A Literature Review of The Family Disease and Family Systems Models of Addiction Ashley Knerr University of Northern Iowa Abstract Introduction Substance use is an ongoing dilemma in society today

A Literature Review of The Family Disease and Family Systems Models of Addiction
Ashley Knerr
University of Northern Iowa

Abstract
Introduction
Substance use is an ongoing dilemma in society today. When one looks at substance use, they see a variety of things. Some people in society see the person as an “addict” or a “junkie”. They only see them for the person that they are on the outside, the disease they suffer from and the unruliness that they may cause in the neighborhood. Others see them as people that are struggling with some sort of issue and having difficulties in sorting it out. A person with a substance use disorder sees themselves in a lot of different lights, but they are much more focused on getting the high that they want. When society looks at a person with a substance use disorder, they struggle to think about the idea that this person has people that love them and are probably hurting. Clinicians who work with those with substance use disorders know and understand that there are a set of systems that interact with them. It is a piece to a puzzle of understanding the person, their addiction, and their social environments.
To better understand the world of systems and disease with addiction, this literature review collected articles regarding the Family Disease Model and the Family Systems Model. While the articles were difficult to find with these exact models listed, there were a number that presented with ideas that followed a similar pattern. Upon reviewing all of the articles that were found, there began to be a commonality with what they were being called. Both the Family Disease Model and the Family Systems Model were evaluated as Etiological Theories of addiction (Cox & Paley, 1997; Rotgers & Walters, 2011; Joanning, H., Mullen, R., Quinn, W., & Thomas, F., 1992; . This meaning that they theorized as being reasonings for the addictions. Upon further research, it was apparent that the Family Systems Model was more recognized when looking at family therapy and family in treatment options. Therefore, it was easier to find information regarding where this model came from. The review will have some minor underpinnings of the Family Disease Model, but it will focus primarily on the findings that occurred with the Family Systems research.
While reviewing information on Family Systems, the articles found contained various factors eight of them were informative about the model (Angres, D., & Angres, K., 2008; Bry, B., 1988; Bump, J., 1991; Cox & Paley, 1997; Csiernik, R., 2002; Koob, G., McLellan, A., & Volkow, N., 2016; Prest, L, & Protinsky, H., 1993; Rotgers & Walters, 2011;), three involved actual studies relating to the model (Feng, X., Slesnick, N., & Zhang, J., 2018; Joanning, H., Mullen, R., Quinn, W., & Thomas, F., 1992; Sheridan, M, 1995), and one had a study as well as provided useful information in studying the model (Edwards, D., Lewis, R.A., Sprenkle, D.H., & Volk, R., 1989). Some of the information in the articles went into detail about where it started, how it came about, and who used it, Whereas, others talked about the pros and cons of the model overall. The majority of them promoted the idea of family systems having a large impact on a person with the substance use disorder as well as family playing a key role in their treatment (Angres & Angres 2008; Bry, 1988; Bump, 1991; Cox & Paley, 1997; Csiernik, 2002; Koob, et al., 2016; Prest & Protinsky, 1993; Rotgers & Walters, 2011; Sheridan, 1995; Feng, et al., 2018; Joanning, et al., 1992),. The findings will be summed up in the literature review below.
Family Substance Abuse Models

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Family Disease Model
The articles that were found during the literature review did not go into great detail regarding how this model works and relates to substance use. However, various articles did touch base with some of the theories behind the Family Disease Model (Angres & Angres, 2008; Prest & Protinsky, 1993; Rotgers & Walters, 2011; Koob, et al., 2016). The basis of the Disease Model is that a number of people born into families with significant drug use or alcohol use histories have a predisposition to those addictions as well (Angres & Angres, 2008; Koob, et al, 2016). The research identified that the topics of discussion for the Family Disease Model are primarily codependency, substance use as a disease, and working with family members to identify what areas they need to work on (Rotgers & Walters, 2011). It is believed that Family Disease Model developed and came about at the same time as Alcoholics Anonymous (Rotgers & Walters, 2011). The theory began by looking at children of alcoholics and identifying the likelihood of them becoming alcoholics as well. Upon doing so, they recognized and developed the idea of codependency. This was created as a way for families to adapt to changes that they made over time in regards to someone in their family who had a substance use disorder. Often times, this would be found in the spouse of someone that was an alcoholic. This leads to the ideas of enabling others to help them feel okay as well as giving in when they want something. Eventually, the family begins to develop around the addiction instead of working to get rid of it (Rotgers & Walters, 2011; Prest & Protinsky, 1993).
Family Systems Model
Topics of Interest with the Family Systems Model
There were several more articles that covered Family Systems Model of treatment. These articles included informational articles (Csiernik, 2002; Sheridan, 1995; Rotgers & Walters, 2011; Prest & Protinsky, 1993; Bump, 1991; Cox & Paley, 1997; Bry, 1988) as well as particular studies that were done in relation to the model (Edwards, et al., 1989; Feng, et al., 2018; Joanning, et al., 1992). Family Systems Model began to influence the alcohol treatment world in the 1970’s. This began with the observation of alcoholics in treatment as they were interacting with their family. Upon watching the interactions, one of the doctor’s identified a clear difference between the interactions when the client was sober versus intoxicated. From there, it was gathered that alcohol could play a role in the ability for some to function as a true family. It can aid in the ability for one to speak about things that they would not speak about sober as well as complete actions that they would not do sober. The family had learned to function with the alcoholic behaviors and continued to the point of normalcy. Thus, it made it difficult when that client was sober, as the interactions needed new adjustments (Rotgers & Walters, 2011; Edwards, et al., 1989). From this, the Family Systems Model has grown to adapt further topics and areas of interest.
While reviewing the literature it appears that there are several main topics that are pertinent in the Family Systems Model these include family patterns (Csiernik, 2002; Rotgers & Walters, 2011; Prest & Protinsky, 1993; Bump, 1991; Cox & Paley, 1997; Bry, 1988; Edwards, et al., 1989; Feng, et al., 2018), family roles (Csiernik, 2002; Rotgers & Walters, 2011; Bump, 1991; Cox & Paley, 1997; Edwards, et al., 1989), boundaries (Rotgers & Walters, 2011; Cox & Paley, 1997; Bry, 1988; Edwards, et al., 1989), behaviors (Prest & Protinsky, 1993; Bump, 1991; Bry, 1988; Feng, et al, 2018), and homeostasis (Prest & Protinsky, 1993; Bump, 1991; Cox & Paley, 1997; Bry, 1988). These topics are areas that are evaluated in order to determine the impact that the substance user has on the family system as a whole, how it relates to the substance use, and what needs to be changed to assist the substance user and/or the family in making necessary changes.
The first topic of family patterns is one that was addressed in several articles(Csiernik, 2002; Rotgers & Walters, 2011; Prest & Protinsky, 1993; Bump, 1991; Cox & Paley, 1997; Bry, 1988; Edwards, et al., 1989; Feng, et al., 2018). This topic was described as evaluating the interactions with in the family to determine how the family works to balance various areas out. One article evaluated how these patterns can emerge. It identified that it can begin with the family subunits of spouses, parents, and siblings. From there, the system starts with the marital interaction. The appearance of this interaction will impact the other family relationships as the marital unit is how the children learn to interact with others and the family. Therefore, if there is dysfunction in the interactions between the parents, it is possible that this dysfunction can continue to the children as it is what they have adapted to being “normal interactions” CITATION. In Edwards, et al., (1989), he identified that there are times where adolescent substance use can be used as a deterrent from troubling marital interactions. The ability for one to focus on the child’s addiction, allows for the dysfunctional marital interaction to go potentially unnoticed. From there, it is possible that the family meshes various ideas, boundaries and roles within the system. This can mean that children take on parental roles such as cleaning, taking care of siblings, or managing dinner. It can also mean that they take responsibility for managing the parents. When working with a person with a substance use disorder who is working on making changes, it is necessary to identify the patterns within the system that impact them, to work on changing those patterns to accommodate them, and to work with the family through this adjustment during family therapy, role playing, and re-structuring (Bump, 1991; Cox ; Paley, 1997; Edwards, et al., 1989). Regardless of how the roles are impacted, addiction can play a significant roll in the changes and determination of what the family roles look like.
Family roles was the next most common topic of the Family Systems Theory (Csiernik, 2002; Rotgers ; Walters, 2011; Bump, 1991; Cox ; Paley, 1997; Edwards, et al., 1989). The primary roles that are associated in the articles are those of the roles of children in dysfunctional families. These include the mascot, the lost child, the hero, and the scapegoat. The mascot is the one that the family looks to help them get through the difficult times. They can often create humor and entertain people around them. The lost child is the one that tries to make themselves less noticeable when things aren’t going well or conflict comes up. They often feel that they are left out. The hero is the person in the family that works to make everything look normal and is deemed as doing everything the best that they can. Lastly, there is the scapegoat. This person is generally “the one that causes the problems” according to others in the family. They often are blamed for various situations or accused of doing something, regardless if they have actually done so (Rotgers & Walters, 2011; Csiernik, 2002). The other articles evaluate the roles of family members within the system and how it pertains to the stress that they endure, how the relationships have been built and the way that the subsystems interact with each other. Sometimes, one subsystem will take on the role of another (Cox & Paley, 1997; Bump, 1991). Also, there are times where the roles will begin to mesh together, where it becomes difficult to those outside of the home to identify where those relationships are or what they might look like (Edwards, et al., 1989). As a person with a substance use disorder works to make changes, it is necessary for the family to review the roles that everyone takes on and how they differ from what they should be. This would be an area that family therapy or family involvement in treatment could work on accomplishing (Csiernik, 2002; Rotgers & Walters, 2011; Bump, 1991; Cox & Paley, 1997; Edwards, et al., 1989). Each family supports their roles in various ways, however, they are usually outlined based on boundaries that are placed within the families.
In the case of the Family Systems Model and boundaries, there are times where the boundaries tend to be a bit blurred, meshed, or unknown (Rotgers & Walters, 2011; Cox & Paley, 1997; Bry, 1988; Edwards, et al., 1989). Most families have their subsystems divided by boundaries, based on what various subsystems can do, can talk about, can work through together, their basic roles, etc. This line can be blurred when looking at a family that has been impacted by addiction. One of these blurred lines generally is the generational boundaries. There are often times where one parent may be over involved, while another is no involved enough. This causes a strain on one relationship as they try to commit to boundaries, while another allows for them to blur (Edwards, et al., 1989). It is important for children to have boundaries and to understand their role as children, to be able to leave adult situations for the adults to work through. This can also be seen when parents try to become friends rather than parents with their children. With addiction potentially being passed from generation to generation, it is not uncommon for one parent to become the person that their child uses with. When this occurs, it removes majority of the boundaries as they are now seen as equal and working for the same purpose with one another. When someone with a substance use disorder is working on making changes, it is necessary for the family to understand changes in boundaries, limits that need set, and roles that should not be meshed (Rotgers & Walters, 2011; Cox & Paley, 1997; Bry, 1988; Edwards, et al., 1989). When boundaries get blurred within the family system, it means that there are probably problematic behaviors occurring as well.
The next topic that was mentioned with the Family Systems Model was individual and family behaviors (Prest & Potinsky, 1993; Bump, 1991; Bry, 1988; Feng, et al., 2018). This often refers back to the family patterns and behaviors. However, this is generally looked at in more of a cyclic manner. When a member of the family presents various behaviors, it is seen by other family members and potentially passed on to them as well. This behavior pattern could then potentially continued to be passed on until someone worked to change the patterns of behavior and the results that occur with it, essentially “breaking the cycle”. When working with people who have substance use disorders who are working to make changes, it would be essential for the family to look at their current behavior and identify if there are any changes that need to be made or adjusted. This would be an area for family therapy to focus and assist the family in doing (Prest & Potinsky, 1993; Bump, 1991; Bry, 1988; Feng, et al., 2018). Family behaviors relate to the homeostasis of a family as well and their ability to adapt.
Homeostasis is the last area that was brought up in a number of the articles (Prest & Protinsky, 1993; Bump, 1991; Cox & Paley, 1997; Bry, 1988). Homeostasis within a family would refer to their ability to maintain stability within the family unit. This can be difficult for a family that is seen as dysfunctional, with illogical roles and a lack of boundaries. The ability for the family to find homeostasis in this kind of atmosphere is through adjusting to meet the areas that are not being met, as they should, in some other way. This is where roles can change hands, boundaries become blurred, and patterns emerge. When a family has found homeostasis in this manner, they have developed a routine and a pattern response to behaviors. Therefore, the Family Systems Model would identify that if the person with the substance use disorder changes their role and behavior patterns, the rest of the family would need to adjust for this as well. This can be a difficult task and often a focus of therapy for families moving forward after addiction (Prest & Protinsky, 1993; Bump, 1991; Cox & Paley, 1997; Bry, 1988).
Other areas that are brought forth in the articles include the 12 steps in correlation with family (Csiernik, 2002), abuse/neglect (Sheridan, 1995), positive functioning of substance use disorder (Rotgers & Walters, 2011; Edwards, et al., 1989), rituals (Rotgers & Walters, 2011), and Communication (Rotgers & Walters, 2011, Bry, 1988). These topics are generally described in these articles, but they can be related back to the topics that have already been described under the other topics. These are areas that family systems impact in general and the patterns that are displayed play a role in making them occur, making the successful, and making changes.
The Family Systems Model can be used in a variety of areas besides substance use. This was just the area that was chosen for this literature review in particular. After reviewing the information, the Family Systems Model demonstrates a way to assess the needs of a family, understand their overall interactions, pick up patterns, and gather the best way to approach the situation. When one has a better understanding of all of the areas mentioned above, it allows for one to potentially understand where to start working on substance use interventions, family therapy interventions, and sometimes trauma interventions as well. The articles provided a substantial outline to what the family system looks like and the areas that can be evaluated when picking apart a situations (Csiernik, 2002; Rotgers & Walters, 2011; Prest & Protinsky, 1993; Bump, 1991; Cox & Paley, 1997; Bry, 1988; Edwards, et al., 1989; Feng, et al., 2018; Sheridan, 1995).
Studies Provided in Correlation with the Family Systems Model
There were three studies that were found while looking at literature dedicated to the Family Systems Model, two of the studies were conducted in treatment centers (Edwards, et al., 1989; Feng, et al., 2018). Each of the studies has their own overall dynamics and area of focus within the Family Systems Model.
One study focused on the differences between Family Systems Therapy, Group Therapy and Family Drug Education (Joanning, et al., 1992). There were 82 families involved in this study with at least one parent and one child the used substances. It was primarily Caucasian families. One quarter of the families were single parent households. The Family Systems Therapy consisted of Structural and Strategic Family Therapy. The group therapy worked on social skills and roles. The drug education area presented various educational topics. While conducting one of the various forms of treatment, the participants were required to evaluate their family and overall relationships with various assessments before and after treatment. The results of the study were difficult for them to gather definite information from. There were only 34 families left to talk to at follow-up making it difficult to identify conclusions. However, the study did identify that the Family Systems Approach showed promise and did appear to be effective in dropping problematic behavior and drug use with adolescents (Joanning, et al., 1992).
The second study conducted evaluated mothers with substance use disorder at a treatment center. The mothers were required to have at least one biological child. This group was a mix of Caucasian and African American. The groups were all committed to treatment as usual. However, there was another group that completed Family Systems Therapy as well, more specifically Ecologically Based Family Therapy. This therapy worked on evaluating patterns that were unhealthy to work on better problem-solving and relationship building between the mother and the child. This demonstrated significant change in substance use as well as psychological control. There was a decrease in the children’s problematic behavior as the mother changed her way of thinking and adapted to having more control in the situation. The study evaluated that there is also a higher retention to those that were in treatment and completing the Family Systems Therapy at the same time (Feng, et al., 2018).
The third study that was conducted evaluated a set of adolescents that were in a treatment program in Indiana. There were 118 males and thirty females, 135 mothers and 68 fathers, with fewer than five percent being non-Caucasian. On top of the rehab program that they were completing, they were required to complete various family assessment that included self-reports measures, tests, and video problem-solving. These were compared to those in a control group. There were hypotheses that were made regarding how the family was viewed from within themselves including being more rigid and more enmeshed in their boundaries, which were based off of more clinical reports. This turned out not to be the case. The study did identify that those within the family system often viewed their thoughts on their family different from that of outsiders due to various reasoning, including stress with the parents versus the children feeling misunderstood (Edwards, et al., 1989).
The three studies that were found in this literature review draw from various areas of the Family Systems Model. It does identify and show that when family is involved, there can be a change in substance use and behaviors, regardless of who is using the substances (Joanning, 1992; Feng, et al., 2008). It also demonstrates the ability for the Family Systems Therapy to be adapted in various ways from the use of assessments to Ecologically Based Family Therapy (Joanning, 1992; Feng, et al., 2008; Edwards, et al., 1989). As all of these articles stated, it is difficult to find empirically researched data on Family Systems Theory, most of it, including in these studies, is based off of clinical information that was gathered (Joanning, 1992; Feng, et al., 2008; Edwards, et al., 1989).
Conclusions

Critical Review
Strengths
The articles that were found for both the Family Disease Model and the Family Systems Model provided a good understanding of what they were, how they are used, and what they entail. It is clear that the Family Systems Model has been reviewed and written about more clearly over time from the articles that were found. The detail that the articles go into for Family Systems provide a clear background, understanding, and support for the family systems idea. They also demonstrate why they are useful and how they pertain to addiction within families. The studies that were provided demonstrated the wide variations that Family Systems can cover when working with substance use, in assessment and treatment. This allowed for a deeper look at the overall model that you wouldn’t get from just informational articles.
Limitations
The biggest limitation that I found while looking through the articles is the lack of empirical studies that have been conducted with this models. It would appear that some of this has to do with them being Etiological Theories in regards to substance use and other disorders. However, it is difficult to get an understanding of how this looks in actual clinical settings if one cannot understand what it looks like in studies. It would be beneficial to be provided with examples of the Family Disease Model and how one might use this in a clinical session compared to the Family Systems Approach of things. However, there was nothing that could be found on this topic.
Gaps in Literature
There were several areas that could be perceived as gaps in literature. The two biggest areas that I can think of come from the lack of studies as well as the lack of more recent information. I was only able to find five sources that occurred since the year 2000. The articles before this identify how these are areas that need to be looked at when someone is evaluating substance use and its impact on the people around that person. However, there is no ongoing proof that they are substantial in treatment modalities or clinical assessments. This would explain why it was a topic that was unknown while looking through it in class as well.
Implications of Practice
The information and studies that were provided created more of an outlook on how Family Systems and the Family Disease Model can impact assessments as well as sessions in treatment. These areas are impactful when analyzing how a family interacts, how their patterns are created, what behaviors they have, and what roles they take on. Understanding these areas are not only significant to assessing families, but they are important when working to understand people. Without understanding how the family system interacts within itself or with other systems, there could be pieces to the puzzle that are left unreviewed or trauma that is missed that needs to be looked at. There could also be significant areas of the family that need to change for one to be successful when working to come off of a substance, to build their supports, or to gain a clear understanding of what they want and who they are.
Conclusion and Summary

References
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