Family Interactions

1. Family Interactions Margaret Jarvis, MD Marworth Geisinger Health System

2. Family Disease? • Some concern for pathologizing family’s response to identified patient’s disease

3. What is a family? • Love (agape) : • The willingness to act in a caring way even when you don’t feel like it • Recognition of self, other and the coupleship as distinct entities and willingness to be loving to all

4. What is a family? • Needs of the relationship (coupleship) need to come first • Needs of the children need to come first

5. Family disease? • In addiction, the needs of the addiction always comes first

6. Family disease? • Addiction is disease of chaos and dysfunction • Family members attempt to re-establish function • Love and caring • Sense of normalcy/homeostasis

7. Family disease? • Over time, behaviors of family members altered or driven in reaction to the addiction • Family members behaviors toward the addicted member are addictive in themselves • Preoccupation to the neglect of other concerns • Shame

8. Change in human systems • Generally, humans only change in response to pain • Change will occur when the pain is great enough • Enabling systems prevent the identified patient from experiencing pain • Family members may prevent pain in one another if it threatens the stability of the system

9. Change in humans • The family (and the individuals) will be healthier for every pain it feels and grows through

10. How to address the family • System to achieve abstinence • Treatment or external control • Very initial stabilization • System to maintain abstinence • Education about effect of disease on member’s behaviors • Contract between addicted person and family about expectations

11. How to address the family • Contract may include graduated steps of treatment/intervention as responses to relapses • Contract to include agreement that family members get some attention (professional or 12 –step)

12. How to address the family • Even in face of relapses, work with the family (without the addicted person) can continue • Extended support needed – keep energy off of addicted person (and therapist!)

13. How to address the family • Assessment of identified patient as usual • Assessment of family includes • other member’s use histories • Family’s responses to intoxicated and sober behaviors

14. Family Roles • Classic system of naming typical responses to disease • All the roles: • Are rigidly held and are reinforced by other family members • Enable denial of alcoholism • Allow family to function as a unit, allows some individual function but NOT FULL HEALTH

15. Family Roles • Caretaker: usually adult, sometimes child – loses self in caring for others • Hero – usually child who excels • Reinforcement for achievement leads to narcissism • Scapegoat – usually child identified as a problem • Carries the shame for the family

16. Family Roles • Mascot – creates diversion away from alcoholism. Usually a child. • Lost child – usually a child, is low maintenance

19. How does the FOO predict kids’ use? • Suburban, higher SES: • Parents more tolerant of drug use than of other non-acceptable behaviors • Parents REALLY knowing what kids were doing/where/with whom decreased use • “Containment” – predictable consequences for behavior reduced use Luthar et al., 2008

20. How does the FOO predict kids’ use? • Low SES: • Boys who have higher use later (20’s-30’s) • Higher alcohol use age 16 • Lower achievement scores age 12 • Maternal use age 16 • Externalizing behaviors age 9 England, et al., 2008

21. How does the FOO predict kids’ use? • Low SES • Girls who use more later (20’s to 30’s): • Drinking more age 16 • Higher achievement age 12 England, et al., 2008

22. How does the FOO predict kids’ use? • Urban African American • Both boys and girls: in families with more rules about drug/alcohol use, less likely to initiate tobacco or alcohol Doherty, et al., 2007

23. How does the FOO predict kids’ use? • Urban African American • Boys and marijuana: • More likely to use than girls (1.5x) • Female-headed household and rule-setting affect use • Girls and marijuana: • Family cohesion reduces risk Doherty, et al., 2007

24. How does the FOO predict kids’ use? • Urban African American • Both genders: • Physical and frequent discipline early increases heroin and cocaine • Maternal substance use increases heroin and cocaine • Girls: • More rules about drug use reduces risk of heroin and cocaine Doherty, et at., 2007

25. How do genetics contribute? • Unequivocal human and animal data to say there is a big genetic contribution (50-60% of variance) • Multi-gene

26. What genes might contribute? • Glutamate receptor genes (alcohol) • Cannabanoid receptor gene (nicotine) • Taq1 (alcohol, all addictions) – D2 receptor deficiency • ALD AST (alcohol) • NO ONE GENE DOES IT ALL

27. How do genetics contribute? • For initiation and early patterns of use of alcohol, cannabis, nicotine: • Family and environmental effects more important in early life • Genetic effects more influential later Kendler, et al. Arch Gen Psych, 2008

28. References • E.E. Doherty, K. M. Green, H.S Reisinger, M.E. Ensminger. Long-term patterns of drug use among an urban African-American cohort: the role of gender and family Journal of Urban Health: Bulletin of the New York Academy of Medicine 85:2, 2007 • M.M. Englund, B. Egeland, E. M. Olivia, W. A. Collins. Childhood and adolescent predictors of heavy drinking and alcohol use disorders in early adulthood: a longitudinal developmental analysis. Addiction103:supp. 1, 2008 • S.S. Luthar, A.S. Goldstein. Substance use and related behaviors among suburban late adolescents: The importance of perceived parent containment Development and Psychopathology 20, 2008

29. References • Kendler, K.S., E. Schmitt, S.H. Aggren, C. A. Prescott. Genetic and environmental influences on alcohol, caffeine and nicotine use from early adolescence to middle adulthood. Archives of General Psychiatry, 65:674-682.