The concept of looking at family members in the etiology and maintenance of psychoactive substance use disorders dates back to the early 1930s, when social workers in state hospitals reported the results of interviews and observations of wives of alcoholics (Lewis, 1937). Lewis (1937) noted that the wives presented with their own symptoms, such as anxiety, depression, and psychosomatic symptoms. These early reports fueled a number of theoretical explorations into the cause of alcohol-related family symptoms. Prevailing theories during the 1930s focused on the idea that psychological symptoms in family members did not result from a reaction to living with a chronic alcoholic. As a result, many theories emerged attempting to explain the phenomena.

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The disturbed personality hypothesis suggested that the wives of alcoholic men were disturbed women who resolved neurotic conflicts through their marriages to alcoholic men (McCrady and Epstein, 1996). Whalen (1953) expanded this theory to include the dynamic correlates that were believed to underlie a family member’s symptomatology — namely, repressed aggression and dependence. In fact, Whalen created psychological profiles to capture the underlying conflict: “Punitive Polly” represents a wife of an alcoholic who has conflicts with aggression; “Controlling Catherine” describes the wife who needs control; “Suffering Susan” identifies the wife who has masochistic trends; and, “Wavering Winifred” captures the wife who struggles with ambivalence. Other psychodynamic theorists postulated that if the male alcoholic is able to stop drinking successfully, his wife will essentially decompensate and present more primitive psychopathology. One study in support of the decompensation hypothesis found that of 18 women studied in a state hospital setting, all of whom were married to alcoholic men, 11 had husbands who had recently decreased their use of alcohol (Macdonald, 1956). It wasn’t until pioneering work by Kellerman (1969), Jackson (1954), and Cork (1969) that theory and treatment options were expanded for assisting family members. Jackson’s (1954) work, in particular, shifted the way clinicians conceptualized the alcoholic family. Clinicians began to view family members’ symptoms as a normal process, secondary to caring for a chronically ill family member. Thus, family members caring for an alcoholic may develop psychological symptoms not as a result of their own pathology, but as a consequence of living in a chronically high-stress environment. Other research by Kogan and Jackson (1965), and Moos, Finney, and Gamble (1982) found support for Jackson’s model.

Steinglass and colleagues (1977) expanded the existing systemic explanations by highlighting the interactive process between the alcoholics and their family members when intoxicated, as well as during moments of abstinence. These observations led to a theory on the function and organizational capacity of alcohol within the family system, such as stabilization of family roles, the expression of both positive and negative feelings, and the enrichment of intimacy. For example, family members often report feeling as though they can share intimate moments with the identified patient only during drinking phases. One family member admitted, albeit reluctantly, that she had the best sexual encounters with her husband when he was high, and that she felt the most intimate with him during those moments. As she reported, “When he was clean, it [sex] was boring. He seemed uninterested in me.”

Family disease models gained popularity during the 1980’s with books by Beattie (1987), Cermak (1986), and Wegscheider (1981), despite earlier beginnings in 1939 with Alcoholics Anonymous (AA) and later by Al-Anon. Contemporary models conceptualize addiction as a family disease, as family members are seen as suffering from a parallel disease process called codependency. Codependency has been written about extensively in the self/help psychology literature but has not gained wide acceptance in research settings, in part, due to broader social questions, generalizations, and the potential dangers of over-diagnosis. Brown (1990) and Anderson (1994) have highlighted some of these important issues.

Nonetheless, clinicians have observed a host of symptoms in family members that do require a more critical analysis of co-dependency. Cermak (1986) proposed criteria for diagnosing codependency as follows: (1) the investment of self-esteem in controlling oneself and others, particularly during adverse situations; (2) taking responsibility for meeting the needs of others before one’s own; (3) experiencing anxiety and distortions of boundaries around issues of intimacy and separation; (4) being enmeshed in relationships with persons with personality disorders or alcohol or drug problems; and (5) having at least 3 from a list of 10 other signs and symptoms including: denial as the primary coping strategy; constricted emotions; depression; hypervigilance; compulsive behavior; anxiety; substance abuse; victim of sexual or physical abuse; stress-related illness; or in a relationship with a substance abuser for more than two years without seeking help. Some have even argued that codependency should have been included in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition-Revised (DSM-III-R) under the category of “dependent personality” (Cermak, 1984; Kitchens, 1991).

Approaches that advocate a 12-Step fellowship are anchored in the disease model of addiction, and follow the principles and traditions of AA or NA (Narcotics Anonymous). This model assumes that addiction is a disease that has biopsychosocialspiritual components (Wallace, 1989a). Thus, the addict is powerless over the substance and must surrender and admit powerlessness. Similarly, the family is powerless over the addict’s use of alcohol and must also surrender and admit powerlessness. In addition, defenses such as denial and rationalization have dominated the alcoholic family’s lifestyle and, therefore, the family’s focus is to abstain from participation in the alcoholic’s behavior.

Theory integration

Historically, psychodynamic theories and 12-step oriented treatment have developed along separate lines, yet these two treatment approaches are not incompatible and, in fact, can be used integratively working with the alcoholic family in recovery. From a psychoanalytic viewpoint, working with families who have been stressed by the chronic abuse of alcohol in the family system requires careful exploration and uncovering of unconscious material. Many family members have survived the often chaotic, unreliable, and emotionally confusing experience of living with or caring for a chronic alcoholic. Consequently, many family members harbor painful emotions that are repressed and denied, as many believe that expressing their feelings will exacerbate the alcoholic’s drinking; result in re-injuring themselves emotionally; or provide no remedy. Thus, feelings such as anger, resentment, guilt, betrayal, disappointment, and fear go unspoken.

In addition, forbidden wishes or repressed desires are equally important to voice, as many family members hold bitter feelings for having to give up their dreams and desires for the family. Dreams such as buying a house, having children, and having more family time are often voiced and tinged with anger. For example, a recently married couple shared the dream of purchasing their first home and beginning to plan for a family. However, as the husband’s use of alcohol escalated, their dreams slowly deteriorated. He felt alone in his drinking and she felt alone and angry in the marriage.

As the alcoholic turns more toward alcohol, the family turns more toward the alcoholic to stop drinking. As a result, the alcoholic feels watched, pressured, and nagged to stop drinking due, in part, to the family’s belief that if the drinking stops, the problems will stop. The family takes on the role of managing the alcoholic to prevent further use and abuse of alcohol, and further deterioration of the family. In this process, family members often lose touch with their own feelings, as they attempt to survive within the alcoholic family system. Modell (1975) and Stolorow & Brandchaft (1987) highlight the defensive changes in one’s capacity to recognize their own internal emotional states in high-stress environments. Family members often feel as though they have lost their own direction, their own identity as a result of structuring their life around the alcoholic.

In combining a psychodynamic 12-step approach, the therapist pays close attention to these unconscious interpersonal processes within the family system, focusing in particular on those processes that enable further drinking and undermine sobriety. These processes include denial as a primary defense strategy, enabling behaviors, and codependency. McKay (1996) suggests the therapist should attempt to elicit unexpressed wishes and feelings, listen in a non-judgmental way, and offer interpretation that brings to light these states of disavowed feeling. It is important to add here that the therapist also needs to educate the family on the disease process of alcoholism and the many forms of enabling. The therapist also will need to be more active in his or her role than in traditional psychodynamic treatment, and can assist the family with identifying their enabling behaviors and the dynamic correlates that lie underneath, such as embarrassment or fear that others will find out.

For example, a wife who repeatedly cleans up after her husband’s nightly drinking episodes can experience some relief once she understands why she continues to clean up after him or why she hides the bottles. Another example is the mother of an adult alcoholic who struggled to emotionally separate from her son’s addictive behavior; she would become entangled with his deception, his extreme behaviors, and seemingly disturbed life. She wanted to “fix” him and was prepared to do whatever was necessary to change him, even if it meant sacrificing her own sanity. When he relapsed on alcohol, she relapsed emotionally. However, once she voiced her deep sadness for her son’s condition and consciously acknowledged her feelings of guilt, embarrassment, and shame, as a parent for having a son who created more pain than joy, she was emotionally ready to take a different action. She realized that her motivation to change him was, in essence, an attempt to change her own feelings. She realized that if she were able to change him, she would have undone her own bad feelings from earlier years where she felt she didn’t protect him enough from his raging father. Her emotional bottom resembled his bottom — that is, she was able to tolerate deeper and deeper levels of psychic pain similar to his increase in tolerance of the substance.

It is not uncommon for a spouse or other family members to experience an emotional insight that leads to behavioral change, once denial is reduced, enabling behaviors are identified, and the dynamic correlates that are linked to these behaviors are explored. In order to further assist in the process of denial reduction, the therapist recommends that each family member attend a self-help support group: AA for the alcoholic, Al-Anon and CoDA (Co-dependents Anonymous) for adult family members, and Alateen for adolescent family members. These programs continue the education process, and empower family members to emotionally detach from the alcoholic’s behavior.

Detachment is the process by which family members are able to live meaningful, enjoyable and satisfying lives, regardless of the alcoholic behavior (McKay, 1996). The detachment process is the key to overcoming codependency and allows each family member to take responsibility for his or her own life. Emotional detachment from the alcoholic’s behavior is similar to abstinence from alcohol for the alcoholic. Many family members have difficulty with the concept of emotional detachment as it appears to represent abandonment of the alcoholic. It is sometimes helpful to reframe the concept to represent a reaffirmation of one’s self rather than the feeling of being swept up in every windstorm of the alcoholic’s disease.

All disease models of alcoholism and other abused substances highlight the central role of abstinence in recovery. The obsessive quality of family preoccupation with the alcoholic discontinuing drinking is the mirror image of the alcoholic’s obsessive preoccupation with alcohol. As a result, the family is encouraged to emotionally abstain from participating in the alcoholic’s behavior and accepts a level of powerlessness over the alcoholic’s disease.

Conclusion

An integrated psychodynamic and 12-step oriented approach in the treatment of the alcoholic family has received limited attention due, in part, to the perception that these two models are incompatible. However, clinically these two models offer a rich resource of techniques and theory that can empower a family to make substantial change in recovery.

The key components to integration are: educating the family about alcoholism and the disease concept; identifying and working through unconscious defense styles and enabling behaviors that undermine sobriety; recommending participation in self-help support groups such as AA, Ala-Anon, CoDA, and Alateen , thereby furthering the educational process and developing community support; and supporting family members through the process of emotional detachment, which includes examining repressed emotions such as guilt, shame, and hurt. These emotions, left unidentified, without some working through, often paralyze families emotionally, and create a vicious cycle of trying to change the alcoholic in order to change each family member’s feelings. These feelings often manifest in the form of nagging and pressuring behavior, as well as creating excuses, covering up, and cleaning up for the alcoholic.

Interestingly, Bill Wilson, the founder of AA, and Harry Tiebout, his psychiatrist for many years, learned a great deal from one another — namely, alcoholics suffer from pathological narcissism. However, treatment could not proceed without the acts of surrender and acceptance. In other words, their collaboration together envisioned an integration of a psychodynamic and 12-step oriented theory for the alcoholic and, by extension, the alcoholic family.

Written by: Errol O. Rodriguez MA, CRC, is the Coordinator of Children’s Services at Inter-Care, an outpatient chemical dependency program in New York City

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Programs such as Narconon Rehab can help with alcohol abuse leading to violence.

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