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Effective Interventions Unit Supporting families and carers of drug users: A review

CHAPTER 3: THE IMPACT OF DRUG USE ON THOSE AROUNDFAMILIES AND CARERS

This Chapter sets out the evidence on the impact that drug use has on families, carers and significant others. It draws on a range of evidence, which includes the EIU literature review, the EIU qualitative study and the EIU conference survey.

1. Estimating the extent of the impact of drug use on families

Putting an exact figure on how many families and family members are affected by a relative's drug use is a difficult task. The hidden nature of drug use and the concealment of drug use by the family means that there is probably a large number of drug users and affected family members unknown to treatment and care services. Estimates of the extent of the problem can be made from a number of sources.

Present estimates of the levels of drug use within Scotland put 'problematic drug use' within the population at 55,800 (Hay et al, 2001). This figure refers strictly to those people using opiate and benzodiazepine drugs only. It is important to note that concern from families about a relative's drug use will often involve any illegal substance, including cocaine, ecstasy and cannabis. A recent report on psychostimulant drug use in Scotland identifies the small, but increasing, number of cocaine users in Scotland (SACDM Psychostimulants Working Group 2002).

Velleman (2002) makes the conservative assumption that 'every substance misuser will negatively affect at least two close family members' to a sufficient extent that they will require primary health care services. Therefore, it ismay be reasonable to estimate that the number of family members within Scotland affected in some way by a relative's drug use will be in excess of 100,000.

The precise number of family members, carers and significant others affected by drug use cannot be identified. Nonetheless, it is clear that the impact of any one individual's drug use can spread widely from close family members to friends, work colleagues and the wider community as a whole (see Figure 1).

Figure 1: The impact of drug use on families

2. The nature of the impact of drug use on families, carers and significant others

A consistent picture of the way drug use impacts on families emerges across the studies we carried out. The impact on families can be identified in four key areas:

• physical and psychological health
• family relationships
• finance and employment
• social life

Physical and psychological health

It was clear from across the studies that the experience of living with drug use in the family produces a great deal of stress leading to a range of physical and psychological health problems. The literature review identified research on short-term effects which include anxiety, guilt, loneliness, worry, fear and confusion. Longer-term effects include significant physical ailments such as shingles, ulcers, raised blood pressure and psychological problems such as depression, panic attacks and anxiety disorders.

Such problems were a common experience for respondents to the conference survey: over three quarters had experienced physical and psychological problems. The incidence of heart and stomach problems was highlighted in both the conference survey and qualitative study. Colds and flu were also attributed in the qualitative study to the strain felt by family members. Depression and anxiety were the most frequently mentioned psychological health problems from both the conference survey and qualitative study. The qualitative study also highlighted the emotional impact on carers, such as grandparents, due to their worry about the impact on children in the family.

Worryingly, the literature review also identified some research showing an increase in 'appetite-related behaviours' such as drug and alcohol use, eating and smoking among family members. The qualitative study also found this: some families admitting that one or both parents had started to drink heavily to cope with stress. The potential longer-term impact of such substance misuse on both physical and psychological health is clear.

Family relationships

The literature review identified how family dynamics can be affected by a relative's drug use. A common example of this is family members having to fulfill a role that differs to their position in the family. This situation occurs, for example, when grandparents take on the caring role for children of drug misusing parents or children have to take on parenting responsibilities for younger siblings or even for the drug using parents themselves.

The conference survey and qualitative study both highlighted the range of ways in which drug use can impact on the relationships between family members. This may vary depending on the degree to which the family is united about how to deal with the situation. But often often family members view the problem, and cope with it, differently and this will produce conflict not only with the drug user but also with each other. For example, the qualitative study highlighted that the attention given to the drug user can result in other family members feeling neglected or excluded. There can also be disagreement about how to treat the drug user. Attempts to try and maintain some sense of normality can result in some family members colluding with the drug user, and this may involve lying. These experiences are common: almost all respondents to the conference survey felt that relationships with immediate family members had been affected.

• increased arguments
• breakdown in communication
• increased tensions within the family

The qualitative study reported that in extreme cases, the stress had caused splits and rifts between families. For example, relationships between spouses/partners were so seriously affected that separation or divorce occurred.

Finance and employment

Financial problems and difficulties at work emerged as a common problem for families in both the qualitative study and the conference survey.

Financial difficulties arose both as a direct result of the drug user's behaviour and through families' attempts to help. The most frequently reported problems from both the conference

survey and qualitative study were:

• theft of money and possessions by the drug user
• repaying users' drug debts
• paying for rehabilitation treatment for the user
• costs associated with caring for dependants

The qualitative study reported examples where debt problems were compounded by parents purchasing drugs for the user themselves. They felt this was the only way to keep the drug user safe. Grandparents caring for grandchildren reported problems arising from child benefit books being held by loan sharks to cover debts incurred by the drug user.

The qualitative study reported some examples where financial difficulties were increased because family members had given up working. They felt unable to cope with the demands of work and the stress resulting from drug use in the family. Over half of the respondents to the conference survey had experienced difficulties at work because of the impact of drug use on the family. Problems included:

• being unable to concentrate at work
• having to take time off, due to their own health problems, or to care for the drug user, or other dependants
• being embarrassed that colleagues knew family circumstances
• reduced confidence in carrying out work

Social life

The qualitative study and conference survey highlighted that the difficulties associated with drug use in the family frequently had an impact on the social lives of family members. For some in the qualitative study, the stigma that can be associated with drug use and their own embarrassment about the situation had led to increased isolation from extended family and friends. For others, it was the practical demands of dealing with all the problems associated with drug use that had prevented them maintaining social contacts.

Over half of respondents to the conference survey reported problems with their social life. The most common issues they identified included:

• being alienated by family and friends
• being afraid to leave the drug user alone at home
• coping with the demands of looking after dependants
• feeling of being talked about by others
• having little energy to go out

(EIU conference survey)

3. Differences in impact

The discussion above identified where problems commonly occur in families of drug users. However, it should not be taken that this indicates that this range of problems impacts universally on all families of drug users. The qualitative study reported that family members felt that there was no single way in which families or family members were affected. The impact could be highly individualised.

The literature review similarly highlighted differences in impact:

• differences between family members
• differences in impact of different substances

Differences between family members

The literature review identified some research studies that treated the family as a single unit but highlights others that have examined the differential impact of drug use on family members depending on factors including:

• their role and position in the family
• their gender
• their relationship to the user

Examples from the review where there may be differences in the way drug use impacts upon individual family members include:

• parents are often initially more shocked than siblings who may already be aware of drug use.
• siblings may conceal the drug use to minimise the impact it can have upon parents and their reaction to the drug user. Siblings may also be resentful towards the drug user and the level of family attention that they receive, resulting in animosity and conflict. Evidence also suggests that siblings are more at risk of using drugs, in part relating to their increased chance of exposure to drug use.
• fathers can be less likely to seek support and will often reduce their relationship with the drug user and internalise their own needs.
• children of drug using parents can be at risk of receiving poorer physical, intellectual, emotional and social development. This can result in them being socially withdrawn, displaying aggressive and erratic behaviour, and displaying greater risk taking behaviour.
• partners/spouses may experience greater levels of verbal and physical abuse, mood swings and pressure for money from users.

The literature review points to a lack of research on different family structures and considers this an important area given that social change has led to increasing family diversity.

Ethnicity was rarely considered as contributing to a diversity of impact. Findings from the qualitative study suggest that the context of religion, custom and the perception of family life may be important factors affecting issues of shame and stigma in families from different ethnic minorities.

Differences in impact of different substances

The literature review also highlights that the use of different substances can be associated with very different impacts on the family. It identifies three factors:

• the social contexts associated with the substance use.
• the moral and social connotations of the substance user's behaviour, mood and physical health
• the effect of the substance on the user

The review highlights differences in family impact between drugs and alcohol. One clear example reported is that families of drug users often have to cope with stealing by the drug user. Families affected by alcohol problems do not report this problem. Across reviewed studies, families tended to want to deal with alcohol problems within the family but were more likely to look for formal help from services in the case of drug problems. The review also highlights differential family impact by different drugs. For example, one reviewed study showed that relatives of people addicted to tranquillisers experienced fewer problems than those associated with illegal drug use.

Stigma and shame continually appear to be significant factors for families and carers. There appears to be a greater stigma surrounding drug misuse than that associated with alcohol problems use.

There can be significant differences oin the traits one drug produces may have in comparison with another and how that may affect those around the drug user. Certain substances, in particular alcohol and benzodiazepines, are more associated with violence and aggression:n; other stimulant drugs such as amphetamines are associated with mental health problems such as paranoia and psychosis. This can have a direct effect on how a relative's drug use may impact upon the family and also on the needs they may have.

4. How do families respond to the stress associated with a relative's drug use?

Family members will respond to the negative impacts of drug use in a variety of ways. The response may, however, increase the problems experienced. Often it is not until behaviour is analysed that people see that they are employing methods of coping and that these can have positive and negative effects upon the individual, family members and drug user.

Often families go through a process where at first they may deny and refuse to acknowledge that there is a problem. Some family members may then attempt to conceal the drug use from others within the family in order to protect other family members or the drug user from the consequences of it being discovered. Many families will wish to conceal the drug use from others outside the immediate family because of the shame and stigma they experience. It may only be after a significant period that eventually the family may seek support and assistance (EIU literature review).

Ways that families respond to drug use include:

• Denial: The family denies there is a problem. This can be a viable response in avoiding confrontation, although its effectiveness is usually short-term. Long term denial tends to store up issues rather than addressing them which can result in greater upset and turbulence
• Self blame: The family takes responsibility for the situation; for example, parents blaming themselves for child's drug use. There is a danger that this is reinforced if family is regarded as part of the problem rather than the solution. This can be a substantial barrier to accessing support.
• Blame: The family assign responsibility for the situation to others: for example, drug user's peer group, social workers or drug workers for not 'solving' the problem. This can result in animosity and anger towards agencies. That makes it difficult for supportive relationships to be developed.
• 'Tough Love': Families can respond by creating distance between themselves and the drug user; either physically or emotionally. This can range from ensuring the family does not give in to pressure from the drug user, to extremes such as removing the drug user from the family home. This can demand a substantial amount of detachment from feelings that the family may have towards the drug user.

There are significant differences between alcohol and drugs in the stress and strain experienced by families coping with drug use because of illegality and associated criminality, level of stigma and level of guilt and shame felt by parents

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