CATR: Dr. Brown, as a pioneer in understanding the interplay of family dynamics and addiction, I thought we’d start our interview with a patient I recently saw in my practice. This was a woman who presented with depression and suicidal ideation. Over the course of the interview, I learned that she had been drinking more wine over the past few months, from a glass or two to a full bottle per night. She said she was using alcohol to cope with her stressful and unhappy life. She mentioned that she first started drinking a few years after marrying her husband, who has long been a functional alcoholic; he works long hours, comes home late, and drinks two 6-packs every night. Since this was a brief medication evaluation, we didn’t have enough time to really get into the nature of their relationship, but it was clear that there was conflict, and that my patient’s drinking was related in some way to her husband’s addiction. How might I think about family dynamics in a case like this, and how would I go about assessing it further? 

Dr. Brown: This is a common scenario. The couple is an “alcoholic dyad”—we’d call it an alcoholic family system if they had children. You’ve learned that your patient’s turn to alcohol is related at least in part to the fact that her husband has been drinking every evening for a long time. There is some dynamic at work here in how she responds to his coming home to be with his partner—which is apparently his two 6-packs of beer, rather than his wife.

CATR: And this dynamic affects how our patient reacts to her husband’s drinking, which in turn affects her drinking?

Dr. Brown: Typically you’ll find that the addict, in this case her husband, makes a fundamental attachment to the substance and then your patient reacts to that in some way. Maybe when she met him, he was already a drinker and that was a good fit for her. Maybe she grew up with an alcoholic parent in a family system where alcohol was at the center, organizing all of the relationship and family dynamics. At some point, she starts drinking herself—perhaps reacting to stress, giving up, and finding her own attachment to the substance. Many partners start drinking with somebody who is already alcoholic with the idea, often unconscious, or out of awareness that “we are going to do this together”: “I can’t fix him; I can’t change him so I’m going to join him.” This process is enormously common and acceptable in the culture. 

CATR: So I’ll obviously need to address this issue with her further. Do you have any specific suggestions?

Dr. Brown: Ask about how she found this partner. Does she see him as alcoholic? Does she believe that she began her own drinking in response to his drinking? You may learn she resists seeing her husband as an alcoholic—“it’s just what he does.” This is a frequent block: the reluctance to identify that somebody in the family has a bond with alcohol. Family members typically react to the alcoholism of another and then deny it, try to explain it, and hope that it will go away. Or they join in, drinking and denying it, becoming a co-creator of their pathological family system. You need to assess how the family system works and if they deny the reality of drinking while explaining it in a way that allows it to be maintained. This is the central organizing dynamic of many actively alcoholic family systems. 

CATR: This is a complicated concept, and not one that I think would be easy to broach with most family members.

Dr. Brown: Yes, it can be tricky. As you are talking with your patient, you are thinking, “What is the role of alcohol as a central organizing principle in this couple, in this family? How dominant is it? Are one or both partners aware of it? Do they acknowledge it? Do they deny it?” What’s interesting is that if you were to ask your patient’s spouse—the person with the substance abuse issue—“How is your family involved in your addiction?” he might be likely to say, “Not at all. Nobody knows,” which is almost never accurate. At the point of early intervention, which is often with a primary physician, many substance abusers and their families truly believe that no one knows—or one or both will resist treatment because they do not want anyone to find out.

CATR: I can see that happening. What do you do in that case?

Dr. Brown: I’ll approach this conversation more indirectly by asking the patient to walk me through a typical day or a weekend in their life. That may be how you got the information from your patient that her husband drinks two 6-packs a night in the first place. She has already told you that her husband comes home and takes up with his beer instead of her. So you may want to 

follow up on this and ask something along the lines of, “How do you feel about that? What happens for you when he walks in with his two 6-packs of beer? Is this something that is long-standing or fairly new? How has that been for you, and what’s been your response to it? Is this reminiscent of growing up for you?” Or you might take a slightly different tack with your questions and ask if there was a point where she was OK with her husband’s drinking. Did it work for her because they had a bad relationship? Did she find herself nagging him? Is he angry with her all the time? The key thing to remember is that no two individuals or families are the same. It’s important to understand, as best you can, how this particular family works. You can cover every possible scenario, and as you gain experience with these families, believe me, you do see every scenario. One person hates the drinking and another can’t wait to join in. 

CATR: I’m sure there are elements of “codependency” here. Do you use that term? Is it still helpful?

Dr. Brown: Codependency has become a catch-all term—what it really means is sacrificing oneself in service to another. In the addictive system, the codependent becomes complicit, tacitly or unconsciously agreeing to join a system of rationalization, denying that somebody is out of control with an addiction. The codependent, often frightened of a threat to the relationship, initially joins in support of these distortions. Many codependent people come into the office with anxiety or depression, perhaps wanting medication, or relieved when the physician suggests it. Part of what drives the emotional pain is their fear of the realities that exist underneath it. The defenses needed to maintain denial can thus cause anxiety and depression. So addressing the family dynamic can actually be quite helpful for symptom relief in psychiatric practice. 

CATR: I was hoping we could discuss the concept of adult children of alcoholics. How useful is it for practitioners to understand this concept?

Dr. Brown: It is very important. The term “adult children of alcoholics” (ACOAs) means that an individual grew up with one or two alcoholic parents and, thus, an alcoholic family of some kind. The ACOA develops a “defensive self” as a child to cope with traumatic family life, including parental neglect, physical and sexual abuse, and serious attachment problems. These defenses include a strong, unyielding need for control; an exaggerated sense of responsibility for everyone and everything; an automatic reliance on concrete, all-or-none thinking; and denial. While they may serve the child well, these coping mechanisms become maladaptive as the ACOA grows up and attempts to form intimate adult relationships. Claudia Black, in her classic text It Will Never Happen to Me, first described these defenses as childhood family roles, including the hero, the lost child, the placater or people pleaser, and the scapegoat (Black, Claudia. It Will Never Happen to Me. Denver: MAC, 1981).

CATR: Who is the hero child?

Dr. Brown: The hero child has created a defensive and precocious super self to keep the family from falling apart. As young children, these heroes will rarely show up in anybody’s office because they’re busy getting straight A’s and making the family look good. Maybe they’re cooking dinner, maybe they’re putting mother to bed, taking care of younger siblings, trying to hold a family together. That child will often do well until leaving home, perhaps for work or college, but the separation from family may lead to depression and anxiety, fueled by survivor guilt, with a fear that the family will go to shambles when that child leaves. The hero often cannot be away from home because of worry and guilt about younger siblings left behind. That’s the so-called “parentified” child.

CATR: What sorts of psychological issues might we see in such people?

Dr. Brown: Typically they don’t allow themselves to have any needs in a relationship. They feel that nobody ever cares about them; they always have to take care of others. If they’re alone, they manage okay; they’re not in therapy because they have this sense of tight control over their lives. One of my patients said, “The best relationship for me is to be alone; otherwise I have to give up myself.” Things start to fall apart for ACOAs when they don’t feel that they are in control. Loads of them are suffering in this out-of-control tech world, especially out here in Silicon Valley where everybody is going so fast, and nobody can really be perfect anymore. Distraught, they seek help for their inability to manage everything. Some will enter your office with the onset of panic attacks, saying, “I just don’t know what’s wrong; everything was fine; I was managing and now I’m panicking.”

CATR: So these children defined themselves as people who had to control an alcoholic and an out-of-control family system, but in their adult lives they get into a work situation or a relationship that they can’t control. 

Dr. Brown: Right. They knew how to please others in the world, how to be a hero, and then that system collapses, and they are scared. Hopefully, these people seek help, begin therapy, and see how much they sacrificed themselves to be a hero. 

CATR: So what’s the therapeutic statement, then, for someone like that? Is it something like, “You learned that you had to be a hero when you were a child, but you don’t have to do that any longer. It’s OK not to be in complete control.”

Dr. Brown: You might say that, depending on the context and the person’s readiness to hear it. But many newly identified ACOAs would not be able to absorb or act on your permission, and they would likely be terrified of the idea that it’s okay to relinquish some control. You might say something like, “One day you won’t have to give up yourself anymore.” It is vital to recognize the complexities of “diagnosis” and treatment in working with all aspects of addiction. While types are immensely helpful, it’s important not to assume that all “heroes” are alike. 

CATR: Thank you for your time, Dr. Brown.

Note: For further information, check the website for the National Association for Children of Alcoholics, which can be beneficial for both doctors and patients.

References: 

    
• Brown S. Treating Adult Children of Alcoholics: A Developmental Perspective. New York, NY: John Wiley and Sons, 1988. 
   
• Brown and Lewis V. The Alcoholic Family in Recovery: A Developmental Model. New York, NY: Guilford, 1999. 
   
• Stephanie Abbot (Ed.), Children of Alcoholics: Selected Readings. Rockville, MD: National Association for Children of Alcoholics, 1995.