A recently published study examines the experience of family members affected by addiction. A recently published study examines the experience of family members affected by addiction.
Why study family members affected by addiction? Because they experience many harms1:
AUD harms the physical, emotional, and mental health of people and their affected family members (AFMs). Research shows AFMs are at high risk for abuse and neglect (Gruber & Taylor, 2006; Lipari & Van Horn, 2017), intimate partner violence (McCrady & Flanagan, 2021), and financial challenges (Orford et al., 2013). Further, AFMs experience strained sleep and fatigue, increased substance use, over- or undereating, diminished mental health, and increased physical illnesses (Orford et al., 2010). AFMs are affected by societal addiction stigma (Corrigan et al., 2006), which can lead to an underuse of community support resources (McDonagh et al., 2019).
What harm(s) was the study focused on? Something referred to as “ambiguous loss.” Specifically, psychological ambiguous loss. What’s that? Here’s how the paper describes it (emphasis mine)1:
Dr. Pauline Boss’s theory defines ambiguous loss as “an unclear loss that defies closure” (Boss, 2006, p. 17). Specifically, physical ambiguous loss involves a family member who is physically gone and psychologically present (e.g., abductions and immigration). Psychological ambiguous loss involves a family member who is physically present and psychologically gone (e.g., dementia and severe mental illnesses; Boss, 2006).
The study explored the impact of psychological flexibility on family member distress and tolerance for ambiguous loss.
Boundary ambiguity accompanies ambiguous loss and is defined as “a state in which family members are uncertain in their perceptions of who is in or out of the family and who is performing what roles and tasks within that system.”2
What is psychological flexibility? Here’s how it was described by the developers of the tool used to measure it3:
…psychological flexibility has been conceptualized as a number of key ways individuals can alter the function of internal experiences by flexibly responding to negative thoughts, feelings, and events, thereby enhancing their well-being. Psychological flexibility helps individuals open up to those experiences, allowing them to be there, while still making behavioral choices in service of the areas of their life that are important to them.
It sounds like a fuzzy concept because there are 12 dimensions to psychological flexibility and inflexibility. (More on that here.)
What did they find?
First, “psychological flexibility served as a protective factor for distress, yet a risk factor for resilience.”1
Second, “psychological inflexibility served as a risk factor in terms of distress, yet a protective factor in terms of resilience. This finding suggests that affected family members who exhibit avoidance, rigid thinking, and non-values-based actions experience high distress, yet paradoxically develop a greater capacity for ambiguity, enhancing their resilience.”1
Third, “increased boundary ambiguity served as a risk factor for distress, yet a protective factor for resilience. AFMs may develop a greater capacity to tolerate ambiguity as they increasingly navigate uncertain family roles. These findings illustrate the complexity of AFMs’ psychological processes and subsequent experiences of distress versus resilience.”1
What are the author’s explanations for the findings?1
…these findings suggest that affected family members (AFMs) may avoid and shut down (i.e., become psychologically inflexible) to survive the ambiguity of AUD in their families, just like trauma survivors. Orford et al. (2010) claimed that when AFMs withdraw from families, it leads to better outcomes for them. Perhaps psychological inflexibility supports AFMs’ resilience because detaching from their family is likely contrary to their values, but it enables them to survive their ambiguous loss situations. Their distress grows, as does their capacity to cope with it, by way of avoidance, distraction, and withdrawal from their family members.
What does this mean for family members affected by addiction?
Family members are often caught in a conflict between values directing them to support and maintain engagement with addicted family members and a recognition that this ongoing support and engagement comes at a personal cost of increased emotional distress.
This study validates that experiential knowledge.
One response to boundary ambiguity is to establish clearer boundaries (either deliberately and explicitly, or unconsciously and implicitly) that may result in disengagement with the person with addiction and a family life that is organized around addiction. That detachment, while difficult, can reduce distress.
Additional thoughts
Given these findings, one would hope that researchers, advocates, and treatment professionals might be a little less likely to pathologize family members who choose to establish such boundaries.
“Psychologically inflexible” could be a neutral descriptor, but it can also take on negative valence when associated with terms like “avoidance, rigid thinking, and non-values-based actions.” Further, the dissonance families experience often relates to conflicting values. It’s not simply a matter of choosing between non-values-based actions and values-based actions; it’s often a matter of choosing which values will guide actions and under what conditions. Indeed, some of the distress family members experience stems from maintaining engagement and support in ways that unmoor them from certain values and role obligations.
It’s easy to imagine that both psychological flexibility and inflexibility are called for in different circumstances.
Finally, the participants in the study were characterized as “adult family members of loved ones with Alcohol Use Disorders (AUD).” Readers of this blog will know that this tells us little about the kinds of alcohol problems participants were affected by. Alcohol Use Disorders as a diagnostic category can include a very broad range of severity and chronicity, with radically different courses and arrays of appropriate interventions.
- Hernandez Navarro, G., & Fickling, M. (2026). Resilience Amidst Ambiguity: Considerations for Family Members Affected by Alcohol Use Disorders. Alcoholism Treatment Quarterly, 44(3), 288–297. https://doi.org/10.1080/07347324.2025.2601679 ↩︎
- Boss, P., Caron, W., Horbal, J., & Mortimer, J. (1990). Predictors of depression in caregivers of dementia patients: Boundary ambiguity and mastery. Family Process, 29, 245–254. https://doi.org/10.1111/j.1545-5300.1990.00245.x ↩︎
- Rolffs, J. L., Rogge, R. D., & Wilson, K. G. (2016). Disentangling Components of Flexibility via the Hexaflex Model Development and Validation of the Multidimensional Psychological Flexibility Inventory (MPFI). Assessment, 25(4), 458–482. https://doi.org/10.1177/1073191116645905. ↩︎
