Summary: Yes, when viewed through the lens of family systems theory, addiction is a family disease. When one family member has an addiction disorder, it can create a dysfunctional family system wherein each family member plays a role that contributes to the ongoing disease of addiction in that individual.
Key Points:
- Family systems theory developed in the 1940s and 1950s as a way to understand human behavior.
- Family systems theory identifies the family as a single entity: an emotionally, behaviorally, and psychologically connected unit.
- In a family system, the actions of one family member affect all family members, and the collective actions of all family members affect each individual family member.
- Applying family systems theory to family therapy in addiction treatment leads to improved outcomes for the individual with the addiction disorder and for the entire family.
Addiction and the Family
We won’t sugar coat this at all:
In families where one person has a severe addiction problem – the disease of addiction – other members of the family may develop dysfunctional roles in response to the disease.
This appears as dysfunction upon dysfunction. The dysfunctional behavior of the individual with the addiction disorder/disease leads to dysfunctional behavior in the rest of the family unit.
Unfortunately, this is a feature of families with a family member with and addiction disorder, rather than a bug.
We often see this in families when one member has alcohol addiction, a.k.a. alcohol use disorder (AUD). In response to the behavior of the addicted family member, each person in the family adapts their behavior to maintain the homeostasis, or balance, to which they’ve become accustomed. Over time, the family itself – in addition to the individual with addiction – develops dysfunctional patterns of behavior that are self-perpetuating and mutually reinforcing.
These patterns promote, rather than deter, addictive behavior in the individual with the addiction disorder.
When we encounter an addiction-dysfunctional family system, one of the most difficult things we have to say to family members is this:
Yes, your [son, daughter, husband, wife, partner] is the one who drinks, but your behavior is also part of the problem. Yes, they must change. However, if you don’t change, too, it reduces the likelihood your loved one will achieve a successful recovery, and that your family will find a new, healthy resting state.
We’ll also be clear about something else:
No one does this on purpose.
Families develop these mechanisms in response to addictive behavior because they’re part of a system in which each part affects the whole and the whole affects each part. They evolve and adapt to the conditions before them, because that’s how natural systems work, and that’s how humans grow and develop. We’re never in a vacuum. We’re always part of a web of interconnected relationships, the first and most formative one being our family.
Families and Addiction: How Family Systems Theory Helps
The benefit of understanding family systems theory is that providers and families can leverage and apply this understanding to improve treatment outcomes for individuals and families impacted by addiction.
In the Treatment Improvement Protocol 39 (TIP 39), “Substance Use Disorder Treatment and Family Therapy” published by the Substance Abuse and Mental Health Services Administration (SAMHSA), addiction treatment experts identify an approach to families impacted by addiction/substance disorder developed by clinical psychologist Sharon Wegscheider-Cruse.
Here’s the essence of the Wegscheider-Cruse theory:
Substance use disorder (addiction) is a progressive family disease affecting every member and every facet of life.
In an addiction-dysfunctional family system, the members, in the interests of their own survival, assume behavioral patterns that maintain a balance.
When one member becomes dependent on a substance, it affects the others, causing psychological and/or biological symptoms. As the member who uses substances becomes progressively more dysfunctional, so does the rest of the family.
What we observe in the families we support aligns with this theory. We see it in various forms and different manifestations, but they all have one thing in common: addiction can change the entire family in a negative way, and to heal, key members of the family must participate in the healing process.
An important step in the healing process is identifying the roles that each family member assumes over time, and by default, in an addiction-dysfunctional family.
The Common Roles When Addiction is a Family Disease
The Wegscheider-Cruse theory proposes that to maintain homeostasis, family members adapt and evolve into one of six basic roles: the user, the enabler, the hero, the scapegoat, the lost child, and the mascot.
Note on the role the user: in this context, we’ll use the word user for person with substance use disorder for the sake of brevity. It’s important to understand that this is the role that person inhabits in the family. They are not entirely and only a user. In the context of the addiction-enabled family, that identity and role dominates the family, and is a role they must vacate in order to heal.
Now we’ll list the core characteristics each of these roles, as defined in the SAMHSA TIP introduced above.
User:
- This is the person with the addiction disorder.
- They become the center of attention and the focus of family life.
- Their emotional and behavioral dysfunction triggers the dysfunction that develops in the rest of the family.
- They accept and rely on the ongoing dysfunction of the rest of the family to facilitate their behavior.
Enabler:
- This person protects the user from the negative consequences of addiction on a personal and family level
- In many families, they’re the primary caretaker/primary caregiver.
- They shield the user from the consequences of addiction in the world as well, attempting to fix things or cover for the user at school, at work, and in relationships and situations outside the family.
- They sacrifice their own needs and wellbeing to care for the user.
Hero:
- In many cases, a role adopted by the oldest child: the overachieving perfectionist.
- Often takes on excess responsibility and excels in many areas in an attempt to make themselves and the family look good or normal from the outside.
- Takes it upon themselves to maintain what they understand as family stability.
- Concerned with family reputation.
- Often internalize strong feelings of shame, guilt, and responsibility around the user in their family.
Scapegoat:
- Often a younger sibling who takes the blame for the problems in the family.
- Engages in rebellious behavior, acts out, gets in trouble, causes other problems in order to draw attention from the behavior of the user.
- Often experiments with substances as well and may misuse substances.
- May also internalize feelings of shame and guilt, may develop long-term difficulties with school, work, and relationships.
Lost Child:
- Retreats from family as a coping mechanism.
- Achievements and value often overlooked by rest of family.
- Feels invisible and neglected.
- May cope with isolation by living in their own world.
- Often becomes self-sufficient early on but also may develop profound sense of loneliness and isolation.
Mascot:
- Adapts to a role of using humor to defuse, distract, or divert attention from painful or difficult family issues, i.e., the consequences of addiction triggered by the person with addiction.
- Often develops charming and gregarious characteristics, becomes the life of the party.
- Avoids conflict and tries to keep everyone happy and laughing.
- May not be taken seriously by rest of family.
- Often develops deep insecurity, which can have a negative impact on long-term mental health.
When we engage a family in family addiction therapy and share these roles with them – almost without fail – lightbulbs flash over heads. Family members recognize themselves in these roles and understand they need to change. It takes longer for some than others, with many family members realizing that although they’re not the person with the addiction problem, addiction has caused very real problems for them and how they function in the family – and they need to do work to heal.
Helping Families Heal: The Value of Family Systems Therapy
While these family roles can develop around any addiction disorder, we can often see them most clearly in families dealing with alcohol addiction. When alcohol addiction goes untreated, the family can experience significant distress and harm. The SAMHSA resource we cite above identifies the following consequences of untreated alcohol addiction on families:
The Impact of Alcohol Addiction on Families
- Communication problems
- Regular and consistent conflict
- Chaotic, disorganized home environment
- Absence of healthy family rituals
- Shifting, shaky family rules
- Breakdown of family norms
- Unclear and undefined boundaries
- Increased risk of maltreatment, neglect, and abuse
In contrast, when a person with alcohol addiction commits to treatment, and the family participates in family therapy, outcomes can improve. The SAMHSA resource we cite above identifies the following benefits of family participation in treatment:
How Family Participation in Addiction Treatment Helps
- Outcomes for the person with addiction improve:
- Reduced alcohol use
- Rates of relapse decrease
- Vocational, academic, and social function improves
- Outcomes for families improve:
- Communication between family members becomes healthy and productive
- Frequency and intensity of conflict decreases
- Emotionality/emotional volatility decreases
It’s also important to mention that when a family commits to treatment at the outset, meaning the family members without addiction, the person with the addiction disorder is more likely to follow up on their commitment, follow through with treatment, and make real progress during treatment.
Finally, when family members can recognize they also need to heal, that they’ve developed maladaptive patterns that impair their personal wellbeing, and that their healing is related to the overall family dynamic and the type and quality of their relationships, the entire family can move forward, into recovery, on a healing journey, together.
