The number of American adults who abuse alcohol or are alcohol dependent is about 17.6 million, or about 8.46% of the adult population (Grant, et al., 2004). Not only is this a primary health concern in itself, but it is additionally of concern because alcohol involvement has significant implications for child well-being and development. Approximately one out of every four U.S. children under the age of 18 years is exposed to the effects of alcohol abuse or dependence in a family member (Grant, 2000).
The field of alcohol treatment began to systematically apply family theories during the mid- to late- 1960s and early 1970s (Zweben & Pearlman, 1983). At that time, family studies began to address the "functions" that alcohol serves in family dynamics, and began to apply a family systems perspective to the understanding of alcohol problems (Berenson, 1976). Another concern involves determining the possible family influences on how individuals develop problems with alcohol-there is consensus that children of alcoholic parents are at a greater risk for developing alcoholism (and other mental or behavioral health problems) than are others, but there is not complete consensus as to the specific mechanisms by which this increased risk is operationalized (Begun & Zweben, 1990). Problems with alcohol (and other substances) have been associated with a number of different family factors, including parental substance use, substance use of siblings, family values and attitudes about substance use, family dynamics and relational patterns, and interaction effects with biological/genetic factors (Waldron & Slesnick, 1998). Family approaches to alcohol treatment have received some research attention, as well (Waldron & Slesnick, 1998).
Critical to a contemporary understanding of alcohol and the family is appreciation for the many diverse forms that families take, and the many different cultural definitions of "family" that apply in the U.S. Early research adopted nuclear family types of definitions involving individuals living together and related to one another through "blood" or legal bonds (e.g., marriage, adoption). Culturally competent social work practice, on the other hand, extends the definition of family membership to include a much wider range of individuals who are linked through various types of formal and informal kinship ties (McGoldrick, Giordano, & Pearce, 1996). American family forms include nuclear, single parent mother, single parent father, ex- and step relations, grandparent/aunt/uncle as parent, foster families, and others. There are tremendous ethnic and cultural differences in family roles, family interdependence and informal support systems, and values about how families interrelate (Fisher & Harrison, 2000).
The family can be conceptualized as a dynamic system that changes over time as membership changes, individuals change and develop, relationships change, and the family's context changes. A family system is interpretable only when its many multiple components are understood-the multiple components include the individual family members, the relationships between them, the family's relationships with its ecological context, the family's history (multigenerational and experience of events), and the host of internal and external forces for developmental change. There are several concepts that are key to a systems perspective on families (Begun, 1996 provides a review):
- The family as a system is more than the sum of its parts. Family systems are composed of interdependent members whose interactions, dynamics, rules, boundaries, and patterns each contribute to family behavior. Individual family members affect the system as a whole, and the system affects individual members-there is a considerable degree of "circularity of influence" involved (Minuchin, 1974).
- Changes in any part of the system affect the entire system. When there are developmental or other changes in an individual family member, changes in the interaction patterns between individuals, new family members are added, or family members leave, the changes reverberate throughout the system.
- Subsystems are embedded throughout the larger family system. Some of the most common subsystems are the couple subsystem, parent-child subsystem, and sibling subsystem; family systems might also include grandparent-grandchild, step-parent and child, half-siblings, ex-partners and other extended family subsystems. Family subsystems do not operate independently of the whole system. Their character and nature are shaped by the overall culture of the family system. Family behavior may be enacted through subsystems rather than the system as a whole. Interactions at the level of the subsystem may impact other family members and subsystems, as well-both directly and indirectly.
- Families exist within a larger social environment context. Families are nested in, are shaped by, and interact with other social systems that affect and are affected by family system processes. Thus, the family system is subject to events that occur within the neighborhood, community, health care, school, workplace, service delivery, societal, economic, historical, and cultural systems. Social workers often rely on eco-maps in order to diagram and assess the nature of a family's complex interactions with its environmental context (Hartman, 1978).
- Families are multigenerational. Family systems are influenced by their histories, as well as by an awareness of their futures. Families may have four or more generations that are currently relevant at one time, and family members are affected by inherited qualities across generations, as well. Social workers often utilize genograms to map the intergenerational and family history influences on family systems (Hartman, 1978).
Another characteristic of family systems approaches is an awareness of the fact that change in family systems is stressful and causes tension in the family. This applies to any change, positive or negative (e.g., death or other loss of a member, marriages, births, adoption, geographic moves, change in social status), because change requires families to dedicate resources and energy to adapt and adjust to their new circumstances.
Family systems are sometimes described by therapists as being very difficult to redirect and resistant to change-once systems have achieved a level of stability or homeostasis, they apply concerted efforts to maintain their hard-earned balance. In fact, warnings have been offered about intervening to change an individual's alcohol abuse without adequately responding to the potentially destabilizing effect of an individual's recovery on the family system-the individual's drinking may represent a family system's homeostatic solution to otherwise distressed relationships (Steinglass, Davis, & Berenson, 1977; Orford, 1975).
The areas and points of family functioning where difficulties are likely to appear during an individual's long-term recovery from alcoholism include:
- Challenges in family role adjustment as the previously alcoholic individual attempts to regain significant roles abandoned through drinking (e.g., involvement in family decision making, authority, sex, intimacy, and other reciprocal exchanges);
- Difficulties in parent-child relationships, especially around behavior management and communication involving adolescent children;
- Developmental changes of family members, family life cycle transition, or situational change events experienced by the family system - e.g., launching children, job loss, adult developmental changes of either partner (Zweben & Perlman, 1983).
In sum, it is vitally important to take into consideration an individual's family (and other social contexts) when exploring the development, maintenance, or treatment of alcohol use disorders. The family system is an important client context, in part because it is one of the interpersonal situations in which the problems occur (Jacob & Leonard, 1988; McCrady & Epstein, 1995). In some cases, the social context of family relationships may be a factor that becomes compelling for the maintenance of the alcohol problems (Shoham, Rohrbaugh, Stickle, & Jacob, 1998)-the specific nature of family interactions may foster the continuation of problematic drinking. In others, this is a context that can facilitate improvement and recovery (Borkovec & Whisman, 1996; Burke, Vassilev, Kantchelov, & Zweben, 2002). Despite the problems related to their substance abuse, individuals with alcohol use disorders typically maintain contact with their parents, brothers and sisters, as well as significant others in their social context, and the family may play an important role in their seeking treatment (Connors, Donovan, & DiClemente, 2001).
Family Influences on the Development of Alcohol Use Disorders
One central finding within the large body of research concerning the etiology of alcohol use disorders is that there exist multiple pathways to these outcomes (Cloninger, Sigvardsson, & Bohman, 1996). Clearly, there are complexly interacting contributions from genetics and other physiological forces, as well as influences from environmental contexts, including family, peer, workplace, neighborhood/community, and media. Alcohol use disorders are multiply determined (Hesselbrock, Hesselbrock, & Epstein, 1999).
Family Genetic Influences
Research indicates that genetic factors may contribute to the development of alcoholism, and family pedigree is the context for this particular source. Family pedigree studies that compare individuals with and without diagnosable alcohol dependency typically show an increase in the lifetime prevalence among biological relatives. The increase in risk for first-degree relatives (brother/sister and parent/child) developing alcohol dependency ranges from four to seven times the risk within the general population (Merikangas, 1990).
Adoption studies have compared children born of an alcoholic parent (usually the father) and reared by nonalcoholic adoptive parents with adopted children born of nonalcoholic parents. In U.S. and Scandinavian studies, the adopted infants of an alcoholic parent developed alcoholism as adults at higher rates than did their counterparts (Cloninger, Bohman, & Sigvardsson, 1981). It is important to note that, while genetic factors are implicated in the development of alcohol use disorders, the findings also indicate that the genetic factors are not deterministic (Kendler, 1995; Slutske, et al., 1998; Cadoret, et al., 1995). In other words, genetic factors interact with other biological and environmental context factors to produce the observed outcomes. Some factors relate to vulnerability and risk, others are protective or resilience factors. Genetics can explain an individual's vulnerability to alcohol use disorders, while environment and other biological factors contribute to their emergence or expression.
In recent years, tremendous progress has been made in uncovering the specific biological mechanisms involved in these observed results. Clearly there is no specific gene or chromosomal "address" that determines who will and who will not develop alcohol use disorders. However, there is increasing evidence concerning the neurotransmitter activity and brain sensitivity that predispose and protect for these disorders. For example, some children of alcoholic parents demonstrate different physiological responses to the effects of alcohol when compared to other individuals. Children of alcoholics may have greater sensitivity to the stress-dampening effects of alcohol than do other individuals (Pihl & Peterson, 1995), as well as less sensitivity to the intoxicating effects of alcohol (Schukit & Smith, 1996). A lack of sensitivity to alcohol's intoxicating effects and increased sensitivity to anxiety-reduction effects of alcohol are associated with greater risk of developing alcohol dependence (Schukit & Smith, 1996), and these features are more apparent among children with alcoholic parent than among individuals with no family history of alcoholism (Molina, Chasin, & Curran, 1994). These physiological mechanisms appear to have a high degree of heritability, at least according to these studies of adult offspring of alcoholic parents.
Family Context Influences
If genetics actually predestined an individual to develop alcohol use disorders, then each alcoholic individual would have first order relatives with the problem, and almost all adopted individuals born of an alcoholic parent would develop the problem-regardless of family rearing environment. Since this is not the case, the genetic factors must interact with other biological and environmental context factors to determine the outcome-both in terms of risk and protective factors. "Individuals reared with an alcohol-abusing parent are at risk for developing alcohol problems due both the genetic factors and to faulty role modeling" (O'Farrell, 1995). Genetics explain an increased vulnerability to alcohol use disorders; family environment contributes to and mediates their emergence or expression (O'Farrell & Fals-Stewart, 1999). For example, alcoholic parents may be more likely to give birth to children with difficult temperaments, which in turn may become a risk factor for substance problems later in life. The impact of temperament on developmental outcomes is not a genetic phenomenon as much as it is a function of a constitutional factor that interacts strongly with social environment contexts (such as parenting environment) to shape an individual's developmental course. Cadoret et al. (1995) reported a higher occurrence of substance abuse among the offspring of alcoholic fathers compared to other individuals, and attributed part of the effect to the increased likelihood of early conduct problems among these offspring.
It is important to note that the very same parenting factors that appear to be linked to adolescent alcohol abuse (e.g., low levels of parental emotional support and a lack of control and monitoring of child behavior) are also linked to a host of other adolescent problem behaviors, such as smoking and early sexual activity (Jacob & Leonard, 1994). Non-substance abusing adolescent children of parents with alcohol use disorders are more likely than others to experience negative emotionality, aggression, stress reaction, alienation, and low well-being (Elkins, McGue, Malone, & Iacono, 2004). Chassin et al. (1996) observed greater emotional reactivity among adolescent children of alcoholic parents than among other adolescents. "Hyperreactivity" to stress may contribute to the emergence of future alcohol use disorders as these individuals attempt to modify their experiences of stress.
Family contexts may provide exposure to key antecedents and consequences for alcohol abuse. For example, many alcohol-abusing individuals cite family arguments, poor family communication, inadequate family problem solving, and nagging at home as antecedents of a drinking episode (O'Farrell & Fals-Stewart, 1999). Family members may also serve to intentionally or inadvertently reinforce or punish the drinking, providing consequences that increase or decrease the likelihood of future drinking episodes.
There also exists research evidence that parenting and other family functioning factors may influence the development of alcohol problems during adolescence or early adulthood. For example, in families with an alcoholic parent, children and adolescents may find that they have easy access to alcohol. It is interesting to note that among preschool aged children, the ability to accurately identify alcoholic beverages simply by smell is directly related to the amount of alcohol consumed by the parents (Noll, Zucker, & Greenberg, 1990). This evidence indicates that an individual's socialization about alcohol begins with the family of origin, and begins at a very young age. Even very young children (aged 3-6 years) begin to formulate expectancies concerning the effects of alcohol, at an age when their primary socialization agents are family members (Zucker, et al., 1995), and expectancies may help to predict later drinking choices (Kushner, et al., 1995). Furthermore, alcoholic parents may present older children and adolescents with a set of norms that tolerate heavy drinking, as well as an absence of parental monitoring for drinking and other potentially harmful behaviors (Dawson, 2000; Rose, 1998; Waldron & Selsnick, 1998).
Alcohol Use Disorder Influences on Family
Drinking and family functioning are linked (Roberts & Linney, 2000), although the relationship may be causal, reciprocal, iterative, or incidental to other causes. There are several family problems that are likely to co-occur with an individual's alcohol abuse, including intimate partner violence, conflict and low relationship satisfaction, economic and legal vulnerability, and child risks. Communication in family systems that involve members with substance problems may be characterized as highly critical, involving considerable amounts of nagging, judgments, blame, complaints, and guilt (Reilly, 1992). Families of individuals with alcohol use disorders are often characterized by conflict, chaos, communication problems, unpredictability, inconsistencies in messages to children, breakdown in rituals and traditional family rules, emotional and physical abuse (Connors, Donovan, & DiClemente, 2001).
Alcohol problems are common among couples that present for relationship/marital therapy (Halford & Osgarby, 1993), and marital problems are common among those who present for alcohol treatement (O'Farrell & Birchler, 1987). Alcohol abuse affects couples' relationships in a variety of negative ways, including communication problems, increased conflict, nagging, poor sexual relations, and domestic violence (Connors, Donovan, & DiClemente, 2001). Individuals married to persons with alcohol use disorders have higher rates of psychological, stress-related medical problems, and greater use of medical care systems, than other individuals (Connors, Donovan, & DiClemente, 2001; Holder, 1998). There is great controversy over the concept of co-dependency in couples' alcohol-involved relationships. On one hand, there exists some literature describing the characteristics of co-dependency. On the other hand, there are research studies indicating that these characteristics are present in the vast majority of the population (up to 95%), and that there is an absence of evidence supporting the validity of a "diagnosis" of co-dependency (Fisher & Harrison, 2000).
Parenting functions performed by individuals who are alcohol-impaired may be characterized as inconsistent, unpredictable, and lacking in clear rules and limits (Reilly, 1992). Children of alcoholic parents frequently experience chaotic parenting and poor quality home environments during significant developmental periods (Blanton et al., 1997; Jacob & Leonard, 1994; Zucker et al., 1996). The children of alcoholic parents may be exposed to high levels of family conflict, as well (Moos & Billings, 1982; Webb & Baer, 1995). Parents with a history of substance abuse, compared to other parents, show lower constraint, control, harm avoidance and traditionalism in relation to their families (Elkins, McGue, Malone, & Iacono, 2004). In some cases, disturbances in parent-child relationships are not only exhibited in the dyad involving an alcoholic parent, but also in the dyad involving the other parent. For example, Eiden and Leonard (1996) observed disturbances in the mother-infant attachments among dyads where the father was a heavy drinker.
There is clear documentation of the cognitive impairments associated with chronic, heavy alcohol consumption, and it is important to consider the ways in which these types of impairments might affect the quality and nature of childcare and child rearing (Sher, 1991). There does seem to be an association between parental alcohol/drug related problems and the development of parenting practices in the grown up children. Among mothers, the effect on their parenting appears to be mediated by their own alcohol/drug problems; among fathers, the effect on their parenting appears to result from their own experiences of parental neglect in childhood, leading to a lack of parental warmth and more child neglect (Locke & Newcomb, 2004).
It is important to note that some of the parenting behaviors being described may be a response to behavioral problems among children, not only a cause of developmental problems. Children with difficult temperaments or conduct disorders present challenges that may contribute to poor parenting practices; if parental alcoholism is associated with these traits in offspring, it is not surprising that it is also associated with the observed differences in parenting (Gee & Cadoret, 1996). Also suggestive of this mutual influence model is the observation that interactions between boys and their mothers were more similar than dissimilar among alcoholic and non-alcoholic families, as long as the non-disruptive children were the ones being compared (Dobkin, Charelbois, & Tremblay, 1997).
Children of Alcoholics
"Of an estimated 28 million Americans who are children of alcoholics, nearly 11 million are under the age of 18" (Adger, 2000, p. 235). The risk estimates of children of alcoholics (COAs) developing an alcohol use disorder vary from 4:1 to 9:1 (Russell, 1990). The variability in estimates is attributable to differences in study sampling, definitions and criteria, and assessment strategies. For example, some COAs have a parent who is currently alcoholic, some have been exposed to a parent's alcoholism at some point in their lives, and still others have a parent (or parents) whose alcoholism predated their birth, but it may still have an impact on their development. Another way of looking at these individuals is to identify (1) children of current alcoholics, (2) children of parental period alcoholics, and (3) children of lifetime alcoholics-a parent who was ever an alcoholic (Eigen & Rowden, 2000). The distinction has important implications for epidemiological and assessment purposes.
In essence, children born to and living with a parent experiencing an alcohol use disorder are exposed to both biological and environmental forces that may contribute to developing alcohol problems themselves (Begun & Zweben, 1990). In addition to being at higher risk for developing alcohol problems of their own, children of alcoholics have higher rates of other challenges than do children of non-alcohol impaired parents-even as adults (Holder, 1998). Children of alcoholic parents may have behavioral and school difficulties, including negative self-concepts, fearfulness, loneliness, difficulties in concentrating, attendance, and work completion (Fisher & Harrison, 2000). Some of these difficulties may be attributed to chaotic home environments where basic needs are erratically met (sleep, food, hygiene, supervision). The environments experienced by adolescent sons and daughters of alcoholic parents tend to be characterized by greater stress than those of other adolescents (Chassin et al., 1996). Studies of the Children of Alcoholics Screening Test (CAST) indicate that the scores on this instrument are associated with greater degrees of family dysfunction and disruption, less family cohesion, less family support, inconsistent child care, increased family conflict, and less close/intimate parent-child relationships (Fisher & Harrison, 2000).
It is clear that tremendous heterogeneity exists among the population of children whose parent(s) have alcohol use disorders, although there is currently an incomplete understanding of this heterogeneity. It is not always clear how the developmental outcomes are affected by alcohol per se or by having experienced a stressful childhood environment (e.g., parental disability/mental illness, parents' divorce, parental death). A long-term Danish study of the developmental outcomes for the cohort of children born in 1966 demonstrated that a parent's alcohol abuse during childhood and adolescent years may affect increased mortality, self-destructive behaviors (suicide attempts, drug abuse), experiences of violence requiring hospitalization, teen pregnancy rates, and unemployment among young people in the 15-27 year age range (Christoffersen & Soothill, 2003). The pathway for influence appears to have been the ways in which a parent's alcohol abuse frames childhood experiences with parental violence, family separations, and foster care placements. Similar results were observed in a study of the impact of paternal alcohol abuse on child development outcomes conducted in Norway-the child adjustment difficulties result from an accumulation of risk factors, rather than being a direct effect of the parent's alcohol abuse itself (Haugland, 2003). The relevant risk factors include parental psychological problems, family climate, family health, family conflicts, severity of the alcohol abuse, the child's level of exposure to the alcohol abuse, and distortions or changes in family routines associated with the drinking behavior. It is not clear how these results translate to United States systems.
While it is clear that some risks exist for children growing up exposed to a parent's alcohol abuse, it is also clear that considerable amounts of resiliency also exist. For example, no significant problems are demonstrated by as many as 44% of adult children of alcoholics (D'Andrea, Fisher, & Harrison, 1994). Research suggests that there are multiple determinants of children's degree of vulnerability to adverse events: the nature of the event, the duration of the event, the dosage or intensity of the event, the presence of mitigating or compensatory factors in the environment, intrinsic and acquired resiliencies, interpretations of the events, and resources for coping with the events (Anthony & Cohler, 1987; Begun & Zweben, 1990; Berkowitz & Begun, 2003). Some children who exist within environments that appear to be high in risk for the development of a host of pathological outcomes appear to develop relatively unscathed, while others are harmed-this includes the diversity of children's responses to living with an alcoholic parent (Begun & Zweben, 1990; Werner, 1986; Werner & Smith, 1982).
A child living with an alcoholic parent may also be living with a non-alcoholic parent who may provide many of compensatory parenting functions. A supportive non-alcoholic parent or other caregiving adult (i.e., grandparent, aunt/uncle, elder mentor, adult friend) provides nurturance, protection, and guidance which optimize the development of a child with an alcoholic parent (Werner & Johnson, 2000). Resilient children of an alcoholic parent very often had a non-alcoholic mother/step-mother who served as the "mainstay" of the family-94% of daughters and 80% of sons leading successful adult lives, compared to only 60% and 33.3% respectively of daughters and sons who experienced coping problems. In short, if the child's home environment involved the presence of a functional, central, "buffering" parent, the negative developmental impact of a father's alcoholism was somewhat mitigated; children had more problems when their family lives did not include a person that could be described in this way.
The adolescents living in alcoholic families that are less likely to begin using substances (including alcohol) are those who perceive that they have control over their environment, have good cognitive coping skills, and report that their families are highly organized (Hussong & Chassin, 1997). Young adults from alcoholic families were less likely to report having drinking problems of their own if their families also managed to preserve rituals, structure, and daily routines (Hawkins, 1997). In short, the strength or disruption of the family appears to differentiate between children of alcoholics who experience greater or lesser degrees of well-being as adults, and drinking behavior and family functioning are strongly and reciprocally linked (Roberts & Linney, 2000).
Providing interventions, both preventive and treatment oriented, for children of alcoholics may be difficult and fraught with barriers (Morehouse, 2000). Some examples of barriers include: children (regardless of age) not wanting their parent to know that they are seeking help; children not having transportation or other access issues, including payment resources; fear, anxiety, lack of trust, embarrassment, and other emotional hurdles; parents minimizing the children's need or failing to provide consent; and, programs not being developmentally appropriate or appealing to this age group.
Fetal Alcohol Exposure
One significant source of risk associated with being the child of an alcoholic mother is the possibility of fetal exposure to alcohol or other substances. Fetal exposure to alcohol is associated with heightened probabilities for developmental delays, temperament difficulties, mental retardation, physical deformities, and neurological or other central nervous system vulnerabilities. There is tremendous variability in the expression of these consequences of fetal exposure. The variability is poorly understood and only partially explicable in terms of amounts of alcohol consumed and timing in fetal development when exposure occurs.
Alcohol research first used sibling studies to address the issue of heritability for alcohol problems. In addition to family pedigree and adoption studies, concordance in alcoholism patterns among monozygotic (identical) and dizygotic (fraternal) twin pairs were compared. The results indicate greater concordance (similarity) in the patterns for monozygotic twins than among dizygotic twins and other non-twin sibling pairs, indicating the presence of a genetic influence on the development of alcoholism (Kendler, et al., 1992; McGue, Pickens, & Svikis, 1992). The outcome, however, has a strong environmental influence-otherwise, the concordance among monozygotic twins would be close to 100% (Kendler, 1995).
Brothers and sisters are important environmental influences on many aspects of individual development. They act as agents for socialization-through modeling, delivery of reinforcement/punishment contingencies, reminding one another of rules, and shaping one another's developmental environments. In one study, it was observed that adopted children were significantly more likely to become drinkers if a sibling in their adoptive family consumed alcohol, and this influence was enhanced if the sibling was of the same gender and close in age to the adopted individual (McGue, Sharma, & Benson, 1996).
When an individual is a heavy drinker, that individual's family relationships often are distorted and dysfunctional-this includes relationships with brothers and sisters that may become distressed as a result of a complex of disruptive behaviors that may accompany heavy drinking (Stevenson & Lee, 2001). In some cases, siblings are role models for drug use and may be the ones providing access to substances (Epstein, Botvin, & Diaz, 1999; Epstein, Williams, & Botvin, 2002; Kaufman & Kaufman, 1992; Vakalahi, 2001). Structured support for siblings of adolescent substance abusers may help reduce the risk that they, too, will develop substance problems, as well as reducing other family and social challenges that cause them distress (Boyle, et al., 2001; Gregg & Toumbourou, 2003). On the other hand, siblings, particularly older supportive siblings/step-siblings/foster siblings, are frequently present in the lives of individuals who made good adaptation despite being the son or daughter of an alcoholic parent (Werner & Johnson, 2000).
Families and Recovery
Family members and family process may play a direct role in relapse during recovery, as family conflict and/or strong negative affect (e.g., anger aroused during conflict) may precipitate renewed drinking by abstinent alcoholics (Maisto, O'Farrell, Connors, McKay, & Pelcovits, 1988; Marlatt, 2004, oral presentation). On the other hand, the family may play an important role in facilitating alcohol treatment and recovery processes (Connors, Donovan, & CiClemente, 2001; McCrady, 1986, 1989). The integration of relapse prevention with couples counseling has been shown to be effective (Connors, Donovan, & DiClemente, 2001). Furthermore, family-based therapeutic interventions with adolescent substance abusers are proving more effective than individual or group therapy treatment approaches (Waldron & Slesnick, 1998).
Treatment of a substance abuser appears to have a preventive effect on the mental health and substance abuse risks among their children (O'Farrell & Feehan, 1999). Intervention goals with children of alcoholics are related to reducing their risk for developing alcohol problems of their own through identifying the dysfunctional behaviors that may be predisposing risks and assessing their risk (Fisher & Harrison, 2000). Social workers need to take into consideration the full gamut of vulnerability, risk, resilience, and protective factors expressed in a population in order to understand the heterogeneity in outcomes observed (Begun, 1993).
Family systems models hypothesize a series of homeostatic functions in families that have implications for the processes associated with an individual's recovery from alcohol problems. The underlying assumption is that an individual's maladaptive behavior (e.g., alcohol abuse) reflects dysfunction in the system as a whole (Van Wormer, 1995). As such, the alcohol abuse serves an "adaptive" function for the family system as a whole. For example, the family is allowed to divert its attention away from and to avoid even more threatening issues (e.g., a source of conflict that threatens the system's integrity as a whole) by attending to a member's drinking behavior. In this conceptualization, the drinking behavior transcends the individual and is relational, thus the relationships are a necessary focus of intervention (Waldron & Slesnick, (1998). These types of approaches are designed to address and restructure family interaction patterns that are associated with the alcohol abuse. As a result, the alcohol abuse is no longer "needed" by the family system for its survival.
In addition, some family systems authors have postulated that the family system adopts a host of "adaptive" responses to an individual's alcoholism-emotional repression, emotional walls and barriers, and other survival mechanisms. When the alcoholic family member stops drinking and attempts to re-engage with the family system, the system risks losing its hard-won sense of balance (equilibrium) that was established around the drinking and drinking individual (Brown & Lewis, 1999; Wegscheider, 1981). It is argued that these "adaptive" behaviors may become functionally maladaptive, and that the family system may fight to regain its equilibrium by encouraging a return to drinking or by refusing acceptance of the changed individual who attempts to re-engage or redefine his or her old roles. Interventions based on this model emphasize interactional elements among family members and family structures-redefining roles, explicating rules that direct family behavior, and redefining boundaries (O'Farrell & Fals-Stewart, 1999).
Behavioral Family Models are founded on the principles of social learning theory. The underlying assumption is that alcohol use disorders are acquired and maintained through interactions with the social environment. This includes observational learning (e.g., imitation of role models), operant learning (e.g., behaviors are enhanced or suppressed through reinforcing or punishing consequences), and the presence or absence of opportunities provided by the environment. In this framework, family is important in the development and maintenance of alcohol use disorders for several reasons (McCrady, 1989; Waldron & Slesnick, 1998):
Their behaviors can act as stimulus cues that trigger drinking responses;
Family members act as models for specific alcohol-related behaviors, as well as for more general coping strategies (e.g., observation of drinking to relieve stress).
The family may influence an individual's emotional and physical reactions which are associated with vulnerability to alcohol abuse;
Their responses can act to reinforce or punish efforts at sobriety, abstinence, or reduction of alcohol use
Family members may interfere with the individual experiencing the negative consequences of drinking, and this shielding encourages perpetuation of the drinking.
Models of behavioral family treatment (including Behavioral Marital Therapy, BMT) encourage family members to address the ways in which they can facilitate recovery by providing positively reinforcing responses for behaviors that are incompatible with drinking, removing responses that might be encouraging drinking behavior, and attending to features in the environmental context that encourage drinking. There may be additional components to specific approaches, such as behavioral family therapy to encourage the alcohol abusing family member to enter into treatment or to comply with treatment regimens (e.g., taking medication). BMT addresses the many ways in which an individual's substance abuse affects family process and marital relationships (e.g., communication, conflict, poor sexual relations, violence).
The Family Disease Model suggests that alcohol use disorders are not only diseases affecting an individual, they affect other family members, as well. The model indicates that the disease is manifested in other family members in terms of phenomena such as anxiety, enmeshment and other dysfunctional relationships, low self-esteem, and "co-dependence" (O'Farrell & Fals-Stewart, 1999). Co-dependence, according to this model, is a complementary or parallel disease to alcoholism, exhibited by the alcoholic's significant others. The codependent person presumably exhibits a number of symptoms associated with the disease (e.g., issues about control, perfectionism, "frozen" feelings/emotional blunting, and external referencing), and engages in "enabling" behaviors. Enabling is described as behaviors that perpetuate another person's substance use-for example, protecting the person from experiencing the natural consequences of substance use that might have led to deterrence in the future; making access easier; covering up for the other person's drinking. Treatment approaches formulated around this model do not address the individual's substance use directly, but encourage the significant others to heal themselves from their own disease and recover from the impact that the drinking has had on their lives. The family members are encouraged to detach themselves from the other's drinking, reduce their own emotional distress, and improve their own coping and functioning. There exists little in the way of empirical support for this model (O'Farrell & Fals-Stewart, 1999) that underlies the Al-Anon program.
Readiness to Change within a family system may proceed in a manner that closely parallels the change process for an individual (Connors, Donovan, & DiClemente, 2001). Families that minimize the drinking problem of an individual member are reflecting a process parallel to the individual who is in the precontemplation phase in stages of change concerning an alcohol use disorder. The tendency is to deny that the problem exists, or to acknowledge that drinking is a problem, but to minimize its significance and severity. This precontemplation phase is also generally characterized by a sense of helplessness to change the situation-poor self-efficacy.
As the family becomes increasingly exposed to and aware of the negative consequences associated with the drinking, family members or the family as a whole may shift into the next stage in the process of change: contemplation. Families in this stage evaluate the situation, considering the ways in which the drinking makes the family vulnerable-children and adolescents may be experiencing difficulties with behavior and school, the partner or spouse finds relationship problems with the alcohol abuser to be less and less tolerable. At this point, the family becomes convinced that something must change in the system, but they have not yet made a concrete commitment to specific change actions. In preparation for change, the family has begun to take some small steps toward change of the situation, and has a "near future" timeline for implementing change. This is a point in which the family is likely to be seeking help alternatives and information about treatment options, and may also be considering the pros and cons of other alternatives to life with an alcohol abuser.
One or more of the family members may become increasingly concerned and may begin to explore popular or professional literature, the local phone directories, Internet websites, substance abuse help-lines, as well as consulting friends, clergy, or health care professionals in an attempt to gain information to help them better understand substance use and dependence and to direct them toward possible treatment options. (Thomas et al, 1987, p. 151)
When a family takes specific, notable steps to change the situation, it is said to have entered into the action phase of the change process. Different families settle on different action plans, and a single family may adopt multiple strategies. During this phase of the change process, it is important that action steps be reinforced and supported if change is to proceed. Otherwise, the family may fall back to its earlier ways of thinking, believing, and behaving about the alcohol abuse, in response to the pain, difficulty, and resistance associate with the change process. Thus, whether or not the individual with the alcohol use disorder seeks help, the family system needs support. When the alcohol abuser does seek help, the family needs assistance in seeking and achieving stable, abstinent relationships, and ultimately, in maintaining long-term recovery and relapse prevention.
There exists a convincing body of literature indicating that marital and family intervention approaches are more successful in substance abuse treatment than individual intervention alone (O'Farrell, 1992; O'Farrell & Fals-Stewart, 1999; Stanton & Shadish, 1997; Waldron & Slesnick, 1998). More specifically, evidence indicates that there is benefit associated with including focus on an individual's "real world" interpersonal relationships as a fundamental component of intervention efforts (Borovec & Whisman, 1996). Family intervention is associated with better compliance and better treatment outcomes for individuals with alcohol use disorders (McCrady & Epstein, 1996; O'Farrell & Fals-Stewart, 1999). Most recent studies of family intervention approaches involve out-patient treatment (Allen & Litten, 1999).
Family members, as significant others (SOs), play an important role in treatment outcomes. Alcohol treatment outcomes are more significant in situations of positive marital adjustment (Moos, Finney, & Cronkite, 1990). There is little doubt that the significant others in a person's life can actively encourage the individual to maintain problematic behaviors like excessive drinking. However, it is also important to note that involving a "supportive significant other" (SSO) in the process of therapy concerning substance problems is associated with improved retention and more favorable intervention outcomes (Miller & Heather, 1998; Zweben & Pearlman, 1983). O'Farrell (1995) reports that the involvement of spouses or significant others in behavioral couples therapy is associated with improved treatment engagement and reduced drinking behavior compared to individual therapy.
The "significant others" in a person's life can have a great influence on the individual's motivation for change-including a spouse, intimate partner, other family member, or friend (Burke, Vassilev, Kantchelov, & Zweben, 2002; Hasin, 1994). Motivation to change is positively affected by individuals in a person's environment who express concern, offer help, and reinforce the negative consequences of the problem-in a non-demanding way (Miller & Rollnick, 1991). In addition to legal consequences, pressure from family members and significant others is a powerful route to treatment and engagement (Stanton, 1997). Proper involvement of a significant other in the intervention process can help in identifying barriers and solutions, as well as providing corroborating or contrary information about what happens outside of the treatment setting (Burke, Vassilev, Kantchelov, & Zweben, 2002). These individuals can facilitate implementation of change strategies, promote self-efficacy, motivate, help recognize triggers, and act as an "early warning system" for relapse. There is some evidence that these individuals can help improve treatment compliance for alcohol medication regimes, as well, although this evidence is somewhat conflicted when different studies are compared to one another (O'Farrell, 1995).
Project MATCH results (a multi-year, multi-site controlled comparison study of different treatment approaches) indicate an interactive effect on treatment outcomes between the type of intervention modality and social support networks. Twelve-step facilitation (TSP) was found to be more efficacious than Motivational Enhancement Therapy (MET) among clients whose natural social networks supported and reinforced drinking behavior. MET was better than TSP, however, among clients whose social networks were determined to be low support for drinking (Project MATCH, 1997a, 1997b, 1998a). This project also found that individuals, in describing the factor most helpful in maintaining their motivation to change, most often identified spousal support as helping them transition from the action to maintenance stage of recovery (Project Match, 1997a). As noted by Burke, Vassileve, Kantchelov, & Zweben (2002), these findings are consistent with the results of other treatment outcome and natural recovery studies. For example, a relatively short, structured series of family therapy and "significant others" intervention sessions was associated with no difference in drinking outcomes among individuals who have high levels of social support for abstinence, but with distinctly improved outcomes for individuals with low levels of support for abstinence (Longabaugh, Beattie, Noel, Stout, & Malloy, 1993). The addition of a specific couples based Relapse Prevention (RP) training program (CALM-2) at the conclusion of a behavioral marital therapy program is associated with better long-term outcomes than behavioral marital therapy alone (O'Farrell, Choquette, Cutter, Brown, & McCourt, 1993; O'Farrell, 1995)-this is especially true for couples experiencing severe relationship problems.
O'Farrell (1995) summarizes a set of factors that predict acceptance and completion of marital and family therapy by alcoholics. Among the factors are: couple living together, or if separated, are willing to reconcile for the duration of treatment; couple enters treatment following a relationship-threatening crisis; other family members (including the partner) do not have alcoholism; the alcoholic and other family members are without serious psychopathology or other drug abuse; and an absence of family violence that has produced serious injury or is potentially life threatening. These factors are important because in order for treatment to be effective, the alcoholic must be retained in treatment and must participate in the process. McCrady, Epstein, and Hirsch (1999) have demonstrated that alcohol-focused behavioral couples therapy (ABCT) results in greater post-treatment marital happiness, fewer incidents of marital separation, and fewer incidents of domestic violence than general family systems approaches (also see NIAAA's "Alcohol Problems in Intimate Relationships: Identification and Intervention-A Guide for Marriage and Family Therapists," February, 2003).
In situations where both partners in a couple have a similar problem (e.g., both have problems with alcohol), there exists a clear advantage to working with them simultaneously (Allsop & Saunders, 1991). Furthermore, it is important to make control of the alcohol abuse the first priority in working with couples, rather than beginning with the marital relationship, because recurrent alcohol-related incidents and interactions undermine therapeutic relationship gains.
Many of our clients have had previous unsuccessful experiences with therapists who saw the couple in MFT without dealing with the alcohol abuse. The hope that reduction in marital or family distress will lead to improvement in the drinking problem rarely is fulfilled. (O'Farrell, 1995, p. 196).
Once the alcohol issues have come under some degree of control, it is important to begin addressing the family problems caused by drinking (e.g., legal problems, income and financial security issues, housing problems, and issues affecting the family's interactions with the social world), as well as other family issues that may have been overshadowed or obscured by the alcohol problems (O'Farrell, 1995).
In order for a significant other to be supportive of the change process, it may be necessary to address (1) his or her difficulties arising from attempting to cope with the partner's alcohol problems and (2) his or her ambivalence about changing behaviors that contribute to the target individual maintaining the drinking behavior, and (3) means of developing a consensus between the partners about the goals of treatment (Burke et al., 2002). Involvement of the significant other may be counterproductive if this individual is overwhelmed, overly angry and resentful, and/or uncommitted to change (Longabaugh, et al., 1993). Training the significant other may be especially important in situations where the alcoholic is not yet contemplating change and this individual can help move the person into treatment.
The Community Reinforcement Training (CRT) approach is based on an assumption that shifts in the patterns of reinforcement and contingencies can be used to change an alcohol abuser's behavior. The Community Reinforcement and Family Training program (CRAFT) engages family in the process, as well as providing family and supportive significant others with skills for self-protection from intimate partner violence, means of encouraging sobriety, abilities to encourage professional help-seeking, and knowledge of how to support the therapeutic process (Sisson & Azrin, 1986, 1993). In a small sample study, CRT (compared to standard treatment controls) was associated with an average 50% reduction in drinking prior to entering treatment and almost total abstinence during the three months after entering treatment; 6 of 7 alcoholic partners entered treatment compared to none of the 5 control group individuals (whose alcohol consumption did not change during the 3 months period).
In a similar vein, the Unilateral Family Therapy approach (Thomas & Ager, 1993) provides support and attempts to increase the well-being and functioning of individuals engaged in relationships with substance abusers. This approach prepares nonalcoholic partners with their own coping mechanisms, skills to enhance family functioning (e.g., reducing nagging and other forms of negative communication), and ways to facilitate sobriety (including treatment entry) on the part of the alcohol abusing partner. Unilateral Family Therapy (UFT) was associated with significantly greater chances that alcoholics will enter into treatment and/or reduce their drinking in small sample study (Thomas et al., 1987).
A more coercive approach, termed The Johnson Institute Intervention, involves training family and significant others to confront an alcohol abuser, request that he or she seek treatment, and impose consequences for not seeking help. The goal of this program is treatment engagement by the alcohol abuser. The approach is controversial (on practical and ethical bases), and there is limited evidence of effectiveness with the widely diverse population of individuals with alcohol use disorders (Connors, Donovan, & DiClemente, 2001).
Another approach which relies on Al-Anon concepts (i.e., detaching oneself from the other's drinking, accepting that they are powerless to control the alcoholic partner) prepares partners to cope with their own emotional distress and motivations for change, rather than attempting to motivate the alcoholic partner to change (Dittrich, 1993; Dittrich & Traphold, 1984). While it is not clear that the intervention is associated with changes in the drinking individual, there have been persistent improvements in some qualities among the supported partners. And, while there is not a base of controlled research concerning Al-Anon outcomes, there have been studies suggesting that Al-Anon members use fewer ineffective means of coping with the drinking (O'Farrell, 1995).
Controlled, randomized clinical trials are beginning to shape a picture of what is effective in family intervention. One such study compared the CRAFT, Al-Anon, and Johnson Institute Intervention approaches for effectiveness in getting an alcohol abuser into treatment. The highest overall treatment rate for the alcoholic family members was associated with the CRAFT therapy (64%). The vast majority of families in the Johnson Institute condition chose not to complete the intervention; 70% failed to follow-up with the critical confrontation session. Since the Al-Anon facilitation is not designed for engaging the alcoholic in treatment, it is not surprising that this was not a common outcome (Miller, Meyers, & Tonigan, 1999).
The bulk of the controlled clinical research trials that include a family component in alcohol treatment examine adults with partners, and possibly the children of adult alcohol abusers. However, it is also important to consider the role of family and significant others in the treatment of adolescents who struggle with alcohol problems (Brown, Myers, Mott, & Vik, 1994). For example, Integrated Family and Cognitive Behavioral Therapy demonstrated effectiveness on several outcome variables when used with adolescents meeting criteria for alcohol and marijuana use disorders (Latimer, Winters, D'Zurilla & Nichols, 2003). Similarly, Multidimensional Family Therapy resulted in better risk reduction and protection promoting processes than peer group therapy with adolescents referred to treatment for substance abuse and behavioral problems (Liddle, et al., 2004). This type of family based, multi-system, and developmentally oriented intervention targets the functioning of adolescents and their parents across multiple systems and a variety of known risk/protective factors.
It is also important to consider that the most important significant others in an individual's life may not be the most obvious ones-it may not be the spouse, it may be an adult's parent or grandparent, child, or best friend. Not only do these individuals have important contributions to offer in the assessment process, creating an accurate picture of the individual's "relational functions" involving them is often an important aspect of the overall assessment process, as well (Waldron & Slesnick, 1998).
There is evidence that identifies several potential barriers to effective family intervention with substance abuse. The first of these is a potential for violence occurring in the family. Where an acute risk of severe violence exists (violence that may result in serious injury or is life-threatening), the immediate intervention goals must be altered to prioritize safety, safety planning, and conflict containment (O'Farrell & Fals-Stewart, 1999). In these situations, it is recommended to treat the individuals separately (Murphy & O'Farrell, 1996). In some cases there may be legal restrictions in place (i.e., court orders, restraining orders, no contact orders) that preclude conjoint family sessions. A second major barrier is the presence of more than one actively substance abusing family member in the family-particularly if these individuals are partners in consumption. Another demonstrated barrier is the existence of high levels of blame and rumination from family members (usually the partner) toward the substance abusing individual. There may also exist practical barriers to social work intervention from a family perspective-for example, geographical distances; family members who are deceased, divorced, mission, incarcerated or otherwise separated; coordination of family members' schedules and child care responsibilities; securing reimbursement for services delivered to multiple individuals. Finally, social workers should attend to the outcomes emerging from recent large-scale, multi-service, service integration and coordination studies with women on welfare who experience problems with alcohol or other substances, compounded by risks for child protective services involvement and domestic violence (e.g., CASA WORKS for families, or TANF-MATE in Milwaukee, Wisconsin).
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Source: National Institute on Alcohol Abuse and Alcoholism
Adapted from Social Work Curriculum on Alcohol Use Disorders Module 10J
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