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Alcohol & Sub. Dep.: Family Struggling with Sobriety
Alcohol & Sub. Dep.: Family Struggling with Sobriety

Section 12
Theories of Etiology, Persons and Systems that Support or Compound the Abuse,
& Substance-Affected Families

Question 12 | Answer Booklet | Table of Contents
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs


Historical and Contemporary Perspectives on Alcohol and other Drug Abuse:
Current Theories of the Etiology of Substance Abuse

Etiology
Alcoholism is familial; an important risk factor for developing the disease is to have an alcoholic parent. Although environmental and interpersonal factors are important, a genetic predisposition underlies alcoholism, particularly in the more severe forms of the disease. Heritability of alcoholism (the genetic component of interindividual variation in vulnerability) is 40 to 60 percent.5 The major genes that have so far been identified are protective against alcoholism; approximately one half of all Southeast Asians have genetic variants of alcohol metabolizing enzymes such that after drinking only small amounts of alcohol, they experience an unpleasant facial flushing reaction with tachycardia, nausea, and headaches as a result of the accumulation of the toxic metabolite acet aldehyde.

While the specific physical and psychological effects of drug abuse and addiction tend to vary based on the particular substance involved, the general effects of abuse or addiction to any drug can be devastating. Psychologically, intoxication with or withdrawal from a substance can cause everything from euphoria as with alcohol, Ecstasy, or inhalant intoxication, to paranoia with marijuana or steroid intoxication, to severe depression or suicidal thoughts with cocaine or amphetamine withdrawal. In terms of effects on the body, intoxication with a substance can cause physical effects that range from marked sleepiness and slowed breathing as with intoxication with heroin or sedative hypnotic drugs, to the rapid heart rate of cocaine intoxication, or the tremors to seizures of alcohol withdrawal.

Recognizing and Intervening with Family Members:
The role of persons and systems that support or compound the abuse
There are three factors which are related to perpetuating substance abuse: denial, enabling and codependency.

Enabling is defined as making possible or easy. In this case, behaviors by family members allow individuals with substance use problems to avoid the negative consequences that may accompany their actions. There are many ways in which this behavior can manifest. In addition, enabling behavior can be instigated by various individuals including:
Parents
Siblings
Co-workers
Supervisors
Neighbors
Friends
Teachers
Doctors
Even therapists

Though initially enabling occurs as a way to protect the individual from their behavior, it can go on to perpetuate actions that cause repetitively bad behavior. Some ways in which enabling takes place is as follows:
Doing something for another that they should do themselves.
Making excuses for the individual’s behavior
A spouse calling his or her significant other’s employer to say that they are sick and can’t work when they are just hung over.
Bailing out a child who has been arrested for possession, use or abuse of drugs, or breaking other societal rules.
Instead of recognizing a problem the enabler may defend the substance abuser thereby allowing the behavior to continue.
Generally covering the tracks of the individual in question whether it be by giving/loaning money, finishing up work, or just generally ignoring behaviors that should have repercussions. Usually the enabler stays silent when faced with repeated inappropriate or destructive behavior.

Part of enabling behavior is the concept of denial. Most striking in the denial phenomenon is the enabler’s refusal to acknowledge the deterioration of the relationship he or she has with the substance abuser. In fact, quite often the denial mechanism will continue until it no longer can. Meaning, until something horrific occurs; the individual may refuse to acknowledge the problem.

The benefits of enabling are twofold: the individual who is using substances can continue the behavior they want and secondly, the enabler does not have to acknowledge that anything is wrong. This action however, is a short term solution to a long term problem. Long term, enabling drug abuse behavior leads to unhappiness for the enabler and the further deterioration of the individual using drugs. Another reason enabling occurs is because of the idea of co-dependency.
Co-dependency is the idea of being overly involved in another person’s life. Having a constant preoccupation with the other person’s behavior and feeling unnecessarily guilty when not taking care of the other person’s needs. This often times stems from not having adequate self-esteem. Some common themes in the co-dependency cycle on the part of the dependent person are as follows:
My feelings are not important
I'm not good enough.
I’m not lovable
My having problems is not acceptable
It's not OK for me to have fun.
I don’t deserve love
I’m responsible for my friend or significant other’s behavior

Co-dependency is a vicious circle in which the person being enabled and the enabler need to extricate themselves. It is recommended by experts in the field, that co-dependent family members or loved ones remind themselves on a regular basis that they did not cause the problem, cannot control or fix the problem. They need to understand that the only thing they can do is offer assistance which may or may not be heeded. The codependent person needs to understand that the only person, who can help the substance abuser, is the substance abuser- he or she needs to go obtain the help that is available.

In a co-dependent situation, both the abuser and dependent person need assistance. The substance abuser needs to fix both the chemical and psychological bonds, he or she has to alcohol or substances and the co-dependent individual has to understand why he or she feels the need for this dependency. Experts in the field recommend that help in the form of substance abuse counseling be obtained for the substance abuser as well as therapy for the dependent person.

Like any other substance abuse problem, steps can be taken towards recovery. In this case, help should be obtained for all parties involved. There are treatment centers in which everyone in this scenario can be assisted. It is a matter of the co-dependent person to realize he or she has a problem and then go from there.

Substance-Affected Families: Involvement of the Family in the Recovery Process

It has been well established that the family plays a critical role in the recovery or relapse of the substance-dependent individual. Studies show that individuals are more likely to relapse when families fail to maintain involvement in treatment activities (educational, counseling, and self-help programs) than individuals from families who do stay involved (Daley & Marlatt, 1992; Daley & Raskin, 1991; Gorski & Miller, 1988; Hawkins & Catalano, 1985). When families participate in the recovery process, they are more likely to be supportive and less likely to "sabotage" the addict's recovery. They are also more likely to encourage the addict to seek support from a self-help network and to recognize factors that may interfere with recovery (Daley & Marlatt).

Involvement in the recovery activities is beneficial to the family in more than just providing support to the substance-affected family member. Other members of the family benefit when they have the opportunity to learn about addiction and its physical, psychological, and emotional effect. Family participation in the recovery plan helps them identify relapse warning signs, support efforts to remain abstinent, and achieve some control over the recovery process (Daley & Raskin, 1991). Participation in the process gives family members the opportunity to heal any emotional pain they may have experienced as a result of the addict's substance abuse history (Daley & Marlatt, 1992).

Effect of Substance Abuse on Children
In addition to the role that the family can play in helping the addict achieve recovery, it is vitally important to recognize the potential negative effect that substance abuse can have on children in the family. Research shows a strong link between parental substance abuse and child maltreatment (Child Welfare League of America, 1990; Famularo, Kinscherff, & Fenton, 1992; Sheridan, 1995). According to the Child Welfare League of America, substance abuse may be involved in as many as 80 percent of all substantiated cases of abuse and neglect. Substance abuse is one of the most common reasons children enter into the care of social services agencies (Children's Defense Fund, 1992). In a study conducted by the Child Welfare League of America (1992), referral of over 40 percent of children to public and private child welfare agencies was related to substance abuse. The study also noted that substance abuse is a major factor in cases involving child protection, family disruption, and placement into foster care.

Psychological, cognitive-behavioral, and behavioral risks to children of substance-abusing parents are well-established (Aktan, Kumpfer, & Turner, 1996; Curtis & McCullough, 1993; Dore, Doris, & Wright, 1995; Julianna & Goodman, 1992; Sheridan, 1995). Dore, Doris, and Wright, in a review of how substance abuse affects children, reported that studies of psychosocial functioning have found that children from substance-abusing families are prone to behavior problems involving hyperactivity and conduct disorder, drug and alcohol use, impaired intellectual and academic functioning, clinical levels of anxiety and depression, low levels of self-esteem, and perceived lack of environmental control. Aktan, Kumpfer, and Turner reported that children in families of substance abusers are inclined to have ability deficits that impair their ability to solve problems, cope with stress, tolerate drugs, communicate effectively, consistently apply good standards, hold reasonable expectation, and be sufficiently interactive and supportive with others.

Effect of Substance Abuse on Parenting
In families in which parents abuse substances, parental control and protection factors are less evident and youths are more likely to exhibit behavior problems at home and school, be involved in delinquent activities, and use drugs and alcohol than youths from families in which parents do not abuse drugs (Julianna & Goodman, 1992). Drug-abusing families are likely to exhibit poor family management skills that lead to disruption, conflict, loss of parental control, low frustration tolerance, unrealistic expectations of children, weak child-parent bonds, low family cohesion, and undefined family boundaries (Julianna & Goodman; Sheridan, 1995). Also, there is evidence that when parents stop using drugs they become better parents (Murphy et al., 1991).

Assistance to Substance-Affected Families
Although the family is increasingly viewed as being important to the recovery process, less attention has been given to helping family members of recovering substance abusers (Aktan et al., 1996). Assistance to families has not been widely available in part because a strong focus on the substance-affected individual has dominated the field. Another, and perhaps more important reason, is simply insufficient attention to the assessment and treatment of families affected by substance abuse by professionals (such as social and child care workers) with responsibilities for serving children and families (Dore et al., 1995; Tracy & Farkas, 1994).

Tracy (1994) noted a reluctance on the part of social workers to address substance abuse problems adequately. Moreover, even when the social worker appropriately recognizes these family issues, the case management plan may be inadequate because of limited treatment sources and lack of preparation for addressing the effect of drug and alcohol use. Few programs have the comprehensive range of services to address the diverse needs of substance-affected parents, which include special and developmental needs of children, child care and parenting skills, housing and vocational assistance, and counseling directed at the emotional consequences (for example, guilt and shame) of substance abuse.

The Child Welfare League of America's North American Commission on Chemical Dependency and Child Welfare (1992) has recommended that child welfare agencies recognize that parental alcohol and drug dependency places children at risk of abuse and neglect and provide services to undo the effects of abuse and neglect, stabilize the family, improve parenting skills, and prevent maltreatment. According to the Child Welfare League of America, "Chemically dependent families need intensive immediate and ongoing assistance to resolve AOD dependency, improve family functioning, and remedy the problems that chemical dependency creates for children" (p. 20). The report asserts that services must be provided to help parents improve their ability to perceive, understand, and respond appropriately to their children's needs. Also, it is important to consider the larger context of alcohol and drug use and how it might affect family needs such as housing, employment, medical care, sufficiency of social network, and contact and integration with the community.

Intervention Domains: The Bridges Program
The program's intervention domains were selected to form a practice model that would support individual and family relapse prevention work. Selection of the components were guided by the relapse prevention model approach (Daley & Marlatt, 1992; Dale), & Raskin, 1991; DeJong, 1994) and by the addiction recovery approach (Gorski & Miller, 1988). The core domains were selected to achieve the service focus of linking parental recovery with family support. The domains and their respective components were included on the basis of their relationship to family and parent functioning and to their identified significance in contributing to relapse prevention.

The four domains are

  1. individual actions and cognitions: behaviors and thinking patterns of the substance abuser that represent facets of functioning that are essential to engaging in a lifestyle not dependent on alcohol or drug use
  2. individual recovery actions: behavioral changes that substance abusers must integrate into their daily lives to achieve and maintain sobriety
  3. family actions and cognitions: behaviors and thinking patterns of the substance abuser's family that represent facets of family functioning that are essential to providing the support and structure the abuser needs to be able to engage in a lifestyle not dependent on alcohol or drug use
  4. family recovery actions: actions that the families of substance abusers need to take to understand substance abuse and help the substance abuser achieve and maintain sobriety.

Achievement in each domains is measured through a series of assessment questions at case opening, case closure, and six weeks after closure of the case. Four levels of progress are depicted on a pictograph of the components of each domain (see Figure 1):

  • Level 1 (innermost)--functioning at an unacceptable level, in urgent need of recognition of problems and actions to begin relapse prevention
  • Level 2--functioning at a minimally acceptable level, needs to identify resources and begin to use them to address addiction-related problems
  • Level 3--functioning at a moderately acceptable level, is inconsistent in practice of appropriate relapse prevention behaviors and uses support resources
  • Level 4 (outermost)--functioning at an acceptable level, is consistent in engaging in appropriate relapse prevention behavior

Components are scaled on a motivation to change or achievement of change dimension fashioned after the preparation stages of the change model of Prochaska and his colleagues (Prochaska, DiClemente, & Norcross, 1992). The domains and their components are used to develop and implement the treatment plan, which addresses family functioning and relapse prevention issues. Level of functioning within each domain is addressed so that the focus on the work with the family is to establish a strong link between family behavior and support actions and the substance-affected parent's functioning and recovery actions. The resulting picture that is created on the pictograph shows the individual and family movement toward recovery functioning and what specific domain components may need further work. (Examples of the intervention strategies derived from the model are presented in Gruber, Fleetwood, and Herring, 1998, which is available from the authors.)
- Gruber, Kenneth, Fleetwood, Thomas, & Michael Herring, In-Home Continuing Care Services for Substance-Affected Families: The Bridges Program, Social Work, Jul 2001, Vol. 46, Issue 3.
- Roxanne Dryden-Edwards, MD, Melissa Conrad Stöppler, MDDrug Abuse and Addiction,http://www.medicinenet.com/drug_abuse/article.htm
- Mary-Anne Enoch, M.D., M.R.C.G.P., and David Goldman, M.D., American Academy of Family Physicians
http://www.aafp.org/afp/2002/0201/p441.html
-Codependency and Enabling Substance Abuse Behavior
http://www.addictionsearch.com/treatment_articles/article/codependency-and-enabling-substance-abuse-behavior_40.html

Personal Reflection Exercise #3
The preceding section contained information about substance-affected families in the recovery process.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 12
In what three ways is involvement in the recovery activities critical not only to the addict but to the family members?
To select and enter your answer go to Answer Booklet.

 

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