family interactions margaret jarvis, md marworth geisinger health system

Family InteractionsFamily Interactions

Margaret Jarvis, MDMargaret Jarvis, MD

MarworthMarworth

Geisinger Health SystemGeisinger Health System

Family Disease?Family Disease?

Some concern for pathologizing family’s Some concern for pathologizing family’s response to identified patient’s diseaseresponse to identified patient’s disease

What is a family?What is a family? Love (agape) : Love (agape) :

The willingness to act in a caring way even The willingness to act in a caring way even when you don’t feel like itwhen you don’t feel like it

Recognition of self, other and the Recognition of self, other and the coupleship as distinct entities and coupleship as distinct entities and willingness to be loving to allwillingness to be loving to all

What is a family?What is a family?

Needs of the relationship (coupleship) Needs of the relationship (coupleship) need to come firstneed to come first

Needs of the children need to come firstNeeds of the children need to come first

Family disease?Family disease?

In addiction, the needs of the addiction In addiction, the needs of the addiction always comes firstalways comes first


Addiction is disease of chaos and Addiction is disease of chaos and dysfunctiondysfunction

Family members attempt to re-establish Family members attempt to re-establish functionfunction Love and caringLove and caring Sense of normalcy/homeostasisSense of normalcy/homeostasis


Over time, behaviors of family members Over time, behaviors of family members altered or driven in reaction to the altered or driven in reaction to the addictionaddiction

Family members behaviors toward the Family members behaviors toward the addicted member are addictive in addicted member are addictive in themselvesthemselves Preoccupation to the neglect of other Preoccupation to the neglect of other

concernsconcerns ShameShame

Change in human Change in human systemssystems

Generally, humans only change in response to Generally, humans only change in response to painpain

Change will occur when the pain is great Change will occur when the pain is great enoughenough

Enabling systems prevent the identified patient Enabling systems prevent the identified patient from experiencing painfrom experiencing pain

Family members may prevent pain in one Family members may prevent pain in one another if it threatens the stability of the systemanother if it threatens the stability of the system

Change in humansChange in humans

The family (and the individuals) will be The family (and the individuals) will be healthier for every pain it feels and grows healthier for every pain it feels and grows throughthrough

How to address the How to address the familyfamily

System to achieve abstinenceSystem to achieve abstinence Treatment or external controlTreatment or external control Very initial stabilizationVery initial stabilization

System to maintain abstinenceSystem to maintain abstinence Education about effect of disease on Education about effect of disease on

member’s behaviorsmember’s behaviors Contract between addicted person and Contract between addicted person and

family about expectationsfamily about expectations


Contract may include graduated steps of Contract may include graduated steps of treatment/intervention as responses to treatment/intervention as responses to relapsesrelapses

Contract to include agreement that family Contract to include agreement that family members get some attention members get some attention (professional or 12 –step)(professional or 12 –step)


Even in face of relapses, work with the Even in face of relapses, work with the family (without the addicted person) can family (without the addicted person) can continuecontinue

Extended support needed – keep energy Extended support needed – keep energy off of addicted person (and therapist!)off of addicted person (and therapist!)


Assessment of identified patient as usualAssessment of identified patient as usual Assessment of family includesAssessment of family includes

other member’s use historiesother member’s use histories Family’s responses to intoxicated and sober Family’s responses to intoxicated and sober

behaviorsbehaviors

Family RolesFamily Roles

Classic system of naming typical Classic system of naming typical responses to diseaseresponses to disease

All the roles:All the roles: Are rigidly held and are reinforced by other Are rigidly held and are reinforced by other

family membersfamily members Enable denial of alcoholismEnable denial of alcoholism Allow family to function as a unit, allows Allow family to function as a unit, allows

some individual function but NOT FULL some individual function but NOT FULL HEALTHHEALTH


Caretaker: usually adult, sometimes child Caretaker: usually adult, sometimes child – loses self in caring for others– loses self in caring for others

Hero – usually child who excelsHero – usually child who excels Reinforcement for achievement leads to Reinforcement for achievement leads to

narcissismnarcissism

Scapegoat – usually child identified as a Scapegoat – usually child identified as a problemproblem Carries the shame for the familyCarries the shame for the family


Mascot – creates diversion away from Mascot – creates diversion away from alcoholism. Usually a child.alcoholism. Usually a child.

Lost child – usually a child, is low Lost child – usually a child, is low maintenancemaintenance

Luthar et al., 2008Luthar et al., 2008

How does the FOO How does the FOO predict kids’ use?predict kids’ use?

Suburban, higher SES:Suburban, higher SES: Parents more tolerant of drug use than of Parents more tolerant of drug use than of

other non-acceptable behaviorsother non-acceptable behaviors Parents REALLY knowing what kids were Parents REALLY knowing what kids were

doing/where/with whom decreased usedoing/where/with whom decreased use ““Containment” – predictable consequences Containment” – predictable consequences

for behavior reduced usefor behavior reduced use

England, et al., 2008England, et al., 2008


Low SES:Low SES: Boys who have higher use later (20’s-30’s)Boys who have higher use later (20’s-30’s)

Higher alcohol use age 16Higher alcohol use age 16 Lower achievement scores age 12Lower achievement scores age 12 Maternal use age 16Maternal use age 16 Externalizing behaviors age 9Externalizing behaviors age 9

England, et al., 2008England, et al., 2008


Low SESLow SES Girls who use more later (20’s to 30’s):Girls who use more later (20’s to 30’s):

Drinking more age 16Drinking more age 16 Higher achievement age 12Higher achievement age 12

Doherty, et al., 2007Doherty, et al., 2007


Urban African AmericanUrban African American Both boys and girls: in families with more Both boys and girls: in families with more

rules about drug/alcohol use, less likely to rules about drug/alcohol use, less likely to initiate tobacco or alcoholinitiate tobacco or alcohol

Doherty, et al., 2007Doherty, et al., 2007


Urban African AmericanUrban African American Boys and marijuana:Boys and marijuana:

More likely to use than girls (1.5x)More likely to use than girls (1.5x) Female-headed household and rule-setting affect Female-headed household and rule-setting affect

useuse

Girls and marijuana:Girls and marijuana: Family cohesion reduces riskFamily cohesion reduces risk

Doherty, et at., 2007Doherty, et at., 2007


Urban African AmericanUrban African American Both genders:Both genders:

Physical and frequent discipline early increases Physical and frequent discipline early increases heroin and cocaineheroin and cocaine

Maternal substance use increases heroin and Maternal substance use increases heroin and cocainecocaine

Girls:Girls: More rules about drug use reduces risk of heroin More rules about drug use reduces risk of heroin

and cocaineand cocaine

How do genetics How do genetics contribute?contribute?

Unequivocal human and animal data to Unequivocal human and animal data to say there is a big genetic contribution say there is a big genetic contribution (50-60% of variance)(50-60% of variance)

Multi-geneMulti-gene

What genes might What genes might contribute?contribute?

Glutamate receptor genes (alcohol)Glutamate receptor genes (alcohol) Cannabanoid receptor gene (nicotine) Cannabanoid receptor gene (nicotine) Taq1 (alcohol, all addictions) – D2 Taq1 (alcohol, all addictions) – D2

receptor deficiencyreceptor deficiency ALD AST (alcohol)ALD AST (alcohol) NO ONE GENE DOES IT ALLNO ONE GENE DOES IT ALL

Kendler, et al. Arch Gen Psych, 2Kendler, et al. Arch Gen Psych, 2008008

How do genetics How do genetics contribute?contribute?

For initiation and early patterns of use of For initiation and early patterns of use of alcohol, cannabis, nicotine:alcohol, cannabis, nicotine:

Family and environmental effects more Family and environmental effects more important in early lifeimportant in early life

Genetic effects more influential laterGenetic effects more influential later

ReferencesReferences

E.E. Doherty, K. M. Green, H.S Reisinger, M.E. Ensminger. E.E. Doherty, K. M. Green, H.S Reisinger, M.E. Ensminger. Long-term patterns of drug use among an urban African-Long-term patterns of drug use among an urban African-American cohort: the role of gender and family American cohort: the role of gender and family Journal of Journal of Urban Health: Bulletin of the New York Academy of Urban Health: Bulletin of the New York Academy of Medicine Medicine 85:85:2, 20072, 2007

M.M. Englund, B. Egeland, E. M. Olivia, W. A. Collins. M.M. Englund, B. Egeland, E. M. Olivia, W. A. Collins. Childhood and adolescent predictors of heavy drinking and Childhood and adolescent predictors of heavy drinking and alcohol use disorders in early adulthood: a longitudinal alcohol use disorders in early adulthood: a longitudinal developmental analysis. developmental analysis. AddictionAddiction 103:103:supp. 1, 2008supp. 1, 2008

S.S. Luthar, A.S. Goldstein. Substance use and related S.S. Luthar, A.S. Goldstein. Substance use and related behaviors among suburban late adolescents: The behaviors among suburban late adolescents: The importance of perceived parent containment importance of perceived parent containment Development Development and Psychopathologyand Psychopathology 20 20, 2008, 2008

ReferencesReferences

Kendler, K.S., E. Schmitt, S.H. Aggren, Kendler, K.S., E. Schmitt, S.H. Aggren, C. A. Prescott. Genetic and C. A. Prescott. Genetic and environmental influences on alcohol, environmental influences on alcohol, caffeine and nicotine use from early caffeine and nicotine use from early adolescence to middle adulthood. adolescence to middle adulthood. Archives of General Psychiatry, 65:674-Archives of General Psychiatry, 65:674-682.682.

family interactions margaret jarvis, md marworth geisinger health system

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