Codependency and enabling seldom occur together

Chapter 10 Family Systems and Chemical Dependency

Catherine A. Hawkins

Texas State University-San Marcos

Raymond C. Hawkins, II

Fielding Graduate University

Previous chapters indicate that alcoholism and other drug addictions frequently impair an individual’s physical, psychological, and social functioning. There is also recognition that alcoholism and other drug addictions adversely affect the individual’s marital and family relationships. In a Gallup poll, more than a third of respondents reported that drinking had caused problems in their family (Newport, 1999). Another Gallup poll based on interviews with 902 U.S. adults with an immediate family member with a drug or alcohol addiction reported that the family member’s addiction had a negative effect on their own mental health (70 percent of respondents) and their relationship with other family members (51 percent) (Saad, 2006). These negative effects are far-reaching, given the prevalence of parental alcoholism. “It can conservatively be estimated that approximately 1 in every 4(28.6 percent) children in the United States is exposed to alcohol abuse or dependence in the family” (Grant, 2000, p. 114).

Defining alcoholism at the family level lacks specificity, despite its intuitive appeal. Many terms in the literature attempt to capture this phenomenon, such as family disease, alcoholic family, addicted or chemically dependent family, alcohol impaired family, or family with an alcoholic member. An understanding of the family dynamics associated with alcoholism or other drug addiction must entail descriptions of interactive processes that occur throughout the life cycle of the family. In addition, family is a term that is no longer clearly defined in society. The material presented here applies to all forms of families, including nuclear, extended, single-parent, communal, kinship, and gay/lesbian.

This chapter examines some of the more noteworthy efforts to specify the etiology and treatment of the family processes associated with chemical dependency. The term alcoholism will be used, although theoretically, much of the scholarly literature can be reasonably generalized to other drug addiction. The literature on a family perspective of chemical dependency, including the theory, research, and treatment of alcoholism and other drug addiction in families, is discussed. Three dominant theoretical approaches—behavioral, stress coping, and family systems—are presented. The constructs of codependency, children of alcoholics, and adult children of alcoholics are explored as they relate to family dynamics. The ways in which theory shapes practice with chemically dependent family systems are addressed along with more specific treatment information. Finally, a case example is presented that illustrates some of the main concepts discussed in this chapter.

A Family Perspective in Theory, Research, and Treatment

During the early decades of the twentieth century, a scientific tradition emerged in the social sciences. The study of alcoholism, however, was restrained by the moral overtones attached to the problem, which led to the belief that alcoholism was not amenable to scientific inquiry. The growing Temperance Movement culminated in the Prohibition amendment in 1919. Attempts at treatment of alcoholism (which were almost exclusively directed at men) consisted largely of removing the individual to a residential program for detoxification and some therapy, known euphemistically as “the cure.” In Alcoholics Anonymous, Bill W., a founder of Alcoholics Anonymous (AA), describes his “rehabilitation” as belladonna treatment, hydrotherapy, and mild exercise (AA, 1939).

In the 1930s, the disease or biological model of alcoholism began to gain acceptance. AA, founded in 1935, embraced this model. Although AA was originally oriented toward men, wives would hold meetings modeled after AA to discuss the effects of alcoholism on their lives. (Lois W., Bill W.’s wife, is credited with organizing the first meeting.) At this same time, psychoanalysis was growing in popularity, and it explained alcoholism in terms of psychopathology. Both these models were limited to an examination of the etiology of alcoholism in the individual. Psychoanalysts acknowledged the impact of family dynamics on psychopathology, and they had some interest in the family aspects of alcoholism, but they looked at psychopathology in terms of each individual partner rather than their interaction (Lewis, 1937). Psychoanalytic practice wisdom prohibited the involvement of family members in therapy with the alcoholic, as this was believed to contaminate the therapeutic transference. Another development of the 1930s was the emergence of the fields of marital therapy and child guidance, with their focus on interpersonal relationships. However, early practitioners used a collaborative approach in which separate therapists would meet with family members, and then the therapists would consult with each other on their treatment session (Goldenberg & Goldenberg, 2008).

Theory and research on alcoholism grew through the 1940s and 1950s but continued to be limited to a study of its physiological and emotional effects on the individual (predominantly middle-aged Anglo males), such as the seminal work by Jellinek (1960). Even the conceptualizations of alcoholism in the marital dyad maintained an individual focus (Billings, Kessler, Gomberg, & Weiner, 1979; Finney, Moos, Cronkite, & Gamble, 1983). For example, the distressed personality model, rooted in psychoanalysis, held that underlying psychopathology in the wife led to the development and maintenance of a drinking problem in the husband (Futterman, 1953; Kalashian, 1959; Price, 1945). Alternatively, the stress personality model, which applied to both genders, viewed personality disturbance in the spouse as resulting from the chronic stress in the home generated by the alcoholic (Jackson, 1954).

In the 1940s, the concurrent approach to marital and family therapy began to emerge. In this model, one counselor would work with a couple but would meet with them separately (Goldenberg & Goldenberg, 2008). One of the first attempts to include families in treatment involved concurrent group therapy for alcoholics and their wives (Ewing, Long, & Wenzel, 1961; Gliedman, Rosenthal, Frank, & Nash, 1956). These early programs demonstrated that involving spouses increased the completion rate of treatment and expanded the criteria of successful outcome to include both partners’ psychosocial functioning as well as abstinence by the alcoholic (Steinglass, Bennett, Wolin, & Reiss, 1987). By 1948, the support groups organized by the wives of AA members had become a formal network called Al-Anon Family Groups, targeting spouses of both genders. (For a description of the Al-Anon program, see Albon [1974], Kurtz [1994], and Keinz, Schwartz, Trench, & Houlihan [1995].) In 1957, Alateen was formed for teenage children of alcoholics, and later, Alatot groups were developed for younger children. By the late 1950s, the conjoint approach to marital and family therapy was introduced, in which one counselor would meet with couples and families as a unit (Goldenberg & Goldenberg, 2008).

In the 1960s, as social science moved away from a strictly individual perspective and began to consider the influences of the environment, a third model for conceptualizing alcoholism in the marital dyad emerged. The psychosocial model integrated the distressed personality and stress personality models (Bailey, 1961). It focused on the consequences of the alcoholic’s drinking behavior and the spouse’s coping style on both the marital partners. Through the 1960s, the rise of systems theory and behavioral theory led to a broader perspective that focused on the interactive, reciprocal nature of family processes. Although conjoint family therapy developed during this time, family treatment for alcoholism continued to consist of a concurrent program for nonalcoholic spouses (i.e., wives). This was attributed to the general ignorance of alcoholism by family therapists, who often failed to identify this problem or considered it secondary to other problems. When alcoholism was recognized as a problem, family therapists frequently referred these families to alcoholism treatment programs, where alcoholism was viewed as an individual disease (Steinglass, 1987). Alcoholism counselors reportedly avoided a family perspective due to lack of training or a belief that it was incompatible with the disease model.

This situation gradually changed during the 1970s and 1980s. Today, some type of family involvement is often included in most alcoholism treatment programs. There is considerable variation across programs, however, ranging from “family night” to full-fledged family therapy. At the same time, both the self-help and clinical movements recognize that family members have problems in their own right due to the dynamics of alcoholism. This led to such concepts as codependency, children of alcoholics, and adult children of alcoholics. According to Seilhamer and Jacob (1990), Western cultures have long recognized the detrimental impact of parental alcoholism on children. However, there was little interest in these children until the first publications identifying the clinical implications of being raised by an alcoholic parent began to appear (Ackerman, 1986; Bosma, 1972; Cork, 1969; Slobada, 1974). This was soon followed by an awareness of the impact of parental alcoholism on the adult functioning of offspring (the Adult Children of Alcoholics or ACOA movement). Being the child of an ACOA (i.e., grandchild of an alcoholic), whether the parent is alcoholic or not, also has a potentially negative impact, since alcoholism can affect families for several generations (Smith, 1988; Stein, Newcomb, & Bentler, 1993). As a result, self-help and advocacy groups (such as the National Association for Children of Alcoholics) have emerged. ACOA support groups originally began in the 1970s under the auspices of Al-Anon. Over the next few years, independent ACOA groups developed, and Co-dependents Anonymous (CODA) groups were also established.

Since the 1990s, with the advent of behavioral managed care, cost containment has affected substance abuse treatment. For example, Platt, Widman, Lidz, Rubenstein, and Thompson (1998) conducted a review of the research literature on support services, including family therapy, as an adjunct to substance abuse treatment. The authors found that despite clear evidence of the need for support services to increase treatment effectiveness, clients often do not receive these services through their health care provider or get adequate referrals to other agencies. Steinglass (2006) and Corless, Mirza, and Steinglass (2009) critique the impact of managed behavioral health care on systemic medicine and call for the family therapy field to more directly address substance misuse.

The scholarly literature on family treatment includes studies in which the alcoholic is typically a parent, spouse, or child. As described elsewhere in this book, there is a long-standing tradition of using a family perspective with adolescents, although empirical studies in which the chemically dependent person is a woman or a member of a racial or ethnic minority group are limited. There is an emerging literature on family treatment in which the alcoholic family member is elderly, mentally ill, or gay/lesbian.

Theories on Alcoholism and the Family

Chapter 2 covered many theories regarding the etiology and treatment of alcoholism. At one extreme is a strict medical model, also known as the disease model, focused on individual biological factors with virtually no consideration of familial, social, or psychological variables. At the other extreme is a strict family systems model, focused on the family as a unit, with little consideration of the individual as distinct from the family. In the middle are theories that address, to varying degrees, both the individual and the familial aspects of dysfunction, such as behavioral and stress coping models. The difference between these various theories can be quite confusing, even to a person familiar with the chemical dependency field. This section will discuss the three predominant models that address alcoholism at the family level: behavioral, stress coping, and family systems.

Family systems theory evolved in the 1950s as an outgrowth of general systems theory, which emerged in biology in the 1940s. This theory represented an epistemological shift from a reductionist, linear (cause and effect) way of thinking to one of circular causality, process orientation, and the interrelatedness of parts. The crux of systems theory, as applied to people, holds that addiction, like any other human behavior, exists in a larger context. However, the family is viewed not merely as the context for an individual’s behavior but also as an entity unto itself. Rather than expressing individual pathology, the presence of problematic behavior (such as alcoholism) in a family member is considered a symptom of underlying dysfunction in the system. The alcoholic is referred to as the identified patient to indicate that it is the system itself that is dysfunctional. Rather than identifying the effects of alcoholism on the individual members of the family, a family systems approach focuses on the individuals and the interactions among them. The structure and dynamics of the family are assessed, and intervention is planned, through applying systems concepts such as homeostasis, boundaries, triangles, and feedback. (See any basic family therapy text, such as Nichols [2009], for a discussion of these concepts.)

The behavioral and stress-coping models first developed as theories of individual behavior but now incorporate a systems perspective. They recognize that relationships among the family members are interrelated and reciprocal and that the individual both influences and is influenced by other family members. In turn, the family exists as part of the larger social system that affects both individual and family functioning. However, these models differ from family systems theory in that the family is generally seen more as a context for individual behavior than as an entity unto itself. Although all three theories share a social systems orientation, the term family systems is used here specifically in reference to that particular theoretical orientation, even though the term is often used more broadly in the literature. Further, it should be noted that most family systems intervention models actually treat the family as a closed system, rather than focusing on the family’s interactions with the larger environment.

Family Systems Theory of Alcoholism and the Family

This section focuses on family systems theory, especially three significant areas of family systems literature on alcoholism: rituals and routines, shame, and rules and roles. A discussion of the behavioral and stress-coping models is presented later in the section on assessment and treatment.

Two criticisms of family systems theory should be noted. First, some critics claim that it is largely descriptive, non-scientific, imprecise, and virtually untestable. However, its defenders consider such criticisms to be irrelevant, since the main value of systems theory is not as a traditional scientific model but as a fundamentally different approach to the conceptualization of clinical problems and therapeutic interventions. Second, feminist theory contends that there is a gender bias in family systems theory. Goldner (1985) argues that the central tenet of context—defined as a boundary that can be drawn around a family, thereby making it a distinct entity—disregards the social forces that influence the family. Another central tenet, circularity, assumes an equal distribution of power when, in fact, women are often regarded as subordinate to men within families just as they are within the larger society. Goldner warns that ignoring the impact of the social context can lead to theorists and practitioners “blaming the victim” and “rationalizing the status quo” rather than challenging oppressive sex-role arrangements in family life.

Rituals and Routines

Steinglass and colleagues (1987) distinguish between an alcoholic family, which is tantamount to an alcoholic system, and a “family with an alcoholic member.” This distinction is made by applying three core concepts of family systems theory: (1) organization, (2) morphostasis or internal regulation, and (3) morphogenesis or controlled growth. The authors cite numerous studies that demonstrate the significance of ritual invasion in the development and maintenance of alcoholism in a family.

In the alcoholic family, chronic alcoholism has become its central, organizing theme. According to Steinglass et al., in these families alcoholism is no longer just operating at the individual level, it has become incorporated into virtually every aspect of the family. The erratic and unpredictable behavior of the alcoholic, over time, often elicits a characteristic response from other family members. Their behavior becomes impaired and contributes to the perpetuation of the drinking behavior, thus establishing a circular, reciprocal pattern within the family. The functioning of a family organized around alcoholism can be further understood by applying the principles of family systems theory, such as wholeness, boundaries, and hierarchies.

This organization occurs through a process in which the family’s regulatory behaviors (morphostasis) are altered to make them more compatible with avoiding the stress and conflict associated with alcoholism. The family accommodates to alcohol-related behaviors in an effort to achieve short-term stability (the process of morphostasis is also called homeostasis). However, this increases the likelihood that the drinking will continue, because the system has (inadvertently) been organized to maintain it. Family rituals offer the clearest opportunity to investigate this developmental process since they are considered to be the most meaningful shared activity.

Rituals, encompassing cultural traditions, family celebrations, and daily routines are symbolic events repeated in a systematic fashion over time that convey a sense of belonging among family members. Cultural traditions include religious and secular events that are generally observed by the larger society, such as Christmas, Thanksgiving, or Independence Day. Family celebrations, such as birthdays, graduations, weddings, vacations, and reunions, are special events that, although perhaps shared with the larger society, are practiced in unique ways by each family. Daily routines are the most distinctive form of activity and vary widely across families. Routines reveal how the family relates in terms of time and space, such as dinnertime, bedtime, and leisure time. “The one construct that more clearly encapsulates the notion of the Alcoholic Family (a family organized around alcoholism) (is the) invasion of family regulatory behaviors by alcoholism” (p. 72). For example, the family may stop having meals together if the mother drinks in the evening and does not prepare them.

The family’s long-term growth and development (morphogenesis) entails three major tasks that determine the family’s identity: defining boundaries, establishing a family theme, and choosing shared values. Although greatly simplified in the present discussion, families accomplish these tasks as they move through a common developmental pathway encompassing early, middle, and late phases. During each developmental phase, the alcoholic family makes crucial, usually unconscious, decisions to either challenge or accommodate the drinking behavior of a family member and thus shapes family identity. In the early phase, the family initiates its identity. A key variable is how closely a couple links with their respective families of origin (which may also be alcoholic), since this will influence how the family responds to emerging drinking behavior. If the drinking behavior is not resolved, the middle phase for alcoholic families is characterized by maintaining this established identity. For alcoholic families, this means organizing around alcohol-related behaviors (i.e., invasion of rituals by alcoholism). In the later phase, the family consolidates and defends its alcoholic identity and, if the drinking is not successfully confronted, transmits this identity to future generations. Thus, according to this model, the etiology of an alcoholic family is rooted in the sacrifice of morphogenesis (long-term growth) for morphostasis (short-term stability).

Shame

Another construct associated with alcoholic systems (which is clinically derived but lacks adequate empirical validation) is shame. Although normative shame is necessary for an individual to be socially functional, shame-bound families are thought to engage in pathological patterns of communication and interaction that instill a sense of toxic shame in their offspring. There is considerable theoretical literature on the relationship between shame and chemical dependency at both the individual and family level (Fossom & Mason, 1986; Hawkins, 1996c; Kaufman, 1985a, 1985b; Potter-Efron, 1989; Potter-Efron & Potter-Efron, 1988).

Fossom and Mason define shame as “an inner sense of being completely diminished or insufficient as a person . . . the ongoing premise that one is fundamentally bad, inadequate, defective, unworthy, or not fully valid as a human being” (p. 5). Shame differs from guilt in that the latter comprises a painful feeling of regret for one’s actions while the former is an acutely painful feeling about one’s self as a person. Guilt offers the opportunity to reaffirm personal values, repair damage, and grow from the experience. Shame, however, is more likely to foreclose the possibility of growth, since it reasserts one’s self-identity as unworthy. Although shame is experienced as an intra-psychic process, its development occurs primarily through the interactions of the family. A shame-bound family operates according to

a set of rules and injunctions demanding control, perfectionism, blame, and denial. The pattern inhibits or defeats the development of authentic intimate relationships, promotes secrets and vague personal boundaries, unconsciously instills shame in the family members, as well as chaos in their lives, and binds them to perpetuate the shame in themselves and their kin. It does so regardless of the good intentions, wishes, and love which may also be a part of the system (p. 8).

Shame-bound systems can be addictive, compulsive, abusive, phobic, or exhibit some combination of these behaviors. Alcoholic families are susceptible to shame in at least two ways. First, members often construct elaborate networks for hiding the alcoholism from each other and from the community. Second, alcoholism is frequently associated with emotional, physical, or sexual abuse. Such abuse, as well as neglect, is usually cloaked in secrecy. Secrets maintain the equilibrium of the system by inhibiting family members from changing their behaviors. Thus, secrets serve to perpetuate the addiction as well as the shame of the people involved.

Kaufman (1985b) provides an explanation of how shame is transmitted from the family level to the individual. He theorizes that a single developmental process is involved that takes different pathways, either to a healthy self or to a shame-bound self. The outcome depends on the prevailing affect encountered by the child over time in his or her interactions with adults, primarily the parents. If the child’s basic needs (physical and emotional) are understood and acknowledged on a consistent and predictable basis over time, the child acquires an inner sense of trust and competence in his or her ability to get needs met. Ultimately, the child develops healthy self-esteem. However, if the parent fails to meet the child’s needs, the child attributes this as personal failure and feels deficient. If this pattern is repeated consistently over time, the normative experience of shame (which occurs when one’s needs are not met) evolves into the person’s inner experience or identity. A shame-bound self is governed by feelings of being diminished, lonely, worthless, and alienated. Given the complexity of any family system, a child is likely to experience a combination of enhancing and diminishing responses. Parents can replace a shame-inducing reaction in a child with an affirming one by accepting and explaining the parent’s own responsibility for the interaction. Thus, they free the child from the sense that he or she failed to elicit the needed response from the parent. Unfortunately, many alcoholic and codependent parents fail to take this corrective step.

Rules and Roles

Wegscheider (1981) proposes a now classic model of family interactive processes. Both the alcoholic and other family members suffer from very low self-worth and reinforce it in each other. Thus, in a reciprocal process the family system does not encourage the health and wholeness of its members, nor do members encourage the health and wholeness of the family. All families, over time, establish rules and roles that determine values and goals, regulate power and authority, specify responses to change, and establish patterns of communication. These rules are seldom recognized consciously. “Alcoholic families are governed by rules that are inhuman, rigid, and designed to keep the system closed—unhealthy rules. They grow out of the alcoholic’s personal goals, which are to maintain his [sic] access to alcohol, avoid pain, protect his [sic] defenses, and finally deny that any of these goals exist” (p. 81). Wegscheider uses the analogy of a mobile, with family members suspended and held together by strings, which represent rules. Any action by the alcoholic reverberates throughout the system. The family’s reactions are intended to bring stability, but they actually produce a long-term maladaptive response.

Families also adjust to alcoholism through the process of establishing roles (i.e., outward behavior patterns). All families function through roles (such as parent, child, etc.), but roles in alcoholic families take on an added dimension. Although there is little empirical study on the subject, the model suggests that these roles are a way of maintaining stability, since families fail to confront the problem of alcoholism, which threatens the system. Thus, the family may preserve its identity, but at a high price of which it is seldom aware. Wegscheider describes six typical family roles: dependent (the alcoholic), enabler (the powerless spouse or partner), hero (the overachieving child), scapegoat (the delinquent child), lost child (the isolated child), and mascot (the immature child). This is only a schema; in small families, one person may assume more than one role and, in large families, one role may be played by several people. Further, roles may shift over time. Although these roles may appear in all families at some time, in alcoholic families, they are “more rigidly fixed and are played with greater intensity, compulsion, and delusion” (p. 85).

Codependency and Related Constructs

As discussed, alcoholism can be viewed at both the individual and familial level: An alcoholic suffers from personal impairment and contributes to the impairment of his or her family. Likewise, other family members can develop individual impairment and contribute to familial impairment. In turn, family dysfunction can exacerbate each individual family member’s problems. The impairment of family members (alcoholic or non-alcoholic) can encompass the three related constructs of codependency, children of alcoholics, and adult children of alcoholics.

Codependency

Several definitional issues need to be considered in a discussion of codependency. It is a ubiquitous concept in the fields of chemical dependency and mental health, yet there is no general agreement as to its meaning. The concept is clinically derived and has received limited empirical attention (e.g., Carruth & Mendenhall, 1989; Cullen & Carr, 1999; Wright & Wright, 1999). Despite its intuitive appeal, this ambiguity has led to much confusion and controversy in the appropriate use of this concept in assessment and treatment. In addition, although the term is used irrespective of gender, it is typically applied more to women (Roth & Klein, 1990). This bias raises concerns about ignoring the oppression of women, discounting gender socialization, or pathologizing what may actually be highly desirable human traits (Bepko, 1989; Frank & Golden, 1992; Jordan et al., 1991). (See Chapter 15.)

The concept originated when chemical dependency counselors first turned their attention to the spouse (i.e., wife) of the alcoholic. They used the term enabler since it was observed that the behavior of the spouse often served to support the alcoholic’s drinking. Another early term was co-alcoholic, which implied that the spouse also suffered from the disease through her relationship with the alcoholic. By the late 1970s, this term was replaced by codependent as the term chemically dependent became the more popular way to describe alcoholics and addicts.