How substance use disorders affect the family

December 12, 2016

Tracey M. Duncan, Ed.S., Ph.D., LPC, ACS
Assistant Professor
Department of Counselor Education
New Jersey City University

It’s been well-documented that addiction is a family disease, affecting every member of the family in some way. Family members organize themselves according to their behavioral and emotional reactions to the loved one suffering from a substance use disorder. In many families, these responses flare up during the holiday season, when spending time with a sibling, parent, or child with an untreated substance use disorder can make family gatherings more stressful than joyful.

Mirroring-image behavior patterns

When addiction becomes the central organizing principle of the family system, it controls and dictates the family's rules and roles. Different members take on various roles to adapt to the disrupted system. 

The family system dictates what I conceptualize as “mirroring-image behavioral patterns.” Both the suffering drug-dependent family member and suffering family members demonstrate these patterns. Mirroring-image behavioral patternsare the result of the substance use disorder becoming the central organizing principle of the family system that guides family members’ assigned rules and roles.

Co-dependency is a primary example of a mirroring image behavioral pattern. In Chemical Dependency Counseling: A Practical Guide, author Robert R. Perkinson describes co-dependency as the result of what happens to someone who is trying to control someone who is addicted. In other words, co-dependency is when “a family member being addicted to the addict.” The family is preoccupied with the suffering addict, in much the same way that the addicted family member is preoccupied with the availability of his or her drug of choice. The family member is as addicted to the addict as the addict is addicted to a drug. 

What do mirroring image behavioral patterns look like?

Family members often automatically and unconsciously take on the same rules for living as their addicted loved one. Mirroring-imaging behavioral patterns have a subtle resemblance of co-dependency behaviors and addictive family roles, yet mirroring-image behavioral patterns are seamlessly related to the behaviors demonstrated by the substance user’s behavioral patterns within the family system. For example, denial by the substance using family member reflects the mirroring-image that resembles enabling behavior by family members (particularly parents). However, at a much closer look into the family system, the denial behavior is actually a mirroring-image of the substance user’s behaviors and played out by family members to adapt to the loved one’s substance use rather than confront it (Kilpatrick & Holland, 2009).

Here’s what mirroring image behavioral patterns might look like in:

·      The parent of a young female adult addicted to opioids:

The mirroring image behavioral pattern the parent would demonstrate would be similar to behaviors that resemble the family role of a “chief enabler.” The parent of a young adult addicted to opioids would demonstrate mirroring-image behavioral patterns such as protection and denial. The young adult would look to the parent to be a rescuer for her use, as her drug use has become a “rescuer” for her to avoid painful childhood memories. The parent and young female adult do not know how to work together to heal from these painful childhood memories and therefore make excuses for the addiction. The addiction to opioids allow both the parent and young female adult to avoid the painful memories, yet also avoid and deny the dangers of her drug use. The parent would need to find healing in disengaging from this behavior as a rescuer, and perhaps even from denial that her daughter’s addiction to opioids is problematic.

·      The ten-year-old daughter of a mother with an alcohol use disorder:

The mirroring image behavioral pattern of the ten-year-old daughter would resemble the behavior patterns of the family role of the “family hero.” The family hero seeks to compensate for a parent’s substance use by performing outstandingly well in school—for example, by earning straight “A”s and participating in extracurricular activities. In addition to the family role as the “family hero,” the daughter would demonstrate the mirroring imaging behavioral patterns of shame and lack of self-worth, similar to the feelings and emotions of her mother with the alcohol use disorder. Additionally, the daughter may attempt to maintain distance from her mother by participating in activities that keep her away from her because of the shame they both share about the alcohol use disorder. This gives the mother an opportunity to drink alone--before her daughter returns home. The mother and daughter mirror the shame, disappointment and lack of self-worth they both experience due to the active addiction in the home. 

 Tools for transforming families

Despite their visible or hidden suffering, families seldom receive the kind of support they need to cope with having a relative with addictive substance use dependency. This highlights the need to develop family recovery models that address mirroring-image and other behavioral patterns. 

In the Family Reconstruction, The Living Theater Model, Sharon Wegenscheider-Cruse and colleagues offer one model for dealing with these patterns. The book provides a foundational understanding of how family members develop survival roles that allow them to experience the least amount of personal pain and stress. In the midst of the active addiction, before recovery, family members are not aware that they are playing out these survival roles to reduce emotional pain and stress. It is important to conduct the initial assessment of a family by identifying these survival behavioral patterns embedded in family roles and rules. The usefulness of this approach is to teach students what to explore as assessment data when working with families and conceptualizing the behavioral patterns to implement appropriate interventions and treatment services.

In addition, recognition of these survival roles that family members play out within the family system would also help to identify the need to create healthy family structure and predictable sequences of interactional behaviors (mirroring-image behavioral patterns) that exist between family members within the family system. These behavioral patterns that have been for so long dictated by the substance use disorder. This treatment approach, Structural Family Therapy, was developed by Salvador Minuchin (Minuchin, 1974). This intervention seeks to alter the family structure and change mirroring-image behavioral patterns so family members can achieve better health and well-being in spite of another member’s active substance use. According to Minuchin (1974), family members must be willing to change their interactions with one another, mirroring-image behavioral patterns in order for change to take place.


Family members need to learn the tools of recovery just as much as their parent, sibling, or child suffering from a substance use disorder does. Yet, family members are often left with the lingering question, “What about us?” unsure of what’s available to address their specific needs and work through their behavioral patterns. Effective family therapy can provide families with the tools they can use to take care of themselves and support their loved one suffering from a substance use disorder, both during the holiday season and beyond.

Related resources

From the ATTC Network

Tools for Treatment: Family Centered Behavioral Health Support for Pregnant and Postpartum Women, ATTC Center of Excellence
Addiction Recovery & Intimate Violence: Online course



Kilpatrick, Allie C., & Holland, Thomas P. (2006). Working with Families: An Integrative Model by Level of Need. 5th ed. Allyn & Bacon: Boston.

Minuchin, Salvador (1974). Families and Family Therapy. Harvard University Press: Cambridge, Massachusetts.

Perkinson, Robert R. (2017). Chemical Dependency Counseling: A Practical Guide. 5th ed. 
Sage: Canton, South Dakota.

Wegschelder-Cruse, S., (1994). Family Reconstruction: The Living Theatre Model. Palo Alto, CA: Science and Behavior Books, Inc.

Dr. Tracey M. Duncan is an Assistant Professor and Post Master’s Student Program Coordinator for the Department of Counselor Education at New Jersey City University in Jersey City, NJ. Dr. Duncan obtained her Ph.D. from Drexel University in Couple and Family Therapy and Educational Specialist Degree in Marriage and Family Therapy from The College of New Jersey. Dr. Duncan is a Licensed Professional Counselor (LPC), Certified Substance Abuse and Addictions Counselor, and Certified Approved Clinical Supervisor. Dr. Duncan has also received specialized training and grant funding for the Adolescent Screening, Brief Intervention and Referral to Treatment (SBIRT) addiction research and training model. She has implemented project-based learning pedagogical course instruction in her teaching of addiction counseling courses and have shared her experiences and the effectiveness of this course design in recent publications such as the Family Recovery Program Curriculum Guide: Project-Based Instructional Learning for Teaching Addiction Counseling Courses: International Association of Addictions and Offenders Counseling (IAAOC). 

Taking Action to Address Opioid Misuse

December 6, 2016

Jeanne Pulvermacher, MS
Project Manager
ATTC Network Coordinating Office

If you scan the headlines in newspapers from across the country, you’ll see a few common words: opioids, heroin, Naloxone, prescription pain medications, drugs, overdose, HIV.  You may recall the 2015 HIV outbreak in Indiana that was fueled by injection drug use, mainly of oxymorphone (Opana), oxycodone, and methadone—all opioids. 

The statistics are grim. According to the Centers for Disease Control and Prevention, Vital Signs: Opioid Painkiller Prescribing:
  • Each day, 46 people die from an overdose of prescription painkillers in the U.S.
  • In 2012, 259 million prescriptions were written for opioids, which is more than enough to give every American adult their own bottle of pills.
In response to the opioid  epidemic, the ATTC Network has launched Taking Action to Address Opioid Misuse, a website that brings together the opioid training and information resources of the entire ATTC Network. It’s one page where you can find:
  • All ATTC Network opioid–related resources: curricula, slides, online courses (with CEs), recorded webinars, toolkits
  • Related resources and articles  
We'll be updating the page regularly to bring you the latest information and tools to help you take action to address the opioid epidemic.

Just what are opioids? 

You may hear the word "opioid" all the time, but have you ever stopped to think about what an opioid actually is? According to, an opioid is
"any of a group of endogenous neural polypeptides (as an endorphin or enkephalin) that bind especially to opiate receptors and mimic some of the pharmacological properties of opiates..." 
Or: "a synthetic drug possessing narcotic properties similar to opiates but not derived from opium..."
An opiate (morphine, codeine, heroin, opium) comes from the poppy plant. An opioid (methadone, percocet, hydrocodone) is produced artificially to work the same way as an opiate.

The National Instittute on Drug Abuse says that half of young people who inject heroin begin with prescription pain medication in pill form. Why the switch to heroin?  Because it's cheaper and easier to obtain tha prescription opioids. 
These days, the term opioid is used to refer to natural and synthetic forms fo the drug.

Codeine, fentanyl, heroin, oxycodone, morphine, and methadone are some of the types of opioids, and they can be taken in a variety of ways:  Orally in pill or liquid form, intravenously in liquid form, or nasally, by snorting crushed pills.

How long has this been going on?

In my research for this blogpost I found a  timeline  that shows just how long people have been using opioids for medicinal and other purposes. A few highlights:

3400 BC: Earliest reference to opium growth and use. Opium poppy cultivated in lower Mesopotamia.

1853: Hypodermic needle invented.

1898: Heroin synthesized from morphine.

1973: Nixon declares the War on Drugs.
America leads the world in the number of heroin addicts.

1980: Just say No to Drugs. 

1996: OxyContin hits the market.

2000's: Prescription painkillers cause 743,000 ER visits/year. 

2016: 48 states implement prescription drug monitoring programs. 

Facing Addiction in America: The Surgeon General's Report on Addiction, Drugs, and Health released.

Facing Addiction in America: The Surgeon General’s Report on Alcohol Drugs and Health

Last month, the Department of Health and Human Services issued the first-ever Surgeon General’s Report on Alcohol, Drugs and Health. It cites the following statistics:  
  • 27 million people in the United States currently use illicit drugs or misuse prescription drugs. 
  • The yearly economic impact of illicit drug use is $193 billion.  
These are major public health challenges that affect, families, neighborhoods, and communities.

The Report’s Vision for the Future says:

“Evidence-based behavioral and medication-assisted treatments (MAT) applied using a chronic-illness-management approach have been shown to facilitate recovery from substance use disorders, prevent relapse, and improve other outcomes, such as reducing criminal behavior and the spread of infectious diseases”
We can make a difference by using evidenced-based practices that the ATTC Network promotes to treat substance use-related issues. Learn more by visiting Taking Action to Address Opioid Misuse today! 

The vision of the ATTC Network is to unify science, education, and service to transform lives through evidence-based and promising treatment and recovery practices in a recovery-oriented system of care. As a Network, we are committed to taking action to address opioid misues.
What ATTC Network or other resources have you used to learn more about effective practices for addressing the opioid epidemic? 

Let us know in the comment section below. 

Standing Rock: Observations

November 23, 2016

Sean A. Bear, 1st
Training Coordinator and Senior Research Consultant National American Indian and Alaska Native Addiction Technology Transfer Center 

My name is Sean A. Bear, 1st. I am a member of the Meskwaki Tribe in Iowa and the Training Coordinator and Senior Research Consultant at the National American Indian and Alaska Native Addiction Technology Transfer Center (National AI/AN ATTC) located in the University of Iowa College of Public Health, Department of Community and Behavioral Health.  After a training event in Fargo, North Dakota, Dr. Skinstad (Director, National AI/AN ATTC) and I decided that it was important for me to make a site visit to the Standing Rock site of the pipeline protests to evaluate if there was any need for assistance from our Center to the participants of the demonstration and their providers. 

Many of us see how trauma-informed care and mental health first aid play a role in healing. It is important to understand that many people have experienced trauma in the past that play a role in their beliefs. In addition, many American Indian/Alaskan Natives have lived in poverty conditions, which has normally been forgotten (or invisible) as many are in rural and frontier areas of America.  It must be mentioned that Natives bring a whole new need for trauma-informed care, information that is needed at the table, as they and their ancestors have experienced historical trauma for generations.  Much as those in Europe whose relatives suffered through the Holocaust, trauma can be passed on genetically from parent to child. Native Americans have experienced not only trauma, but circumstances that also hinder the healing that is needed for recovery.  So, as we move forward in developing programming and care, we must also remember to make decisions that will benefit all peoples instead of pushing others, like the American Indians and Alaskan Natives, out by not understanding what they and their ancestry have experienced. 

While at Standing Rock, I made several observations that I want to share with you. 

Eight ways to overcome resistance to medication-assisted treatment

November 17, 2016

Maureen Fitzgerald
Editor, Addiction Technology Transfer Center & NIATx

Outcome studies and research will help get some patients, staff, and community members on board for medication-assisted treatment. But not everyone may embrace a treatment like buprenorphine (Suboxone®) for opioid use disorders based on scientific evidence of its effectiveness. Lack of staff buy-in can easily sabotage the potential success of any MAT program.

Opposition to MAT can take many forms, from open hostility to subtle resistance.  

This can include segregating MAT clients from non-MAT clients in treatment groups. Or discounting sobriety accomplished with the help of medication as not “true” sobriety. Sometimes, MAT patients are told that they won’t be successful in long-term recovery because they haven’t suffered enough.

Words Matter in Stories

November 9, 2016

Merlyn Karst

From the Faces and Voices of Recovery Blog

Obviously, history has been made since the beginning of time but wasn’t recorded until relatively recent times. One thing certain is that the travelers, teachers, and troubadours of old told and sang stories that informed and entertained. Circles around campfires and huddles around hearths created communities. The means of the telling have changed dramatically but the personal stories with the important element of humanity provide the power. Tahir Shah, a travel writer, said,  “Stories are a communal currency of humanity.”  We can read and enjoy stories; however, a story’s power comes from seeing the face and hearing the voice of the person with feeling, gestures, smiles, and tears. This is the case for the stories of cancer survivors and of those who have overcome addiction to alcohol and other drugs.

Read the complete post

Recovery: It's a global thing

November 2, 2016

Maureen Fitzgerald
Editor, NIATx
Communications Coordinator, ATTC Network Coordinating Office

During National Recovery Month 2016, more than 1100 communities celebrated recovery with Recovery Walks, workshops, and other activities.  

And not all of these celebrations happened in the U.S! 

  • A Recovery Camp in Tiona Park, Australia, brought together people celebrating recovery from mental illness. Watch a brief video about the camp here. 
  • And in Ghana, Recovery Africa held its second annual Recovery walk this year. 
Bill White has written a lot about the Recovery Movement, and he shares perspectives from people in recovery from around the globe in these Leadership Interviews on Recovery Around the World

Marijuana: What's new?

October 12, 2016

Maureen Fitzgerald, Editor
ATTC Network Coordinating Office/NIATx

Marijuana continues to make headlines daily, and it can be hard to stay on top of the latest news about marijuana research, trends, and legalization. To help you stay in the know, we've collected some of the most recent and relevant resources and news items in one compact blog post.

1. "Does smoking marijuana make me stupid?" Short answer: Yes.
Find this infographic and more on the
ATTC Network's Marijuana Lit page! 
A recent Canadian study adds to the body of research showing that marijuana does affect IQ. This is one study to turn to when talking to teens and others who think that marijuana is harmless.

Read more about it in this brief from Science Daily:
Early marijuana use associated with abnormal brain function, lower IQ

2. But it really won't hurt me. That's the prevailing attitude about marijuana among 12-17 year-olds in the U.S. today. Find out more about efforts to change teens' attitudes:
CAPT webinar focuses on changing youth perceptions of marijuana risk. 
And here's a link to the webinar recording:
Preventing Youth Marijuana Use: Changing Perception of Risk

Dr. Kari Franson tells more about marijuana's affect on teens (and their IQs) in this video in the ATTC Network's Marijuana Lit series: Youth and Families

And it's not just kids who think that: That's based on an analysis of National Survey on Drug Use and Health data collected from 2002 to 2014. Read all about it: Increasing number of US adults using marijuana as few people perceive the drug as harmful

And Dr. Wilson Compton tells more about how marijuana affects people young and old in the Marijuana Lit video: Marijuana's Effects on the Body.