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. Luthar et al., 2008 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

20. England, et al., 2008 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

21. England, et al., 2008 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

22. Doherty, et al., 2007 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

23. Doherty, et al., 2007 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

24. Doherty, et at., 2007 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

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. Kendler, et al. Arch Gen Psych, 2008 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

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. Addiction 103: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.