Healthcare Training Institute - Quality Education since 1979
CE for Psychologist, Social Worker, Counselor, & MFT!!

Section 5
Families of Addicts: A Systems Perspective

Question 5 | Answer Booklet | Table of Contents

For the family to meet the basic needs of its members and society, it must 1) physically protect and sustain its members by providing shelter, safety, food, and clothing; 2) promote a sense of individuality or autonomy, so that each member can think and feel independently; 3) promote a sense of connectedness, so that each member meets emotional needs for affection and intimacy appropriately; 4) foster a sense of competence and self-worth, so that each member feels good about him/herself and contributes productively to society; and 5) encourage each member to develop a sense of right and wrong and conform to basic values and rules of society. It is useful to keep in mind that all families have strengths, some more than others. To help an individual, it is as important to identify the strengths of a family as it is to detect its weaknesses. Children of substance-abusing parents often grow up in chaotic family environments that lack consistency, stability, and emotional support. Poor communication, permissiveness, undersocialization, and neglect are common and can be devastating. A basic understanding of family systems and the characteristics of healthy and substance-abusing families is essential to identifying and working with high-risk children and youth. Families affected by substance abuse frequently develop issues around boundaries, communication, problem-solving styles, and role assignments. Recognizing these family systems issues is an important aspect of working with children from all backgrounds.

Family Disease Model
As the substance abuse progresses, the family’s actual life becomes divergent from the family’s intended lifestyle. There is little congruence between what the family wants their life together to be and what it has actually become. Because the realization of the disparity is very painful, suppression of feelings and secretiveness is common. If family members begin to be concerned that substance abuse may be the cause of their problems, they develop strategies to preserve their intended integrity. A dysfunctional family system develops around the disease that is protected by defense mechanisms, isolation, rules, and roles. As the members slip deeper into these behaviors, reality becomes distorted and the pain of the family dysfunction is displaced away from the cause, the family disease of substance abuse.

Denial is the defense mechanism used most commonly. Its primary purpose is to maintain ego integrity in the abuser and family members. Denial may stem from ignorance of what chemical dependence is or may be motivated by wishful recall of previously happy times. The family denial can be stronger than that of the affected member and usually is related to the amount of stigmatization felt by the family members. Because of the power of the denial, the illness can progress notably, and therapists can feel frustrated In their attempts to confirm a suspected diagnosis with a family member. Because denial is below the level of awareness, family members do not acknowledge that denial is occurring. Once denial begins, it becomes automatic and progressive.

Minimization is the attempt to dilute the action of the substance abuser and lessen the impact on the family. For example, a wife may say that her spouse yells a lot but has never hit her, thus, she does not believe that he is a substance abuser.
Projection attributes the cause of the problem to another person or thing. A husband may cover for a wife’s marijuana use by complaining that the children are behavior problems.

The isolation that develops around the family is both social and emotional. Because of the shame associated with substance abuse, family members do not share their painful experiences with anyone inside or outside of the family. The boundaries around families become rigid and impermeable, with a restricted flow of information passing into and out of the family. In such situations, normal needs may be gratified in abnormal ways. For example, the incidence of sexual abuse is reportedly high in substance-abusing families.

Family Rules
As in any system, rules develop for self-regulation and order. In the chemically dependent family, the rules restrict behavior, limit creative problem-solving, and restrict autonomy. The emphasis is on following the rules and not on developing intimate, nurturing relationships. Although not overtly required, the following rules have been described clinically:
1. Don’t talk--Even young children learn not to share painful observations. A mother with strong denial will not confirm her child’s observation of Dad’s out-of-control drinking behavior. When observations are not validated, family members stop making them and important issues are not discussed. The drinking is neither mentioned nor confirmed, and the family secret grows. Everyone knows it is there, but no one mentions its existence.
2. Don’t feel--When painful experiences are not shared, feelings do not get words attached to them and they remain undefined. Comments such as "No, I wasn’t scared," "I never get angry," and "Why should I cry, it wouldn’t help" are frequent. The only feeling that usually gets displayed is anger. Instead of understanding that anger is a normal reaction to certain experiences, anger is often used explosively in chemically dependent families as a defense to prevent others from approaching the real problem.
3. Don’t trust--Chemically dependent people often make promises and plans with the best of intentions of fulfilling them. Nonabusing family members add to the inconsistency in the environment by expecting behaviors that they realize the chemically dependent person cannot perform. For example, a father who always arrives home very late on pay day will be asked to bring ice cream for dessert. Subsequently, the disappointed children are angry at both Mom and Dad when dinner ends with no dessert and feel that both parents broke their promises.

Family Roles
Roles help maintain balance in the family system and provide another method for individuals to insulate themselves against the emotional pain of living in a chemically dependent family. There are two reasons why the therapist must understand these roles. First, patients may describe themselves in these terms, and it is supportive for the patient when the therapist understands. Second, and more important, when individuals use role-dominated behaviors, they do not develop to their full potential. If therapists understand the behaviors, albeit through stereotypic roles, they are in a better position to recognize the limitations in their patient’s life, to diagnose the health problems related to maladaptive behaviors, and to assist the person in learning more functional conduct. Individuals who feel trapped in role-related behaviors may suffer from stress-related illness or may demonstrate behavioral manifestations of their emotional pain. Therapists who understand these behaviors and associated symptoms can be helpful in uncovering the underlying problem of substance abuse, in explaining to the family how they are being affected, and in helping the patient understand the ways that chemical abuse is affecting various members of the family.

Wegscheider has described one potentially useful model to conceptualize family roles in the alcoholic family. The so-called chief enabler protects the chemically dependent person from facing the consequences of his/her disease by assuming the alcoholic’s responsibilities and by shielding his/her actions from others. They do not understand that they can not control the chemically dependent person’s AOD use or other behaviors. Although enablers look responsible and capable, they can harbor a variety of negative feelings. Although they work hard to maintain stability, the situation can deteriorate. Frustration, anxiety, and stress-related symptoms are an understandable corollary of enabling behaviors.

The so-called family hero brings pride to the family by being successful at school or work. At home, the hero assumes the responsibilities that the enabling parent abdicates. By being overly involved in work or school, he/she can avoid dealing with the real problem at home and patterns of workaholism can develop. Although portraying the image of self-confidence and success, the hero may feel inadequate and experience the same stress-related symptoms as the enabler.

The so-called scapegoat diverts attention away from the chemically dependent person’s behavior by acting out his/her anger. Because other family members sublimate their anger, the scapegoat has no role model for healthy expression of this normal feeling. They become at high risk for self-destructive behaviors and may be hospitalized with a variety of traumatic injuries. Although all the children are genetically vulnerable to alcoholism, this child is often considered the highest risk because of his/her association with risk-taking activities and peers. Although tough and defiant, the scapegoat is also in pain.

The so-called lost child withdraws from family and social activities to escape the problem. Family members feel that they do not need to worry about her/him because s/he is quiet and appears content. S/he leaves the family without departing physically by being involved with television, video games, or reading. This child does not bring attention to her/ himself, but also does not learn to interact with peers. Many clinicians have noted that bulimia is common in chemically dependent families and feel this child is prone to satisfy his/her pain through eating.

The so-called family clown brings comic relief to the family. Often the youngest child, s/he tries to get attention by being cute or funny. With family reinforcement, his/her behavior continues to be immature and s/he may have difficulty learning in school.

Another approach for understanding the alcoholic family has been proposed by Steinglass and colleagues. Through careful study, these research clinicians have found that families differ in their responses to the effects of alcoholism. They affirm that the family’s priorities, rituals, behavioral styles, and use of energy and resources are altered by the presence of alcoholism. Most families are successful at maintaining their primary tasks and are not identified as problematic. In families in whom the alterations are the greatest, the disease is passed on to the next generation. When the family is able to resist the full effects of the disease, the children do not necessarily recreate an alcoholic family after their own marriages.

Personal Reflection Exercise #1
The preceding section contained information about a systems approach to understanding the families of addicts.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Transitions in mental health and addiction care for youth
and their families: a scoping review of needs, barriers, and facilitators

- Markoulakis, R., Cader, H., Chan, S., Kodeeswaran, S., Addison, T., Walsh, C., Cheung, A., Charles, J., Sur, D., Scarpitti, M., Willis, D., & Levitt, A. (2023). Transitions in mental health and addiction care for youth and their families: a scoping review of needs, barriers, and facilitators. BMC health services research, 23(1), 470. https://doi.org/10.1186/s12913-023-09430-7

Peer-Reviewed Journal Article References:
Ariss, T., & Fairbairn, C. E. (2020). The effect of significant other involvement in treatment for substance use disorders: A meta-analysis. Journal of Consulting and Clinical Psychology, 88(6), 526–540.

Church, S., Bhatia, U., Velleman, R., Velleman, G., Orford, J., Rane, A., & Nadkarni, A. (2018). Coping strategies and support structures of addiction affected families: A qualitative study from Goa, India. Families, Systems, & Health, 36(2), 216–224.

Eddie, D., White, W. L., Vilsaint, C. L., Bergman, B. G., & Kelly, J. F. (2021). Reasons to be cheerful: Personal, civic, and economic achievements after resolving an alcohol or drug problem in the United States population. Psychology of Addictive Behaviors, 35(4), 402–414.

QUESTION 5
What are the three rules in the families of addicts? To select and enter your answer go to Answer Booklet.