We all know that substance use disorders can exact a terrible emotional and physical toll on the person struggling. A person overusing substances can suffer lower quality of life, impaired functioning at work, school and in family roles, and financial, legal and health problems. What you may not realize is that a significant part of this pain is attributable to stigma, as people with substance problems are labeled all sorts of negative things (“liars,” “losers,” “junkies,” “addicts”) and are often judged to be immoral, full of character defects and somehow carelessly and even willfully deciding to use substances instead of prioritizing more valued things in life like relationships and productivity. When you add higher rates of sexually transmitted disease, unemployment, co-occurring mental health issues, domestic violence, broken families, and racism, the weight of stigma is compounded. People with substance use problems are at a minimum avoided, insulted, or misunderstood and worse, they are discriminated against, jailed, and abandoned. Thankfully in recent years there has been a push on a national level to reduce the shame and stigma associated with substance use problems and progress is being made.

What you may not realize however, is that the families of people who struggle with substance use problems also face stigma by association, which is essentially guilt by association. There are approximately 21.5 million people in the United States who have substance use disorders, and estimates are that for every one of them, at least one family member and as many as five other individuals are negatively impacted in a variety of ways, one of which is the negative impact of stigma.

Stigma and the Family

By being in a relationship with a person with a drug or alcohol problem, family members are also looked at by others through the lens of stigma. Research shows that they are often blamed as the cause of the problem, or the reason the problem is not resolving (Corrigan and Miller, 2004; McCann and Lubman, 2018) and often judged as incompetent. They often suffer in silence as they hear people talk about substance users—people they love, care for, and identify with—in derogatory ways. A large survey of US health consumers found that 80% had overheard hurtful or offensive comments about mental illness (Wahl, 1999) and as we have already noted, the labels for people who abuse substances are particularly caustic.

Family members who are worried about a loved one struggling with substances are often emotionally overwhelmed with fear, anger, disappointment and confusion. They are often distracted or in constant crisis management mode. And when they are brave enough to ask for help or talk about the problems they face, they often get admonishment (“you are doing too much” or “you need to stop enabling him”) or advice that runs counter to their values and goals (“kick them out,” “cut them off,” “let them hit rock bottom”). They are labeled with the disease of “codependency” and are assumed, often by treatment providers, to have “bad boundaries,” to live in “denial” and derive their self-esteem from “rescuing” their loved one. The solution, they are often told, is that they need to attend Al-anon meetings in order to change. Whether they are talking to other well-meaning friends and family or treatment providers, the message they get comes through loud and clear: you are doing something wrong; you are too lax, too strict, too involved, and the list goes on.

Many family members also face the added stigma of being involved in the criminal justice system since 65% of the 2.3 million people incarcerated in the United States meet criteria for a substance use disorder (CASA, 2010). There is a significant chance that a person with a substance use disorder will interact with the legal system, possibly go to jail, and in the process be stigmatized for their substance use problem and their history of incarceration. The family will share in all this stigma as they have to live with other people’s assumptions about their loved one.

The Impact of Stigma on Family Members

Family members often agonize about the impact of gossip, “What will people think?” and “How will our family be treated?” and doubt themselves. Parents of children using substances are perhaps hit hardest as they often think, “Maybe I am a bad parent.” Unfortunately all of this blame and internalized stigma and shame lead to a reluctance to ask for support or help in helping their loved one. The terrible shame in all of this is that research has shown repeatedly that family members can play a critical role in change, by supporting and advocating on behalf of their loved one (Copello et al., 2009; Orford et al., 2013) and helping facilitate better engagement with treatment (Roozen et al., 2010, Myers and Wolfe, 2004).

What we don’t talk about enough is the reality is that it is normal to try and be helpful when someone you love is hurting themselves. It’s normal to want to protect people we love from consequences of their behavior, especially when the outcome might be public humiliation, shame and even incarceration or death. For example, parents may minimize or hide their child’s substance problem if they fear the child will be treated differently at school or may not get into the school of their choice. Spouses may try to ignore or even help cover up a problem because the whole household depends on the substance user not losing her job. It’s also normal to be anxious, and distrustful of others when you hear the way other people talk about a person who struggles with their use of substances. And, just as substance users resist treatment because they don’t want to be labeled an “alcoholic” or “addict,” family members understandably want to avoid the label of “codependent” or “enabler.” And as humans, it’s normal to hope against hope that things aren’t as bad as they look.

Changing the Conversation

If someone in the family has a non-stigmatized illness like cancer, other people volunteer to help with household chores, bring food, or offer emotional support. There is often a sense of a community that can “rally around.” The family doesn’t get avoided or blamed for the problem and their judgement is not immediately questioned. Why is it that when a child is struggling with substance use, their parents feel like “bad parents” rather than “pillars of strength” supporting a child through a life-threatening struggle. Why does a child of someone struggling with substance use feel the profound need to hide and overcompensate for their parent instead of being able to ask for help? Why is it that they often know on a profound level that their parent is more likely to be punished than helped?
The science is in and we all need to pay attention. Instead of blaming families as part of the problem, families should be seen as sources of strength and understanding, and valued as key motivators of change!