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| Chemical Dependency and the Family |
| Feature Articles - Family | ||||||||||||||||||||||||||||||||||||||||||||
| Written by Robert J. Ackerman, PhD | ||||||||||||||||||||||||||||||||||||||||||||
| Tuesday, 04 March 2008 | ||||||||||||||||||||||||||||||||||||||||||||
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One of the best questions I ever heard about the family and chemical
dependency came from an adult daughter of an alcoholic. She asked, “Let
me see if I understand this; my father is an alcoholic, and therefore,
he has alcoholism, which they say is a disease; but what do I have?”
Ever since the founding of Al-Anon in the early 1950s, this question has been debated and has lead to an enormous amount of conjecture and research studies. Much of this past work has focused on the negative impact of addiction on family members, including: the increased risk of developing alcoholism for those from alcoholic families, particularly sons; the breakdown of traditional family rules and rituals; impairment of positive family communication patterns; domestic violence, emotional and physical abuse and sexual abuse; increased levels of family stress; increased use of health services by spouses and adult children of alcoholics with higher diagnosis of stress-related diseases and post-traumatic stress disorders, including adult emotional problems, anxiety, depression and chemical dependency; and an increased risk for children of chemically dependent families for adjustment problems, educational difficulties, suicide, substance abuse, lower self-esteem and fetal alcohol syndrome. In addition to these and many other findings about families with chemical dependency, there is no doubt that the family has become a critical focal point in the treatment of chemical dependency. However, this focus needs to be expanded beyond assessment of negative outcomes, to include survival techniques and strengths to better help those impacted by addiction and for children of all ages from these families. There have been times, since the early 1950s, when the focus on family and children impacted by addiction has facilitated some of the needed expansion, such as the founding of the National Association for Children of Alcoholics (NACOA) in 1983. NACOA, more than any other organization in recent history, addressed the need for treatment for all family members — especially for children of alcoholics. The children of alcoholics movement was a very unique mental health movement, as it was not started or guided by mental health professionals, but rather, began as a grassroots movement driven primarily by adult children of alcoholics who felt the need to be heard, and who wanted recovery for themselves, as well as for the many children of alcoholics to follow. In many cases, counselors and other helping professionals needed education and training in order to understand the issues of addiction that their clients were talking about. Their clients wanted treatment and recovery from addiction. They wanted to be part of the recovering community. Also, there was a national response to this need with the emergence of many national conferences on the family, children and addiction. Training organizations such as the U.S. Journal of Alcohol and Drug Dependence, Hazelden and others led the way in bringing the professional treatment providers in line with the many needs of family members affected by addiction. Responses from federal agencies, such as the Substance Abuse and Mental Health Services Administration’s Center for Substance Abuse Treatment and the Center for Substance Abuse Prevention, as well as many others, soon followed. Many alcohol and drug abuse treatment centers, such as the Caron Foundation, Father Martin’s Ashley, Gateway Rehabilitation Center, the Betty Ford Center and others, responded with the development of family treatment programs. Hospitals got involved by opening alcohol and drug treatment programs, as well as detoxification units. By the end of the 1980s, intervention, support and treatment for children and families impacted by addiction had become widespread in the United States. It seemed as if the hard work of many presenters, counselors and organizations had finally created the vehicles for true family recovery. However, during the past 15 years we have seen a re-emergence of the need to continue to not only support families, but also to expand our knowledge about families and addiction. Many of the agencies — especially hospitals — that provided treatment for families with addiction problems, are no longer filling this need. Inpatient treatment has been replaced by outpatient treatment, in many instances, due to economic concerns and managed care. The length of inpatient treatment is shorter today, compared to the 1980s. On the positive side, nearly all of the agencies that continue to provide treatment for addiction have family programs. The problem is that there are far fewer agencies available. Another positive factor has been the expansion of research and external grant funding to better understand the dynamics of addiction in the family, and to use these evidence-based findings to improve intervention and treatment. In addition to these improvements, we need to expand our focus in order to better understand today’s families who are affected by addiction, and to offer better intervention and treatment. This expansion will not be limited to individuals and family members within the addicted family, but it will need to consider the social context in which contemporary families develop and survive. The following ideas can lead to an expanded focus: All Drug Abuse: Disproportionately, what we know about addiction and the family has come from research about the dynamics of families affected by alcoholism. The abuse of legal and illegal drugs may have a different set of circumstances. We have seen a tremendous increase in the use of painkillers in the United States; from 1997 to 2005 the use of five major painkillers rose 90 percent. That’s enough painkillers to give every person in the country 300 milligrams of pain medicine. It is doubtful that this trend is going to change, given our aging population and that marketing for these drugs has increased from $11 billion dollars in 1997 to $30 billion dollars in 2005 (Bass, 2007). Family Diversity: Over the past 50 years, American families have changed. These changes will need to be reflected in how we support and treat addicted families. For example, the very definition and structure of the family is changing, and the classic nuclear family is now a minority structure in America. Marriages have declined and cohabitation with partners and children has increased. Families are no longer defined by having the same last names. W.R. Beavers indicated in his work that the most important aspect of a family is how well that family functions as a group on behalf of its members (Beavers, 1982). Furthermore, he did not see family structure (i.e. a single parent family, blended families, etc.,) as the critical variable in treatment. Rather, he was concerned with the emotional states of those who considered themselves family, and that these states were dependent on intimacy, power, and control within a family. Our national cultural diversity is reflected in our families, and certainly, this is a challenge to the one-size-fits-all approach for intervention and treatment. Family members bring who they are to treatment, and they want to be understood and respected for their diversity. Author Alex Haley believed that there is one common denominator in the world — family — but that does not mean that family members are all the same (Haley, 1981). Even within a given family impacted by alcoholism, not everyone is affected in a similar way. I was always surprised in my work that I have met more adult children of alcoholics whose siblings are not adult children of alcoholics! Many years ago I wrote a book titled, Same House, Different Homes, in which I offered eight variables to explain the diversity among alcoholic families (Ackerman, 1987). These variables include: 1. The degree of addiction and the level of impairment of fulfilling ones role(s) in the family (i.e., how it affects being a parent, spouse, partner, etc.) 2. The type (personality) or kind (behaviors) of addict (i.e., the difference between living with a passive alcoholic versus a violent alcoholic) 3. Different reactions to stress at both the individual and familial levels 4. Different personalities of family members and different perceptions of the addiction 5. Gender dynamics (i.e., whether one is a daughter or son of the addicted person and the gender of the addict; there are six possible combinations: daughter-mother, daughter-father, daughter- both parents, son-mother, son-father, son-both parents 6. Age and developmental factors (Contrary to popular belief, everything that is going on in an addicted family is not due to the addiction. Thus, we still must consider theories of human development, ages of each family member and the resolution of normal developmental issues, and how addiction might impact these normal tasks.) 7. The importance of cultural diversity 8. The existence or absence of off-setting or protective factors at the individual or family levels Mutually beneficial family treatment: Recently, I observed the beginning of a family weekend program in an addiction treatment facility. The first presenter began with a lecture on neuroscience and addiction. Although this is important and contains much cutting-edge information, this was not the mind set of those family members in attendance. The room was full of emotions — fear, hope, helplessness, self-blame, resentment, anger, love and doubt. Affective education was not what they initially needed. They needed to be “heard” and to have their feelings acknowledged. The question, “What’s in it for me?” needed to be addressed. To ignore this would leave the family members in the same position they were in before treatment — that is, even in treatment it is all about the addict. It is about what you can do to support the addict; how you respond when the addict returns home; how you act around the recovering addict, etc. These are very important issues for the addict, but if family members do not perceive treatment as mutually beneficial, then it will be hard to sustain their involvement and support. This includes children, who may not understand the dynamics of addiction, but are very aware of what they hear and see. Beyond victimization to what’s missing: There is no doubt that addiction can victimize not only the addict, but also his or her family members. After all, living in an addicted family is not a spectator sport. Although victimization can lead to feeling great emotional pain, it is not the only source of pain. I believe the greatest emotional pain occurs not when a person realizes the pain of addiction in his or her family, but when he or she realizes what has been missed as a result of living with addiction. What is missing can be as obvious as the realization of a child of an alcoholic knowing that inviting friends over is something you just don’t do; or the adult child who becomes a parent and realizes that they are poorly trained for the new role. Focusing on victimization keeps the person past oriented. Intervention approaches need to facilitate the individual beyond that thinking as quickly as possible. However, it is not always easy. For example, I often give adult children of alcoholics a blank sheet of paper and ask them to divide the paper into three columns. At the top of the first column I ask them to write the word “victim” and list the ways that they feel or believe that they have been victimized. Usually they can make a list relatively quickly. At the top of the second column I ask them to write the word “missing” and answer the question, “As a result of being victimized, what did you miss?” At this point, the exercise gets more difficult because they are not accustomed to thinking this way. However, after a while, they begin to see that each aspect of victimization does not equate to just one thing missing at different times in their lives due to addiction, and it becomes easier to make the list of what they missed. This process is critical for recovery, and at the same time, can be an indicator of growth. As people get healthier, they become more aware of what is unhealthy. As recovery continues, a person might be surprised to discover that they are getting angry over things that did not anger them before. This can be a sign of growth, however, because it indicates that they are more aware of healthy behaviors, as well as unhealthy ones. Finally, I ask them to write the word “change” above the third column and list the ways that they would like to be, not how they would like it to be. This process can help to identify goals in recovery. We cannot change the past, but we can focus on some of the things we missed, such as developing quality relationships, growing strong families ties in our families of procreation, and accepting responsibility for our own physical, emotional and spiritual health. Beyond negative labels: There are certain phrases or words that helped to frame new concepts related to the addiction field. Initially, I think these words helped, but in many cases they have been carried to extremes or trivialized by others. These words were very descriptive of past behaviors in addicted families, but offered little direction for recovery. Although they may contribute to a person’s better understanding of the impact of addiction on his or her life, it is important that these concepts do not become an individual’s identity. We must be careful in treatment that the words dysfunctional family, codependency, at-risk or high-risk child, and enabler don’t become blaming-the-victim-labels. For example, I totally agree with dropping the term, “enabler” and replacing it with “family manager,” as discussed by Katherine van Wormer and Diane Rae Davis (Van Wormer & Davis, 2003). Although we mean well with programs for at-risk children, it is still labeling children and defining them as different. Also, are there dysfunctional families? Yes, but recently the phrase has been applied so loosely that it has lost its theoretical power. Healthy families are not healthy all the time and dysfunctional families are not dysfunctional all the time. The dysfunction in dysfunctional families is by degree; it is not absolute. W.R. Beavers, in his work on assessing family functioning, offered five descriptive categories of families that included: severe dysfunctional families, borderline families, mid-range families, adequate families and optimal families (Beavers, 1982). If we continue to apply the phrase dysfunctional family indiscriminately, we will continue to narrow the definition and acceptance of behaviors in functional families. Additionally, even within chemically dependent families, the concept of labeling children according to the familial roles they fulfill, produces a narrow focus with regard to really understanding these children, and it ignores their strengths. The roles to which I refer are: hero, scapegoat, lost child and mascot. These roles were initially developed by Nathan Ackerman, who indicated that children in dysfunctional families fell into one of two roles that he named as hero or scapegoat (Ackerman, N., 1958). Virginia Satir added lost child and mascot (Satir, 1964). These role descriptions became very popular when they wee applied to children of alcoholics. Although these roles help to create awareness of children of alcoholics, they are very limiting. For example, most of the characteristics identified with each role are negative. They do not account for some of the positive or healthy behaviors found in children of alcoholics. Additionally, these roles were presented as mutually exclusive categories and were based on ordinal positions. Thus, the hero role was believed to be fulfilled by the eldest child, but if ordinal position contributes to these characteristics, then wouldn’t we find some “heroitis” in the eldest child in functional families? Expanding our focus to include strengths as well as needs for children of chemically-dependent families will provide a better assessment. Finally, we need to differentiate between what is situational and what is developmental, or potentially pathological. Living with an addict or being the child of an alcoholic is situational; it is the environment in which a person lives. Adjustments to the situation do not automatically imply pathology. Most people living in an addicted family see their adjustment behaviors as positive, simply because they work and it is their way of surviving with the least amount of disruptions. Problems can occur, however, when a person leaves the negative environment and continues with the learned adjustment behaviors, even though they might be in a healthy environment. At this point, the individual can become very confused by trying to figure out what is happening. After all, how could the very behaviors that helped them survive a crisis, now create a crisis? How could the very behaviors that helped to make a negative situation tolerable, now make a positive situation intolerable? How could the very behaviors that helped them survive, now be the behaviors that fail them or create problems? Strength perspectives and integrative family treatment When it comes to working with addicted families, getting all family members to participate is a goal. Usually, only some members of the family participate. Begin with those who are there and, hopefully, integrate other members of the family into the treatment process as move forward. This integration process may be facilitated when those who are attending begin to share with non-attending family members the positive things that are happening for them in treatment. Obviously, some family members will continue to refuse to participate. Integrative family treatment is not limited to just recruiting all family members to attend, but also to integrating the needs all who are attending. Integrative treatment occurs when the family system becomes stronger, and at the same time, supports individual family members’ needs. Without a doubt, the emergence of strength perspective treatment models have expanded the focus for treating chemically addicted families and children of all ages. The ideology of these models, “come from the practical understanding that a focus on capabilities rather than defects fosters hope (where there was despair), options (where there is a perceived dead end), and increased self-efficacy (where there is a feeling of helplessness)” (Van Wormer, 2003). Regardless of which strength-based model is used, according to Charles A. Rapp, there are six critical elements conducive to recovery: identity as a competent human being; the need for personal control or choice; the need for hope; the need for purpose; the need for a sense of achievement; and the presence of at least one key person (Rapp, 1998). A common component to many strength perspective models is resiliency. During the past 15 years, there has been much research and debate about resiliency and its contribution to treatment and recovery. There are a variety of definitions of resiliency, including: “the ability to withstand and rebound from disruptive life challenges. Resilience involves the key processes over time that foster the ability to ‘struggle well,’ surmount obstacles, and go on to live and love fully” (Glicken, 2006); or “the capacity for successful adaptation, positive functioning, or competence despite high risk, chronic stress, or prolonged or severe trauma” (Henry, 1999); or “resilience is the part of the genetic makeup of humans and that it is the norm rather than the exception. What began as a quest to understand the extraordinary has revealed the power of the ordinary” (Masten, 2001). Certainly, the development of individual and family resiliency characteristics has contributed to a more balanced understanding of survival behaviors. Although the concept of resiliency was initially applied at the individual level, especially for children, it is now being applied at the family systems level. Froma Walsh, in her book, Strengthening Family Resilience, states, “A family resilience approach aims to identify and fortify key interactional processes that enables families to withstand and rebound from disruptive life challenges … This approach is based on the conviction that both individual and family strengths can be forged through collaborative efforts to deal with sudden crisis or prolonged adversity” (Walsh, 1998). Recovery lag There is individual recovery and there is family recovery. However, even within the same family, not all persons will recover at the same rate. Differences in degrees of recovery and outcomes are known as recovery lag (Ackerman, R., 2002). The characteristics of recovery lag in a chemically dependent family are: 1. Not all individuals /families are affected the same way. 2. Not all parts of individuals/families will need intervention. 3. Not all individuals/families will respond the same way to treatment. 4. Not all individuals/families will recover at the same rate of time. 5. Not all individuals/families will need the same amount of support. 6. Not all individuals/families will recover to the same degree. Understanding recovery lag is important for family members in order to make them feel comfortable in their recovery. There is a myth about change that indicates that all change, in and of itself, is stressful. What can make change stressful, however, is the rate of change and the direction of change. If change happens too quickly or too slowly, it can cause stress. I believe that the daily devastation in addicted families demonstrates this, when day after day nothing changes and the stress levels continue to rise. On the other hand, when change happens too quickly, it does not allow sufficient time for comfortable adjustment. Stress can also come from the direction of the change. If you think you are better off because of a change, the direction usually does not produce stress. Conversely, if you do not like the direction of the change, it can be stressful. Surviving a chemically addicted family is emotionally exhausting. The amount of change initially proposed for family members needs to equal the amount of energy they still possess, which increases the probability that they might try new things. If the proposed changes are perceived as overwhelming, it is unlikely that they will proceed, and at the same time, see their lack of commitment as just one more indicator of their helplessness. Common characteristics of healthy families It is important to remember that persons who come from unhealthy, addicted and dysfunctional families may not have a good working knowledge of what makes a family healthy. It is to provide to persons who come from addicted families, information, discussions, guidelines, behaviors and characteristics that are found in healthy or functional families. Some of the most common characteristics of healthy families include: 1. Balancing togetherness and individuality 2. Developing and maintaining positive rituals 3. Teaching right from wrong 4. Supporting and affirming members 5. Remaining flexibile during stressful times 6. Interacting positively as a group 7. A sense of spirituality Rather than seeing the above as characteristics of healthy families, they can be reframed as goals for the family in recovery. The emergence of these changes can be used as indicators of individual and family growth. Individuals and families who are impacted by addiction do recover. The emotional impact of addiction and the realization of what has been missed in one’s family is not something to hide from or deny. We cannot expect anyone to become a fully functioning individual if they deny part of themselves. The goal is to integrate all the parts of our lives, accept where we have been, and take responsibility for where we are going. As Daniel Goleman stated, “Responses to an emotional trigger can be relearned, but the trigger does not disappear … emotional lessons — even the most deeply learned in childhood — can be reshaped. Emotional learning is lifelong” (Goleman, 1995). So is recovery. Robert J. Ackerman, PhD is Professor and Director of the Mid-Atlantic Addiction Training Institute at Indiana University of Pennsylvania and a co-founder of the National Association for Children of Alcoholics. He has published numerous books, articles and research findings, and is best known for writing the first U.S. book on children of alcoholics in 1978. References Ackerman, N. (1958). The Psychology of Family Life: Diagnosis and Treatment of Family Relationships. New York: Basic Books. Ackerman, R. (1987). Same House Different Homes. Pompano Beach: Health Communications. Ackerman, R. (2002). Perfect Daughters: Adult Daughters of Alcoholics. Deerfield Beach: Health Communications. Bass, F.(2007). Retail sales of painkillers in U.S. up dramatically, analysis finds. Indiana Gazette, 1,12. Beavers. W. (1982). Healthy, midrange and severely dysfunctional families. In F. Walsh (Ed.), Normal Family Processes. pp.45-66. New York: Guilford Press. Glicken, M. (2006). Learning from Resilient People. Thousand Oaks: Sage. Goleman, D. (1995). Emotional Intelligence. New York: Bantam. Haley, A. (1981). Lecture. Western Michigan University: Kalamazoo. Henry, D. (1999). Resilience in maltreated children: Implications for special needs adoption. Child Welfare, 78 (5), 519-540. Masten, A. (2001). Ordinary magic: Resilience processes in development. American Psychologist, 56, 227-238. Rapp, C. (1998). The strength model: Case Management with people suffering from severe and persistent mental illness. New York: Oxford University Press. Satir, V. (1964). Conjoint Family Therapy: A Guide to Theory and Technique. Palo Alto: Science and Behavior Books. van Wormer, K. and Davis, D. (2003). Addiction Treatment a Strengths Perspective. Pacific Grove: Books/Cole. Walsh, F. (1998). Strengthening Family Resilience. New York: Guilford Press.
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