A brain-imaging study of the family members of people with alcohol use disorder

A colleague in the field sent me a 2024 paper titled, “Family Members’ Reward-Based Activation in Response to an AUD Loved-One” published in the journal called Contemporary Family Therapy. The full citation is below.

That colleague suggested a blog post be written about this paper. So, this post is both a “topic from the field” and a “research article review”.

I wasn’t even half-way through reading the abstract before I was super happy I had the chance to read this paper. Why was I so happy? Because this study used brain imaging techniques to look at the family members that live with someone who has an active alcohol use disorder.

To me, this area of research is vital, the body of literature reviewed in this paper is important for our field, and the findings of this particular study are fascinating. For an expanded view of this kind of topic, consider reading my post about the birth of a new child happening inside an alcoholic family, and the fractures and other defects in the system the birth of that child can help cause. (We normally think of so-called birth defects happening in the child, not the family system).

But in this post, I’ll briefly cover some sections of the article I was sent and share my thoughts along the way.

Abstract

The authors state,

Family members of a loved-one with an alcohol use disorder (AUD) experience much stress and other adverse impacts, especially those that are frontline caregivers and therefore most proximal to AUD

And,

Previous research has shown such family members experience altered functioning of the prefrontal cortex in response to images of their loved-one, and these responses have similarities to brain responses to alcohol cues for a person with AUD

The authors continue by saying,

The current study aimed to expand this research by examining whole-brain functional activation of family members’ brains. Functional magnetic resonance imaging (fMRI) was used to measure activation responses of 10 family members with a loved-one with diagnosed AUD, as well as that of 10 control group participants…

It is no surprise to me that family members display the collateral damage of this illness, but it is very interesting to note that here we see specific damage etched within their brain function.

I blogged “WHERE Is Addiction?” and argued that the literal physical location of addiction illness is not only inside the skull of the one with the SUD, not only in their essence as a person, and not only in their developmental history. And also not only found within those in combination.
Rather, I argued that based on my decades of clinical work I am of the opinion that the SUD is located or nested in a space that comprises those elements AND the nexus of the patient’s social system. That is, I argued that addiction has a location that is beyond the user only.
To me, the findings of this research study would seem to support my notion about the central “location” of the illness being beyond the limit of the user only.

Further, I have written elsewhere about Marc Galanter’s 2014 paper within which he: listed the functional components of working a personal program in AA, operationally defined each functional component by the use of formal psychological terms, and listed the associated brain region for each. I described the framework he provided as a landmark change in our field’s research agenda because it turns brain science and brain imaging measures in the direction of recovery.

Here in this paper we have that same approach starting to be extended to family members and the whole family system. And such an approach brings much potential.

Introduction

In the Introduction section, the authors report on existing research describing the evaluation of

…reactivity to affective cues – and more specifically to images of a loved-one with a substance use disorder…” showing “…important alterations of functioning in cortical regions of the prefrontal cortex…

They continue by stating

…research has not yet examined potential associations between such affective images and whole brain activation responses….” And thus, “In the context of AUD as a family disease, the current study examines whole brain activation responses to images of a loved one seeking recovery from AUD, for significantly impacted family members

In doing so the authors use the phrase, “Frontline and proximal” to describe these key family members and note this phrase,

…refers to those family members who are most heavily participating in the observation and care of their loved-one. In many ways, these family members often serve as ‘informal caregivers’ (Tambling et al., 2022, p. 341) and as such are under duress, exceedingly stressed, and experience fear and anxiety related to the wellbeing – and in some cases even the survival – of their AUD loved-one

They continue by saying,

Such stress, especially if chronic, may lead to interactions between stress and reward systems in the brain that result in functional and potentially even structural changes in the brain…

And the authors hypothesize that these changes might be similar to those found in the brain of the drinker.

They clarify their hypothesis and tie it to AUD specifically by stating,

In the context of AUD as a family disease, we argue that a similar allostatic process of the stress and reward systems may occur for impacted family members. More recently, ‘codependency’ of family members of those with AUD has been considered a behavioral addiction associated with brain alterations

In my opinion the authors thus provide both an empirical target and empirical method for the exploration of the harms resulting from the stress, trauma, and providing of help that family members of those with alcoholism experience. And in that way, they both widen and clarify the meaning of healing for the SUD patient, and open the door to exploration of healing specifically for family members. (And frankly, as it pertains to witnesses and helpers, this might help with our problem of clinical burnout and clinician retention in our entire SUD arena).

Interestingly, they highlight a body of previous fMRI studies of family members of AUD patients that show a “saliency bias” in favor of the drinker. And they note that the results of these fMRI studies resemble the craving and preoccupation for alcohol found in the problematic drinker.

That is, people with AUD show a fMRI reaction to pictures of alcohol. And that same reaction as shown in fMRI is also found in family members when shown pictures of the drinker.
The authors then describe changes in neural structure and neural function that underlie what is observed to be, and described, as “codependency”.

The paper then moves to the Method and Results sections. Those sections are rather technical. So I’ll skip those and comment next on the Discussion section.

Discussion

The authors note,

Family members often feel bewildered and frustrated as to why they engage in behaviors at the cost of the wellbeing of themselves, their AUD loved-one (despite their intention to be helpful), and all other family members. This phenomenon is magnified for informal caregivers (Tambling et al., 2022) who are immersed in the experience, most often parents and spouses (D’Aniello et al., 2022; Russell et al., 2023), who seem to develop an obsessive need to protect, save and promote the survival of their loved-one

Frankly, I applaud this research agenda for many reasons.
But I can’t help noticing that children living in the home are not specifically mentioned here as caregivers – while they all too often are.

Summarizing the study and its findings, the authors note,

Regarding hypothesis one and activation in reward regions of the brain, significant activation was found in the left hippocampus and left amygdala…with extreme caution given the preliminary nature of the results of the current study and small sample size, we could interpret this activation to be associated with a craving-like response in the brain of family members that is triggered by cues of their AUD loved-one

And,

Support was also found regarding hypothesis two. That is, greater activation was found in the left hippocampus and left amygdala for the AUD family group than for the control group….These results merit discussion about hemispheric specialization in the brain, and in particular the left amygdala and left hippocampus

The authors go on to summarize the relevance of these findings in the context of:

The broad area of the specialization of brain function according to brain hemisphere;
The approach vs avoidance of the loved one with AUD, based on specific brain hemisphere differences in reward pathway activation (lateralization of function) of the family member;
Expectancies of reward based on “approach” – aimed at helping the one with the AUD

The paper concludes with a robust section about clinical implications of these findings and directions for continued research. And I’ll also say the article covers much more content in each section than I have discussed here, and is well worth a full read.

Some final thoughts of my own

For me the research path put forward by this article puts us in a position where:

We can no longer discard the ideas inside the term “codependency”. And the opportunity for construct validation rooted in empirical brain science comes to mind.
We can no longer limit the location and kind of problem we face with the drinker to only being inside the skull or inside the personal experience of the person with the AUD.
We can widen our consideration of slogans such as “nothing about us without us” to include the children of alcoholics, and their significant others – when studying alcoholism.
We can improve our education and training programs and methods to include engagement, persuasion, and stabilization of the family members as an early entrance or starting point for the problem of AUD. (And it occurs to me that this is precisely what Bob Myers trained us to do in his consultation with us in my former workplace on the model called Community Reinforcement Approach and Family Training/CRAFT).
We can ensure Harm Reduction approaches consider the goals and objectives prioritized by the stakeholders living in the home of the one with the active SUD (such as the children and significant other of the one using substances).
We can answer the question, “Should we include a moral dimension?” with the word, “Yes”.