The SAGE Encyclopedia of Abnormal and Clinical Psychology
Substance Use Disorders and the Family
Contributors: Erin Smith & Dennis C. Daley
Edited by: Amy Wenzel
Book Title: The SAGE Encyclopedia of Abnormal and Clinical Psychology
Chapter Title: "Substance Use Disorders and the Family"
Pub. Date: 2017
Access Date: April 13, 2017
Publishing Company: SAGE Publications, Inc.
City: Thousand Oaks,
Print ISBN: 9781483365831
Online ISBN: 9781483365817
Print pages: 3378-3382
©2017 SAGE Publications, Inc.. All Rights Reserved.
This PDF has been generated from SAGE Knowledge. Please note that the pagination of
the online version will vary from the pagination of the print book.
Contact SAGE Publications at http://www.sagepub.com.
Several national epidemiological studies conducted in the United States show high rates of
substance use disorders (SUDs). Findings of the Epidemiological Catchment Area Study
show lifetime prevalence rates for alcohol use disorders at 13.5% and for drug use disorders
at 6.1%. In addition, 37% of those with an alcohol use disorder and 53% of those with a drug
use disorder met the lifetime criteria for a mental health disorder. However, the majority of
those with an SUD never receive help for their disorder. In any given year, less than 10% of
individuals with SUDs are engaged in treatment.
Biological, psychological, and social factors influence the likelihood of developing an SUD,
genetic influence being among the strongest. SUDs run in families and can profoundly shape
the ethos of the family system as well as of its individual members. The burden of living with
an SUD falls beyond individuals with an SUD. It is estimated that at least 25% of the
population have a first-degree family member with an SUD, many of whom live with family
SUDs can cause or worsen medical or dental problems, contribute to mental health issues, or
interfere with recovery from a mental health disorder. Family and interpersonal conflicts are
common, as are academic decline, unemployment, involvement with the criminal justice
system, and loss of healthy leisure activities or spirituality. More severe levels of SUDs are
associated with an increase in mortality and a significant decrease in life expectancy, due to
medical disease, accidents, suicides, or becoming victims of homicide.
SUDs affect family systems and individual family members in profound ways. According to
family systems theory, SUDs cannot be fully understood, nor will treatment be successful,
without examining how individuals function within their family “system,” because families
shape one’s identity, one’s relationships, and how one views the world. SUDs and the
behavior of family members can be understood through three key concepts: (1) homeostasis,
(2) feedback, and (3) boundaries. Homeostasis is the tendency toward a stable equilibrium
among interdependent elements. In addiction, family members often attempt to maintain a
stable and balanced family system. A wife may provide excuses to her husband’s boss to
cover up his drinking and help keep his employment. In the short term, this effectively
maintains the status quo and equilibrium but at great cost to the individual, whose addiction is
maintained, and to the family. Feedback refers to the interactions between parts of a system.
A child’s school performance may plummet and oppositional behaviors increase when his
mother is in active addiction. She may identify that substances help her cope with her son’s
difficult behavior. Without intervention, each behavior is maintained or escalates in tandem,
and the cycle is reinforced. Boundaries are what separate individual members within a family
system. In healthy families, children and parental subsystems are separate. In families
affected by SUDs, these often blend and merge in unhealthy ways, with children becoming
caretakers for younger siblings or fulfilling the role of a supportive person to the nonaddicted
parent. This entry focuses on the effects of SUDs on the family system as well as on
individual family members and presents several interventions aimed at helping families.
Effects of SUDs on the Family System
An SUD in a parent, child, or sibling may produce differing personal and family reactions.
SUDs frequently begin in adolescence, and parents and siblings of adult patients often cope
with the illness for years. Some family members become estranged, whereas others become
codependent or harmfully enmeshed with the individual’s SUD and chaotic behavior. An
example of codependency is a child who cares for his or her intoxicated parent, thereby encouraging and maintaining the addictive behavior. Enabling is a maladaptive way of coping
and interacting that frequently develops in these relationships and is a core feature of
codependency. Enabling can be supportive or hostile, although both have similar outcomes:
The SUD continues with increasingly dire consequences. An example of supportive enabling
is a family paying for car repairs after the son has had a car accident while driving under an
impaired state. Hostile enabling occurs when family members express pent-up anger and
resentment toward the individual in the mistaken belief that fostering guilt and shame will lead
to recovery or a desire to seek help; SUDs often intensify, however, causing further damage to relationships.
Other factors mediating the impact of SUDs on families include the substances used,
methods of administration, severity and duration of the SUD, and behaviors of the affected
individual, and whether a co-occurring mental health or medical disorder is present. Coping
skills of individual members and access to supportive people or organizations (e.g., church,
mutual-support programs) also matter, as do socioeconomic class, rural versus urban
communities, and family attitudes toward addiction. Family rituals such as holidays, birthdays,
weddings, and graduations either do not occur or are unhappy occasions.
With homeostasis, feedback, and boundaries altered by the SUD, the overall structure of the
family system weakens. As expressed and internalized conflicts increase, family stability and
cohesion decrease. Relationships become strained, and family members often disagree on
how best to help their loved one. Sometimes, families disagree among themselves or with
clinicians as to whether the individual even has an SUD.
Effects on Individual Family Members
Although individual family members suffer and cope with addiction in unique ways, several
key underlying themes may be noted. Physical, sexual, or emotional abuse is common,
particularly when individuals are intoxicated. The individual with an SUD may have no memory
of the event or may deny that the abuse occurred, which can confuse or damage the victim.
Neglect is also common, as is elder abuse; often, both remain undetected. Physical
separation may occur through divorce or separation due to marital strife, incarceration, and
repeated admissions to hospitals or rehabilitation centers. With their time and energy
dominated by the pursuit of substances, many individuals with SUDs are absent from their
children’s lives and may leave them alone or in the care of unsuitable adults. Loss is another
common theme among families affected by an SUD. Parents of adolescents with SUDs cope
with the loss of their hopes and expectations for their child. Children lose parental figures,
and spouses lose intimacy and support. Some families confront death through overdose,
accidents, medical complications, or suicide. They often feel anger, depression, worry, or guilt.
Communication breakdown is another consequence of SUDs as families operate under
secrecy, confusion, embarrassment, and chaos. Anger, frustration, and a profound sense of
helplessness contribute to conflict and division between spouses, among siblings, and in the
Effects on the Unborn Child
Nicotine contributes to premature birth and low birth weight and is associated with motor,
sensory, and cognitive deficits in toddlers. The association between smoking and sudden
infant death syndrome is well documented. In the United States, exposure to alcohol during
pregnancy is the most common cause of birth defects. Fetal alcohol syndrome is a constellation of symptoms including facial deformities, slow development, intellectual
disabilities, and neurological problems. Other problems include learning disabilities and low
frustration tolerance. Babies born to mothers who abuse cocaine and heroin are often
premature, small for gestational age, and underweight. Intrauterine death is also common.
Opiate use during pregnancy is associated with neonatal abstinence syndrome, which
consists of neurological hyperactivity, disturbed sleep, and poor feeding, requiring close
monitoring and treatment in hospital. Ultimately, the full impact of SUDs on the developing
fetus is difficult to gauge given the high rate of poor maternal nutrition, poor prenatal care,
and intimate partner violence in this population.
Effects on Children
Neglect is common, as are other forms of child abuse. Academic performance often declines.
These children are at increased risk for SUDs, internalizing (mood and anxiety) and
externalizing (anger or acting out) behaviors, or disorders. Older children are often forced to
supervise younger siblings, while siblings of adolescents with SUDs are often neglected.
Some of these children may be driven to overachieve, whereas others develop mood and
behavioral disturbances. Siblings may introduce one another to substances. When a parental
figure has an SUD, responses to his or her infant are often erratic and inappropriate (i.e.,
yelling when the child is crying), leading the infant to develop insecure or disorganized
attachment. These responses shape childhood behavior and influence adult relationships as
Effects on Spouses
SUDs lead to significant strain and tension in marriages and romantic relationships. Spouses
often become neglected and may believe that they are helpless to intervene. Feelings of
anger and resentment often emerge. Financial pressures add further tensions. A spouse may
inadvertently further addiction if the consequences are diminished or removed. Intimacy is
altered by substance use; sex often does not occur or can be violent or forced. A parent with
an SUD may underfunction, placing pressure on his or her spouse to raise the children. Mood
and anxiety disorders are common among affected spouses, some of whom may also develop
Effects on Parents
Parents often struggle with guilt, embarrassment, confusion, and anger. Marriages can break
down if one parent blames the other for their child’s SUD. Denial of the SUD or refusal to
acknowledge the problematic behavior is common and can delay treatment. Parents may feel
obliged to pay bail and other legal fees for their child. Parents of adults with SUDs often
become primary caregivers to their grandchildren and may need to come out of retirement in
order to provide financial support.
Interventions to Help Families
A host of therapeutic interventions and mutual-support programs can help individuals with an
SUD engage in treatment, strengthen and support affected families, and help family members
reduce the emotional burden or other adverse effects of the SUD. Manual-driven family
interventions with empirical support include Behavioral Marital Therapy (BMT), A Relational
Intervention Sequence for Engagement (ARISE), Community Reinforcement and Family Training (CRAFT), Brief Strategic Family Therapy (BFT), Multidimensional Family Therapy
(MDFT), and Network Therapy (NT). BMT was developed for individuals with SUDs and their
spouse or partner. One iteration of BMT incorporates a relapse prevention intervention for
couples. Numerous clinical trials and meta-analyses (i.e., studies that integrate findings from
multiple studies) show that these family and marital approaches increase treatment
engagement and retention rates, encourage abstinence or reduction of substance use, result
in lower rates of relapse, improve academic functioning and behaviors of adolescents, and
improve marital or family communication and functioning.
Engaging the Member With the SUD in Treatment
The majority of individuals with an SUD never receive help. Those who engage in treatment
often do so as a result of interventions from the legal system, employers, or families. Family
approaches lead to significant improvements in treatment engagement and retention. The
ARISE (A Relational Intervention Sequence for Engagement) model helps the family (or social
network) develop specific strategies to influence the person with the SUD to engage and
participate in treatment. Strategies used include “joining” the family, eliciting family strengths,
reviewing previously attempted engagement strategies, determining alliances within the
family, and identifying options to engage the member with the SUD in treatment. The CRAFT
and BSFT models encourage families to change the way they communicate and interact with
their loved one as a strategy to influence engagement in treatment. All three of these models
show significantly higher engagement rates compared with a control condition or treatment as
CRAFT family sessions focus on the motivation, triggers, and consequences of substance
use; family communication; positive reinforcement (rewarding behavior changes); life
enrichment; and safety training (to stop domestic violence). Studies show that CRAFT is more
successful than usual care in (a) helping individuals with an SUD enter and remain in
treatment, (b) getting the member to stop or reduce substance use, and (c) helping families
enrich their own lives. Improvements are enhanced when motivational incentives are added,
which reward positive behavior change.
BSFT was developed for families of adolescents and views SUD and other problems of the
adolescent as the result of maladaptive family interactions, poor boundaries within the family,
and parental beliefs that the adolescent is responsible for the problems in the family. BSFT is
used with diverse cultural groups, and sessions may be held in a clinic or at the family home.
It aims to (a) prevent, reduce, or treat adolescent behavior problems such as drug use,
conduct problems, delinquency, or sexually risky behaviors; (b) improve school attendance
and performance; and (c) improve family functioning. Numerous studies show positive effects
of BSFT compared with control groups in terms of (a) reduction of substance use, (b)
improved family adherence to sessions, (c) improved adherence of the adolescent to
treatment sessions and school attendance, (d) reduction of aggression and other conduct
problems, (e) improved academic performance, and (f) improved family functioning.
MDFT is used with adolescents who have substance use, mental health, or co-occurring
disorders and with those at high risk for behavior problems, such as a conduct disorder or
delinquency. MDFT helps the adolescent improve his or her coping and problem-solving skills
and helps the family improve communication and functioning. This therapy targets the
adolescent’s relationships with family and peers, parental roles and practices, parent-
adolescent interactions, and communication in the family or between the family and social
systems such as the school or juvenile justice system.
NT has fewer studies than the other interventions and has been used with adults with opioid
or cocaine use disorders. Outcomes of clinical trials show higher rates of abstinence among
clients receiving NT compared with usual care.
BMT aims to help the partner with the SUD achieve abstinence or reduce substance use or
relapses after a period of sobriety. This couple-based therapy also aims to improve
relationships and support recovery for both partners. Developing a “recovery contract” is a
central component, with “daily rituals” that the couple engages in to reward continued
abstinence. BMT emphasizes communication and reintroduction of positive experiences,
which are often lost when one partner is in active addiction.
Addressing Family Issues in Individual or Group Therapies for SUDs
Most of the individual or group therapy approaches for individuals with SUDs address family
issues with the client. Manual-driven psychosocial therapies include individual drug
counseling, group drug counseling, the Matrix model for stimulant addiction, cognitive
behavioral therapy, relapse prevention, and twelve-step facilitation therapy. Depending on the
specific model, interventions for clients in treatment include examining the impact of their
SUDs and behaviors on their family, involving families in education and/or therapy sessions,
and helping clients and families improve communication and resolve problems and conflicts.
Approaches such as the Matrix model include a “family module” that provides family
counseling and structured family education sessions on SUDs, their treatment, recovery and
relapse, as well as how family members can help themselves. Others such as individual drug
counseling, group drug counseling, cognitive behavioral therapy, and relapse prevention
address family issues as needed during treatment sessions. Interventions such as
motivational interviewing or motivational incentives benefit the family indirectly by helping the
member with the SUD resolve ambivalence and engage in treatment, reduce substance use,
and improve adherence to treatment.
Active involvement in Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous,
other twelve-step programs, and other mutual-support programs can help an individual
sustain long-term recovery. Two of the twelve steps (Steps 8 and 9) address family issues by
recognizing and admitting to the harmful effects of the individual’s behaviors on others and
making amends to family members who were harmed. Family mutual-support programs such
as Al-Anon, Alateen (for adolescents), and Nar-Anon offer a similar program for family
members. These include recovery meetings, sponsorship, a twelve-step program of recovery,
recovery literature, and ongoing support from other family members. Educating family
members and linking them with specific programs can aid their recovery. Because many
individuals with SUDs also have mental health disorders, programs such as the National
Alliance on Mental Illness can provide support, education, and resources for families affected
by these disorders. Also, some family members may need professional help with their own
substance use or mental health disorder.
The impact of SUDs extends beyond the individual; family systems and individual members
experience a range of adverse effects as well. The relapsing and remitting nature of
addictions and the resultant chaotic behavior deeply affect families, creating an emotional
burden. Awareness of this is essential when planning treatment. Many effective interventions
are available to strengthen family influence on the member with the SUD to engage in
treatment, address the challenges of recovery (e.g., triggers, relapse, negative emotions), and
improve family interaction and communication. Professional interventions and mutual-support programs for families or couples can help them engage in recovery and encourage positive
changes in their lives. Professionals from all disciplines need to be aware of the impact of
SUDs on families and strategies to help them.
Erin SmithDennis C. Daley
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