Alcohol, Addiction and the Family -

Coping Strategies and Resilience

among Children affected by Parental
Alcohol Problems
Michael Klein
Katholische Hochschule North Rhine-
Westphalia (NRW), Köln
Catholic University of Applied Sciences
NRW, Cologne

Lecture at the Meeting of the Estonian Temperance Movement,

Tallinn, May 6th, 2009
 Part I

Introduction and Overview

The reality of children in families with
alcohol problems is full of stress
Many of these children
experience severe
problems of stress and
insecurity. In other cases
there also is violence and
abuse. The consequences
concerning development
are serious: There can
arise serious, long-lasting
psychological problems
from living in such
families. Living there can
be hard stress.
Children living with parents with alcohol
problems are the biggest risk group for
substance abuse problems in the future
 Direct and indirect effects of alcohol
on children

Direct (drug related) effects: Indirect effects:

• Family violence
• Impairment through • Broken home
fetal alcohol syndrome • Neglect, maltreatment, abuse
(FAS) • Social isolation, social descent
• Family distress
• Impairment through • Parental discord
alcohol intoxication • Negative family atmosphere
because of overdose
during childhood and • More negative (critical) life eve
youth • Achievement problems in schoo
• Other adverse childhood effects (A
 Health threats for children affected by
parental alcohol problems (ChAPAPs)

 There are 24.3% more hospital admissions

 The average duration of hospital treatments is
61.7% longer
 The overall treatment costs are 36.2% higher
(Woodside et al., 1993).
 Subjective health: 35.6% of children from
alcohol families report that they often feel sick
(control group: 15.9%) [Klein, 2003].
 Social and health policies for ChAPAPs

European Action Plan on Alcohol (1995):

1. All children and adolescents have the right to grow up

in an ecology where they are protected against all
negative consequences of alcohol use and alcohol
advertisements.
2. All citizens with alcohol problems and their relatives
have the right of access to therapy and help.

UN-Convention of children´s rights (1989):

The right to be protected against drugs (Art. 33)

Part II: Facts and data
 Facts and data
In Germany there are approximately 2,65 Million children of
parents with alcohol abuse and dependence and 40,000
children with a parent being drug addicted

In other words: one in seven children is affected

Every third child living in a family with alcohol problems
suffers from frequent physical violence (> 5 times/month)
(Klein & Zobel, 2001).
In addition, there are 2,200 children with FAS born each year

In EU-27 there are about 10 to 12 millions ChAPAPs affected

(estimation)
 Main characteristics experienced by
children of addicted parents:
Increased prevelance of …
 familial instability
 volatile family life

 uncontrollability of family life

 unpredictability of parental behavior

 violence (physical, emotional, sexual)

experienced as victim a/o witness

 child abuse, neglect, and

maltreatment
 critical life events (losses, injuries,

discontinuities)
Common theme: volatile parental behavior
Maria (5 years) from Finland
 Frequency of alcohol problems in parents

(N = 2427; Lifetime, %w; source: EDSP-

study; Lieb et al., 2003)
Either parent 22.5

Both parents 3.1

One parent 19.5

Father only 15.0

Mother only 4.4

0.0 10.0 20.0

 Children in Families with Alcohol Problems
Familial risk of transmission of alcohol disorders
 Homopathological risk of transmission of alcohol disorders

Parent with Diagnosis of Odds Odds

alcohol use descendents ratio ratio
disorder boys girls
only father alcohol 2.01 8.69
only mother dependence 3.29 15.94
Both 18.77 28.00

(Lachner & Wittchen, 1997)

 Is it risky to live in a family with
drug and alcohol problems?

There are increased risks among children

living with parents with drug a/o alcohol
problems for …

Drug and alcohol use disorders (OR = ca. 4.0 to 6.0)

Anxiety disorders (OR = ca. 2.0 to 3.0)
Affective disorders (depression) (OR = ca. 2.0 to 3.0)
Posttraumatic stress disorders [PTSD] (OR = ca. 5.0 to
16.8)
Parasuicidal tendencies and behaviors (OR = ca. 2.0 to
4.0)
[Sources: Klein, 2005; Lachner & Wittchen, 1997]
 Children in Families with Alcohol Problems.
Familial risk of etiology of drug dependence
[Lachner & Wittchen, 1997]

Parent with diagnosis odds ratio

alcohol use of
disorder offspring

only father drug 4.13

only mother dependenc 7.79
both parents e 16.68

N = 3029
 Children in Families with Alcohol Problems
(young adult ChAPAPs from clinical samples; N=428)
Violence experiences and risks (Klein & Zobel, 2001)

daily or regular N % N %
(>5 times/ ChAPAPs ChAPAPs non- non-
month) violence ChAPAPs ChAPAPs

physical violence 68 32.5 20 9.1

psychological 122 59.0 48 21.7

violence
 Violence in Families with Alcohol and Drug
Problems: Parents maltreating Children
(CTSPC-CA; N=19)

During the last year at least one incident of …

Scale (CTSPC-CA) Father against Mother against
child child
psychological aggression 58 % 68 %

light 37 % 32 %
physical heavy 16 % 16 %
violence
extreme 5% 16 %

European Project ALC-VIOL (Klein & Reuber, 2007)

Part III: Coping and Resilience
 Coping with familial alcohol problems (KIDCOPE)
[European ALC VIOL study; 2007]
Coping strategy frequency effectiveness

I wish, the situation never rank 1 rank 8

would have been there.
I try to feel better by spending rank 2 rank 1
time with others.
I wish, I could change things. rank 3 rank 11
I try to cope with the situation rank 4 rank 2
by doing something or talking
to somebody.
I try to calm myself. rank 5 rank 4
I try to do something like rank 6 rank 3
watching TV or playing in order
to forget.
 Protection (Velleman, 2007)
Protective Factors: There are Protective Factors as well
as Risk Factors.
In families with parental alcohol problems these include
 the provision of stability, time and attention from at

least one parent,

 the presence of a cohesive parental relationship with

overt parental affection,

 the retention of a cohesive set of family relationships

involving shared family activities and shared family

affection,
 the ability of the child(ren) to disengage from the

disruptive elements of their family lives,

 and the presence of significant external support

systems which provide the stability which may be

absent from their normal family life.
 Protection
There is a similar range of protective factors in the research
literature on domestic violence: adverse effects on children
are less likely when (Werner, 1986; Velleman, 2007):
 parental problems are not associated with family discord and
disorganisation;
 do not result in the family breaking up;

 when the other parent or another family member can

respond to the child’s developmental needs for security and
love (= buffering);
 and when the child has inner resources (such as a positive
sense of self esteem and self confidence, feeling in control
and capable of dealing with change), and has a range of
approaches for solving problems.
These are all traits fostered by secure, stable and affectionate
relationships and experiences of success and achievement.
 Resiliencies of ChAPAPs
Wolin & Wolin (1995) identified seven areas of
resiliencies, that can protect from the
transmsission of addictive and mental health
disorders:

 Suspicion, knowledge, insight

 Good relationship capacities, social network
 Independence, autonomy
 Initiative
 Creativity
 Humor
 Morale
Part IV: Intervention needs of children
living in families with alcohol
problems
 Structural aspects of the help system

Point of departure (current reality):

ChAPAPs

…do not get reliably and regularly help

and support
…are often overlooked, not recognized
…are an unpopular target group because
of their behavior and above all their
parent´s behavior
 Early intervention
Early intervention means:
to reduce the risks and costs of unfavorable
developmental processes.

Early intervention necessarily presupposes early

detection:

early detection comprises in any case diagnostics.

Methods of early detection are for example risk
screenings (of persons, in settings) and support
from neighbourhoods concerning child protection
for endangered children.
 Consequences and improvements
In order to help children affected by parental alcohol problems
the following measures are recommended:

(1) Early intervention (start early)

(2) Selective prevention (realize the risk adequately)
(3) Case management (work comprehensively and
continuously)
(4) Family counselling and therapy (see the whole family
system)
(5) Motivational Interviewing (addicted parents want to be
good parents, too)
(6) Resilience orientation (promote and increase resiliencies)
 Clinical Issues
Cutting Edge 2004
Palmerston North, New
Zealand
September 3, 2004

Joan E. Zweben, Ph.D.

Executive
Executive Director:
Director: EBCRP
EBCRP and
and 14
14thth Street
Street Clinic
Clinic
Clinical
Clinical Professor
Professor of Psychiatry;
Psychiatry; University
University ofof
California,
California, San
San Francisco
Francisco
 General Treatment
Considerations
 Need for realistic expectations
 Offer appropriate forms of hope to
counteract despair
 Accept chronicity of the disorder without
viewing self as a failure or using this as
an excuse
 Educate about other mental disorders as
well as AOD use
 Prioritizing Treatment Tasks

 Safety
 Stabilization
 Development/growth
 Maintenance of gains; relapse
prevention
Psychosocial Treatment Issues
 client attitudes/feelings about medication
 client attitude about having an illness
 other clients’ reactions: misinformation,
negative attitudes
 staff attitudes
 medication compliance
 control issues: whose client?
 History & Current Context
 patients referred from other services
with insufficient attention to motivation
 no specific arena to address
ambivalence
 “Wait until they are ready”
 AOD programs: discharge for non-
compliance with high expectations
 discovery that untreated substance
abuse is expensive
 Reasons to Resist an
Abstinence Commitment

 fear of failure
 addiction pattern in family of origin
 self medication
 trauma history
 survivor guilt
 Negotiating an Abstinence
Commitment
 Connect AOD use with presenting
complaints
 facilitate progress through initial
decision making phases of change
 blend careful inquiry, giving
information, gentle confrontation
 experiment with abstinence; sobriety
sampling
 enhance motivation, vs punish
ambivalence
 Motivational Enhancement
 Your relationship is a great asset, in
addition to your leverage
 Identify where people are on the
continuum of readiness to change and
move them forward
 Connect the pain in their life with AOD use
 Explore benefits and problems of AOD use
 Use forthright feedback that is not harsh
or punitive
 Offer options for change
 Confrontation
 Many practices are believed helpful
because we don’t follow our dropouts
 Firm feedback needed in supportive
atmosphere
 More disturbed clients are highly
vulnerable to aggressive exchanges
and become disorganized; they do
better with low levels of expressed
emotion
 Educate Clients about
Psychiatric Conditions
 The nature of common disorders;
usual course; prognosis
 Important factors: genetics,
traumatic and other stressors,
environment
 Recognizing warning signs
 Maximizing recovery potential
 Misunderstandings about medication
 Teamwork with your physician
 Barriers to Accessing Offsite
Psychiatric Services
 Distance, travel limitations
 Obstacle of enrolling in another
agency
 Stigma of mental illness
 Cost
 Fragmentation of clinical services
 Becoming accustomed to new staff
(COD TIP, in press)
 Prescribing Psychiatrist Onsite
 Brings diagnostic, behavioral and
medication services to the clients
 Psychiatrist learns about substance
abuse
 Case conferences, supervision allow
counselors to learn more about dx and
tx
 Better retention and outcomes
(COD TIP, in press)
 Attitudes and Feelings
about Medication
 shame
 feeling damaged
 needing a crutch; not strong enough
 “I’m not clean”
 anxiety about taking a pill to feel better
 “I must be crazy”
 medication is poison
 expecting instant results
 Medication Adherence
 important relationship to positive
treatment outcome
 reasons for non-compliance: denial of
illness, attitudes and feelings, side
effects, lack of support, other factors
 role of the counselor: periodic inquiry,
exploring charged issues, keeping
physician informed
 Work out teamwork, procedures with
docs
 Treating Co-
Occurring Mental
Disorders:
Depression & PTSD

Joan E. Zweben, Ph.D.

Executive
Executive Director:
Director: EBCRP
EBCRP and
and 14
14thth Street
Street Clinic
Clinic
Clinical
Clinical Professor
Professor of
of Psychiatry;
Psychiatry; University
University ofof California,
California,
San
San Francisco
Francisco
 Mood & Anxiety Disorders:
Counselor Recommendations
 Distinguish anxiety and mood
disorders from:
• Normal feelings in recovery
• Symptoms of severe mental illness
• Medical conditions
• Medication side effects
• Substance-induced changes
(COD TIP, in press)
 Mood & Anxiety Disorders:
Counselor Recommendations (2)
 Maintain calm demeanor, reassuring presence
 Teach deep breathing, relaxation
 Start low, go slow
 Respond immediately to any intensification of
symptoms
 Understand special sensitivities to social
situations
 Gradually introduce and teach skills for
participation in self-help groups
(COD TIP, in press)
 Suicidality
 AOD use is a major risk factor, especially for
young people
 Alcohol: associated with 25%-50%
 Alcohol & depression = increased risk
 Intoxication is associated with increased
violence, towards self and others
 High risk when relapse occurs after
substantial period of sobriety, especially if it
leads to financial or psychosocial loss
(COD TIP, in press)
 Suicidality:
Counselor Recommendations
 Treat all threats with seriousness
 Assess risk of self harm: Why now? Past

attempts, present plans, serious mental illness,

protective factors
 Develop safety and risk management process

 Avoid heavy reliance on “no suicide” contracts

 24 hour contact available until psychiatric help

can be obtained
Note: must have agency protocols in place
(COD TIP, in press)
 Elements of PTSD
• Acting or feeling as if the traumatic event
were recurring
• Intense psychological distress at exposure
to internal or external cues that symbolize
or resemble an aspect of the traumatic
event
• Physiological reactivity on exposure to
internal or external cues that symbolize or
resemble an aspect of the traumatic event
• Intrusion symptoms and/or numbing
symptoms
 Complex PTSD
Alterations in:
 Affect regulation

 Consciousness

 Self perception

 Perception of perpetrator

 Relations with others

 Systems of meaning
Treatment Issues
 Relationships between
Trauma and Substance
Traumatic experiences increase likelihood of

Abuseif PTSD develops
substance abuse, especially
 Childhood trauma increases risk of PTSD,
especially if it is multiple trauma
 Substance abuse increases the risk of
victimization
 Need for linkages between systems: medical,
shelters, social services, mental health,
criminal justice, addiction treatment (Zweben et al
1994)
 PTSD
Counselor Recommendations
 Identify clients who are high risk
 Develop a plan for increased safety
 Listen to behavior more than words
 Limit questioning about details of the trauma
 Help client de-escalate intense emotions
 Teach coping skills
 Prepare client for long term treatment
(COD TIP, in press)
 How PTSD Complicates
Recovery
More difficulty:
 establishing trusting therapeutic alliance

 obtaining abstinence commitment;

resistance to the idea that AOD use is

itself a problem
 establishing abstinence; flooding with

feelings and memories

 maintaining abstinence; greater relapse

vulnerability
 Impact of Physical/Sexual
Abuse on Treatment
Outcome
N=330; 26 outpatient programs; 61% women and 13% men
experienced sexual abuse
 abuse associated with more psychopathology for both;
sexual abuse has greater impact on women, physical abuse
has more impact on men
 psychopathology is typically associated with less favorable
tx outcomes, however:
 abused clients just as likely to participate in counseling,
complete tx and remain drug-free for 6 months post tx
(Gil Rivas et al 1997)
 How Substance Abuse
Complicates Resolution of
 early treatment goal:PTSD
establish safety (address
AOD use)
 early recovery: how to contain or express feelings
and memories without drinking/using
 firm foundation of abstinence needed to work on
resolving PTSD issues
 full awareness desirable, vs emotions altered by
AOD use
 relapse risk: AOD use possible when anxiety-laden
issues arise; must be immediately addressed
 Building a Foundation
BEWARE OF DOGMA
May need to work with client who continues to
drink or use for a long time
 avoid setting patient up for failure

 reduce safety hazards; contract about

dangerous behavior
 carefully assess skills for coping with feelings

and memories; work to develop them

Possible Meanings of Drug Use
in the Context of PTSD

 Access feelings and memories

 Shut off feelings and memories
 Revenge against the abuser
 Re-abuse of self
 Slow suicide
 Learned behavior
(Najavits, 2001)
 Trauma & Recovery:
Stages of Healing
“Recovery is based on the
empowerment of the survivor and
the creation of new connections.”
 Safety

 Mourning

 Reconnection
(Herman, 1992)
 Seeking Safety:
Early Treatment Stabilization
 25 sessions, group or individual format
 Safety is the priority of this first stage tx
 Treatment of PTSD and substance abuse are
integrated, not separate
 Restore ideals that have been lost
• Denial, lying, false self – to honesty
• Irresponsibility, impulsivity – to commitment
 Seeking Safety: (2)
 Four areas of focus:
• Cognitive
• Behavioral
• Interpersonal
• Case management
 Grounding exercise to detach from
emotional pain
 Attention to therapist processes:
balance praise and accountability;
notice therapists’ reactions
 Seeking Safety (3):
Goals
 Achieve abstinence from substances
 Eliminate self-harm
 Acquire trustworthy relationships
 Gain control over overwhelming symptoms
 Attain healthy self-care
 Remove self from dangerous situations (e.g.,
domestic abuse, unsafe sex)
(Najavits, 2002)
 Safe Coping Skills
 Ask for help
 Honesty
 Leave a bad scene
 Set a boundary
 When in doubt, do what is hardest
 Notice the choice point
 Pace yourself
 Seek understanding, not blame
 Create a new story for yourself
( from Handout in Najavits, 2002)
Detaching From Emotional
Pain:
Grounding
 Focusing out on external world - keep eyes
open, scan the room, name objects you see
 Describe an everyday activity in detail
 Run cool or warm water over your hands
 Plan a safe treat for yourself
 Carry a grounding object in your pocket to
touch when you feel triggered
 Use positive imagery
(Najavits, 2002)
 EMDR
Eye Movement Desensitization and
Reprocessing
 information processing model
 trauma “freezes” the system, preventing healthy
processing; intrusion & numbing symptoms result
 AOD use as numbing agent; chemical dissociation
 eye movements facilitate an altered state in which
traumatic experiences can be integrated in a new way
 support from controlled research
 EMDR: Basic Components

 the image
 the negative cognition

 the positive cognition

 the emotions and their level of

disturbance
 the physical sensations

Integrates cognitive, affective and physical

EMDR: Phases of Treatment
 Client history and treatment planning
 Preparation
 Assessment
 Desensitization
 Installation
 Body Scan
 Closure
 Reevaluation (Shapiro 1995)