Addiction isn’t a spectator sport, eventually the whole family gets to play
One of the things that still haunts me, years into recovery, is the memory of the impact of my addictive behaviour on others – particularly those I love but also my colleagues. There was plenty of suffering to go round, the debris spread far and wide. In some ways the cleaning up operation has never quite concluded.
This experience of ‘collateral damage’ is true for most of us who have experienced addiction, yet research is relatively restricted on the phenomenon, despite the fact that the impact on third parties may be as great (or greater) than the impact on the person with the substance use disorder.
It was interesting then to read a study from Germany, published in the journal Addiction, which looked at the impact of addictive disorders on family members and how this affected their health and mood. Previous studies have shown that relatives can have increased problems with mental health, injuries, higher use of healthcare services and loss of productivity and that these negative consequences are improved by abstinence.
This was a big study involving almost 25,000 people living in Germany. The researchers wanted to get a feel for the proportion of family members impacted in the general population and how severe those impacts were. In this representative sample of people 15 and older, they found that almost 10% of individuals had a relative with an ongoing addictive disorder problem in the last year. A further 4.5% reported that they had a relative with a past dependency. They found that alcohol was by far the most common drug causing problems (80%), followed by cannabis (16%) and other illicit drugs (12%).
Family members affected by addictive disorders had higher levels of depression (doubled) and lower levels of self-rated health. Family members also had higher rates of smoking and risky or binge drinking. There was the suggestion of some good news though relating to the impact of recovery from dependence:
Findings suggest a strong association between the recency of the addictive disorders and ill-health and depression and correspond to the results of analyses from the United States based on health insurance data, which suggest that the psychosocial burden on partners of males with an alcohol use disorder decreases after successful treatment.”Bischof and colleagues, 2022
I fear we do not pay attention enough to this in our research and practice even though Government Policy in Scotland emphasises the needs and role of family when we consider how we deliver treatment. The recently published final report of the Drugs Deaths Task Force recommended the adoption of a whole family approach and that families should have their own specific support for wellbeing and psychological health.
When families are not considered as part of an evaluation of the impact of treatment, we are missing something very important. Recovery may or may not include abstinence, but measures of recovery progress ought to include the positive gains family members and loved ones make as the individual with a substance use disorder recovers. How well do the families of the people in alcohol and drug treatment in Scotland fare?
A few years ago when I was part of a group supporting the production of the Independent Expert Review of Opioid Replacement Therapies in Scotland, I had an opportunity to take evidence from family members of those with substance use disorders members attending a national conference. It was a bruising experience. Families were not happy with the care on offer at the time.
At the end of the session, although I had gathered a wealth of evidence for feedback, I was left feeling responsible for all of the sins of the treatment system. It was not easy to hear the experiences of people who felt they had let down. The message was clear, family members felt excluded from treatment decisions, did not generally support opioid substitution (though they liked buprenorphine more than methadone) and felt stigma stopped them coming forward.
“The needs of the relatives, friends, co-workers and communities affected by the drinking of people in their social networks are seldom voiced, counted or responded to.”
Brian Coon, writing on this blog last year, picked up some themes that are relevant to this. Commenting on a paper that showed improvements in those with alcohol use disorder who cut back on their drinking but continued to drink heavily – arguably a kind of recovery – he references Kelly and Bergman who point out that heavy drinking can continue to impact on families and that their needs have to be taken into account.
Brian highlights the danger of separating research data from experience. If we are too narrow in our exploration we will not see other things that are important. We are not islands, we are connected into rich social networks, including our family members. Our behaviours affect others. A finely focussed microscope is a limited tool when the big picture is what matters.
Classifying someone as being in successful “recovery” due to the fact that they appear to be functioning but while engaging in very heavy drinking, ignores the potential collateral damage to close significant others (eg, children, partners), whose well-being can be severely impacted by the enduring unpredictability of heavy use. – John F Kelly, Brandon G Bergman
Of course, family members’ recovery ought not to be dependent on the recovery of their loved one. In the residential rehab service I work in, we have a family programme running alongside the patient programme. This is aimed at supporting the families of those we treat. While most people in the treatment programme will go on to complete it and most of those who complete it will find sustained recovery, we have the philosophy that the wellbeing of the family members is not contingent on how well their loved one does – that families can improve their emotional and physical health by mutual support and self-care regardless.
Families can also be supported through mutual aid groups like AlAnon and via local and national support groups. I think the therapeutic effect of family members coming together and supporting each other is very powerful – perhaps more so than one to one support.
In Scotland, the national organisation, Scottish Families Affected by Drugs and Alcohol captures this ethos in their impact report. I’ll finish with a quote from it because I can’t say it better than they do.
“Being able to enjoy a relaxed family meal, ignoring your phone for a while, giving yourself permission to go for a walk or meet a friend for a coffee, or joining a class or a group for the first time are all huge steps for family members. Their everyday lives have been wholly shaped and controlled by their loved one’s alcohol or drug use, often over many years.
Working with families to learn new ways to communicate and interact, be confident in setting boundaries, prioritise self-care, and understand more about substance use and recovery really does change lives and save lives.”
Amen to that.
Continue the discussion: @DocDavidM
Picture credit: Oatawa istockphoto, under license
 Bischof G, Bischof A, Velleman R, Orford J, Kuhnert R, Allen J, Borgward S, Rumpf HJ. Prevalence and self-rated health and depression of family members affected by addictive disorders: results of a nation-wide cross-sectional study. Addiction. 2022 May 31. doi: 10.1111/add.15960. Epub ahead of print. PMID: 35638375.
 Kelly JF, Bergman BG. A Bridge Too Far: Individuals With Regular and Increasing Very Heavy Alcohol Consumption Cannot be Considered as Maintaining “Recovery” Due to Toxicity and Intoxication-related Risks. J Addict Med. 2020 Oct 14. doi: 10.1097/ADM.0000000000000759. Epub ahead of print. PMID: 33060467.
3 thoughts on “Addiction: the whole family gets to play”
“This experience of ‘collateral damage’ is true for most of us who have experienced addiction, yet research is relatively restricted on the phenomenon, despite the fact that the impact on third parties may be as great (or greater) than the impact on the person with the substance use disorder.”
Well, David, this topic is very central to my thinking.
From the position of the disorder, outward to the world, there is no “collateral” damage. Damage is damage. The person using is damaged, the person 4 feet away is damaged, and so forth.
Thus, in my opinion, we must see recovery like that – from the position of the disorder, out to the world. The person who had been using needs to recover, true enough. But considered from the position of the disorder out to the world, others must be considered when considering recovery.
Without that consideration the damage that happened to those other people lingers. And without that consideration recovery itself can ironically cause unnecessary side effects or even damage. Recovery that is self-centered or not wholistic or nested in the disorder can cause damage when it focuses on isolated improvements without regard for the whole and for others. Those damages are the ironic damages others experience while the one person “recovers”.
A different way to get to my idea about addiction from the vantage point of a wholistic location, and then also recovery from a wholistic location, is here:
Here’s another piece on this same concern, David. You have touched on a truly central portion of my thinking.
Hi Brian. I did post a response but I see it didn’t get through. I agree with you, ‘collateral’ doesn’t feel the right word. In treatment settings, we are often looking at a small part of the whole picture (this is true across much of healthcare). We let people down when we don’t see them in the context of the family system. Thanks for your thoughtful response and the links.
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