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Substance Use Disorder Treatment and Family Therapy: Updated 2020 [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2020. (Treatment Improvement Protocol (TIP) Series, No. 39.)

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Substance Use Disorder Treatment and Family Therapy: Updated 2020 [Internet].

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Chapter 2—Influence of Substance Misuse on Families

KEY MESSAGES

Substance misuse and substance use disorders (SUDs) affect families in many ways. Use of alcohol and drugs can influence family dynamics, communication styles, patterns of conflict, and cohesion (degree of closeness with one another), among other effects.

When substance misuse is present in a family, dysfunctional patterns and relationships often occur as the family struggles to keep their life as normal as possible. Family members are usually doing their best to cope, but sometimes their ways of coping and keeping balance in the family can be unhealthy.

SUD treatment providers should approach families with empathy and understanding, not judgment and blame.

Almost all families in which substance misuse occurs share certain features. Even so, family types can influence how families experience and attempt to cope with substance misuse. Families with young children, families with adult children, couples, blended families, same-sex couples, and families in which an adolescent is misusing substances have their own unique family dynamics and outcomes.

Parental substance misuse is especially damaging to both young and adult children. It increases children's risk of experiencing SUDs and mental disorders, among other negative outcomes.

Chapter 2 of this Treatment Improvement Protocol (TIP) summarizes how SUDs affect families and family functioning. It will help SUD treatment providers understand the types of relationships and patterns of behavior they are likely to encounter in the delivery of family-based SUD treatment and related services. This chapter:

Summarizes effects of SUDs on families, including family factors associated with substance misuse and the biopsychosocial consequences for spouses/partners, parents, and children of varying ages.

Introduces the roles of family history and genetics in substance misuse and recovery.

Identifies common family features and dynamics associated with substance misuse (e.g., high levels of conflict, low-quality communication, low levels of cohesion).

Discusses the unique dynamics, interrelationships, and effects of SUDs in five specific family types:

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Couples in which a partner has an SUD.

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Parents with an SUD who have young children.

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Parents with an SUD who have adult children.

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Blended families in which a family member has an SUD.

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Families with an adolescent who has an SUD.

SUDs affect more than just the person who misuses substances; they can potentially affect the person's entire family as well, influencing breakdown in the ways in which family members get along, communicate, and bond with each other. A family is a system consisting of different “parts” (the family members), so a change in one part can cause changes throughout the system. When a family member has an SUD, the effects on that person's family can vary significantly, depending on factors such as SUD severity, access to resources, family type, patterns of substance misuse, and the presence of substance misuse or related activities in the family home, to name just a few.

In reading Chapter 2, you will learn to recognize common family features and dynamics associated with substance misuse to help guide you toward the interventions and services that will best meet each family's needs. Improving your grasp of these factors will help you avoid judging or pathologizing families dealing with SUDs and, instead, offer them understanding and empathy.

The Role of Genetics and Family History in the Development of and Recovery From SUDs

Family history of substance misuse is linked to an increased risk of developing SUDs (Huibregtse et al., 2016; Prom-Wormley, Ebejer, Dick, & Bowers, 2017; Reilly, Noronha, Goldman, & Koob, 2017). Genetic research suggests that there are multiple genes for alcohol use disorder (AUD) and SUDs involving nicotine, cannabis, cocaine, and opioids (Prom-Wormley et al., 2017). Genetic risk of SUDs may vary according to parent gender (Nadel & Thornberry, 2017). (For more information on gender differences in families and risk of SUDs, see the section “Traditional Gender Roles, SUDs, and Family Dynamics.”)

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COUNSELOR NOTE: CAN FAMILIES BENEFIT FROM GENETIC COUNSELING FOR SUDs?

Genes play a role in the development and progression of substance misuse and SUDs (Schuckit, 2014). For example, the quantity and frequency of alcohol, nicotine, and cannabis use in one study were greater among nonadopted adolescent siblings than adopted adolescent siblings, although a shared home environment (a nongenetic factor) that includes substance use was also thought to contribute to an extent (Huibregtse et al., 2016). However, earlier data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (Yoon, Westermeyer, Kuskowski, & Nesheim, 2013) found lifetime rates of SUDs were greater among adopted adults than nonadopted adults, which also points to the importance of shared environment.

One allele (a variant form of a gene) is associated with an increased risk of relapse for individuals with AUD (Dahlgren et al., 2011). In a comparison of people in recovery from alcohol dependence conducted in Sweden, those with the DRD2 A1 allele had a significantly higher rate of relapse (89 percent) than did those without the allele (53 percent). Other studies suggest that a family history of substance misuse increases relapse risk for people in SUD remission (McLaughlin et al., 2010; Milne et al., 2009). Certain genes/alleles related to reward mechanisms and neurotransmitters in the brain (e.g., dopamine, serotonin) also may increase cravings and, thus, returns to use (Blum et al., 2017; Leventhal et al., 2014).

Exhibit 2.1 further demonstrates how biology fits into a framework for understanding SUDs in families.

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Exhibit 2.1. The Role of the Medical Model When Working With Families.

Common Characteristics of Families With SUDs

No two families are exactly alike, but families in which substance misuse occurs often share common features. They typically (Bradshaw et al., 2016; Elam, Chassin, & Pandika, 2018; Klostermann & O'Farrell, 2013):

Show a lack of flexibility, rather than an excess.

Have high levels of distress and dysfunction.

Have low levels of family expressiveness, cohesion, and agreement.

Experience what has been termed the “reciprocal causality” of maladjustment. This means the substance misuse leads to family dysfunction, but that family dysfunction and conflict also affect substance misuse and relapse. Thus, the two are interconnected.

See Exhibit 2.2 for more family characteristics linked with SUD onset, maintenance, and recovery.

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Exhibit 2.2. Family Traits That Affect SUD Initiation, Maintenance, and Recovery.

A literature review and meta-analysis (Yap, Cheong, Zaravinos-Tsakos, Lubman, & Jorm, 2017) identified common factors in the families of adolescents who misuse alcohol. These factors include:

Parents using alcohol.

Parents expressing a positive attitude about alcohol use.

Parents providing children with easy access to alcohol.

Families experiencing higher levels of conflict.

Parents and children having low levels of quality relationships with one another.

Exhibit 2.3 gives examples of ways in which certain substances commonly affect families.

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Exhibit 2.3. Effects of Different Substances on Families.

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MINI-CASE EXAMPLE.

Homeostasis

In nearly all families affected by substance misuse, there is a tendency to try to maintain homeostasis. This means that family members will behave in ways to try and keep the family functioning as it always has, even if that means supporting the family member's substance misuse to prevent change or imbalance. Unhealthy family relationships, roles, rituals, and functions often develop in part because families are attempting to maintain homeostasis. The following case is just one example of an attempt to keep the balance in a family dealing with an SUD.

“When one person in a family begins to change his or her behavior, the change will affect the entire family system. It is helpful to think of the family system as a mobile: when one part in a hanging mobile moves, this affects all parts of the mobile but in different ways, and each part adjusts to maintain a balance in the system.”

(Lander, Howsare, & Byrne, 2013, p. 197)

As an SUD treatment provider, you need to understand the role of homeostasis in family dynamics and help family members develop healthier behaviors and relationships with one another without blaming, lecturing, or judging them.

It also is critical that you identify and understand a family's efforts to maintain homeostasis. The family members’ readiness to change (or lack thereof) may affect family functioning, and family functioning may affect their readiness to change (Bradshaw et al., 2016). Both factors—family readiness to change and functioning—may affect the person with an SUD and his or her willingness to seek recovery.

Traditional Gender Roles, SUDs, and Family Dynamics

Traditional gender roles are an important factor in understanding family dynamics and SUDs. In U.S. culture, family functions and roles have traditionally differed by gender, such that men were typically the “breadwinners” and primary decision makers for the family, whereas women were caretakers and sources of emotional support. The relationships, roles, and functions in a family are affected by that family's view of gender roles in general. For example, in a family that believes women should not work outside the home, a wife having to take a job because of family financial strain may become a major source of stress or shame. Further, it is common for family bonds to differ across gender, with the formation of strong mother-daughter and father-son dyads but, in many cases, comparatively weaker bonds between parents and their children of the opposite gender.

Traditional gender roles relate to substance misuse. Strict adherence to stereotypical gender expectations may increase SUD risk in young people. For instance, adolescents with high scores of male-typicality (i.e., behaviors and attitudes typical in men) had a 70-percent higher frequency of intoxication and 79-percent higher frequency of cannabis use than adolescents with the lowest scores of male-typicality (Mahalik, Lombardi, Sims, Coley, & Lynch, 2015). Similarly, men who are more adherent to male-typical behaviors and norms are 256 percent more likely to use alcohol, tobacco, and cannabis as adolescents and 66 percent more likely to use them as young adults compared with men who are less adherent to male-typical norms (Wilkinson, Fleming, Halpern, Herring, & Harris, 2018).

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COUNSELOR NOTE: WHAT DOES GENDER HAVE TO DO WITH SUBSTANCE MISUSE?

Research suggests that there are gender-related differences in the dynamics and functioning of families in which substance misuse occurs:

Among parents in SUD treatment (Burstein, Stanger, & Dumenci, 2012):

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Mothers were significantly more likely than fathers to identify internalizing, externalizing, and substance use-related behaviors in their adolescent children.

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Maternal, but not paternal, scores on a measure of psychopathology predicted adolescents’ internalizing problems and substance use.

Family functioning and adolescent substance misuse may differ by gender. In their survey of more than 1,000 high school students, Ohannessian, Flannery, Simpson, and Russell (2016) found that:

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Decreased family functioning (such as low-quality father-adolescent communication) predicted greater alcohol use among girls but had no bearing on boys’ alcohol use.

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Low level of quality mother-daughter communication plus family dissatisfaction predicted alcohol use in girls, but only because of girls’ depressed mood.

In boys, lower quality adolescent-mother communication, family cohesion, and family adaptability were linked to greater alcohol and cannabis use (Russell, Simpson, Flannery, & Ohannessian, 2019):

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The relationship between adolescents’ alcohol use and low levels of family cohesion and adaptability were accounted for by boys’ depression but not girls’ depression.

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Instead, among girls in the study, there was a relationship between higher depression and lower family functioning but no relationship with substance misuse and family functioning.

Gender differences in parent-child dynamics also may influence substance misuse in families with adult children. In one study (Reczek, Thomeer, Kissling, & Liu, 2017), parent-child relationships influenced adult sons’ but not daughters’ smoking behaviors. For sons only, more contact with mothers was associated with a steeper decrease in smoking over time; less contact with mothers, with a steeper increase in smoking over time. Greater support from fathers also was associated with greater smoking in sons (but not daughters) at baseline but a steeper decline over time.

Different family members may be at different risk for harmful outcomes of family-related substance misuse. Do not assume that mothers, fathers, sons, daughters, or other family members all experience the same effects. In providing family-based SUD treatment, keep in mind that:

A family's expectations and beliefs about gender roles may influence dynamics and functioning as well as substance misuse among family members. For instance:

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A family's belief that a son's alcohol misuse is not as serious as a daughter's and not worth treating because “boys will be boys” may contribute to the son's continued substance misuse.

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A wife who believes it is her job to support her family and “keep the peace” may feel the urge to “cover up” her husband's opioid use disorder (OUD) rather than confront him about it directly.

You may need to address a family's unhealthy dynamics and dysfunction. One approach is to provide education about the effects of gender-related beliefs and expectations, especially if such beliefs and expectations are worsening a family member's substance misuse.

Because of gender-based differences, female and male members of the family may benefit from different interventions and services to address their unique risk factors and needs.

Family Types: SUDs and Family Dynamics

Not all families develop the same patterns or dynamics in response to SUDs. Families are incredibly diverse, and their presenting problems and concerns are influenced by many contextual factors and life events. However, there are common threads among families with similar family types and identified SUDs. Common relational dynamics and issues surrounding SUDs arise when you work with couples without children, families with adolescents, or blended families. So, too, do different treatment issues emerge based on the age and role of the person who uses substances in the family, whether small children or adolescents are present, and the type of SUD.

Using available research and organized according to family type, the following section highlights the effects, dynamics and patterns, and experiences of five different family types:

Couples in which a partner has an SUD.

Parents who have SUDs and young or adolescent children.

Parents who have SUDs and adult children.

Blended families in which a family member has an SUD.

Families with adolescents who have SUDs.

Descriptions of the five family types in the following sections reflect availability of relevant research. If you provide SUD treatment or recovery support services for other family types, you are still likely to see some patterns and effects of substance misuse similar to those in the types this TIP does address.

Couples in Which a Partner Has an SUD

Substance misuse can be toxic to intimate partnerships (i.e., married and nonmarried couples). Relationships often have difficulty sustaining when at least one person in the relationship has an SUD. Data from the NESARC (Cranford, 2014) show that rates of marriage dissolution among couples with lifetime AUD are significantly higher than in couples without lifetime AUD (48 percent versus 30 percent). A 10-year follow-up on the National Comorbidity Survey (Mojtabai et al., 2017) similarly found that alcohol or drug misuse significantly increased the risk of future divorce by 1.62 times.

Be aware that one of the most well known factors associated with SUDs in intimate relationships is the occurrence of violence, especially when the person with the substance misuse is male. Pooled data from years 2008 through 2015 of the National Survey on Drug Use and Health (NSDUH) (Harford, Yi, Chen, & Grant, 2018) found that symptoms of SUDs were associated with significantly higher rates of self- and other-directed violence. Results from the NESARC-III match these findings and show an increased risk of violence among people with AUD, cannabis use disorder, or other drug use disorders (Harford, Chen, Kerridge, & Grant, 2018).

Drug use and alcohol misuse are associated with increased intimate partner violence specifically (Reyes, Foshee, Tharp, Ennett, & Bauer, 2015). For example:

The American Society for Addiction Medicine reports that substance misuse occurs in about 40 percent to 60 percent of cases of intimate partner violence (Soper, 2014).

In women who have experienced intimate partner violence, rates of substance misuse are 2 to 6 times higher than in women without intimate partner violence, ranging widely from 18 percent to 72 percent (SAMHSA, 2017).

Rates of lifetime intimate partner violence among SUD treatment-seeking women vary from 47 percent to 90 percent (SAMHSA, 2017).

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COUNSELOR NOTE: WHAT ARE THE EFFECTS OF SUBSTANCE MISUSE BEYOND THE NUCLEAR FAMILY?

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COUNSELOR NOTE: WHAT IS CODEPENDENCE?

Just because a person is in an intimate relationship with someone with an SUD does not mean that violence will occur in that relationship. However, intimate partner violence is common in such relationships and leads to negative, unhealthy dynamics. It also creates ethical and safety concerns for counselors and clients.

Consequences of a partner's substance misuse may go beyond issues of trauma and physical safety; there also can be financial effects (e.g., money spent on drugs rather than rent, medical costs related to treating SUDs or related physical problems) and psychological consequences, which may include:

Denial or protection of the person with the substance misuse.

Anger.

Stress.

Anxiety.

Hopelessness.

Neglected health.

Shame.

Stigma.

Isolation.

When substance misuse is present in an intimate relationship, both partners need help. The treatment for either partner will affect both, so SUD treatment programs should make both partners feel welcome.

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COUNSELOR NOTE: HOW DO “ENABLING BEHAVIORS” INFLUENCE SUBSTANCE MISUSE IN FAMILIES?

Even when people are in recovery and seeking to improve their lives, relationships can suffer. For instance, during early stages of recovery, partners may (Ast, 2018):

Have difficulty adjusting to and expressing feelings about their partner's recovery.

Experience loneliness/separation (e.g., physically, upon the person entering residential treatment).

Struggle with changes in intimacy and communication with their partner.

Feel threatened by their partner forming new and emotionally intimate bonds with others in recovery (e.g., 12-Step sponsors and attendees) or spending much of their time participating in recovery activities that do not involve the partner (e.g., attending “90 meetings in 90 days”).

Struggle with no longer being the person's only source of support.

Feel that their partner has made recovery, not the relationship, the primary focus and top priority.

Feel left out of the recovery process (especially if not invited to participate in services).

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CLINICAL CASE EXAMPLE: UNDERSTANDING FAMILY CHANGES THAT OCCUR WITH SUBSTANCE MISUSE.

A review of quality of life issues affecting partners of people who misuse substances (Birkeland et al., 2018) found that substance misuse was linked to partner reports of low quality of life—even more so when substance misuse was severe. In many studies included in the review, the partner's quality of life was worse than that of the general population— sometimes as low as that of the partner with the SUD.

The disruption of family life and the stress of being a caregiver not only increase the risk of relapse for people with SUDs and mental disorders, they also contribute to SUDs and mental disorders among family members. On the other hand, family members (particularly between spouses, intimate partners, or parents and their adolescent or transition-age children) who can provide general support to the recovering person; goal direction; and monitoring of substance use, medication adherence, and early warning signs of relapse can have a positive influence on recovery by lessening the risk of relapse and reducing hospitalizations, healthcare costs, and family stress.

Parents Who Have SUDs and Young or Adolescent Children

Substance misuse among parents with young or adolescent children affects family dynamics, often because substance misuse makes it hard for parents to fulfill their childrearing responsibilities. For example, parents with SUDs often have affective dysregulation that can make it hard for their children to develop healthy attachments, form trusting relationships with others, and learn how to regulate their own emotions and behaviors (Lander et al., 2013). Children often develop complex systems of denial to protect themselves against the reality of the parent's SUD. But denial is harder for children to maintain in a single-parent household in which the parent misuses substances. In such circumstances, children are likely to behave in a manner that is not age-appropriate to compensate for the parental deficiency—for example, they may act as surrogate spouses for the parent with the SUD. (For more information, see TIP 51 [SAMHSA, 2009].)

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COUNSELOR NOTE: IS IT COMMON FOR CHILDREN TO LIVE WITH PARENTS WHO MISUSE SUBSTANCES?

SUDs in families may increase the likelihood of child abuse/neglect (Kepple, 2017; Smith, Wilson, & Committee on Substance Use and Prevention, 2016). Per the National Survey of Child and Adolescent Well-Being (Kepple, 2018), past-year SUDs increased occurrence of child physical abuse by 562 percent; emotional abuse by 329 percent; and neglect by 140 percent. Past-year light-to-moderate drinking, heavy drinking, or illicit drug use significantly increased chances of physical and emotional abuse and neglect.

Substance misuse by parents is itself considered an adverse childhood event (others include domestic violence and child abuse/neglect). Parental substance misuse is associated with significantly increased risk in children of later developing an SUD (Finan, Schulz, Gordon, & Ohannessian, 2015; Smith et al., 2016) or an impairment in the ability to cope with stress, which can affect relapse (e.g., among heroin users who were abstinent, as per Gerra et al., 2014).

Most data on enduring effects of parental substance misuse on children suggest its effects to be often detrimental (Calhoun, Conner, Miller, & Messina, 2015). Parental substance misuse can have cognitive, behavioral, psychosocial, and emotional consequences for children (Smith et al., 2016), including:

Receiving inconsistent parenting.

Experiencing disruptions in family routines.

Witnessing parent conflict.

Lacking a sense of security and stability from parents.

Being involved with Child Protective Services or other child welfare programs.

Living in an unsafe home (e.g., open flames or access to lighters; if crystal methamphetamine is being made at home, possible exposure to toxic chemicals).

Living in a dirty or cluttered home.

Having household needs go unmet, given lack of money (e.g., not enough food, unpaid utility bills).

Living with a relative or unrelated caregiver (e.g., foster parent), especially if child safety is at risk.

Being exposed to strangers coming and going in the house (e.g., to purchase, sell, or use drugs), which increases the risk of harm to the child (e.g., sex trafficking).

Witnessing criminal behavior.

Becoming separated from the parent because of incarceration.

Being exposed to harsh discipline.

Having an increased risk of missing school.

Having an increased risk of medical illness and hospitalization.

Having an increased risk of mental disorders, including co-occurring mental disorders.

Incurring permanent neurodevelopmental changes affecting later risk of mental/physical disorders.

As with people who were maltreated and believe the abuse was their fault, children of parents with SUDs may feel guilty and responsible for their parents’ substance misuse as well as for finding them treatment (Smith et al., 2016). Children whose parents use illicit drugs must cope with knowing their parents’ actions are illegal, and they may be forced to engage in illegal activity on their parents’ behalf.

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COUNSELOR NOTE: GRANDPARENTS AND YOUTH SUBSTANCE MISUSE.

Generally, children with parents who misuse substances are at increased risk for negative consequences, but positive outcomes are possible. In a review of the literature on children of parents with SUDs, Wlodarczyk, Schwarze, Rumpf, Metzner, and Pawils (2017) identify some positive developments, including resiliency and reduced risk of substance misuse. These were especially likely in children who had certain protective factors, such as:

Secure attachments to parents.

Flexible use of multiple coping strategies.

A high degree of parental support.

A high degree of family cohesion.

Low levels of parent-related stress.

High levels of social support for the child.

Nonetheless, substance misuse can lead to inappropriate family subsystems and role taking. For instance, in a family in which a mother uses substances, a young child may be expected to take on the role of mother. When a child assumes adult roles and the adult misusing substances plays the role of a child, the boundaries essential to family functioning are blurred. The developmentally inappropriate role taken on by children robs them of a childhood, unless healthy, supportive adults intervene.

The spouse of a person misusing substances is likely to protect the children and assume parenting duties that are not fulfilled by the parent misusing substances. If both parents misuse alcohol or use illicit drugs, the effect on children worsens. Extended family members may have to provide care as well as financial and psychological support. Grandparents frequently assume a primary caregiving role. Friends and neighbors also may be involved in caring for the young children. In cultures with a community approach to family care, neighbors may step in to provide whatever care is needed.

Because of its potential effects on recovery and relapse, another factor in family life you should assess for is the need to care for dependent others, such as children. Losing custody of a child, whether formally (i.e., removal from the home by child welfare or other legal authorities) or informally (e.g., sending the child to live with a relative), is associated with an increased risk of maternal substance misuse (Harp & Oser, 2018). Fear of loss of custody can be a barrier to a mother accessing SUD services. This has implications for the safety and well-being of her child and also affects the family unit. Loss of custody among women who misuse substances is more likely when those mothers face socioeconomic stressors (e.g., unstable housing, unemployment, low education level), have a history of childhood trauma, or have co-occurring mental disorders (Canfield, Radcliffe, Marlow, Boreham, & Gilchrist, 2017). Other research has associated caregiving for a child or an ill family member with increased odds of remaining abstinent from alcohol or reducing drinking (Jessup et al., 2014).

Parents Who Have SUDs and Adult Children

Parental SUDs can negatively affect both young children and grown children. Compared with research on young children affected by parental SUDs, comparatively less research has examined the effects in adulthood. And much of the available literature concerns adult children of parents with AUD, so less is known about adult children of parents with OUD or cannabis use disorder, for instance.

Adult children of people with SUDs are at risk for negative biopsychosocial outcomes, and they may:

Feel stigmatized, especially when parental substance misuse is severe (Haverfield & Theiss, 2016).

Hesitate to disclose parents’ SUDs to others for fear of rejection (Haverfield & Theiss, 2016).

Have more negative life events (Drapkin, Eddie, Buffington, & McCrady, 2015).

Have an increased mortality rate. One study looked at data from the National Health Interview Survey Alcohol Supplement-Linked Mortality File (Rogers, Lawrence, & Montez, 2016). Compared with people who did not grow up in a household with problem alcohol use:

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People who lived with a mother with problem drinking had a 23-percent higher risk of death.

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People who lived with a father with problem drinking had a 14-percent higher risk of death.

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People who lived with both parents with problem drinking had a 39-percent higher risk of death.

Have increased risk of SUDs (Eddie, Epstein, & Cohn, 2015), major depressive disorder (Klostermann et al., 2011; Marmorstein, Iacono, & McGue, 2012; Yoon, Westermeyer, Kuskowski, & Nesheim, 2013), and persistent depressive disorder (Thapa, Selya, & Jonk, 2017).

Be at increased risk for suicide attempt (Alonzo, Thompson, Stohl, & Hasin, 2014).

A study of personality features and functioning among adult children of parents with AUD identified five personality types that commonly occur in this population (Hinrichs, Defife, & Westen, 2011):

Inhibited adult children, who may feel anxious, depressed, and guilty about their parents’ SUDs. They may behave passively and may be at an increased risk for generalized anxiety disorder.

High-functioning adults, who are emotionally healthy, responsible, and empathic.

Adults with externalizing features, such as alcohol misuse and psychopathology.

Emotionally dysregulated adults, who may have a history of childhood abuse or otherwise traumatic childhood environment and are especially at risk for depression or bipolar disorder.

Reactive/somaticizing adults may react to stress via physical symptoms and be anxious, angry, and controlling.

Having grown up in traumatic, unstable environments, adult children of parents who misuse substances may feel angry with, resentful of, or otherwise negatively toward their parent with an SUD (Haverfield & Theiss, 2016). Difficulties in establishing trusting, healthy relationships as a child or adolescent may carry over into adulthood. Similarly, problems with affective regulation that arose during childhood may remain later in life (Haverfield & Theiss, 2016). Other emotional and behavioral features and patterns that may appear in these individuals include anxiety, dysfunctional intimate relationships, low self-esteem and insecurity, antisocial behaviors (e.g., aggression), problems communicating with others, and ignoring one's own needs to care for others (Haverfield & Theiss, 2016).

Unhealthy family patterns that emerge when a parent of a young child has an SUD also may occur in families in which the children are grown. For instance, adult children may engage in “enabling” behaviors to try to maintain homeostasis. Their families often experience chaos and unpredictability. See Exhibit 2.4 for more discussion of family roles and dynamics that can occur among adult children of parents with SUDs (as well as among young children and spouses of people with SUDs).

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Exhibit 2.4. Family Roles When a Parent Has an SUD.

Blended Families in Which a Family Member Has an SUD

The Census Bureau estimates that, in 2018, about 2.4 million U.S. households included stepchildren under 18 years of age (U.S. Census Bureau, 2019c). Blended families, in which a nonbiological parent lives in the household (typically because one or both spouses have had children from a previous relationship), face their own challenges apart from intact nuclear families. For instance (Papernow, 2018):

One or both of the people in the couple have a child from a previous relationship, so the couple has not had time to experience being a couple alone, without children.

The “architecture” of the family is often different from traditional nuclear families, where both parents are living and are residing in the same household.

Blended families come in many forms and can join together because of separation, divorce, death, or a combination thereof. The partners may not necessarily be married or be a heterosexual couple.

You are likely to observe unique dynamics in blended families, which may worsen or intensify in the presence of substance misuse. These dynamics also may increase the chances of substance misuse by family members. Common blended family dynamics and struggles include (Papernow, 2018):

Stepparents and stepchildren feeling like “outsiders,” especially in relationship to the nonbiological parent/child. This can result in family members feeling anxious, lonely, or rejected.

Children struggling with the loss of a biological parent, loyalty to a biological parent, or both. Children may worry that bonding closely with a stepparent is “betraying” their biological parent. This worry may be stronger in adolescents and girls versus young children (under age 9) and boys.

Divisions between stepparents, especially related to parenting tasks like discipline. This can create conflict between couples and confusion among children.

Attempts by couples to build their own family culture while respecting and honoring biological family members not living in the home. The desire to quickly “blend” the new family together may be strong, but doing so too quickly or forcefully can be stressful for children.

Struggling with the fact that biological family members living outside the home are also part of the blended family and need to be included.

Substance misuse in blended families can lead to additional strain that can weaken family bonds and cause unhealthy patterns of behavior.

Furthermore, the challenges of being a blended family may increase the chances of family members misusing substances. Indeed, children in blended families appear to have higher rates of substance use (such as tobacco and cannabis use) than children in traditional intact families (van Eeden-Moorefield & Pasley, 2013).

By helping blended families build strong, supportive relationships with one another, you play a critical role in addressing or preventing families’ substance misuse. Consider the following:

High relationship quality with the residential biological parent predicts a lower likelihood of nonmedical use of prescription drugs by emerging adults (Ward, Dennis, & Limb, 2018). The authors suggest that closeness may help protect against stress and strain common in blended families.

Having a close bond with a stepparent living in the home also can protect against substance misuse in children. Per Amato, King, and Thorsen (2016), adolescents with weak or moderately strong ties to their resident parents (the parents with whom the adolescent lives, regardless of biological relation) were more likely to report tobacco use, cannabis use, and binge drinking than adolescents with strong ties to their resident parents (but no ties to their nonresident parent).

Families With Adolescents Who Have SUDs

Substance misuse among adolescents continues to be a serious condition that affects cognitive and affective growth, school and work relationships, and all family members. In the 2019 NSDUH (Center for Behavioral Health Statistics and Quality, 2020), an estimated 4.9 percent of adolescents ages 12 to 17 engaged in past-month binge use of alcohol (five or more drinks on one occasion for males and four or more for females), and approximately 0.8 percent took part in heavy alcohol use (at least five binge episodes in the previous month). Additionally, in the same survey, about 8.7 percent of adolescents ages 12 to 17 were currently using illicit drugs.

Divorce significantly increases the risk of adolescents’ binge drinking and use of alcohol, tobacco, and cannabis compared with adolescents of married couples (Gustavsen, Nayga, & Wu, 2016).

Like adults, adolescents who misuse substances are at an increased risk for many negative individual and societal consequences (Gutierrez & Sher, 2015; Welsh et al., 2017). These include:

Co-occurring mental disorders (e.g., anxiety, depressive, conduct, and bipolar disorders).

Sexual activity at an early age.

High-risk sexual behavior.

Car accidents.

Medical visits/hospitalizations.

School dropout.

Continued substance misuse into adulthood.

Risk of suicide (especially when substance misuse co-occurs with mental disorders).

Family functioning, including parent-child bonds and communication, is connected to adolescent substance misuse in many ways. In a systematic literature review (Hummel, Shelton, Heron, Moore, & van den Bree, 2013), family factors associated with adolescent substance initiation and misuse included:

Poor family functioning.

Low levels of mother-child warmth.

High levels of mother-child hostility.

Low parental monitoring.

Harsh maternal parenting practices.

Other family factors that appear to increase risk of adolescent substance misuse are (Ali, Dean, & Hedden 2016; Barfield-Cottledge, 2015; Cordova et al., 2014; Gutierrez & Sher, 2015; Kim-Spoon et al., 2019; Kuntsche & Kuntsche, 2016; Lee et al., 2018):

Parental substance misuse.

Parental mental disorder.

Parental co-occurring mental disorders and SUDs (especially among mothers).

A lack of rules, or failure to enforce rules, about underage substance use.

Lower quality parent-child communication.

Household chaos.

High family risk-taking behaviors (e.g., criminal behaviors, substance misuse).

Socioeconomic strain.

Low parental education level.

Low levels of parental support.

Low levels of family attachment.

Parental substance misuse is especially problematic for adolescents, as it models unhealthy behavior and can lead to a dangerous combination of physical and emotional problems for the youth. If a responsible adult offers calm, consistent, rational, and firm responses to adolescent substance misuse, the effect on adolescent learning is positive. However, if a parent who misuses substances attempts to address an adolescent's substance misuse, the hypocrisy will be obvious to the adolescent, and the result is likely to be negative. In some instances, a parent with an SUD may form an alliance with an adolescent who is misusing substances to keep secrets from the parent who does not misuse substances. Sometimes in families with multigenerational patterns of substance misuse, extended family members may feel that the adolescent is just conforming to the family history.

Adolescent substance misuse can affect families in the following ways (Smith & Estefan, 2014):

Common family reactions include confusion, fear, shame, anger, and guilt.

Parent conflict may arise or, if already present, worsen in response to feelings of blame and disagreements over how to handle the child's substance misuse. When parents differ in their conflict and communication styles (e.g., avoidant versus direct), this can further increase tension.

Families often feel isolated, alone, and unsure of what to do or where to turn for help.

In some families, a family member with an SUD is considered a family “secret” that should be kept well hidden from others. In these cases, the silence is a form of protection, and talking about “the secret” may be seen by other family members as an act of betrayal against the family as a whole.

Because mothers are typically the primary caregivers, it is not unusual for mothers to feel guilty, blame themselves, and question whether they did something to “cause” their child's SUD.

When an adolescent misuses alcohol or uses illicit drugs, siblings may find their needs and concerns ignored or minimized while their parents react to constant crises involving the adolescent who misuses substances. Neglected siblings and peers may look after themselves in ways that are not age appropriate. They also may feel that the only way to get attention is to act out. Do not miss opportunities to include siblings in family-based treatment, because siblings often are as influential as parents. (See also the counselor note “How Does One's Substance Misuse Affect One's Siblings?”)

When working with families to address an SUD in one family member, note that other family members may engage in “hidden” substance misuse. Take, for example, adolescents in SUD treatment. Their parents’ substance misuse may be just as problematic as the adolescents’ misuse, but families may consider the adolescents’ to be the problem. In a couple, one person's misuse may be more pronounced than another's, but the other person also may have an SUD. Use of substances may be a significant activity throughout some relationship histories.

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COUNSELOR NOTE: HOW DOES ONE'S SUBSTANCE MISUSE AFFECT ONE'S SIBLINGS?

Where Do We Go From Here?

Families are all unique in their structure, functions, and needs. But families in which SUDs occur often share common features that contribute to substance misuse and can make recovery difficult. As a counselor, once you identify the dynamics and patterns in a family dealing with substance misuse, what should you do next? How can you help them improve dynamics and patterns that are unhealthy and enhance ones that are supportive of recovery? Chapter 3 answers these questions by exploring the latest evidence-based family counseling approaches for couples and families affected by SUDs. It includes not only a summary of recent research but also practical guidance to support you in implementing and assessing the effectiveness of family-based interventions and services.

Copyright Notice

This is an open-access report distributed under the terms of the Creative Commons Public Domain License. You can copy, modify, distribute and perform the work, even for commercial purposes, all without asking permission.

Bookshelf ID: NBK571087

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