Richard Velleman

Addiction problems (which include problems with substances such as alcohol and drugs, and also ‘behavioural addictions such as gambling) are highly prevalent in society, across the world1. Although often thought of as a ‘first world’ set of problems, the World Health Organization lists addiction problems as amongst the most serious issues affecting all low and middle income countries.

But addiction problems do not occur in isolation: these problems develop and then are maintained in people who live in a social context, and the most important aspect of that social context is the family.

The family, then, can play a major role in both prevention and treatment; but it is more complicated than that, as individual family members are also very frequently badly affected by living with a relative with an addiction problem, and the family unit as a whole is also often badly disrupted. As well as the stress of living with someone with an addiction problem, alcohol, drug and gambling consumption are all strongly linked to other problems such as domestic violence, homelessness and crime. As a result of all of these problems, a significant number of close family members of people with alcohol and drug problems are at risk themselves of experiencing a great deal of stress. I term such people Affected Family Members (AFMs). It is important for society as a whole, and for services that exist to help people in distress, to consider AFMs, for two important and related reasons: first, family members in these circumstances show symptoms of stress that merit help in their own right; and second, involvement of family members in the treatment of their relatives with addiction problems can enhance positive outcomes for the person with the addiction problem.

How big is the problem?
It is impossible to estimate the numbers of AFMs other than
by simply applying a multiplier to the estimated prevalence of addiction problems. The WHO has estimated that more than  100 million people worldwide suffer from addiction problems (and many people consider this a gross under-estimate). If it is assumed, very cautiously, that on average each case of addiction has a detrimental or adverse effect on only one adult, and on average each case has a detrimental or adverse effect on only one child, then the number of AFMs worldwide would be in the region of 200 million (100 million adults, 100 million children). But even though these are colossal numbers, AFMs remain largely unknown and uncounted by governments across the world, and they mostly suffer in silence. This is partly because AFMs are not a group of people who themselves suffer from a single diagnosable illness – although they are at heightened risk for a wide variety of stress-related conditions – or who constitute an obvious threat to public health or order. Nor do they generally wield collective power for social change. So they are largely marginalised and invisible.

The impact that substance misuse can have on the familyThere is a very solid evidence base for the claim that substance misuse has negative effects on the family: especially with spouses and parents, and with children.

Early research into the impact of substance misuse on spouses was conducted in the 1960s and 1970s, and subsequent research has extended the work to look at the impact on a wide range of family members, examining the differential impact of alcohol versus drugs, and the differential impact of being a parent, a partner, or another family member. Research has also examined this area from a cross-cultural perspective, comparing the impact on family life in relatively economically advantaged urban and rural areas of the world (UK, USA, Europe), with the impact in largely economically deprived populations with issues of poverty, overcrowded accommodation, and environmental pollution (such as with urban slum dwellers in Mexico City, or poor family members in South India, or indigenous Aboriginal inhabitants in Australia.

All of this research has demonstrated that adult AFMs experience considerable stress. One major area is ‘worry’: worry for the relative is often at the forefront; including worry about the relative’s physical and mental health, self-care, educational, work or other performance, finances, the company the relative is keeping, and his/her future. But it usually also includes concern about the functioning of the whole family, the maintenance of good quality relationships both within the family and with others and concern about the ability of the family to function well, now and in the future, for the sake of all its members. The greatest weight of worry is often about possible effects on children: concern at
the possibility of violence or neglect, more general worry about interference with good upbringing of the children, or concern that children might repeat the relative’s behaviour. Another major area is concern about the more ‘actively disruptive behaviour’ of the relative with the addiction problem. People are concerned about a decline in the quality of family relationships, at how (at the very least) good communication is diminished; and how the sort of behaviour expected of a partner, or a now-adult child, or a parent or some other family member, is to some degree neglected. Usually there is some element of open conflict and very often there is aggressiveness and physical violence.

AFMs also often talk of their feelings of ‘loss’ of the good quality relationships they once had with their now-addicted children, partners, parents or siblings, along with altered feelings towards these substance misusing relatives. Such feelings usually contain negative elements such as feelings of hurt, bitterness, being let down, anger or hatred, but in total are almost invariably highly ambivalent, containing positive references to good qualities the relative showed in the past, or which are on display when substances are not being used, or positive hopes for the future.

In addition, there is a solid evidence base for the impact of addiction problems on children, both as children and when adults. There are a very large number of studies that demonstrate negative effects on children whilst they are still young and in early adolescence. These studies show that many of these children experience negative childhoods: including high levels of violence and inconsistency from one or both parents. Children may also have to adopt responsible or parenting roles at an early age. These studies also show that many of these children subsequently demonstrate negative effects of these experiences, such as higher levels of behavioural disturbance, anti-social behaviour or conduct disorder, emotional difficulties, school problems, ‘precocious maturity’, and a more difficult transition from childhood through adolescence, than children who have not had this upbringing. One review on the impact of parental substance misuse on children suggested that these children’s lives were affected by six overarching themes: denial, distortion and secrecy; attachment, separation and loss; family functioning, conflict and breakdown; violence, abuse and living with fear; role reversal, role confusion and child as carer; and what the children said they needed.

There are also increasing amounts of research that have demonstrated longer-term impact on these children. The children of those with addiction problems are more likely to themselves develop problems with substances, often linked to earlier onset of use, and therefore can be at greater risk of developing problems in other areas of life. Again, family factors seem to predominate, and adults who were the children of problem drinkers reported more problems, both when they were children and upon reaching adulthood, as a result of family dysfunction and disharmony than from the drinking itself.

On the other hand, there is also growing evidence that not all children are adversely affected, either as children or adults; some children are resilient and do not develop significant problems. This has important implications for prevention and intervention.

It seems clear from all of this research that individuals who develop a serious problem with their use of alcohol or drugs or gambling, etc, can and often do behave in ways that have a significantly negative impact on family life in general, and on other individual members of the family. The addiction problems can impact negatively on a range of family systems and processes, including family rituals, roles within the family, family routines, communication structures and systems, family social life, and family finances. The addiction can also often impact negatively on other individuals within the family, as well as on family systems: problems such as domestic and other types of violence, child abuse, individuals driving whilst intoxicated, or disappearing for days on end, are all typical of the types of behaviour which people have described as stressful and with which they have to cope. The results of these and other uncertainties are that family members commonly develop problems in their own right, often manifested in high levels of physical and psychological symptoms.

In conclusion, family members suffer bio-psycho-social stresses as a result of living in this environment, which may impact on physical and mental well-being and lead to the development of problems both for themselves and other family members. This is a world-wide phenomenon. These family members need help, both for themselves, and in relation to dealing with their addicted relative. And many of them ask for help – for example, many phone helplines report a high volume of calls from AFMs, asking for help. It is about time that AFMs, both children and adults, received the help that they need.
1 All statements in this article can be corroborated with research findings and are available upon request.

Professor Richard Velleman is a leading authority on substance misuse. He is a leading member of the new International Network, AFINet, concerned with Addiction and the Family and of the UK component: AFINet UK (formerly the UK Alcohol, Drugs and the Family research network); a Senior Research Fellow in India where he is developing and researching the use of community lay health workers to deliver psychological interventions to people with severe depression or serious alcohol problems, and to their affected family members. He is Vice-President of ENCARE, an EU-wide network which he co-founded, concerned with developing resources to assist professionals across the EU to improve the help they offer to children in families affected by substance misuse.