Substance Use Disorders & The Family

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Substance Use Disorders and the FamilyWelcome to the module on substance use disorders and the family.Welcome to the module on Substance Use Disorders and the Family. By the end of thisLearning Module, you will be able to: understand some concepts associated with familysystems theory as it relates to the impact of substance use disorders; understand thestructure, functioning, and dynamics of families impacted by substance use disorders;assess the effects of substance use disorders on the family and its functioning; considerstrategies for working with families impacted by substance use disorders; apply HIPAAregulations when communicating with concerned family members.

Understanding Substance Use Disorders and How They Impact a Family.Family systems theory is a body of knowledge that has arisen out of the observations byclinicians as they work with individuals and their families. The theory suggests thatindividuals cannot be understood in isolation from their families. A common exampleuse to illustrate the functioning of a family system is a hanging mobile with manydifferent parts. When you move any one piece of a mobile, all the other pieces movetoo. They do not exist in isolation from one another, and “movement” in any one partof the “system” will affect all the rest of the parts of the system.

Family Systems approach suggests that sometimes our behavior may have as much todo with the “systems” (groups) of which we are a part and the patterns that getestablished within these systems as it may have to do with the personality of eachperson within the system.Family Systems focuses on the process of family interactions and is less concernedabout the specific content around which the family interacts. Process questions areemphasized in analyzing the family interactions in terms of patterns. For example, howdoes Amy’s behavior fit into family patterns? How do members shape and reinforceeach other’s behavior? How do families solve their problems?Systems develop typical ways of being which are reliable and predictable. Family roles& family rules are examples of what is meant by “typical ways of being.” Families havecertain rules and roles which define how they operate. These tend to remain the same.Whether these roles & rules are adaptive, functional, helpful or not helpful for thefamily, there is a pull from the system not to change, to remain the same, to continuefunctioning as things have always been.This tendency of systems to keep doing things as they’ve already been done is known ashomeostasis or the system’s equilibrium. Often families may experience externalchanges (loss of job, a substance use disorder, severe illness) which demands a change.The family’s ability to adapt to the external situation effectively is important in copingwith the crisis at hand. Some family changes are predictable. For example, childrenmaturing, developing, and transitioning to adolescents requires adaptations in parentingto accommodate the developmental changes in the family.

The parents’ inability to adapt to developmental changes of children may cause familyproblems and/or family crisis possible displayed in rebellion and risky behavior by teenswanting to express their independence and autonomy.Often the behaviors of various family members are related to one another. Forexample, in the distance - pursuer dyad, there may be one person who seeks outcloseness with the other person (the pursuer) while his/her partner (the distancer)wants more space or independence and pulls back from the relationship. This patternmight occur in the marital relationship but might also occur in the parent-childrelationship.Outside the family, you might see this pattern in dating relationships or even in closefriendships. You may also see this pattern by one family member pursuing a familymember with a substance use disorder in order to control or alleviate the familyconcern, resulting in the family member with the substance use disorder to distance himor herself from the pursuer. As you might imagine, as the distancer & pursuer act outtheir “roles” within the relationship, a cycle can develop. The pursuer pushes forcloseness while the distancer pulls back.The pursuer then feels “abandoned” and thus feels even more of a need for connectionand so pushes even harder for connection. As a result, the distancer feels “smothered”and pulls away even further. Consequently, this dance, pattern, or cycle develops. Inthe cycle, both behavior patterns cause the other. Family systems theorists refer to thisconcept as circular causality.Another circular dynamic is seen in the dyad of the over-functioning person versus theunder-functioning person. The over-functioning person tends to view the underfunctioning person as irresponsible and immature. We often see this dyad in families

impacted by a substance use disorder. The under-functioning person tends to see theover-functioning person as controlling and rigid. The more the over-functioning personoverachieves, the more the under-functioning person underachieves (in reaction) andvice versa. The causality is circular!Once the cycle has started, each person’s behavior contributes to the other person’sbehavior. The distancer-pursuer and overfunctioner-underfunctioner are just twoexamples of the sorts of circular patterns that can develop in families. There are manyother possibilities. A good clue to a “circular” pattern is when people tend to respond inpredictable ways to each other, and their responses may become more extreme overtime.Another way of observing family dynamics is through the lens of power, hierarchy, orinfluence, i.e., who is on top and most influential in the family and who follows orcomplies with the person who is perceived to be on top. Understanding who has themost power can be helpful in helping a family and offering recommendations for theperson in the family with whom there is a concern about his or her substance usedisorder. Sometimes who has the most influence is not obvious or demonstrated inconventional ways of thinking of power.Sometimes you will be able to perceive who has the most influence by observing thebehavior of the various family members. For example, a mother tells son to be quietand sit still and the son complies, which may imply the mother is in charge. A daughterrelinquishes a comfortable chair to a grandfather and grandfather accepts this may bean indication the status of the grandfather within the family. An older brother feedsinfant brother or a younger brother’s behavior reflects the behavior, interests andvalues of an older brother. A father speaks and other family members interrupt, so the

mother intervenes and the children listen to the mother may say something about therelative status and influence of the father and mother in relation to the children.Being sensitive to the relative hierarchy of a family may be helpful in assisting a familywith a family member experiencing a substance use disorder. Allying with the familymember with the most power or influence may help in intervening positively in behalfof the family member with the substance use disorder.The roles of family members will have bearing on the influence of various familymembers on others within the family. If roles are not differentiated clearly andconsistently enough, the needs of family members relating to socialization, nurture maynot be met. With no hierarchy, family life can be unpredictable and children may lackneeded support. If roles are too rigid, individual growth toward autonomy andindependence may be hindered and result in family crisis. For example, if parentalcontrols are too rigid, this may result in children rebelling, engaging in risky behaviors,and precipitate a family crisis.

In observing the interactions of members of a family, it is helpful to look for familymember’s behavior related to frequency, physical proximity, intensity of affect (tone &volume of voice, posture, facial expressions, etc.) and duration of interaction. Look forwho reacts to whom, who argues with whom, who is engaged with whom, who sitsclose to whom, who physically distances him or herself from whom in the family. Arethese interactions indicative of an ongoing pattern of relating? These interactions mayprovide information and patterns about the dynamics of the family system.Observing the involvement of various family members with each other provide cluesabout the interactional patterns within the family. The obvious question to patterns ofinvolvement is “what does this mean”? Why is one person dominant? How do othersfeel about this dominance? Who is withdrawn and why? How might these patterns be

a result of the substance use disorder impacting the family. Even who sits next to whomand how close family members sit in proximity to one another may provide informationabout the functioning of the family.Alliances refer to close associations between certain members of the family. Sometimesalliances may be generational or cross generational. The family may have a strongparental alliance or as in some families there may be a strong alliance between a parentand a child or a child and a grandparent or between certain siblings. Alliances betweenfamily members may be around a certain agenda or issue like protecting a familymember with a substance use disorder. Alliances can be functional for the family or insome instances can create challenges within the family.Examples of alliances might include: Alliances between father and daughter, and motherand son. Alliance between father and daughter against mother. Alliance betweenmother and the responsible son against the son with a substance use disorder, or analliance between a mother and son against a father with a substance use disorder.Alliance between daughter and father against the step-father in the family system.Sometimes two siblings might be allied against a third sibling over a specific issue.Alliances are necessary in families to make decisions, control unacceptable behavior andaccomplish goals.Alliances need to be consistent enough to be effective, and flexible in order to change tomeet different and changing situations. Family members of the same generationworking toward the same goal need to be able to ally effectively with each other.Consistent cross generational alliances help to maintain problem behaviors.

Families draw boundaries between what and who is included in the family system andwhat and who is external to the system. Boundaries occur at every level of the systemand between subsystems. Boundaries influence the movement of people into and out ofthe system. Boundaries also regulate the flow of information into and out of the family.Rigid boundaries may prevent families from seeking help about a substance use disorderbecause the family resists the involvement of someone outside the family.Some families have very open boundaries where members and others are allowed tofreely come and go without much restriction, whereas in other families there are tightrestrictions on where family members can go, and who may be brought into the familysystem. Boundaries also regulate the flow of information about a family. In more closedfamilies, the rules strictly regulate what information may be discussed and with whom.Family secrets may be tightly kept about a family member experiencing consequencesdue to a substance use disorder. In contrast, information may flow more freely infamilies that have more permeable boundaries.When observing the family to determine the boundaries, consider the followingquestions: 1. Who’s in or out of the system or subsystem based on behavior? 2. Who’sin what group? 3. Are there clear distinctions between family subgroups or are theyblurred? 4. How do family subgroups interact? 5. What do boundaries look likebetween nuclear family and systems outside the family?

Salvador Minuchin, the founder of Structural Family Therapy articulated the concept offamily boundaries and differentiated rigid, clear and diffuse boundaries. According toMinuchin, the goal is to achieve clear boundaries for open family communication and tocreate clear parameters to facilitate empathy and understanding between individuals.Practicing healthy boundaries within the family system (and teaching your children howto create and maintain healthy bounds) enables you to create those same clearboundaries with relationships outside the family. Maintaining healthy parameters canlead to more effective communication and healthier, less stressful relationships.Rigid boundaries often leads to distance and a sense of isolation between familymembers, between family subsystems and between the family system and thoseoutside the system. In rigid family systems, communication often become obstructed.Inflexible boundaries fail to respond to changing demands on a family system. Otherimpacts of rigid family boundaries may include family members acting autonomouslyand lacking loyalty to the family unit, rebellion or over-compliance by children, engagingin risky behavior or high risk substance use, anger, resentment, and struggles ofautonomy, independence and power.With diffuse boundaries, family members become enmeshed with each other and havedifficulties developing their own identity and autonomy. The emotional state of thefamily member is often dependent on those of other family members within the system.With diffuse boundaries, roles of family members often become confusing and blurred,authority within the family becomes undefined or confused and families may lackadequate structure and direction. When boundaries are diffuse, sometimes a familymember may become enmeshed with a family member who is struggling due to asubstance use disorder and loses a sense of their own identity and autonomy. Theiractions become overly focused on the behavior of the family member with thesubstance use disorder.Boundaries change between parents and children over time. Boundaries change as the

developmental needs of the family change. Families failing to adapt boundaries to meetchanging developmental needs of the family experience stress and sometimes familycrises.Observing family interactions provides information regarding boundaries. For example,a daughter obeys mother but challenges step father by stating “ You can’t tell me whatto do”. In this case the mother may define family by including stepfather, but thedaughter does not. When a mother states: “Until I get back from the store, Annie is incharge,” differentiates the Executive subsystem (mother & Annie) from the Siblingsubsystem (other children).Look for repeated instances where the same people interact with each other regardlessof the issue, and others are consistently left out.Triangulation typically occurs when a third person is drawn into a stressful situation orconflict between two other family members. For example, two siblings in tension mayresult in a parent intervening to mediate and resolve the tension, or when two parentsin conflict or in tension about one parent’s substance use disorder, one parent mightvent about the tension with her daughter, brother, or mother. There are pros and consto triangulation. Triangulation may perpetuate an issue since the principle parties avoidresolving their tension.For example, parents in conflict over a substance use disorder in which one parenttriangulates with a daughter may result in the parents avoiding necessary work onaddressing the conflict. When an individual feels as if he or she has been pushed out ofan important relationship by a third party, for example, he or she may often feel angry,confused, and rejected which negatively impacts the relational dynamic.

Triangulation also may ease the tension and allow the party involved to gain perspectiveand address the tension directly with the other party. Triangulation may prove to bebeneficial if the third person avoids taking sides and provides help ideas about resolvingthe conflict. Triangulation also may result in the third party drawn into the triangle tobe placed in an awkward situation and to feel uncomfortable. Triangulations may blurfamily boundaries leading to enmeshment or disengagement involving the parties of thetriangle.As the behavior of the individual with a substance use disorder becomes moreunpredictable, out-of-control, and unmanageable, this behavior has greater impacts onother members of the family system. These impacts can include conflict, obstructedcommunication, abuse of various kinds, economic adversity due to money spent ondrugs and alcohol, legal fees, health care needs related to the substance use disorder, orloss of employment. As the behavior of the individual with the substance use disorderbecomes more unmanageable, often the behavior of other family members becomesmore controlling leading to a more unmanageable and dysfunctional family system.Affected family members become angry, resentful, and often overcompensate in anattempt to maintain some sort of family equilibrium. These family conditions mayprecipitate anxiety, depression, and a sense of insecurity about the instability of familyconditions.I recommend reading and reviewing “The Treatment Improvement Protocol” (TIP) seriesnumber 39 published by SAMHSA entitled Substance Abuse Treatment and the 9/) This publication provides helpful

information about how families are impacted by substance abuse (chapter 2), substanceabuse treatment needs of the family (chapter 1), and approaches and strategies forworking with clients and families (chapters 3 and 5). The TIP series of publications arefree and can be downloaded from the SAMHSA website. There are scores of publicationrelated to substance use disorders, substance use disorder treatment, and recovery thatare helpful and free.Rielly identified and described 6 characteristic family patterns in families impacted bysubstance use disorders. They include: patterns of communication and interaction thatare critical of others in the family and negative; parental inconsistency in setting rules,boundaries and enforcing them; parental denial about the presence of a substance usedisorder; obstruction in the appropriate expression of anger and suppressing angerthrough the use of drugs; self medication to deal with stress and other dysfunctionalfamily dynamics; and unrealistic parental expectations.

Substance Use Disorders and the Family Disease ModelFamily Disease model has been very popular and influential in the treatment communityand general public. It proposes that not only are substance use disorders a disease but a“family disease” since family members are impacted by extension. The Disease Conceptof substance use disorders has been applied conceptually to the entire family. Not onlyis the person with the substance use disorder identified as having a primary disease, butthe family system became identified as having a “family disease” by association with thesubstance use disordered family member.Is it realistic to view substance use disorders as a “Family Disease” or is the behavior offamily members mutually and reciprocally impacting each other by the mere fact theyare part of a dynamic and living system? I personally believe the family systems model

is a more appropriate and accurate model in conceptualizing the impact of substanceuse disorders on the family rather than seeing family members as “diseased” as if asubstance use disorder is some how contagious. The impact on family members can besevere and often family members are in need of significant professional help/treatmentas is the individual with the substance use disorder.The common experience identified in this slide and subsequent ones identify not onlycommon family experiences in families impacted by substance use disorders but also aprogression in the severity and intensity of experiences. Effects of substance usedisorders on the family shown in this slide tend to be indi

family members may be around a certain agenda or issue like protecting a family member with a substance use disorder. Alliances can be functional for the family or in some instances can create challenges within the family. Examples of alliances might include: Alliances between father and daughter, and mother .

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