like the Outcome Star tool, have some relevance: ‘Family, children, dependents and social relationships’; ‘Recovery capital’; ‘geno-grams. Further to this, the current Victorian Alcohol and Drug Collection (VADC) (2018) outcome data reporting system includes some prompts for possible relational changes. What is generated by these items is base-line information rather than dynamic curriculum content designed to further pedagogical intent.
Our concern with personal relationships is not, primarily, about outcome measurement. For the current purpose, this concern is not merely slight, it is irrelevant. Beyond outcome measurement, there is some promise in a focus on ‘Recovery Capital’ and ‘Socio-grams’ as areas of interest in pre-admission processes and as dynamic concerns through a person’s treatment course. Our intention has been to locate or, if nothing is found, develop an interventive tool designed to be a change agent in a pedagogical process.
In summary, our investigations to date have not identified any publicly available social functioning measures (or pop psychology publications) which seek to promote the capacity of prospective service users or those in AOD rehabilitation services to initiate and maintain personal relationships.
Starting from scratch
We could not identify a precedent, or even relative, in the research and practice literature that sought to improve, rather than assess, the capacity for relationships. We had also excluded the relevance of traditional data gathering tools and the aspiration to approach objectivity these tools represented.
At this point, the project became a generative process – an outlier project to build something new out of a half-glimpsed ‘left field.’ This outlier position become all the more apparent because the subject of the exercise – personal relationships, and how they might be improved – has a quality that is as uncertain as it is contestable. With this degree of indeterminacy, a practical first step was to define and map the field of interest –what are the different examples of relationship that can be identified in the category ‘personal relationships?’ What we sought to do was to name the members of the class ‘personal relationships.’
Personal relationships: Listing the members of this class
Mindful biological and legal dimensions have significance, the decision was made to begin from a phenomenological starting point – the meaning of a relationship is subjectively determined. Starting with, but modifying over time, Furlong’s (2014) typology, the following set became the working focus:
- parent / s
- partner / ex-partner(s)
- bosses / other authority figures
Naming the members of the class was a practical step because it partialised a subject that is amorphous, even overwhelming. For example, rather than asking a resident to map their relational world or asking the open question ‘how are your relationships going?’ there are advantages in stating – ‘It can be really confusing. There are many kinds of relationship. From the above list, and taking as long as you like, can you select one or two specific relationships that are (a) going well, and (b) that are not going so well which, maybe, you would like to improve. Maybe, you would like to take 24 hours to do this?’ Moreover, at a later point in the program, the question can be asked – ‘When you look over what you wrote (say) a month ago, would you answer the same questions the same way?’
The project’s next step was to nominate the principles the practitioner-researchers wished to prosecute. In effect, this involved a process of values-clarification given there is no academic, inter-cultural or public consensus concerning the characteristics of a ‘good relationship’ nor empirical consensus concerning the elements that constitute ‘relating well.’ Guided by Colgate’s (2004) approach to reviewing relationship ethics, and eventually milled into a linear description, the following statements were identified:
- positive personal relationships are valuable
- elective (‘freely chosen’) relationships should be fair and respectful – no one should be a winner or a loser
- each person has the right to their own thoughts and feelings
- being interested in, and curious about, how another person thinks and feels is part of relating well
- it is important for people to be able to accept responsibly for their own actions
- in parent-child and carer-cared-for relationships, responsibilities should be allocated according to need and role.
The above set is not proposed to be objectively true, consensual or inclusive. Nonetheless, this set of propositions made a successful claim to credibility with the practice researchers.
Two different kinds of decision were taken at this point. First, it was resolved to carry forward the above six principles (in an, as yet, unclarified form) into the in-progress instrument. A second, more conceptual, decision was also made to present ‘values’ as a domain – as a major category of concern – in the body of the tool.
Importantly, the latter decision prompted a subsequent question – if values is one major category of concern, what other domains should the instrument include? Following an open-ended literature review, the decision was taken to complement the category ‘values’ with two additional domains – ‘knowledge’ and ‘skills.’ This decision was the result of many interactions, necessitated considerable debate and included the interrogation of many personal and conceptual assumptions. Two particular ‘items’ of knowledge and a six item list of skills were articulated. Each will be discussed in turn.
The domain ‘knowledge’ is open-ended in relation to personal relationships. Amongst a large set of contending ideas, two particular items were selected for their topical relevance and practicality. Derived from a theoretical preference, as well as considerable practice experience, these two items are expressed in the following statements:
- There is often a difference between a person’s feelings and intentions and the outcome of their actions.
- What a person thinks and feels is often different to how another person thinks and feels.
These items are derived from two distinct yet complementary sources. The first relates to the construct of the ‘generalised other’ originally formulated in sociology (Mead, 1962) mindful that a related idea – the ‘theory of mind’ – is available in developmental theory (Mitchell, 2011). In essence, what these ideas denote is the ability to ‘perspective take’ – to imagine, and to operate in relation to the other as a distinct, but equally valid, entity, vis-à-vis, oneself. It has been argued that a practical grasp of these truths seems to be eroding, a phenomenon attributed to the impact of ‘the process of individualisation’ (Bauman, 2001; Howard, 2007). However theorised, it is increasingly clear that many citizens, including many of those found in AOD treatment settings, are insufficiently (what might be termed) other-cognisant to be agile in their relationships.
Why might this be so? Many clients feel they have been hurt by others, including their intimates and care-providers. Understandably, these experiences increase self-absorption, impact on optimism and diminish the prospects for positive risk-taking in relationship practice. Suspicious of others, bunkered-down, these people will tend to position themselves defensively with respect to new relationships and exhibit a pattern of self-referencing in their internal dialogue: ‘I’m feeling worried so I’d better not say much’; ‘I’ve learned it’s better to hide your feelings’; ‘Be careful! Don’t let yourself get hurt again’; You can’t trust wo/men (and professionals).’ This type of stance inhibits an awareness of the ‘generalised other’. The horizon of awareness has been reduced to ‘the me’ (Furlong, 2013b).
Clinical experience in individual, couple, family and group work, supports the contention that if someone is overly self-referential this is not relationship-wise. It is therefore useful to challenge and undermine the habit of being overly self-referential. To this end, the adoption of the above two items is an element of a complex process of intervention. Inserting the above two knowledge items into the program, in association with the commitment to encourage meaningful discussion around their meaning and utility, enables the outcome of recent scholarship on the social determinants of health to inform content in the program (Wilkinson & Pickett, 2009). The rhizome that is a self-reinforcing oppression – ‘I am only thinking about me’ – can be challenged at multiple levels.
The nomination of items for the skills domain involved an inductive process. A range of texts and programs are available if it is recognised that much of this material is problematic. For example, some texts are culturally imperialistic – they include programs of assertiveness training that will not transpose from their North American context to, say, Aboriginal Australians. More, a cohort of troubling self-help texts have recently become available. Amongst a larger group, Koga & Kishima (2018) argue for the ‘courage to be disliked’ and Manson (2016) the merits of the subtle art of not giving a f***. Not to be left out, Knight (2018) ups the ante and promotes the life changing magic of not giving a f***. Academic iterations of this phenomenon include Kipnes’ (2003) Against love and Professor Kevin Dutton’s (2014) The wisdom of psychopaths.
Inputs that agitate the reader to be careless about the feelings and rights of others offer no data that is relevant to the current project and were excluded. Our process began with a literature review of mainstream texts, e.g. Goodman, (2009); Goleman, (2006); Seeman, (2001); Vangelisti & Perlman, (2006). A key resource in this search was Furlong (2013a). Milling these texts in an inductive process produced an extensive, initial set of elements relating to ‘the capacity for relationships.’ Using a qualitative process involving both content and thematic analyses over a period of several months, an extensive and diverse set of propositions and statements were reduced into an initial iteration of six elements. This set of skills concerned being able to:
- recognise one’s own feelings and biases
- tolerate difference
- communicate one’s own feelings and thoughts
- reflect on one’s own behaviour and its impact
- ask interested questions about the other’s experience, feelings and point of view
- apologise, back down, negotiate, and offer feedback.
At this point, a draft with four sections was produced. This draft comprised
- a list / typology of different relationship types
- a set of six values
- two specific knowledge items, and
- a set of six skills
The contention was, that this rubric – the overall composite of values, knowledge, and skills – would be internally coherent and mutually supportive. The next developmental step was to bring this material into an engagement with key stake-holder groups.
The consultative process
Three groups were identified and asked to provide feedback. This process was undertaken serially with the same draft presented to, and discussed with, each group individually. After this deliberation had concluded and the group had offered their feedback, each group was provided with a summary of the feedback received from the previous group/s and asked for their response to this feedback. The three consultations occurred over a two-month period. These meetings were with
- current residents of the Youth Program (18 – 26 years of age)
- a program consumer advisory group – adult consumers (over 26 years of age)
- a group of relatives and carers of drug-users.
Each consultation was audio-recorded and closely reviewed by the first author.
In summary terms, each stake-holder group found considerable merit in the draft they were presented with. More specific comments prompted specific changes to the draft. Recurrent, decisive items of feedback included:
- the content needed to be more accessible, e.g. the language should be less abstract and less ‘technical’
- the draft needed a brief introduction
- the formatting could be substantially improved
- ‘values’ was too narrow as a major heading
- the skills set was confusing and too narrow
- items directly addressing the increasingly digital nature of relating should be added, and
- the scale of the draft should be reduced to enable greater engagement.
A key result of the consultations was that the material was trimmed in length. This related to the concerns that the tool should not be a burden to engage with or that clients would skim-over its contents due to an over-bearing length. We also simplified much of the language and re-arranged the order of the sections. Additionally, ‘attitudes’ was added to ‘values’ in the title of the first domain; a brief introduction composed; the skills section was sub-divided, elaborated and extended; and the formatting was re-developed through several evolutions. As a result of this process, a formative draft was finalised: see Appendix 1.
The rehabilitation process can be viewed as a project to redeem a mythologised ideal of autonomy or re/develop a positive and meaningful connection with community. This journey can be imagined as a process to rescue the drug user from the negative effects of bad associations past and present whilst a more optimistic position understands that a positive outcome is only possible if the person has a ‘good-enough’ set of attachments. We do not believe such attachments can be ‘delivered’ to service users as passive recipients; no one can be granted an entitlement to ‘access’ such connections by programs or practitioners however expert or well-intentioned. Rather, a ‘good-enough’ quality of connection is a status that can only be learned-and-earned. Towards this end, the current paper has documented the first stage in an innovative project based on the premise that relational capacity can be developed in a focused, incremental manner. If viewed in this way, relationship capacity is a particular arena for growth within which service users can realise an important wellspring of empowerment and general well-being.
Mindful the formative material presented in this report has clear limits, we take the view that the innovation that was developed has a good deal to offer. First, the self-assessment tool and the scholarship it stands on is informed by progressive socio-cultural research. This research takes as its starting point, the assumption that all humans, including those with an AOD challenge, are social beings rather than autonomous republics. In this position, we are taking an optimistic attitude to the possibilities of relationships– if it takes a whole village to raise a single child, it takes a relational network to sustain a single adult.
Currently, the pilot version of the program that uses the self-assessment tool is being implemented in a single residential unit. It is our intention to prepare a report of the implementation stage as the subject of a further paper. A further paper is also proposed that will examine the reflections of residents and staff who have used the tool in its first round of operation. We look forward to the process of constructive interrogation that the preparation of these papers necessarily involves.
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