When working with individuals with Substance Use Disorder (SUD) or mental health issues, it is imperative to address the larger family system in order to provide an understanding and context for the suffering and to elicit an opportunity to heal the entire family.  In order to effect long-lasting change, the support of family members is essential. Equally, the family members need to examine their own issues and recognize that a loved one’s getting help affords an opportunity for change and healing for all.

Often, the traumatic issues one family member is experiencing have generational roots. These families have often dealt with SUD, mental health issues, or trauma for generations, and an intervention and treatment yield an opportunity to rewrite the family script.

Many have written about the importance and understanding of family systems (Salvador Minuchin, Jay Haley, Cloé Madanes, Carl Whitaker, Sharon Wegscheider-Cruise, Murray Bowen, Monica McGoldrick, Judith Landau, and Claudia Black, to name a few). All of these clinicians agree on the importance and value of addressing the entire family system and advocate for clients receiving treatment to gain a better understanding of themselves.

Everyone is Uniquely Affected

Each family and individual within a given family may be uniquely affected in a variety of ways, including but not limited to suffering^[1]:

• Unmet developmental needs
• Impaired attachment
• Economic hardship
• Legal problems
• Emotional distress
• Violence perpetrated against him or her

Families form systems whereby family members develop particular ways of acting and reacting with one another as well as with the outside world. Such patterns of interaction mean that each family system has its own style and equilibrium. This “balance” includes:

• Family members’ expectations (spoken or unspoken)
• The expression of their feelings
• The management or avoidance of conflict
• Communication with the outside world and the roles which they are assigned
• Triangulated communication
• A closed family system where it is difficult to request or receive help

Correcting for Imbalance in the Family

All of these dynamics help shape the personality styles and behaviors of family members. Sharon Wegscheider-Cruse likened the family system to a mobile, for example, with butterflies. In her model, the butterflies represent the family members, and the sticks and strings represent the family rules, roles, and norms holding them together. When one or more family members find themselves suffering from pain or stress in their lives or when unexpected change occurs, a family with healthy interpersonal relationships will sway, bounce, and then fall back into balance. Other members of the family adjust and compensate with their own behaviors, and eventually the equilibrium is re-established.

Wegscheider-Cruse notes that within a family where SUD or mental health issues are present, it is as though that family member has added a paper clip to their butterfly. All of the other family members have their lives altered by the suffering individual, and the mobile’s balance cannot be recreated. Each family member, in turn, adds their own paperclip or compensatory behavior to balance out this system. Consequently, the family may become more closed and unable to express opinions or talk about problems, and the rules that hold the family together will often become rigid and unable to support change and individual uniqueness. The same concepts that Figley and Kiser use to describe how relationships and support can become disturbed in response to trauma  apply to Substance Use Disorder and mental health within the family system as well:^[2]

Intra-Familial Relationships Experience:

• Compromised family solidarity
• Poor communication channels
• Heightened levels of negativity and conflict
• Decreased relational security
• Family membership transitions or dissolution

Extra-Familial Relationships Suffer From:

• Mistrust; Heightened levels of anxiety and conflict
• Social withdrawal and isolation

Support Systems are Lacking and Families Have:

• Difficulty identifying resources
• Difficulty asking for or accepting support
• Compromised and burned out support networks
• Limited or absent reciprocity
• Avoidance of seeking help

Changes in Outlook for Substance Use Disorder Recovery

Since the 1980s, the approach to recovery from addiction has evolved. Whereas family members were previously viewed as “enablers” and contributors to the disease, today we have a better understanding of how addicts’ brain chemistry is affected and how they struggle with Post Traumatic Stress Disorder (PTSD).

The de-pathologizing of families has been important in the growth of the mental health and SUD fields. For this healing process to begin, the family needs to be educated about the true nature of the illness^[3]. It is imperative for all involved to realize that allocation of blame and feelings of shame are not conducive to recovery.

Helping families discover ways in which they may support their loved ones’ health versus contributing to their demise pushes family members out of their comfort zones. These new behaviors or ways of interacting will be supportive and loving and will account for the fact that SUD and mental health issues often do not play by fair rules.

For example, no parent wants to see their child in pain, but often giving a young adult who is struggling with SUD cash helps them buy their drug of choice. Parents may be advised, instead, to pay bills directly for their child, offer them a sandwich instead of cash, or even stop financial support while offering treatment or presenting the suggestions of a professional as an alternative.

Provided that adequate professional support is in place during this transition period, these new actions from family members can prove transformational. Gradually, the person with the SUD or mental health issues may begin to realize that the destructive and painful life that they are living is less sustainable when family members withdraw their “consent.”

How Professionals Can Help the Families of Those Suffering from Substance Use Disorder and Mental Health Disorders

Counselors, therapists, and other mental health professionals can bolster the confidence of family members throughout the process. Initially, however, it is essential that the destructive nature of denial is recognized. In fact, psychiatrists today recognize that the trauma brought about by SUD and mental health disorders is experienced by all family members in one form or another^[4]. This trauma descends through the generations and manifests itself in varying other forms of psychological and emotional disorders. Having understood that this trauma does not appear in isolation, family members will begin to see that they all need to enter a period of recovery and experience the opportunity to heal.

How Can We Encourage the Suffering Individual to Focus on Their Needs?

In conjunction with this enlightenment, the strengths and love present within the family must also be cherished and nurtured. Only then will siblings, grandparents, aunts, uncles, parents, and children be able to refocus their energies on behaviors that can help the individual and the family. Their relationships with each other may need to be studied and restructured.

For example, an aunt who has lied to her husband for years about the food and support she has given to her desperate niece/nephew with an SUD has unwittingly caused much damage to her marriage. Through mending these interpersonal relationships, the family system becomes a far more stable environment without heated arguments fueled by shame and anger, which then allows the suffering individual to focus on their own predicament and decisions about their recovery.

These healthier family dynamics, in which there is no longer denial, will encourage calm approaches to open conversations with the suffering individual. Much support from outside professionals is generally needed in order for these new and loving, but still tough, approaches to be maintained by family members.

Stigma is a Major Inhibitor of Open Dialogue

Both mental health issues and SUD feed on the guilt, shame, and fear inherent in our society, and the stigma surrounding these conditions can inhibit open dialogue. In order for families to heal and take action towards professional help, this stigma must be lifted and be replaced with a modern day understanding of how these are illnesses just like cardiac disease or diabetes. Recovery involves learning, growth, and healing, and while it may be an “inside job” for the individual struggling with the disorder, it requires a team effort from the surrounding family.

 

Sources:

^[1] Lander, L., Howsare, J., & Byrne, M. (2013). The impact of substance use disorders on families and children: from theory to practice. Social work in public health, 28(3-4), 194–205. https://doi.org/10.1080/19371918.2013.759005

^[2] Figley, C. R. & Kiser, L. J. (2013) Helping Traumatized Families, Second Edition, NY: Routledge

^[3] Meyers RJ, Miller WR, Hill DE, Tonigan JS. Community reinforcement and family training (CRAFT): Engaging unmotivated drug users in treatment. J Subst Abuse. 1998;10(3):291‐308. doi:10.1016/s0899-3289(99)00003-6

^[4] Center for Substance Abuse Treatment. Substance Abuse Treatment and Family Therapy. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2004. (Treatment Improvement Protocol (TIP) Series, No. 39.) Chapter 2 Impact of Substance Abuse on Families. Available from: https://www.ncbi.nlm.nih.gov/books/NBK64258/