Vicki L. Loyer, Ph.D., LMFT
First published in the Desert Leaf September 2016
"I don't know" statements spill into the room: an illness or addiction is unfolding. "I don't know really when it started, but I can tell you when I knew something was wrong."
The discussion starts with the ambiguity. The family members have searched for answers through numerous discussions. They can recount how the problem-though it may not yet be named-is affecting the system, where it is occurring, who is symptomatic, how long it has been going on, and how severe are its consequences. An assessment of these factors and others will help in identifying the problem and determining what level of treatment is needed and in what setting.
The onset of addiction or mental illness in a loved one is often subtle. The diagnosis is feared yet appreciated. The frustration of family members permeates the air, and the loved one struggles to find his or her own truth about the family's experience. Ambiguity-specifically, boundary ambiguity is the first issue to be managed in the treatment of mental illness and/or addiction. The family must take a risk and adopt a way to refer to "the problem."
This way of thinking about family issues when the condition of the loved one is unknown was developed by Dr. Pauline Boss, an emeritus professor at the University of Minnesota, and a researcher and pioneer in the field of family stress. Dr. Boss's research on the families of soldiers missing in action in Vietnam presented a unique insight into the heartbreak that results when families are facing the invisible. The essence of her findings is that for these families to be healthy they need to make decisions that create boundary clarity. For example, when a family member is ill or addicted, the rest of the family must "let go" of the ideal family member so they can accept the real family member. This concept is the basis for the often-heard aphorism "It is what it is."
Once the illness or addiction is severe, there is boundary clarity: the decision whether to have the loved one in a hospital, in outpatient treatment, or simply change behaviors, is fairly easy, and the agreement among family members increases dramatically. The standard questions they ask to reach their decision: Is their loved one in imminent danger to self or to others? Does this person's illness prevent her or him from being able to attend to her or his own care? When the answers to those questions are yes, the loved one is admitted to a level-one behavioral health hospital for observation and rapid stabilization (e.g., Banner-University Medicine Crisis Response Center, Palo Verde Behavioral Health, Sonora Behavioral Health).
Very early in the illness or addiction there is also boundary clarity: "If it isn't broken, don't fix it." The family member does strange things. Don't we all? The member sometimes uses poor judgment. Isn't that normal? The member is acting out of character. Is that still normal?
As the mental illness or addiction progresses, boundary clarity becomes boundary ambiguity. Family members anxiously search for answers without knowing the questions, while the member of concern often denies and blames others for the situation. There is often a rapid spiral of attachment attempts, response strategies, rumination, and an overwhelming accumulation of medical and legal bills. Episodes often end with trips to the doctor, the hospital, or the police. More frighteningly, if the member with the illness does not experience his or her own consequences, that person sees no reason to change their behavior. Family members become susceptible to stress related illnesses such as heart conditions, aches and pains, depression, strokes, and cancer.
In 1958, neuroscientist Joseph Brady conducted his Executive Monkey Study, in which one group of monkeys was subjected to regular electric shocks every 20 seconds for six-hour shifts, for 23 days. Another group, the "executive monkeys," could prevent the shocks by pressing a lever in each 20-second period. The executive monkeys died from stomach ulcers. Although there have been extensive debates about the credibility of the study and the true meaning of the results, Keith Payne in a Scientific American article (2013) summarized one possibly justified takeaway from the study: "If you are trying furiously to control a situation because you are terrified of what would happen if you don't, you are not really in control at all."
Family members of addicted or mentally ill loved ones work so hard to avoid the "shock" that they are much more likely to experience serious illness due to stress-related disorders than are others who are not under stress. Particularly in those first two years, when the family is questioning but much is unknown and invisible, family members remain in a state of hyper alertness. The evidence of the illness is uniquely exhibited in the interactions and transactions between the loved one and others in their family and community. Family members become more controlling, more unreasonable, and more frightened. They can become ill-exhibiting an acute stress disorder- as a consequence of their love for a family member who is spiraling into a very dangerous place.
Behaviors change one subtle, hardly noticeable step at a time. There are rarely big leaps into addiction or mental illness. What is clear is that family members have been keeping track. When the doctor asks, "What have you noticed?" The family readily re-creates a story from about two years prior to the situation "getting really bad." Cycles of behaviors and their length and severity are identified. The family's early attempts to control behavior might include crying, clinging, and protesting. As they try to solve problems, create solutions, and extract promises of change.
What can a family do? Observe.Calmly and lovingly inform the loved one of what they have noticed. Don't nag. Don't threaten. Don't soften the consequences. Be prepared with the names and phone numbers of professionals who can help. Engage in family therapy and learn to manage themselves and their stress.
If you and your family are looking for help with mental-health and/or addiction issues, there are organizations that provide information and support. Al-Anon is a free nonprofessional group of persons whose lives have been affected by a loved one's alcoholism (alanon. Org; 888-425-2666). The National Alliance for the Mentally Ill (NAMI) is a nonprofit organization for persons with mental illness and their families (nami.org). Be with others who can share their experience, strength, and hope. Loved ones are more successful in recovery when they have a family system of support. You can be that system when you are healthy. You are not alone.