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). 

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