A stress coping model for conceptualizing the impact of substance abuse on families

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A Stress-Coping Model for Conceptualizing the Impact of Substance Abuse on Families Samuel A. MacMaster

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University of Tennessee, College of Social Work , Nashville, Tennessee, USA Published online: 25 Jan 2007.

To cite this article: Samuel A. MacMaster (2006) A Stress-Coping Model for Conceptualizing the Impact of Substance Abuse on Families, Stress, Trauma, and Crisis: An International Journal, 9:2, 119-137, DOI: 10.1080/15434610500406327 To link to this article: http://dx.doi.org/10.1080/15434610500406327

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Stress, Trauma, and Crisis, 9:119!137, 2006 Copyright # Taylor & Francis Group, LLC ISSN: 1543-4613 print/1543-4591 online DOI: 10.1080/15434610500406327

A Stress-Coping Model for Conceptualizing the Impact of Substance Abuse on Families SAMUEL A. MACMASTER Downloaded by [University of Tennessee, Knoxville] at 10:39 16 April 2015

University of Tennessee, College of Social Work, Nashville, Tennessee, USA

Substance abuse can have such a destructive impact on a family that it can both interrupt and transform the entire family’s life.

The impact of chronic illness on the family has been researched primarily from a stress-coping paradigm. Within the mental health literature, the impact of one family member’s mental illness on other family members has begun to be investigated in a systematic and scientific manner. Within a stress-coping paradigm, the results of this empirical research have borne out the tremendous objective and subjective burdens placed on family caregivers (Biegel, Song, and Chakravarthy, 1994; Lefley, 1996). This article suggests that the impact of substance abuse on families may also be conceptualized within this paradigm and posits an evidence-based stress-coping model for conceptualizing this process.

KEYWORDS families, stress-coping, substance use

While the impact of chronic illness on the family has been researched primarily from a stress-coping paradigm, the same is not true for families of substance users. Although the impact on family caregivers due to mental illness in any family member would appear to be obvious, it has only been a recent phenomenon that these changes have been investigated in a systematic and scientific manner. This paper therefore suggests the use of a stress-coping paradigm when viewing families of substance users and presents a specific evidence-based stress-coping model.

Address correspondence to Samuel MacMaster, University of Tennessee, College of Social Work, 193E Polk Ave., Nashville, TN 37210. E-mail: smacmast@utk.edu 119

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THE IMPACT OF SUBSTANCE ABUSE ON FAMILIES A significant amount of literature has examined the impact of substance abuse and chemical dependency on the family. Wives of alcoholics have been extensively studied (Asher, 1992; Troise, 1992), as have spouses in general (Favornini, 1995; Isaacson, 1991; Jackson, 1954, 1988; Jacobs & Seilhamer, 1987), children (Lyon & Greenberg, 1991; Wotitz, 1983), and even grandchildren (Guebaly & Offord, 1977; Rice, 1996). Most of the work presented in the literature on families of persons with substance abuse disorders has been theoretical or based on clinical practice experience (Miller, 1995). However, there is a smaller subset of studies that are empirically based and use a scientific approach to arrive at their conclusions. These studies have primarily used stress-based theories and samples of spouses. These studies have focused primarily on measuring either the psychological impact of a family member’s substance abuse, specifically increases in stress, depression and anxiety (Finney, Moos, Cronkite, & Gamble, 1983; Hill, 1949; Jackson, 1954; Jacobs & Seilhamer, 1987; Kogan & Jackson, 1964; Moos, Bromet, Tsu, & Moos, 1979; Moos, Finney, & Chan, 1981; Moos & Moos, 1984; Steinglass, Bennett, Wolin, & Reiss, 1987), as well as physical health status (Holder & Blase´, 1986; Holder & Hallan, 1986; McGann, 1990; Roberts & Brent, 1992; Ryan et al., 1997).

Findings of a psychological impact have been consistent despite varying methodologies. Early studies by Kogan and Jackson (1964) comparing the MMPI results of the wives of active alcoholics, the wives of inactive alcoholics, and the wives of non-alcoholics found significant differences which were attributed to the effects of increased stress related to the spouses’ drinking.

Similar studies comparing wives of alcohol abstaining men with alcoholism and wives of actively drinking men with alcoholism also found decreased psychopathology attributed to the decreased level of stress associated with alcohol abstinence (Bailey, 1967; Haberman, 1964). These results were also supported over time, as longitudinal studies of the spouses of individuals with alcoholism found less anxiety and depression in the spouse when the person with alcoholism was abstinent (Paolino, McGrady, Diamond, & Longbaugh, 1978). High levels of stress despite long-term abstinence on the part of the family member with the substance abuse problem have also been reported ( Jackson, 1954). Moos, Finney, and Gamble (1982) attribute this finding to the long-term nature of substance abuse and the chronicity of the stressors associated with it and question whether the impact is similar over time. Rudolf Moos and colleagues completed several studies in the early 1980s to lend support to their hypotheses. Moos, Finney, and Gamble compared spouses of individuals with alcoholism who were still drinking, spouses of persons without alcoholism, and spouses of individuals with alcoholism in remission. They found that those individuals in the first group

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had higher levels of stress, and experienced more mood and health-related dysfunction when compared to the other two groups. Moos and Moos (1981) compared the families of recovering alcoholics, the families of relapsed alcoholics, and a control group of one hundred and five families in the same community. These results bore out similar results, the spouses of the individuals who relapsed were under more stress and functioned less well, reported more depression, and experienced more disruption in their families than the other two groups. A multivariate analysis of the impact of seven variables on spouse functioning found that partner impairment was the most important factor in the variance in functioning (Finney et al., 1983). Steinglass et al. (1987) found results consistent with the other studies, with the corollary that there is significant variability from family to family.

Despite individual variation between families, there is clear support for the idea that spouses of actively drinking individuals fared the least well on comparisons of health outcomes.

THE STRESS-COPING PARADIGM The idea of stress and the impact of stress have been with humans since the beginning of time. Weiner (1994) suggests that Aristotle may have been the first person to clearly articulate this concept. However it is only within the last few centuries that humans have begun to conceptualize and study stress. The first recorded stress theorist was Charles Darwin who suggested the concept of stress as an organism’s struggle with the environment in competition with other organisms in order to survive. Outside forces causing a threat or challenge to the integrity and survival of a particular organism have generally been understood to be the concept of stress (Weiner, 1994). This concept became a theory through the experiments and works of Seyle (1936), Cannon (1929), and Bernard (1865). These three theorists conducted a series of experiments on animals that supported their belief in the biological effects of environmental stress on an organism.

Seyle (1936) was the first theorist to link stress with physical disease and ill health in human beings. There has been ample support for the link between stress and ill health either measured directly (Norman, McFarlane, & Streiner, 1985), or in exacerbating the effects of a pre-existing disease (McCabe, Schneiderman, Field, & Skyler, 1991). This link, however, is now not considered to be a direct link, but is instead effected by other social forces that allow the individual to adapt, or cope, to the stress. Rooted in the work of Emile Durkheim, the concept of social support is now considered to be integral to this process (Waltz, 1994). The model that puts these three concepts together, stressor, health impact, and mediation by social support to explain a human being’s response to the stressor has become known as the Stress-Coping Paradigm.

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This Stress-Coping Paradigm has been widely used to describe the coping behaviors of persons with their own severe health problems. These problems have included chronic physical health problems (Felton, Revenson, Hinrichsen, & Gregory, 1984; Zautre & Manne, 1992), mental health problems (Billings & Moos, 1984; Farhall & Gehrke, 1997; Moos, 1993), and substance abuse problems (Hawkins, 1992; Moos, 1993; Tucker, 1982). It has also been used to describe the impact of other environmental stress including coping after a divorce (Nelson, 1989), during a war (Milgram, 1993), with peer pressure exerted on adolescents to use substances (Wills, Vaccaro, & Benson, 1995), of workers with stressful jobs (Ramathan, 1995), and the daily decisions of very young children (Kliewer, Fearnow, & Walton, 1998). Proponents of the model suggest that it can be used to better understand coping under most life situations which produces measurable levels of stress (Moos, 1997).

Although the model appears to be relatively elastic and to have a multitude of applications it speaks specifically to the issues of the impact of a family members’ substance abuse on the other family members. Within the mental health literature there is empirical research utilizing this framework to explain the impact on a family of a relatives’ mental illness, and ultimately impact the delivery of appropriate services to both family members and individuals with mental illness.

Use of the Stress-Coping Paradigm within the Mental Health Literature Within the mental health field the application of the stress-coping model to the impact of a family members’ mental illness offers an explanation for the caregiving outcomes (Biegel, Song et al., 1994). Although primarily descriptive in nature and relying on case studies, research on the impact of a relative’s mental illness has been conducted for over forty years (Clausen & Yarrow, 1955; Hoenig & Hamilton, 1966). The important change in this research occurred with the application of the explanatory stress-coping model by Erickson (1968) to explain similarities he found between MMPI profiles of parents of persons with emotional disturbances and parents of persons with mental retardation. This was the first time someone had used a stress-related concept to explain the impact of mental illness on family caregivers. Other research followed with the use of similar stress-based conceptual models to describe the same phenomena (Miller & Kiern, 1978; Pearlin, Mullan, Semple, & Skaff, 1990).

Historically, it is important to point out that Erickson developed his hypothesis in reaction to other theorists that suggested all mental health problems originated with parents. This was an important change in the professional literature. Prior to Erickson’s work psychodynamic or Freudian theories were used to describe what was perceived to be family caregivers’ aberrant behaviors which were thought to cause and=or exacerbate the

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mental health problems of their family members. From Erickson’s perspective, the problems that family caregivers develop are a direct result of stress caused by their family members’ mental health problems and not caused by the family caregivers themselves. ‘‘One interpretation of these different test results has been that the clinical elevations [on the MMPI profiles] reflect the clinic parent’s personality problems that are contributory to the child’s aberrant behavior. Erickson, however, has posited the stress reaction hypothesis to account for the data by which the MMPI elevations are said to reflect the clinic parents’ pathological reactions to the presence of a disturbed child’’ (Miller & Keirn, 1978, p. 686).

Research in this vein has gone a long way in reducing stigma and blame for family caregivers and in improving services for mental health consumers and their families (Biegel, Farkas, & Flint, 1989; Biegel, Milligan, Putnam, & Song, 1994; Biegel, Sales, & Schultz, 1991; Bulgar, Wandersman, & Golman, 1993; Burns, Farmer, & Anglin, 1996; Doll, 1975; Doll, Thompson, & Lefton, 1976; Friesen, 1996; Hooyman & Gonyea, 1995; Noh & Avison, 1988; Potsazanik & Nelson, 1984).

Deinstitutionalization and the return to the community of individuals with severe mental illness have also contributed to these changes (Hollingsworth, 1994). Families are now seen as possible sources of strength and support for individuals suffering from mental illness rather than as a casual factor in the development or exacerbation of the illness. This has been brought about in part by the return to the community during deinstitutionalization and the related need for family caregivers to help to provide care for their family members (Solomon, 1994). These duties have brought additional stress and burden on these families members as they provide this care. It is this ‘‘caregiver burden’’ and its impact on family caregivers that these studies investigate (Biegel et al., 1989; Biegel, Milligan, Putnam, & Song, 1994; Biegel et al., 1991; Bulgar et al., 1993; Burns et al., 1998; Doll, 1975; Doll et al., 1976; Friesen, 1996; Hooyman & Gonyea, 1995; Noh & Avison, 1988; Potasznik & Nelson, 1984; Tessler & Gamanche, 1994).

Use of the Stress-Coping Paradigm in the Substance Abuse Literature Within this literature base stress based coping paradigms have been used to conceptualize the impact of a relative’s substance use on other family members. A significant portion of the literature discusses co-alcoholism and enabling behaviors in terms of a reaction to the stress brought on by alcoholism in another family member. Although the specific concept of burden is not used, many phenomenon often associated with burden are incorporated into these studies. Issues such as financial problems, increased stress, social stigma, depression, anxiety, are measured or discussed. (Finney et al., 1983; Jackson, 1954; Jacobs & Seilhamer, 1987; Kogan & Jackson, 1964; Moos et al., 1979; Moos et al., 1981; Moos & Moos, 1984).

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Within this model, the drinking and related behaviors in a family member increase the stress in the drinker’s family members. This stress, in turn, has an impact on family members both in the behaviors they use to cope with the drinker’s use and behavior and directly impacts their physical and mental health. There has been some empirical support in the alcohol and other drug abuse literature of the effects of stress on family caregivers by another family member’s alcoholism or drug abuse (Bailey, 1967; Finney et al., 1983; Haberman, 1964; Jackson, 1954; Kogan & Jackson, 1964; Moos et al., 1982; Moos & Moos, 1981; Paolino et al., 1978; Steinglass et al., 1987).

The stress reaction hypothesis was applied to the wives of men with alcohol problems in several early studies. These studies used measures of psychological functioning as the outcome variable (Bailey, 1967; Haberman, 1964; Jackson, 1962; Kogan & Jackson, 1964; Moos et al., 1982; Paolino et al., 1978). Moos and colleagues completed several studies in the early 1980s based on the stress reaction hypothesis and used both measures of psychological functioning as well as measures of physical health, family disruption and overall functioning as outcome measures (Finney et al., 1983; Moos et al., 1982; Moos & Moos, 1981). In a theoretical discussion of these results Cronkite, Finney, Nekich, & Moos (1990) report that the results of their studies are consistent with the stress-coping paradigm and run counter to the competing personality deficit models. Their findings of comparable functioning and stress levels between the groups of spouses when alcoholism was in remission, and the drop in functioning and rise in stress when the spouse returned to drinking were used to support these contentions.

AN EVIDENCE-BASED STRESS-COPING MODEL There have been several empirical studies within the mental health literature utilizing stress-related theories (Biegel et al., 1989; Biegel, Milligan et al., 1994; Biegel et al., 1991; Bulgar et al., 1993; Burns et al., 1996; Doll, 1975; Doll et al., 1976; Friesen, 1996; Hooyman & Gonyea, 1995; Noh & Avison, 1988; Potsazanik & Nelson, 1984). The substance abuse literature has also used these theories (Finney et al., 1983; Jackson, 1954; Jacobs & Seilhamer, 1987; Kogan & Jackson, 1964; Moos et al., 1979; Moos et al., 1981; Moos & Moos, 1984). Each of the independent, dependent and conditioning variables chosen for inclusion in this conceptual model have been tested in prior research with various populations of individuals with family members with mental illness and=or substance abuse problems.

The specifics of the proposed model are based on the work of Biegel et al. (1991). This model is in turn, based on their review of the theoretical and empirical literature on caregiving in chronic illness. Included in this model are elements of the standard ABCX model (Hill, 1949), and later adaptations of this model into the caregiver stress-coping model as it relates to caregiving

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FIGURE 1 Conceptual stress-coping model. Based on the work of Biegel, Sales, and Schulz (1991) whose framework is based on the works of Hill (1949), House (1974), and George (1980).

in physical health care by House (1974) and George (1980). Within Biegel et al.’s (1991) model, the stressor of the illness characteristics and symptomatology of the family member with dual-diagnosis is used. The impact of the perceived stress is understood in this study as the level of perceived burden on the family caregiver. The enduring outcomes measured in this study are the level of caregiver depression and anxiety, and the caregivers’ physical health perceptions. This application also includes the conditioning variables of social support, service use and relationships with professionals, which buffer the impact of the stressors on the caregiving burden and the caregiving burden’s impact on the enduring outcomes.

The central concept of this framework when applied to substance use is that the existence of substance abuse in any family member serves as a source of stress to the family caregivers, which in turn has an impact on their well-being. Within this framework (see Figure 1) the independent variables, or stressors, impact the dependent variable of perceived stress, which in turn leads to the dependent variables of the enduring outcomes. This model also provides for the inclusion of conditioning variables, which can affect the various processes.

Stressors The independent variable or stressors in this model are the level of symptomatology in the mental health consumer. Symptom and symptom-related behaviors are defined as any behavior that is related to an individual’s mental

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health or substance-abuse problems. Symptoms and symptom-related behaviors have been included in most explanatory models of caregiver burden for family caregivers with a relative with mental illness (Biegel et al., 1992; Hatfield, 1978; Lefley, 1987b; Maurin & Boyd, 1990; Noh & Turner, 1987; Thompson & Doll, 1982). Even from the earliest descriptive studies, it was generally assumed that the level and type of symptoms would have a negative impact on the other members of the family (Doll, 1976; Grad & Sainsbury, 1963, 1968; Hoenig & Hamilton, 1966).

More recent research has given empirical evidence to what was once assumed from clinical experience. Johnson (1994) reports that ‘‘There is one common feature [to burden research] the extent and degree of burden appears to be related to the amount of patient dysfunction’’ (p. 312). This variable has been empirically tested within the mental health literature and the relationship between symptomatology and perceived burden has been borne out (Burns et al., 1998; Cornwall & Scott, 1996; Greenberg, Kim, & Greenley, 1997; Mueser, Webb, Pfeiffer, & Gladis, 1996; Pickett, Cook, Cohler, & Solomon, 1997; Song, Biegel, & Milligan, 1997). The substance-abuse literature too has found a relationship between symptoms and stress in family caregivers (Bailey, 1967; Finney et al., 1983; Haberman, 1964; Jackson, 1962; Kogan & Jackson, 1964; Moos et al., 1982; Moos & Moos, 1981; Paolino et al., 1978).

The association between symptoms and burden is well documented in the literature, which show a clear and strong positive relationship between the two factors. Within the mental health literature, it is quite clear that some types of symptoms and illness characteristics are more burdensome to family caregivers than other types. Although symptomatology in general is related to burden, it is important to note that family caregivers particularly find violent and destructive behavior to be the most burdensome (Lefley, 1996; Torrey, 1994). A 1986 study of 1,156 National Alliance for the Mentally Ill (NAMI) members found that more than a third of these families (38%) were subjected to their family members’ violent or destructive behavior. The longterm impact of these behaviors was an increase in burden-related limits in social and recreational activities and increased worries (Swan & Lavitt, 1986). It is important to note that violent and destructive behaviors are characteristic of a minority of persons with mental illness, primarily those individuals with co-occurring substance-abuse disorders (Skinner, Steinwachs, & Kasper, 1992; Steadman et al., 1998). Although symptoms and illness characteristics in general affect families of persons with mental illness, those behaviors that appear to elicit a tremendous effect on a specific group of family caregivers relate directly to the substance use of their loved one.

Perceived Stress The stress-coping model suggests that the stressor of symptomatology will lead to the perception of stress of caregiver burden. Caregiver burden is

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defined as the emotional, social, and physical costs of caring for another person (Gubman & Tessler, 1987). By defining the concept in this manner, both objective and subjective burden is understood as one concept. This too is a direct and positive relationship. The higher the level of symptomatology, the higher the level of perceived burden among family caregivers of persons with a substance-use disorder. This relationship has been documented in the mental-health literature, as several empirical studies provide evidence of the relationship (Falloon, Graham-Hole, & Woodroffe, 1993; Solomon & Draine, 1995; Steuve, Vine, & Struening, 1997).

Enduring Outcomes Enduring outcomes, also known as caregiving endpoints, are described by Biegel, Sales, & Schultz (1991) as, ‘‘the prolonged or cumulative consequences of being exposed to the stresses of caregiving’’ (p. 54). In this model, caregiver burden can lead to the two outcome variables of decreased mental health status, (specifically depression and anxiety), and decreased physical health status. Depression is defined as the sense of sadness or despair often including a sense of hopelessness and poor self-worth (Andreasen, 1984).

Anxiety is defined as heightened musculoskeletal tension including reports of somatic tension and observable psychomotor manifestations (McNair, Lorr, & Doppelman, 1971). Likewise, physical health is defined as the individual’s perceptions of his or her well-being or physical health status.

There is considerable evidence of the relationship between high levels of perceived stress and these two outcomes in studies with many different types of stressors (Moos, 1997). Within the mental-health literature, several empirical studies have found specific and clear empirical support for the relationship between burden and mental-health consequences for family caregivers of persons with severe mental illness (Cornwall & Scott, 1996; Oldridge & Hughes, 1992; Song et al., 1997). The substance abuse literature too has found this connection (Bailey, 1967; Finney et al., 1983; Haberman, 1964; Jackson, 1962; Kogan & Jackson, 1964; Moos et al., 1982; Moos & Moos, 1981; Paolino et al., 1978). The impact of caregiver burden not only affects the family caregivers’ mental health, but also has a profound impact on physical health status. In surveys of family caregivers this relationship has been found to be associated with poorer self-reports of physical health within both literature bases (Finney et al., 1983; Gallagher & Mechanic, 1996; Greenberg et al., 1993; Lefley, 1987; Moos et al., 1982; Moos & Moos, 1981).

Conditioning Variables Conditioning variables are contextual or situational variables that contribute to caregiving outcomes (Biegel et al., 1991). Three variables in this equation serve as buffers to the effects of the stressor on burden, depression, anxiety,

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and physical health status. These three factors, which potentially reduce or increase the impact on family caregivers are social support, service use, and relationships with service providers.

Social support has always been considered to be part of this equation, having its earliest roots in the work of Durkheim (Waltz, 1994). Within this model, social support is defined as interactions, either emotional or taskoriented, with other individuals or groups that provide assistance and validation (Caplan, 1974). There is some evidence of the power of social support as a conditioning variable for the burden of caregiving for family caregivers of individuals with mental illness (Abramawitz & Coursey, 1989; Crotty & Kulys, 1986; Maurin & Boyd, 1990; Potasnik & Nelson, 1984; Solomon & Draine, 1995; Song et al., 1997; Singer, 1996). This can also be a negative relationship, increasing the effects of the stress, as insufficient social support or dissatisfaction with the support network has been found to have the opposite effect (Biegel et al., 1992; Song et al., 1997).

The second conditioning variable used in this model, service use by the caregiver, has also been found throughout the literature to be an important effect in this equation (Abramowitz & Courtney, 1989; Hatfield, 1987; Johnson, 1994; Lefley, 1996; Riesser, Minsky, & Schorske, 1991; Smith & Birchwood, 1987). Specific services that fall within this definition include: psycho-education, family consultation (supportive family counseling), family education, family support and advocacy groups, and interventions aimed at specific issues or populations (Solomon, 1998). Like the conditioning effects of social support, some types of service use (specifically psycho-educational interventions) can influence both the level of burden and the level of the caregivers’ outcomes. In addition, it also has a relationship with the amount of social support that caregivers receive. Several empirical studies bear out these results (Falloon et al., 1993; Guarancia, 1998; Medvane, Mendoza, Lin, & Harris, 1995; Pickett, Cook, & Heller, 1998).

The literature for family caregivers of persons with alcohol and drug problems has also discussed the conditioning variables of service use and social support. Al-Anon, the twelve-step support program for family members, has been given some attention in the literature. The majority of these studies did not investigate the impact of social support on stress, but simply described these programs (Ablon, 1974; Cutter & Cutter, 1987; Huppert, 1976; Jackson, 1954; Johnson, 1971; Reddy & McElfresh, 1978). Other researchers have completed surveys of Al-Anon members and noted that positive coping skills (Bailey, 1963, 1965; Edwards, Harvey, & Whitehead, 1973; Gorman & Rooney, 1979), increased self-esteem (Keinz, Schwartz, Trench, & Houlihan, 1995), and increased functioning (Friedman, 1996) were associated with involvement in the groups. A study looking specifically at this group and its effect on the stress levels of family members has been reported in the literature.

McBride (1991) conducted a survey investigating the relationship between stress and Al-Anon membership. Attendance of Al-Anon by family members

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by itself was not indicative of decreased reports of stress levels in the family member, but a longer duration of attendance and involvement were.

The third conditioning variable of relationships with professionals has also been shown to be important to this process. There are several studies that have described family caregivers’ frustrations with professionals (Biegel et al., 1992; Biegel et al., 1995; Hatfield, 1978, 1979; Holden & Lewine, 1982; Lefley & Johnson, 1990; Marsh, 1992; Solomon, 1994; Spaniol & Jung, 1983).

Although positive interactions with professionals can positively effect the equation, it like the other variables can have negative effects can for family caregivers. Lefley (1996) points out that ‘‘interactions and frustrations with the treatment system’’ (p. 65) can increase caregiver stress and ultimately have an impact on outcomes.

Although the majority of family caregivers report satisfaction with their relationships with professionals, a significant minority has voiced concerns about these relationships (Biegel et al., 1995; Tessler, Gamanche, & Fisher, 1991). Concerns about these relationships are both attitudinal, family caregivers do not want to be stigmatized by mental health professionals, and behavioral as family caregivers strongly desire ‘‘mutual working partnerships’’ with mental health professionals and are dissatisfied when these do not occur (McFarlane, 1994; Solomon, 1994). Some families often feel blamed by professionals for their relative’s illness (Bernheim, 1990; Lamb, 1990). Other family caregivers complain about the lack of practical information about their relatives’ illness and care (Biegel et al., 1995; Francell, Conn, & Gray, 1988; Hatfield, 1978, 1979; Holden & Lewine, 1982; Solomon, 1994). Families have reported that they feel that they become default case managers due to a lack of treatment monitoring by mental-health professionals (Spaniol, Zipple, & Fitzgerald, 1984). Other studies have reported that ethnicity, race, and the culture of the mental-health profession may play significant roles in these concerns (Biegel, Song, & Milligan, 1995; Solomon, 1998).

SUMMARY From all of this literature several broad ideas become clear. First the StressCoping Paradigm appears to be an adequate framework to conceptualize the impact of a family member’s alcohol or drug problems on family caregivers. Secondly this framework provides specific factors whose relationships can be measured: the independent variables of symptoms and illness characteristics; the conditioning variables of social support and service use; and the dependent variables of burden, and physical and mental well-being. These variables have been investigated in samples of family caregivers of individuals with mental illness and impacts to the dependent variables have been shown. Finally, this evidence suggests that this model may also be appropriately applied to family members of individuals with substance-use disorders.

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Such applications may improve services to both families and individuals living with substance-use disorders in the same manner that they have improved services for families and individuals with mental-health disorders.

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