It was the second week of group therapy. My second attempt and so far, the longest I’ve made it sober. This was also the second Wednesday of the month which meant it was “family night”. Every second and fourth Wednesday group members were asked to bring at least one family member with them to the group. So, there I was sitting between my mom and younger brother.
There were usually about six or seven people in my group but that night there was more than double that. Probably about twenty people in all with moms, dads, husbands, wives, and a few siblings joining in. We went around the group and did the usual “check-in” with everyone introducing their family members.
Then the counselor asked the family members to “check-in”. She started off with John who brought his parents and his young sister. When the counselor asked John’s sister how she was feeling I could see her face turning red and her fists clenching. She said, “I don’t want to be here, I can’t stand him” and stood up and walked out. John said that when he relapsed this last time he went into her closet and stole the big glass bottle full of spare change she was using as a piggy bank.
When the counselor got around to my mom and brother, I was preparing myself to hear everything that I had done. I was waiting for my brother to tell everyone how we would get into fights over my car keys. When I was drinking, he would try to take my car keys so I couldn’t drive. As a “good drunk”, I would get angry that he or anyone else could possibly think that I was too drunk to drive. I would try to get them away from him by any means necessary, usually resulting in a physical altercation. I was rarely successful, being too intoxicated to walk let alone drive or try to wrestle my car keys away from my much larger brother.
I was also waiting for my mom to tell everyone how I would come home at three or four in the morning and search through her purse looking for any money I could find so I could go back out and buy more drugs. When I was drinking and using drugs, I always saw them as just an obstacle to keeping my addiction going. For a lot of people who are using and drinking heavily that’s what family members become – an obstacle.
Addiction is a disease of isolation. The people who are closest to us and care deeply about our welfare become the “enemy” preventing us from getting high or drunk resulting in further isolation that can tear a family apart. A lack of understanding surrounding the behavioral manifestations of addiction, i.e., someone stealing from their mom or sister, leads to even further strain on the family.
The Disease
The American Medical Association officially recognized alcohol use disorder as a disease in 1956 and then all substance use disorders as diseases in 1987. Despite this medical recognition, the stigmatization of individuals with substance use disorders and their families persists.<sup>1 </sup> This stigmatization often results in individuals’ and family’s resistance towards getting the help they need by seeking treatment.
Addiction is not just an affliction of an individual but impacts almost everyone that the person comes into contact with. The disease has a ripple effect where it starts with the individual but then begins creeping into every aspect of their life including their health (physical and mental), work, school, and relationships. As Isaacson points out “The pervasive and destructive nature of addiction extends beyond the individual, fundamentally impacting and often originating within the intricate dynamics of the family unit”<sup>.6</sup>
The emotional, psychological, and even economic burdens imposed by addiction reverberate through the family, manifesting as heightened stress, conflict, and often, the neglect of individual members' needs.<sup>3</sup> The focus tends to be on the individual struggling with addiction. There is a tendency to view addiction as the individual’s problem and there tends to be a lack of concern for how each and every family member is being impacted.
Many treatment approaches just focus on the individual. There is this view that if the individual can stop the addictive behavior every other aspect of their life will be “fixed”. Csiernik states “The historical focus of addiction treatment has predominantly centered on the individual, often overlooking the critical role of family involvement in both the etiology and recovery processes”.<sup>2</sup>
In the late 1940s and 1950s a psychiatrist named Murry Bowen developed his Family Systems Theory. Bowen's theory posits that individuals are inextricably linked to their family of origin, with their behaviors and psychological functioning understood best within the context of multigenerational family processes. This theoretical framework emphasizes the interconnectedness of family members and how their interactions contribute to either maintaining or disrupting the family's equilibrium.<sup>10</sup>
“System” implies that the family must be viewed as a whole organism. During the many years that a family is together, family members develop habitual patterns of behavior after having repeated them thousands of times. A system is a collection of interconnected parts that function as a cohesive whole, and within the context of family dynamics, this implies that each member's behavior influences and is influenced by the behaviors of others.<sup>8</sup>
Utilizing Family Systems Theory we can see how addiction is not just something the individual deals with, but it affects the whole family. It also impacts every aspect of family dynamics. According to Daley “This perspective re-conceptualizes addiction not merely as an individual pathology but as a systemic ailment affecting relational patterns, communication, and overall family functioning.<sup>3</sup>
Homeostasis, Rules, Roles, & Boundaries
All systems try to maintain balance including our family system. This concept is known as homeostasis. Homeostasis refers to the natural tendency of a family system to maintain a state of equilibrium, even if that equilibrium is dysfunctional or maladaptive, such as one maintained when someone in the family is abusing substances.<sup>10</sup> Any change in one family member will elicit a response from the other family members to maintain balance and keep the family functioning.
Family rules are components of the attempt to maintain balance. They dictate what types of behaviors are acceptable and what are not acceptable. The manner in which family members engage with one another is frequently dictated by a framework of rules, which may be either expressly stated or implicitly understood. Family rules govern interactions dictating acceptable behaviors and responses within the system.<sup>7</sup>
Another component of maintaining balance is family roles. What are expected behaviors from the various roles in the family such as mother, father, son, daughter, etc.? Typically the parental role implies maintaining the household. Family roles often become rigid in families affected by substance use disorders, for example, a child might consistently assume a parental role due to the parent's impaired functioning.<sup>7</sup>
How these roles and rules are defined involve boundaries. There are boundaries that individuals set and maintain but also boundaries that the family has with society. For example, who or what is part of the family system is a boundary. Boundaries are conceptual delineations that define the parameters of interaction, roles, and emotional space within and between family members, playing a crucial role in maintaining this equilibrium.<sup>10</sup>
Enabler, Hero, Scapegoat, Lost Child, Mascot
In an addicted family system family members take on specific roles outside of the traditional as a way to keep the system functioning. The roles are an adaptation to the addiction as the family tries to maintain homeostasis. They are a way to keep the family functioning despite having a disease. The roles are fluid in the sense that a family member may not stay fixated in just one role but can take on a different role at different times as a result of changing circumstances.
There is the “Enabler”. Enabling just means helping or supporting someone. However, addiction is being enabled in an addicted family system. In this context, enabling is “doing all the wrong things for all the right reasons”. For example, a dad may pay off his daughter’s court costs and fines after getting a DUI or a husband will clean up all the empty bottles from his wife’s drinking the night before. This enabling behavior, while often well-intentioned, inadvertently perpetuates the substance use by shielding the individual from the natural consequences of their actions, thus preventing motivation for change.<sup>8</sup>
The Hero is an overachiever who attempts to compensate for the family's dysfunction by excelling in academics or other activities. They seek to bring positive attention and distract from the underlying problems.<sup>4</sup> A wife may think “if I can just get that promotion everything will be ok” or a brother will try to get into that good school as a way to show everyone that everything is just fine in his family.
The Scapegoat, conversely, draws negative attention through rebellious or problematic behavior, diverting focus from the individual with the addiction and becoming the locus of family distress. A sibling may start “acting out” as a way to draw attention to themselves in an attempt to balance out all the attention being placed on their addicted brother. A spouse may develop a behavioral addiction such as gambling, shopping, or excessive exercise.
The Lost Child as the name implies, is withdrawn and isolated. They seek to avoid conflict and maintain an invisible presence. They remove themselves from all the drama of the addiction and attempt to avoid any conflict. When a husband comes home drunk his wife may just leave to avoid any conflict.
The Mascot employs humor and self-deprecation to lighten the mood and reduce family tension.<sup>9</sup> The role involves attempts at making the situation seem less serious than what it is. A dad may joke “what’s the big deal, everyone gets a DUI”.
These roles are behaviors family members exhibit as they try to balance the impact of another member’s addiction. They are a way to maintain balance. These roles, while seemingly disparate, represent maladaptive coping mechanisms developed in response to the chronic stress and instability inherent in a household affected by addiction.<sup>5</sup>
Central Organizing Principle
The addiction becomes the Central Organizing Principle determining the rules, roles, and boundaries of family members. This centrality means that all family behaviors, decisions, and emotional responses begin to revolve around the substance use, perpetuating a cycle of dysfunction. It’s like if a hurricane were moving through the family. The addicted individual is in the “eye of the storm” sometimes unaware of all the damage and destruction that is playing out around them. Meanwhile, family members caught in the outer bands of this "hurricane" experience profound trauma and stress, leading to a "conspiracy of silence and denial" and the development of "robotlike patterns of adaptive behaviors" to cope with the unpredictable environment.<sup>11</sup>
A Family Focused Approach
Addiction is often considered a "family disease" that necessitates a relational approach in treatment, rather than focusing solely on the individual with the addiction.<sup>4</sup> Strategies may involve identifying what role a family member is playing in the system and changing that role. If someone is enabling addictive behavior a change needs to take place involving enabling sober behavior. For example, a parent no longer pays court costs and fines, provides cash, and sets firm boundaries. A husband stops cleaning up all the empty bottles the next day.
Addiction is about isolation and sobriety is about connection. This means reconnecting with family members but in a different way once someone is sober. The key to this process involves including family members in treatment. Emerging evidence increasingly supports the integration of family-focused approaches, recognizing the family as a crucial, albeit often underestimated, factor in achieving sustainable rehabilitation outcomes.<sup>12</sup>
Once someone gets sober it takes time for an addicted family system to accommodate the new reality, often requiring systemic interventions to recalibrate roles, boundaries, and communication patterns. This recalibration is crucial because the family, as a dynamic system, will resist change and attempt to revert to its familiar, albeit dysfunctional, equilibrium. Therefore, therapeutic approaches must address the family's ingrained patterns to support sustained recovery and prevent relapse, facilitating a healthier, adaptive homeostatic state.<sup>8</sup>
Turns out my mom didn’t say too much about the money I used to steal from her. My mom just said how proud she was of me for being sober this long. My brother told the group how he would take my keys because he didn’t want to have to feel responsible for me getting another DUI or worse. The individuals that are closest to us, who experience the effects of our drinking and getting high the most are usually the ones who love us the most. That’s what it really comes down to. Our family members are not an obstacle, they are our biggest supporters.
