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Alcohol and the FamilyAlcohol and the Family

NIAAA Social Work NIAAA Social Work EducationEducation

Module 10JModule 10J(revised 8/04)

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OutlineOutline

BackgroundBackgroundFamily SystemsFamily SystemsFamily Influences on Alcohol Use Family Influences on Alcohol Use

DisordersDisordersAlcohol Use Disorder Influences Alcohol Use Disorder Influences

on Familyon FamilyFamilies and RecoveryFamilies and Recovery

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BackgroundBackground

Approximately 17.6 Approximately 17.6 million American million American adults abuse alcohol adults abuse alcohol or are alcohol or are alcohol dependentdependent

Approximately 1 in 4 Approximately 1 in 4 children is exposed to children is exposed to effects of alcohol effects of alcohol abuse or dependence abuse or dependence in a family memberin a family member

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Background (continued)Background (continued)

““Family” is relevant Family” is relevant because:because:

Alcohol may influence Alcohol may influence family functioningfamily functioning

Family functioning Family functioning affects alcohol affects alcohol use/abuseuse/abuse

Alcohol use disorders Alcohol use disorders “run in families”“run in families”

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Background (continued)Background (continued)

Family takes many Family takes many diverse formsdiverse forms– NuclearNuclear– Single parent motherSingle parent mother– Single parent fatherSingle parent father– Ex- and Step- Ex- and Step-

relationsrelations– Grandparent, Grandparent,

Aunt/Uncle as parentAunt/Uncle as parent– Foster familiesFoster families– And others….And others….

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Background (continued)Background (continued)

Family and family functions are Family and family functions are defined differently in different defined differently in different culturescultures– ““Blood” relativesBlood” relatives– Legal bonds (marriage, adoption)Legal bonds (marriage, adoption)– Kin (extended family, multiple Kin (extended family, multiple

generations, close friends as kin)generations, close friends as kin)

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Background (continued)Background (continued)

Family roles, rules, values about Family roles, rules, values about interdependence and relations, interdependence and relations, support systems vary by culturesupport systems vary by culture

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Family SystemsFamily Systems

Family systems are Family systems are dynamic, changing dynamic, changing over time as: over time as: membership membership changes, individuals changes, individuals change, change, relationships relationships change, context change, context changeschanges

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Family Systems Family Systems (continued)(continued)

1 Family system is more than sum of Family system is more than sum of partsparts– InteractionsInteractions– DynamicsDynamics– RulesRules– RolesRoles– BoundariesBoundaries– PatternsPatterns– Circularity of influence between Circularity of influence between

individuals and wholeindividuals and whole

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Family Systems Family Systems (continued)(continued)

2 Change in part of a system affects Change in part of a system affects the entire systemthe entire system– Developmental change of individualDevelopmental change of individual– Loss of member (death, divorce, Loss of member (death, divorce,

runaway, incarceration, cut offs)runaway, incarceration, cut offs)– Gain new membersGain new members– Shift in a relationshipShift in a relationship

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Family Systems Family Systems (continued)(continued)

3 Subsystems are embedded and Subsystems are embedded and operate in larger systemoperate in larger system

CoupleCouple

Parent-childParent-child

SiblingSibling

Extended familyExtended family

Gender dynamics, etc.Gender dynamics, etc.

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Family Systems Family Systems (continued)(continued)

4 Families exist within a larger social Families exist within a larger social environment contextenvironment context

family

extended family

neighborhood

church

School/workplace

Legal system

Health/Mental Health services

Human servicesSociety

History

friends

Ethnic/cultural systems

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Family Systems Family Systems (continued)(continued)

5 Families are multigenerationalFamilies are multigenerational

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Family Systems Family Systems (continued)(continued) CHANGE = STRESSCHANGE = STRESS

– All changes: positive, negativeAll changes: positive, negative– Change requires adaptive energy, Change requires adaptive energy,

adjustment requires resourcesadjustment requires resources– Systems resist change (systems seek and Systems resist change (systems seek and

preserve homeostasis, equilibrium, preserve homeostasis, equilibrium, balance)balance)

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Family Systems Family Systems (continued)(continued)

Points of difficulty between Points of difficulty between individual in recovery and family individual in recovery and family system:system:– Person tries to regain roles, Person tries to regain roles,

positions in family system positions in family system (decisions, authority, sex, (decisions, authority, sex, intimacy, other reciprocal intimacy, other reciprocal exchanges)exchanges)

– Difficulties in parent-child relations Difficulties in parent-child relations (discipline, communication)(discipline, communication)

– Developmental changes, family Developmental changes, family life cycle transitions, situation life cycle transitions, situation changeschanges

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Family Systems Family Systems (continued)(continued) Conclusions: Family is a Conclusions: Family is a

context for an individual’s context for an individual’s drinking problems—may drinking problems—may play a role in emergence play a role in emergence and maintenance of the and maintenance of the alcohol use disorder, may alcohol use disorder, may also play a role in treatment also play a role in treatment and recovery processes; and recovery processes; family remains relevant to family remains relevant to individualsindividuals

17Family Influences on Family Influences on Alcohol Use Disorders: Alcohol Use Disorders: GeneticsGenetics

Genetics matter in risk and Genetics matter in risk and resilienceresilience– Family pedigree studies (4-7 Family pedigree studies (4-7

x risk for 1x risk for 100 relatives) relatives)– Adoption studiesAdoption studies

Physiological aspects of Physiological aspects of alcohol use disorders appear alcohol use disorders appear to have considerable to have considerable heritabilityheritability

Genetics alone do not explain Genetics alone do not explain outcomes—not deterministicoutcomes—not deterministic

18Family Influences on Alcohol Family Influences on Alcohol Use Disorders: Genetics Use Disorders: Genetics (continued)(continued)

Genetic factors interact with other biological Genetic factors interact with other biological and environmental context factorsand environmental context factors

GGeneticsenetics x x BBiologyiology x x EEnvironmentnvironment=O=Outcomeutcome

Some factors are risk/vulnerability factorsSome factors are risk/vulnerability factors Some factors are protective/resilience factorsSome factors are protective/resilience factors Genetics explain vulnerability, environment Genetics explain vulnerability, environment

contributes to emergence or expressioncontributes to emergence or expression

19Family Influences on Alcohol Family Influences on Alcohol Use Disorders: Genetics Use Disorders: Genetics (continued)(continued) Specific pathways are Specific pathways are

becoming better becoming better understoodunderstood– E.g., differences in E.g., differences in

physiological physiological responses and responses and sensitivity to alcoholsensitivity to alcohol

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Family Influences on Alcohol Family Influences on Alcohol Use Disorders: Family ContextUse Disorders: Family Context

““Individuals reared with an Individuals reared with an alcohol-abusing parent are alcohol-abusing parent are at risk for developing at risk for developing alcohol problems due both alcohol problems due both to genetic factors and to to genetic factors and to faulty role modeling” faulty role modeling” (O’Farrell, 1995)(O’Farrell, 1995)

Some effects are direct, Some effects are direct, others are indirect effects others are indirect effects (e.g., child temperament or (e.g., child temperament or hyperreactivity to stress)hyperreactivity to stress)

21Family Influences on Alcohol Family Influences on Alcohol Use Disorders: Family Context Use Disorders: Family Context (continued)(continued) Exposure to key antecedants Exposure to key antecedants

to heavy drinking episodes:to heavy drinking episodes:– Family argumentsFamily arguments– Poor family communicationPoor family communication– Inadequate family problem Inadequate family problem

solvingsolving– Nagging at homeNagging at home

Exposure to key consequences Exposure to key consequences for heavy drinking episodesfor heavy drinking episodes– Deliver reinforcementDeliver reinforcement– Remove negative consequencesRemove negative consequences

22Family Influences on Alcohol Family Influences on Alcohol Use Disorders: Family Context Use Disorders: Family Context (continued)(continued)

Exposure to a parent’s alcohol Exposure to a parent’s alcohol use disorder mayuse disorder may::– Result in easy access to alcohol by Result in easy access to alcohol by

children, adolescents, young adultschildren, adolescents, young adults– Establish norms of tolerating heavy Establish norms of tolerating heavy

alcohol use by family membersalcohol use by family members– Result in poor/absent parental Result in poor/absent parental

monitoring of alcohol use by monitoring of alcohol use by children, adolescents, young adultschildren, adolescents, young adults

– Lead to development of risky Lead to development of risky “alcohol expectancies” early in life“alcohol expectancies” early in life

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Alcohol Use Disorder Alcohol Use Disorder Influences on FamilyInfluences on Family Relationship of alcohol abuse to other Relationship of alcohol abuse to other

family problems may be:family problems may be:

Causal A BCausal A B

Reciprocal A BReciprocal A B

Iterative Iterative AA BB AA BB A B A B

Incidental to other causes A BIncidental to other causes A B

CC

24Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: CouplesCouples Alcohol Use Disorders affect Alcohol Use Disorders affect

couples’couples’

CommunicationCommunication

Conflict levels increasedConflict levels increased

NaggingNagging

Poor sexual relationsPoor sexual relations

Domestic violenceDomestic violence

Partner stressPartner stress

25Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: Parent-Child RelationsParent-Child Relations Parenting practices can be Parenting practices can be

affected by alcohol use affected by alcohol use disordersdisorders

Family life may be chaotic, Family life may be chaotic, involve poor quality involve poor quality environments when parents environments when parents have alcohol use disordershave alcohol use disorders

Children’s exposure to Children’s exposure to conflict is common when conflict is common when parents have alcohol use parents have alcohol use disordersdisorders

26Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: Parent-Child (continued)Parent-Child (continued)

27Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: Children of AlcoholicsChildren of Alcoholics

children of current alcoholics

children of parental period alcoholics

children of lifetime alcoholics

28Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: Children (continued)Children (continued)

filterin

g

influences

29Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: Children (continued)Children (continued) Resilience factors Resilience factors

also act as filters also act as filters that help shape that help shape the the developmental developmental impact of impact of parental alcohol parental alcohol use disordersuse disorders

30Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: Children (continued)Children (continued) Preventive and treatment Preventive and treatment

interventions for children of interventions for children of alcoholic parents face barriers:alcoholic parents face barriers:Children having access, transportationChildren having access, transportation

Payment, resourcesPayment, resources

Fear, anxiety, embarrassment, trust, Fear, anxiety, embarrassment, trust, other emotional hurdles of childrenother emotional hurdles of children

Parent’s minimization and no consentParent’s minimization and no consent

Developmental appropriateness of Developmental appropriateness of programprogram

31Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: Children (continued)Children (continued) Fetal alcohol exposure Fetal alcohol exposure

concerns are important concerns are important considerations with considerations with regard to alcohol use regard to alcohol use disorders and their disorders and their potential impact on potential impact on children children

32Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: SiblingsSiblings

Sibling research helps address Sibling research helps address heritability questions—there is a heritability questions—there is a genetic influence combined with genetic influence combined with an environmental influencean environmental influence

Siblings act as agents of Siblings act as agents of socialization through:socialization through:ModelingModelingReinforcement/punishmentReinforcement/punishmentRule enforcementRule enforcementShaping developmental Shaping developmental environmentsenvironments

33Alcohol Use Disorder Alcohol Use Disorder Influences on Family: Influences on Family: Siblings (continued)Siblings (continued)

A person’s drinking can A person’s drinking can affect relationships with affect relationships with brothers and sistersbrothers and sisters

Siblings may be role models Siblings may be role models for each others’ drinking for each others’ drinking behaviorbehavior

Siblings may be a source of Siblings may be a source of access to substances like access to substances like alcoholalcohol

Structured sibling support Structured sibling support interventions may helpinterventions may help

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Families and RecoveryFamilies and Recovery

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Families and Recovery Families and Recovery (continued)(continued)

Family Systems Models:Family Systems Models: family homeostatic functions family homeostatic functions preserve balance for system preserve balance for system as a whole, regardless of as a whole, regardless of “cost” to individual members“cost” to individual members

Individual’s alcohol use Individual’s alcohol use disorder “serves” a family disorder “serves” a family “stabilizing” function and “stabilizing” function and system maintains the system maintains the behavior to prevent changebehavior to prevent change

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Families and Recovery Families and Recovery (continued)(continued)

Behavioral Family Models:Behavioral Family Models: based on social learning theory, based on social learning theory, alcohol use disorders are learned alcohol use disorders are learned and maintained through interaction and maintained through interaction with social environmentwith social environmentObservational learningObservational learningOperant learningOperant learningPresence/absence of Presence/absence of opportunitiesopportunities

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Families and Recovery Families and Recovery (continued)(continued)

Family can affect recovery if Family can affect recovery if they:they:

Provide drinking stimuli/cues (-)Provide drinking stimuli/cues (-) Model drinking (-) or other Model drinking (-) or other

“coping strategies” (+)“coping strategies” (+) Influence vulnerability (+ or -)Influence vulnerability (+ or -) Reinforce or punish sobriety Reinforce or punish sobriety

efforts (+, -)efforts (+, -) Prevent negative consequences Prevent negative consequences

from being experienced (-)from being experienced (-)

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Families and Recovery Families and Recovery (continued)(continued)

Family Disease Model: Family Disease Model: Alcohol use disorders Alcohol use disorders represent diseases that represent diseases that affect both individuals and affect both individuals and the family the family

Treatment from this Treatment from this approach helps family approach helps family members heal themselvesmembers heal themselves

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Families and Recovery Families and Recovery (continued)(continued)

Family “Readiness to Change” Family “Readiness to Change” parallels individual change parallels individual change processprocess

PrecontemplationPrecontemplation

ContemplationContemplation

PreparationPreparation

ActionAction

MaintenanceMaintenance

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Families and Recovery Families and Recovery (continued)(continued)

Interventions involving Interventions involving family and “significant family and “significant others” are more others” are more effective (better effective (better compliance, better compliance, better outcomes) than treating outcomes) than treating individuals with alcohol individuals with alcohol use disorders in isolationuse disorders in isolation

SSO=supportive SSO=supportive significant othersignificant other

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Families and Recovery Families and Recovery (continued)(continued)

Relative effectiveness of Relative effectiveness of intervention type interacts with intervention type interacts with nature of the social support nature of the social support networks (e.g., family at home)networks (e.g., family at home)

MET>TSP if low support for MET>TSP if low support for drinking, TSP>MET if support for drinking, TSP>MET if support for drinking in social networkdrinking in social network

SO intervention and family SO intervention and family therapy improves outcome for therapy improves outcome for individuals with low abstinence individuals with low abstinence supportsupport

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Families and Recovery Families and Recovery (continued)(continued)

Factors affecting family therapy Factors affecting family therapy acceptance by alcoholics:acceptance by alcoholics:Couple lives together or Couple lives together or reconciling if separatedreconciling if separatedCouple enters treatment after Couple enters treatment after relationship threatenedrelationship threatenedOnly one person has alcohol use Only one person has alcohol use disorder; others do not have disorder; others do not have serious mental health problemsserious mental health problemsNo family violence problemNo family violence problem

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Families and Recovery Families and Recovery (continued)(continued)

When both partners have When both partners have alcohol use disorder, alcohol use disorder, advantages gained by working advantages gained by working simultaneouslysimultaneously

In all couples, priority should In all couples, priority should be addressing alcohol abuse be addressing alcohol abuse before relationship work, then before relationship work, then address family problems address family problems caused by alcoholcaused by alcohol

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Families and Recovery Families and Recovery (continued)(continued)

Most important “significant others” Most important “significant others” might not be the most obviousmight not be the most obvious

For a particular individual, it might be:For a particular individual, it might be:ParentParent

PartnerPartner

FriendFriend

GrandparentGrandparent

Sibling, cousinSibling, cousin

Son/daughterSon/daughter

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Families and Recovery Families and Recovery (continued)(continued)

Barriers to family intervention Barriers to family intervention with alcohol use disorders:with alcohol use disorders:Potential for violence/safety Potential for violence/safety risksrisksLegal restrictions Legal restrictions More than one family member More than one family member actively abusing substancesactively abusing substancesHigh blame levelsHigh blame levelsPractical barriers (geography, Practical barriers (geography, separations, schedules, child separations, schedules, child care, reimbursement)care, reimbursement)