It is well recognized that having a parent with a substance use disorder (SUD) can have adverse effects on a child (Fisher & Wampler, 1994; Rogosch, Chassin & Sher, 1990), but research is scarce on how the family environment changes when one or both parents are in recovery; and few studies have evaluated the impact of recovery on child functioning. A prevailing notion, based on a very small group of studies with clinical samples, is that prolonged remission can positively impact child functioning and family functioning (Moos & Billings, 1982; Callan & Jackson, 1986; Andreas & O’Farrell, 2007; Andreas, O’Farrell & Fals-Stewart, 2006). The purpose of this article is to describe the parenting challenges associated with various stages of recovery and how children might benefit from their parents’ recovery process. Through discussion of these issues, addiction professionals can help facilitate such positive effects.  

Pain is universal and important to all beings—it is a warning that something is wrong and needs attention to prevent further damage to the body. Whereas acute pain protects the body while it heals from trauma or injury, chronic pain is simply ongoing, persisting beyond its usefulness.

People commonly react by resisting the pain—tightening muscles, stiffening posture or trying to avoid movement. Resistance causes anxiety, sadness, fear, anger and frustration; and the more resistance, the worse the pain and suffering. Chronic pain includes the physical pain coupled with the emotional pain (suffering), triggered in the brain and generated by the limbic system (the emotional center of the brain). Physical pain and emotional pain are equally real.

As our population ages, chronic pain and its costs—both financial and on a human level—are increasing. Today, medical systems treat chronic pain in over 70 million Americans with a methodology known as “pain management,” which typically includes medications and procedures, such as injections and surgeries. The estimated annual cost of chronic pain treatment in the U.S. is $100 billion. The longer we live, the more likely we are to develop pain from a variety of conditions: autoimmune disorders, diabetes, arthritis, cancer, etc. Every time there is a car accident or a sports injury, someone is set up for chronic pain. Furthermore, in the case of back pain, research suggests that obesity, depression and/or increased awareness of the condition contribute to an increase in back pain (Griffin, 2009).

Chronic pain syndrome is charac­terized by:
• intractable pain lasting longer than six months;
• marked alteration of behavior;
• depression or anxiety;
• marked restriction in daily activities;
• excessive use of medications and medical services;
• no clear relationship to organic disorder; and
• multiple, non-productive tests, treatments and surgeries.

Drugs and chronic pain
Addiction treatment professionals will see the similarities and the relationship of addiction to chronic pain, both of which: involve feelings and loss of control; affect personality; are characterized by preoccupation, rationalization and denial; and have a profound effect on those around them. If medications are used for chronic pain, it is not uncommon for dependence and compulsive use to occur, especially with opioid pain­killers. People with chronic pain often end up medicating their anxiety, fear, anger and depression with these same drugs, and often have difficulty differentiating physical from emotional pain.

Christine, who struggled with chronic pain from migraines for several years, repetitively commented, “It just hurts, and I want relief.” This was her rationale for continuing to use her drugs. But she had developed dependence, loss of control and compulsive use—in other words, addiction.

Families and chronic pain
With the co-occurring disorders of pain and addiction, the treatment of each becomes much more complicated. Living with someone in chronic pain also has many similarities to living with someone with an untreated addiction.

The problems for families are more diffuse and life-altering than those of the person living with the pain itself. The family suffers along with the person in pain, developing their own dysfunctional symptoms, and they need to find strategies and solutions that allow them to cope in more self-enhancing ways. Just as addiction is insidious, the role of pain in a person’s life also is insidious. In time, for those within the family’s intimate circle, the pain becomes the central organizing feature of the relationship. Everyone is fixated on and responding to the pain. Families often need to make adjustments to accommodate both the person in pain and the results of the pain. They have myriad feelings depending on their relationship and role, and those feelings ultimately drive the highly enmeshed family members to frustration, anger and social isolation.
Kevin was in a severe sports accident as a teenager, which led to several surgeries and chronic back pain. Kevin’s father, now divorced from his mother and remarried with much younger children, is blatantly angry with Kevin. He is angry at Kevin for not working and for making excuses for not working. He is tired of hearing how his son’s life has been ruined by the accident and tired of calls from his ex-wife about Kevin’s escapades. The latest problem is that she wants him to pay for drug rehab treatment because now Kevin has become addicted to drugs and his behavior is out of control—all related to the accident and what his dad calls “this so-called chronic pain.” Kevin feels victimized by his father and the chronic pain and views his mother as his only ally. He also feels entitled, “After all, look what happened to me.” Kevin’s mother is totally preoccupied with his life and problems, and in turn, views Kevin as a victim because of these horrible things happening to him. She is unable to set any limitations on his behavior, regardless of how upsetting it is to her and the family. His dad is lost in anger and blame, both of which are equally ineffective vehicles for improving his son’s life.

Bill’s wife Eleanor, who suffers from chronic pain—originally emanating from scoliosis surgery, and more recently with a diagnosis of fibromyalgia—has spent 20 hours a day in bed for nearly four years. Bill handles her medical appointments, dispenses her medications and mediates contact with family members. He feeds her, ensures that she is somewhat comfortable, and takes care of all household duties, such as cleaning and laundry, in addition to working full-time. When the decision is made for Eleanor to enter a chronic pain treatment program, he is beside himself. ­Fearful of being without her, he calls or e-mails staff several times every day to find out when she will be home. In effect, he is going through his own form of withdrawal from Eleanor in this highly enmeshed and dysfunctional relationship. Both these families are reacting to the many ramifications and complexities of having a family member in chronic pain.

The family is a complex organism, with diverse parts making up the whole. It functions best when all the different elements are in good working order. When one member is in pain, the equilibrium of the family shifts, and family members change, adjust and accommodate in response to the strain on the family system. This is understandable, however, in time, even if someone has a strong sense of self and worth, the concerned other finds him- or herself acting out self-defeating behaviors.

Families need to develop an understanding of the consequences of their emotional and behavioral responses that may be impeding healthy family function. As an alternative, they need to develop positive coping and relational skills. Often, families may ­benefit from time apart (which treatment affords) so the person with chronic pain can improve and the family has some breathing room to do work on their own recovery and their healing process.

Biology of caring
Neuroscience has done much to help us understand what occurs in the brain of the addict, and now it also offers us a better understanding of what occurs for family members. The brain is wired to react empathetically to someone in pain in order to warn others of danger and elicit help. Functional MRI scans show that when watching someone undergo electric shock, the observer’s brain lights up in the same areas in which the brain of the person in pain lights up (Bufalari et al., 2007). One doesn’t have to witness the painful experience for the brain to react, simply seeing a person act as if he or she is in pain causes
the brain to light up. When the person in pain is a family member, the reaction to his or her pain is exponentially stronger.
In another study, when researchers delivered electric shocks to people with chronic pain, they found that in the presence of a solicitous spouse, pain levels and brain activity increased substantially. This study suggests that even though well-intentioned, when a caring person is present, the pain is reinforced (Flor et al., 2002).

Lessons for family embers:
• You are suffering as you witness your family member suffer, but your concerned and doting manner causes more pain in the very person you want to help.
• This research implies that family connections may well be the biological basis for enabling a loved one in chronic pain.
• Treatment implications involve developing a sense of equilibrium despite another’s experience of pain.

Fundamental therapeutic issues for family treatment

Chronic loss. To be in a relationship with a person in chronic pain results in multiple losses. There is the loss of the relationship as it once was, loss of shared social and recreational opportunities, loss of financial security, loss of hopes and dreams being fulfilled, and loss of sexual satisfaction and intimacy, to name a few. With these losses come a multitude of ­feelings:
• Fear that he or she will not get any better
• Fear of financial ruin (e.g., bankruptcy, poverty)
• Fear that your life is over
• Anger for thinking he or she is not trying hard enough
• Anger for what happened to cause this (e.g., God, the drunk driver who was responsible for the accident)
• Anger with the medical system for not having the answers
• Anger at the doctors for creating and perpetuating the addiction
• Anger at insurance companies for denying procedures and holding up the approval processes
• Anger at friends or family for not being there to help
• Embarrassment for his or her behavior when overmedicated
• Guilt for being angry
• Guilt for not being able to do more to make a difference
• Guilt for wanting out of the relationship and feeling trapped
• Sadness for the lost social times
• Loneliness that comes with social isolation
• Loneliness because of the emotional disconnection as he or she is preoccupied, distant, medicated

Understandably, family members often feel guilty just for having these feelings, knowing that the pain is not willful behavior. Their reluctance to express their feelings reinforces the dysfunctional family “Don’t talk” rule. In family systems in pain, people learn to minimize, discount and deny their feelings. So what do they do with all of those feelings? They learn to stuff them, reinforcing another dysfunctional family rule, “Don’t feel,” which culminates in being stuck in a perpetual, unresolved grief process. Consequently, as with addiction, and to an even greater extent, family members become increasingly more emotionally isolated, not sharing their thoughts and feelings with others.

In addition to the emotional disconnection, they are increasingly socially isolated. They become restricted to the home, not wanting to leave the person in pain for fear that he or she will need them or fear that he or she will put the house or someone else in jeopardy due to being under the influence of drugs. They become the caregiver, nurse, chef and parent—their lives consumed with telephone calls, medical appointments and wading through paper work. They limit people visiting for a host of reasons, such as not wanting to face the questions visitors ask, or not knowing to what degree the person in pain will be overmedicated on any given day.

Chronic caregiving/perfect helper. It is only natural to do what is necessary to help when seeing a loved one in pain, but the role of caregiver often becomes overwhelming and burdensome. Sometimes, efforts to make things better actually make them worse. The primary caregiver becomes the insurance expert and patient advocate, running interference with major medical systems and other family and friends, and often takes on a nurse-like role, controlling the dispensing of medication. When this continues for years, it often becomes the caregiver’s primary source of identity and esteem. The consequence of accepting such a role is the essence of codependency: becoming selfless in the service to another. The caregiver no longer acknowledges his of her own needs and wants, abandoning his or her own desires. In the process of being a good caregiver, self-care is forgotten. The ultimate consequences for such a lifestyle encompass the unhealthy expression of anger, martyrdom, sacrificing one’s needs to the needs of another, believing there are no options, and feeling helpless to create change in your own life. Without support and clarity about what is happening, caregivers can ultimately spiral into their own depression or find themselves self-medicating with food, alcohol, and/or other drugs.

Distorted Boundaries. Feeling sorrow and pity for someone in pain, families often take on responsibilities for that person, when in fact he or she is capable of managing those responsibilities independently. This not only creates an unhealthy dependency, it creates a disparate relationship and doesn’t allow the person in pain the opportunity to maintain self-accountability. Enmeshment is extremely common, fueled by feelings of guilt (often false guilt) and fear. Consequently, family members of people in pain act on their behalf, not allowing them to act for themselves.
Kevin and his mother were so used to her taking care of his needs, that he had become virtually helpless.She acted from a place of sympathy rather than empathy, which only reinforced Kevin’s helplessness. Engaging in empathy rather than sympathy will allow Kevin to maintain a stronger sense of self.

High Tolerance for Inappropriate Behavior. People who are in pain and on various medications frequently express anger in hurtful ways. They feel frustrated, helpless and scared.

Kevin’s family members are experiencing these emotions, but also want to be empathic with Kevin. As a result, they have developed a high tolerance for inappropriate behavior. They are often raged at, called names and treated with hostility. In spite of Kevin’s physical limitations, family members were also physically abused by him when he would throw objects at them. They made excuses for his behavior and developed a level of tolerance that had disastrous results, including Kevin’s dad ending up hospitalized for a bleeding ulcer. The belief that Kevin’s pain means he can’t help himself only leads to an abnormally high tolerance for inappropriate behavior. This allows Kevin to become an offender, and his family to move into a victim/martyr role. “After all, poor Kevin is in pain—who am I to complain because he shouts every once in a while? I can take it since I’m the healthy one.” Lacking healthy boundaries, Kevin and his parents are using faulty judgment and in danger of making poor decisions.

Preoccupation. As helpless as family members feel about the pain, they often become highly vigilant and preoccupied with the pain and with the person in pain, who becomes the central force in their lives. The family members come to faulty conclusions based on assumptions and inadequate information. They are practicing mindreading, which frequently leads to misinterpretation of the truth. For example:
• When Bill’s wife says, “You go, I’ll be fine,” that must mean she wants him to stay home with her.
• When she rolls over in bed that must mean the pain is worse and she needs more medications.
• When Kevin doesn’t say he feels etter that must mean he’s ready to have another temper tantrum.

The preoccupation with the pain and the person in pain also leads to social and emotional isolation.
When Bill is with others he cannot focus on connection, let alone have fun, because he is consumed with not being present for Eleanor. Bill talks himself out of being with others so he can stay vigilant, believing Eleanor is incapable of managing for herself. He even started working from home so he could keep an eye on her, not satisfied with his daughters’ offers to help him.

Controlling behavior. In an effort to bring stability to what is a fragile situation, family members become controlling and preoccupied by trying to read everything they can find about the problem, searching out all possible remedies. While there is no doubt that everyone needs advocates within the healthcare system, in time this became Bill’s identity and only focus, negating all other needs. Eleanor had cause to be more dependent; for Bill there is a fine line between trying to be helpful and taking over. Controlling behavior is having things done your way, in your time frame, without respect for other people’s needs and boundaries. It is created by a fear (an often unrealistic fear) of imminent disaster, and then it feeds on itself. This controlling behavior is demonstrated not just toward the person in pain, but also toward healthcare providers, other family members and all aspects of life. The chronic pain has become the central feature of the family member’s life.

Secondary gain. Preoccupation of this type is also very connected to secondary gain. Family members frequently, consciously or unconsciously, sabotage recovery by being attached to their identity within the caregiving role. It becomes the major source of their identity and esteem, and without it they don’t feel of value. They feel displaced. They may have found a power in such responsibility and are left with a sense of worthlessness when they don’t get to operate in that role. While recovery may be consciously desired, the human element of “but what about me?” needs to be acknowledged and addressed.

Bill’s identity and worth is totally attached to attending to Eleanor’s needs. Likewise Kevin’s mom relies on her relationship with Kevin for the meaning in her life. As Kevin and Eleanor get well and more independent, Kevin’s mother and Eleanor’s husband find their sense of self falters, requiring them to rediscover their own lives. As Kevin improves and becomes more accountable for his actions, his father loses the primary focus of his deep-seated anger, which stemmed in large part from his own issues of an abusive childhood. Having more clarity about his feelings enables him to respond in a healthier manner to the present reality.

Treatment goals
Successful treatment must include family members. Similar to any effective treatment for codependency, clinicians should consider the following when working with families:
1. Offer a framework to understand the differences between emotional and physical pain.
2. Validate that all pain is real.
3. Validate the experience of loss.
4. Help family members decrease their isolation.
5. Help family members recognize codependent behaviors as self-defeating to both themselves and their partner/family member in the long run.
6. Offer them a framework to understand the basis of their codependency.
7. Assess for primary disorders, including pain, addiction, and psychiatric co-morbidities.
8. Assist them to engage in greater self-care practices and establish their own program of recovery.
Throughout this process it is critical to help the client and family members discuss their hopes and expectations. Expectations are many times simply fantasy—the expectation that there will be instant intimacy, healthy communication and no conflicts. Counselors should remind families that they are not performing “brain transplants” in treatment; rather, they are simply eliminating toxic substances and helping clients’ change their patterns of thinking, feeling and behaving as the first steps in establishing a healthy lifestyle. As with the client, the family members need their own self-care plan, wherein they identify both the behaviors and thinking that need to stop, as well as the behaviors and thinking that support recovery. They must also learn the areas that are triggers for self-defeating thoughts and behaviors and develop a way in which to address them. Family treatment will facilitate learning healthy communication skills to assist in family members’ ability to talk about the process as they engage in their newly learned ways of relating to the fact that the pain is real, but that the suffering is modifiable and optional.

Successful recovery practices for the client and family draw from many ­disciplines. Through mindfulness, cognitive practices and 12 Step philosophy, families and clients can develop skills to work around the “edges” of the pain (Kabat-Zinn, 2005). Instead of being absorbed in the search for a cure, families can learn that the solution lies with accepting the situation and the condition. Drawing from the gifts of addiction treatment, recognizing your powerlessness ultimately leads to genuine acceptance and improvement of health for the person in treatment and the family.
Kevin gradually learned about pain recovery—the process of knowing that the pain exists, will always exist and will not kill him. Though they came from opposite directions, Kevin’s parents ultimately came to a mutual understanding and acceptance of healthy boundaries. As a consequence of Bill’s recovery work, he and Eleanor both took responsibility for their parts in coping with the pain, and now were better able to take responsibility for their roles in establishing a healthy, interdependent relationship with one another.

By giving up the struggle, pain is lessened and suffering diminishes for the person in pain and his or her family.

References
Bufalari, Ilaria et al. (2007). Empathy for Pain and Touch in the Human Somatosensory Cortex. ­Cerebral Cortex. 17: 2553–2561.
Flor, Herta et al. (2002). Conditioning: Learning that Pain Can Elicit Reward. Presented at Society for Neuroscience Annual Meeting, Orlando, Fla. November 2–7, 2002.
Griffin, M.R. (2009). “Is Chronic Pain on the Rise?” Pain Management Health.
Retrieved Dec. 2009 at http://www.webmd.com/
pain-management/features/is-chronic-pain-on-the-rise.
Kabat-Zinn, J.(2005). Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain and Illness. Bantam Dell.

Claudia Black, PhD is Senior Clinical and Family Services Advisor for Las Vegas Recovery Center, and Senior Editorial Advisor for Central Recovery Press, publishing materials on addiction, recovery and behavioral health-care topics. For more information visit lasvegasrecovery.com, centralrecovery.com, or claudiablack.com.

Mel Pohl, MD, FASAM is a Board Certified Family Practitioner and the Medical Director of Las Vegas Recovery Center. Has published numerous works on AIDS and addiction and chronic pain and addiction, including A Day without Pain and Pain Recovery: How to Find Balance and
Reduce Suffering from Chronic Pain.

Janette, a 46-year-old woman who was recently divorced from her third husband, walked into a community mental health center with slurred speech, unable to make decisions, exhibiting extremely poor self-care and diminished expectations. All of her husbands were drug addicts; and the last one also was a sex addict (a term that was not readily used in the therapeutic process at the time). Janette was treated with antidepressants, and although she responded positively to the medication, she demonstrated a long-standing anxiety disorder. She fretted and worried about every minor and major detail in her life. Everything was a potential problem. Treatment with anti-anxiety medication improved her functionality. It was noted at the time of her intake that she was raised in a physically threatening, alcoholic home; and for a period of two years, experienced sexual abuse by two perpetrators who were friends of her parents.

Thomas started experiencing panic attacks shortly after he began recovery from his compulsive overeating. He was raised in an alcoholic family with a schizophrenic mother who subjected him to extremely cruel physical punishments. Food had always been his self-medication. Without the sugar, and without any recovery from the emotional pain in his life, his underlying fears quickly rose to the surface. He was hospitalized three times for what would ultimately be diagnosed as panic attacks characterized by intense anxiety, often accompanied by a feeling of impending death, heart palpitations, shortness of breath and sweating. He was never asked about his experiences growing up.

Both Janette and Thomas sought help in traditional settings that were not familiar with the dynamics of trauma or addiction. Although both experienced a stabilizing effect when treated for their presenting symptoms, the underlying issues were neither identified nor addressed. Ultimately, until the role trauma played in their belief systems and defense structures is recognized, the prognosis for a long-term favorable outcome is limited. Their trauma history will most likely continue to contribute to maintaining self-defeating belief systems and low self-esteem, resulting in poor decision-making and lack of healthy relational skills. That combination will, in turn, work against both of their potential for recovery from anxiety and depression, as well as Janette’s capacity to make healthier partner choices.

Familial trauma
When people think of trauma it is common to think of the trauma experienced by our soldiers in Iraq and Afghanistan, or the thousands of people who are survivors of natural disasters, such as hurricanes, tornadoes or tsunamis. Shoot­ings on our college campuses or in corporate offices leave behind many trauma survivors. However, the majority of people who experience trauma will experience a more subtle, chronic form that most often occurs within their own family ­system.

Blatant forms of trauma in the family include being subjected to and/or witnessing physical and sexual abuse. Trauma also occurs in more subtle forms—for example, living with fear on an ongoing basis, such as the fear of not knowing if or when a parent is coming home; or the fear that comes with listening to one’s parents argue night after night; or the fear of not being able to rely on a parent attending a significant event. To live with chronic fear during the vulnerable childhood and adolescent years—when one is developing beliefs about oneself and the world at large—is traumatic to emotional, psychological and spiritual development.   

For those who are familiar with the early years of the adult children of alcoholics (ACoA) movement, this work offered a model and a language that enabled people to understand their childhood experiences; and created a process for healing to occur. Post-traumatic stress disorder (PTSD), once called delayed stress, is what the “adult child” dynamic encapsulated. It offered a framework for how the vulnerability of children who live with chronic stress and loss, self-protect against their pain with a host of different defenses, while learning faulty beliefs and developing cognitive distortions in the process. PTSD then described the resulting consequences, which often would not present as problematic until many of these individuals were of adult age.

When intervening with those who were raised with addiction in the family, it is critical to address issues of chronic stress, chronic abandonment, and in some cases, blatant violence, all of which are aspects of trauma.

A 1999 report from the National Center on Addiction and Substance Abuse at Columbia University stated, “There is no safe haven for the abused and neglected children of drug- and alcohol-abusing parents. They are the most vulnerable and endangered individuals in America.” The report further noted that substance abuse causes or exacerbates seven out of 10 cases of child abuse or neglect, and that children whose parents abuse drugs and alcohol are nearly three times more likely to be abused, and more than four times more likely to be neglected (Reid, J., Macchetto, P. & Foster, S., 1999).

Callee, a 23-year-old client told me, “As I was growing up I really remember wanting only one thing, and that was to do it differently than how it was being done around me. Two days before my 23rd birthday, with my husband in jail for a drinking and driving charge, I looked into the passive eyes of my child, whom I had just thrown across the living room floor, and I felt my world and sanity crumble. I was doing it exactly as they had done.” Callee was raised with both substance abuse and physical abuse, and at a young age was quickly repeating her family script.

The culminating act of abuse is when someone is killed, but for many family members the physical abuse is not the hitting, slapping or punching someone until they bleed or are bruised; rather, it may be the shoving, pinching, slamming someone up against the wall until their teeth rattle or terrorizing car rides.

Also traumatic to a child’s development is the witnessing of abuse. Jake shared, “When I was about 10, Dad would regularly come home drunk about three in the morning and drag my 13-year-old brother out of bed. He’d be yelling things at him, slapping him about the face, making his nose bleed. Sometimes he’d beat him with his fists. My brother would be bleeding and crying and Dad would hold him up to the mirror and say, “Is this what a man looks like?” The tears and fear that filled my brother’s eyes were my tears and fear. I always wondered when Dad would come home and if it would be my turn for him to make me a man.”

While there is no substantiated causal relationship, addiction and sexual abuse frequently coexist in the same family. Children are primed for victimization as they:
• Are starved for attention—perpetrators are known to groom their victims, to initially engage a child under the guise of friendship and give them positive attention.
• Are less likely to speak up for fear of not being believed. They already live in a family system where the truth is not supported.
• Give others the benefit of the doubt.
• Don’t trust own perceptions.
• Have difficulty identifying their feelings, making it less likely they can use their feelings as cues and signals to propel them to action that may mobilize assistance.
• Are already confused about what constitutes appropriate boundaries.
• Are already experiencing shame (from the addicted family system), which then accompanies the added shame from the sexual abuse, fueling powerlessness rather than action (reaching out for help).

In addition to the more blatant forms of abuse, these children are often subjected to covert forms of sexual abuse; being called sexual names such as, “whore,” “slut,” or being asked if he or she got “laid” last night and then being laughed at in a humiliating tone; or being exposed to drunken nudity, which often reinforces negative statements to a child about his or her own body.

Even more prevalent is emotional and spiritual abuse within the addicted family. This may consist of verbal abuse, name calling, blaming or severe and cruel criticism. It is living with ­broken promises, lying and unpredictability—not knowing what will happen next. With this type of trauma comes a myriad of feelings, such as:
• Fear—of being with an under–the-influence driver; of divorce, or no divorce; that someone will get seriously hurt or die.
• Sadness—for the parent not showing up; for what the parent said or didn’t say to the child.
• Anger—for broken promises; for the message that the parent’s using is more important than the child; that the parent does not try to quit or is not able to quit.
• Embarrassment—for outbursts in front of friends; for the unkempt appearance of the parent; for what the parent said or did in public.
• Guilt—for thinking that they are responsible for their parents’ behavior; for having negative feelings for someone they are supposed to love.
• Confusion—about why this is all happening and who is at fault.

Children learn to tolerate the hurt. With continuing exposure, they come to expect it, often developing a greater tolerance for hurtful behavior. They succumb to the dysfunctional family rules—Don’t Talk. Don’t Feel. Don’t Trust. Don’t Think. Don’t Question—all in an attempt to cope. It is the Don’t Talk rule, the rule of silence, when people just pretend things are different than they really are that sits on top of all of the pain and dysfunction. There is no doubt that these are children raised with chronic stress.

Stress responses and trauma
The experience of stress can either promote growth or cause serious damage. There are three types of stress: positive, tolerable and toxic. Positive stress is associated with moderate short-lived physiological responses, such as the stress that comes with meeting new people, handling frustration, coping with parental limit-setting, etc. Positive stress is an important and necessary aspect of healthy development.

Tolerable stress is associated with physiological responses that could actually disrupt brain architecture, but are relieved by supportive
relationships, among other protective factors. These are stress situations such as the death or illness of a loved one; a frightening
accident; or a natural disaster. Certainly, these types of experiences can have long-term consequences, and they often become traumatic, particularly when coinciding with toxic conditions in childhood, which are traumatic in and of themselves. However, such stresses are emotionally and mentally tolerable when they are time-limited and the child has access to supportive people to provide buffering protection.

Toxic stress, the most threatening, is associated with strong and prolonged activation of the body’s stress management systems in the absence of the buffering protection of support. Toxic stress emerges in the face of loss—conditions of extreme poverty; continuous family chaos; persistent emotional, physical and/or sexual abuse; chronic parental depression; persistent parental substance abuse or other manifestations of addiction; and ongoing emotional or physical neglect. Without the protective factors that allow children the space to disengage, they become trauma victims.
Stereotypically, when we think of trauma, what comes to mind are public catastrophic events than can overwhelm an adult. What distinguishes childhood trauma from occurrences like combat stress is simply that the injuries occur to children. “Dear Lord, be good to me,” reads the epigram for the National Children’s Defense Fund. “The sea is so wide and my boat is so small.” A child’s personality and neurology—the little boat he or she must navigate in—are still developing.

For children, home is supposed to be safe. In times of trauma, the natural response is to run. This is not just about running from, but also of running toward. Trauma survivors typically run toward home, but where can a child go when the trauma is in his or her home? When it is not safe psychologically or physically to be the person you are, to own your truth, and what you see and how you feel, then you move into various trauma responses—you fight, you flee or you freeze.

Today we know the body cannot tell the difference between an emotional emergency and physical danger. When triggered, it will respond to either situation by pumping out stress chemicals designed to impel someone to flee to safety or stand and fight. In the case of childhood problems, where the family itself has become the source of significant stress, there may be no opportunity to fight or flee. For many children, the only perceived option is to freeze and shut down their inner responses by numbing or fleeing to the inside.

When young children get frightened and go into flight, flight or freeze, they have no way of interpreting the level of threat or using reason to modulate or understand what is happening. The brain’s limbic system becomes frozen in a fear response. The only way out is for a caring adult to hold, reassure, and restore the child to a state of equilibrium. When primary caregivers are not available to soothe and reassure, the child is left to live through repeated ruptures in his developing sense of self, his fundamental learning processes and his relational world.

By virtue of their extraordinary vulnerability, children are at special risk for trauma. Childhood injuries, even when mild by some people’s experiences, can have long-lasting effects because they occur while the very structures of the body, brain and personality are being formed.

The legacy  
Most children growing up in troubled families learn to function by developing a false sense of self, adapting to the needs and demands of the family system. The family legacy then continues as family members act out and cause spiritual and emotional bankruptcy. Most who are raised in a family with addiction or other painful circumstances are determined not to repeat history, and genuinely believe they are going to be able to do it differently.

While a trauma survivor may no longer be subjected to abuse, he or she may not have found a therapeutic avenue through which to resolve his or her pain. Survivors often try to cope and quiet the pain by using substances, such as alcohol, cocaine, methamphetamine, heroin or even food. Often their use of a medicating substance or high-risk behavior is in response to an anxiety disorder or depression. It is
common to see both addiction and co-occurring disorders among those with greater trauma histories. Addiction, depression and/or anxiety are common flight or fight responses, and certainly freeze responses among this population.

Another dynamic characteristic of trauma is the fact that it repeats itself generationally. While the names change, the stories of repetitive partnering with an addict are nearly universal. This is referred to as trauma repetition.

Usually something that took place in childhood and started with a trauma; reliving a ‘story’ from the past; repeatedly engaging in abusive relationships; or repeating painful experiences, including specific behaviors, scenes, persons and feelings (Carnes, P., 1997). It is often repeating what you know, the familiar or what you believe you deserve. It may be an attempt to change the outcome of an old family script. Ulti­mately, it is as futile as attempting to survive the sinking Titanic by repeatedly changing your seat as the ship is going down.  

The evidence
For more than a decade, the Centers for Disease Control and Prevention (CDC) and Kaiser Permanente in San Diego, along with leading researchers, have been conducting an ongoing study, the Adverse Childhood Ex­periences Study (ACE), to examine the childhood origins of many of our leading health and social problems. The ACE score is used to assess the total amount of stress during childhood and has unequivocally demonstrated and quantified for the first time that which we have observed clinically—as the number of adverse childhood experiences increase, the risk for the following health problems increases in a clear and progressive fashion (Anda, R. & Felitti, V., 2003):
• Alcoholism and alcohol abuse
• Depression
• Illicit drug use
• Risk for intimate partner violence
• Smoking
• Suicide attempts
• Multiple sexual partners
• Health-related quality of life—specific health issues of liver disease, chronic obstructive pulmonary disease (COPD), ischemic heart disease (IHD) and sexually transmitted ­diseases (STDs).

In his book, The Truth about Depression, Charles Whitfield, MD summarizes 251 peer-reviewed published reports that examine the relationship of childhood trauma to subsequent depression and other mental illness. Of the 209 studies that linked depression with having a history of childhood trauma, the reports found that among those with a history of childhood trauma, depression was from 1.6 to 12.2 times more common than was found among the controls. Further, an additional 70 published studies from the community on nearly 70,000 trauma survivors and controls showed up to a tenfold increase in depression; and two prospective studies following 11,000 people for up to 20 years revealed an increase in depression of up to tenfold (Whitfield, 2003).

In his book, The Truth About Mental Illness, Whitfield cites a total of 153 data-based research studies that document the firm association of the link between alcohol and other drug problems and having a history of repeated childhood trauma (Whitfield, 2004).

The possibilities
The possibility for recovery from trauma begins with identifying whether or not there is a primary disorder and the potential for co-occurring disorders and multiple manifestations of addiction. In addiction treatment programs, it means recognizing family treatment is not merely an educational process, but that family members have the right and need the opportunities to heal from their ­familial pain.

For the primary clinician, it means asking clients about their original family history, asking pointed questions about the use of alcohol and other drugs, and exploring the possibility of other addictive disorders. It means asking about the possibility of physical or sexual abuses, and recognizing the impact of toxic stress, chronic loss situations and less than nurturing environments. And, in this process of asking, we as treatment professionals need to demonstrate a willingness to identify and address trauma as a clinical issue.

In some situations it is easy to not recognize the role past trauma continues to play in someone’s life. Or it may be easy to discount the role of trauma because the trauma itself or its apparent consequences may not seem to be as severe as someone else’s experience. But no one person’s losses negate anybody else’s experience. The prevalence and impact of traumatic experiences are not to be underestimated. Everyone deserves a life of choice versus living a script written by a dysfunctional family system.

Claudia Black, PhD is a well-known and respected educator and author of more than 15 books in the field of addictive disorders. She is Senior Clinical and Family Services Advisor for Las Vegas Recovery Center specializing in the treatment of chronic pain and substance abuse, and Senior Editorial Advisor for Central Recovery Press, publishing materials on addiction, recovery and behavioral health care topics. For more information contact lasvegasrecovery.com; centralrecovery.com; or claudiablack.com.


References
Anda, R. & Felitti, V. (2003). The Health and Social Impact of Growing Up with Alcohol Abuse and Related Adverse Childhood Experiences: The Human and Economic Costs of the Status Quo. Centers for Disease Control and Prevention (CDC) and the Kaiser Health Plan’s Department of Preventive Medicine in San Diego, CA.
Carnes, P. (1997). The Betrayal Bond: Breaking Free of Exploitive Relationships. Health Communications, Inc. Deerfield Beach, FL.
Reid, J., Macchetto, P., & Foster, S. (1999) No Safe Haven: Children of Substance-Abusing Parents. Center on Addiction and Substance Abuse at Columbia University. New York, NY.
Whitfield, C. (2003). The Truth About Depression. Health Communications, Inc. Deerfield Beach, FL.
Whitfield,C. (2004). The Truth About Mental Illness: Choices for Healing. Health Communications, Inc. Deerfield Beach, FL.

This article is published in Counselor, The Magazine for Addiction Professionals, December 2009, v.10, n.6, pp.10-15. 

“From small beginnings come great things.” – Dutch Proverb

Speaking to a client, or parent/caregiver about addiction is easier if you understand what motivates them to change. Change is not an event, but a process that is composed of several steps, all of which begin with how you approach a client or family/caregiver in need.

Policy changes in one system can have major and sometimes unintended effects on other systems. This is the case in the United States, where the child welfare, substance abuse and mental health fields all service high-risk families who have problems in all three areas. At highest risk is the group whom the legislation was designed to protect, the children. The solution is to have all three systems work together to strengthen the parenting skills of the adults in their care.

The concept of looking at family members in the etiology and maintenance of psychoactive substance use disorders dates back to the early 1930s, when social workers in state hospitals reported the results of interviews and observations of wives of alcoholics (Lewis, 1937). Lewis (1937) noted that the wives presented with their own symptoms, such as anxiety, depression, and psychosomatic symptoms. These early reports fueled a number of theoretical explorations into the cause of alcohol-related family symptoms. Prevailing theories during the 1930s focused on the idea that psychological symptoms in family members did not result from a reaction to living with a chronic alcoholic. As a result, many theories emerged attempting to explain the phenomena.

Alcoholism is a fire that has raged through my family for generations. We’ve all been burned. We all carry its scars. — A client