When Substance Use Is the Symptom We Can See

When substance use enters a family, something fairly predictable can happen: attention begins to organize around the person who is drinking or using. Family members may begin thinking, She needs to stop drinking. He needs to get sober. If they would just get help, perhaps things could finally return to normal.

Sometimes that focus is entirely warranted. Substance use disorders can profoundly affect families, contributing to broken trust, financial instability, neglect, secrecy, frightening or unpredictable behavior, chronic conflict, and tremendous emotional pain. The person struggling with substance use remains responsible for their behavior and for participating in their recovery.

At the same time, I think we make a clinical mistake when we assume that the most visible behavior tells us the entire story. The person displaying the most obvious symptom may be the person who most clearly needs immediate intervention, but that does not necessarily mean they are the only person — or the only part of the system — that warrants our attention.

The Identified Patient Is One Lens, Not an Explanation In family-systems work, the term identified patient has historically been used to describe the person whose symptoms have become the primary focus of concern within a family. I think the concept can be useful, provided we are careful about what we do with it.

It is a clinical lens, not an explanation for why someone developed a substance use disorder.

When substance use is involved, it is easy to understand how one person becomes the focus because the consequences can be highly visible: excessive drinking or drug use, missed work, legal problems, disappearing money, behavioral changes, damaged relationships, or repeated crises.

What may be considerably harder to see are the experiences surrounding that person. These might include chronic stress, trauma, anxiety, depression, shame, loneliness, relational conflict, emotional cutoff, criticism, instability, or family patterns that have existed across generations. For some people, there may also be limited experience safely expressing, tolerating, or regulating difficult emotions.

None of this means that every person with a substance use disorder comes from a dysfunctional family. It does not mean a spouse causes someone’s drinking or that parents cause their child’s addiction, and it certainly does not mean harmful behavior associated with substance use should be excused.

In fact, sometimes careful assessment may reveal that the family has primarily been responding to the disruption created by addiction rather than contributing meaningfully to it.

Examining the family system is not an assignment of blame.

It is an attempt to understand the entire clinical picture.

What Is the Substance Doing for This Person? Rather than asking only, “Why won’t you stop?” I think there is another question worth asking:

“What is the substance doing for you?”

Perhaps alcohol quiets anxiety. Perhaps using temporarily slows racing thoughts, numbs shame, reduces social inhibition, provides relief from loneliness, interrupts painful memories, or helps someone tolerate emotions they have difficulty regulating.

Some people understand exactly why they use substances. Others may simply know, I feel better when I drink, without having enough awareness yet to identify what better actually means.

Importantly, this does not mean substance use necessarily began as self-medication.

Someone may have started drinking socially as a teenager or young adult because it was enjoyable, because friends were drinking, because alcohol was readily available, or because experimentation is common during adolescence and young adulthood. Years later, however, that same person may have learned that alcohol reliably changes an uncomfortable emotional state.

How substance use begins and what eventually maintains it are not necessarily the same question.

Research gives us good reason to remain curious about these relationships. A large meta-analysis of 102 studies involving 901,864 participants found significant associations between adverse childhood experiences and later problematic alcohol use, heavy alcohol use, cannabis use, illicit drug use, and smoking. For problematic alcohol use specifically, exposure to adverse childhood experiences was associated with approximately 1.8 times the odds compared with those without such exposure. PubMed

That is an association, not proof that trauma causes addiction.

Substance use disorders are multifactorial. Genetics, neurobiology, development, mental-health conditions, social environment, stress, availability of substances, learning, and many other factors can contribute.

What the evidence allows us to say is more modest, but still important:

Context matters.

The Brain Learns What Brings Relief One of the most painful questions families ask is, “They know what this is costing them, so why do they keep doing it?”

Part of the answer is that understanding consequences intellectually and being able to regulate behavior are not neurologically identical processes.

One useful framework for understanding addiction involves interconnected brain systems associated with reward and habit formation, stress and negative emotional states, and executive control. NIDA describes the basal ganglia, extended amygdala, and prefrontal cortex as important components of these processes. The basal ganglia participate in reward and habit formation; the extended amygdala is involved in stress and negative emotional states; and the prefrontal cortex contributes to planning, problem-solving, decision-making, and impulse control. NIDA IRP

This is a useful model, not a claim that addiction can be reduced to three areas of the brain. Human neurobiology is substantially more complex.

With repeated substance use, however, learning occurs.

If someone repeatedly experiences alcohol as reducing anxiety, the brain can learn an association between anxiety, alcohol use, and relief. If a drug repeatedly changes the experience of shame, loneliness, hyperarousal, or emotional pain, those internal states may eventually become cues associated with using.

NIDA describes a progression in which repeated exposure can diminish sensitivity within reward circuitry while stress-related processes become increasingly important. Over time, some people may use less for the original pleasurable effect and increasingly for temporary relief from discomfort. NIDA IRP

This helps explain why addiction cannot adequately be reduced to character weakness or a simple lack of willpower.

It also does not eliminate agency.

Understanding what contributes to a behavior is not the same as excusing the consequences of that behavior. Explanation and accountability can exist at the same time.

Now Look at the Family System When one member of a family is clearly struggling with substances, an entire family can gradually begin organizing itself around that person’s behavior. Family members may watch them, worry about them, anticipate the next crisis, attempt to control their behavior, compensate for their mistakes, or rearrange their own lives according to what the person using substances may do next.

When so much attention is directed toward one individual, there can be relatively little attention left for examining what else is occurring within the relational system.

In some families there may be chronic conflict, poor boundaries, unresolved trauma, emotional cutoff, triangulation, criticism, secrecy, or patterns in which difficult emotions cannot be discussed without someone attacking, withdrawing, becoming defensive, or shutting down.

In other families, none of those dynamics may have meaningfully contributed to the addiction.

Some loving, stable, emotionally healthy families are profoundly affected by a loved one’s substance use disorder. We should never infer family dysfunction simply because someone develops an addiction.

The relationship can also move in both directions. Family or relational distress can contribute to vulnerability or become relevant to relapse for some individuals, while addiction itself can create enormous dysfunction in a family that previously functioned relatively well.

That is precisely why assessment matters.

SAMHSA’s Treatment Improvement Protocol on substance use disorder and family therapy recognizes the importance of understanding substance use within family systems and describes ways family-based approaches can be incorporated into SUD treatment. SAMHSA Store

Family involvement should, of course, be used when clinically appropriate and safe. It should never simply be assumed to be appropriate in every family or every circumstance.

Compassion and Accountability Can Coexist Families understandably struggle to determine how they should respond. They may wonder whether helping is supportive or enabling, whether they should confront the person or give them space, whether consequences will motivate change or deepen shame, and where healthy boundaries end and abandonment begins.

Become a Medium member There is no single answer that applies to every family, every substance, or every stage of addiction.

What I think is particularly important is recognizing that compassion and accountability are not opposites.

A family can communicate something along the lines of: I love you, I believe recovery is possible, and I am willing to help you access appropriate treatment. I am also willing to examine myself and the patterns within our family that may need to change. At the same time, I will not participate in behavior that is unsafe, abusive, deceptive, or destructive.

Those positions can coexist.

Support does not require protecting someone from every natural consequence of their behavior, just as boundaries do not require abandoning someone. Accountability does not require humiliation, and loving someone does not obligate a spouse, parent, child, or sibling to accept behavior that harms them.

Family members may also need support themselves. SAMHSA recognizes that families can have an important role in treatment and that quality care may include family involvement along with evidence-based behavioral interventions, medication when indicated, and support for other areas of a person’s life. Samhsa

Sometimes the family needs help not because the family caused the addiction, but because addiction has happened to the family as well as to the individual.

Sobriety Can Be Foundational Without Being the End of Treatment For many people, sobriety or cessation of problematic substance use is foundational to recovery. In some circumstances, it is lifesaving.

For certain substances and levels of physiological dependence, stopping abruptly can also require medical management, which is one reason appropriate assessment and evidence-based treatment are so important.

Once substance use has stopped, however, another clinical question remains:

What will this person do with whatever the substance was doing for them?

If alcohol became someone’s primary strategy for managing anxiety, stopping drinking does not automatically teach emotional regulation. If substances became a means of avoiding trauma-related distress, that distress may remain after the substance is gone. If drinking was the primary way someone dealt with shame, loneliness, social anxiety, or sleep, those experiences may still require attention.

Likewise, if a family communicates through criticism, withdrawal, explosions, secrecy, or emotional cutoff, one member becoming sober does not automatically teach the entire family how to relate differently.

Evidence-based treatment can therefore involve more than stopping substance use. Depending upon the individual and the disorder, care can include behavioral therapies, counseling, FDA-approved medications for some substance use disorders, treatment of co-occurring conditions, peer and recovery supports, and attention to the person’s broader life circumstances. Samhsa

Perhaps the distinction I find most important is this:

Sobriety matters tremendously, but removing the substance is not always the same thing as addressing everything that kept someone reaching for it.

What Should Our Investment in Recovery Look Like? Thinking about recovery this way has also led me to consider what we fund as a society.

California’s Alcoholic Beverage Tax generated $415 million in fiscal year 2024–25. According to the California State Board of Equalization, those revenues went to the state’s General Fund. California State Board of Equalization: California law provides for alcoholic-beverage-tax proceeds, after applicable refunds, to be transferred to the General Fund. CDTFA

That does not mean California spends none of that money on healthcare, behavioral health, or substance-use services. General Fund dollars support a broad range of public programs.

My question is narrower:

What if some portion of the revenue generated specifically through alcohol excise taxes were intentionally dedicated to substance-use prevention, treatment, and recovery?

Alcohol is legal, and most people who consume alcohol do not develop an alcohol use disorder. I am not interested in demonizing alcohol or the people who consume it.

I am interested in the funding question.

Could a designated portion support medically appropriate withdrawal management, residential and outpatient treatment, medications for substance use disorders when indicated, mental-health and trauma treatment, family therapy, parenting interventions, peer support, prevention, and long-term recovery services?

As a marriage and family therapist, I would not suggest that clinical expertise makes me a public-finance expert. Determining whether earmarking alcohol-tax revenue is economically sound, how much to designate, and how to administer such a program are legitimate policy questions that require fiscal analysis.

What clinical work does give me is a perspective on how complex recovery can be.

If addiction involves interactions among neurobiology, behavior, mental health, learning, stress, environment, and relationships, it seems reasonable to at least ask whether our investment in recovery adequately reflects that complexity.

Asking Better Questions When someone we love is struggling with substance use, it is understandable that the first goal may simply be to make the substance use stop, particularly when someone’s health, children, finances, or safety are at risk. There are circumstances in which stabilization appropriately takes priority over exploring the deeper psychological or relational context.

Once immediate safety has been addressed, however, we can begin asking more than “How do we make this person stop?”

We can ask what function the substance has come to serve, what this person will need to learn or develop in order to live without it, what mental-health or trauma concerns are present, what relational patterns support recovery and which interfere with it, and what each person involved needs to take responsibility for changing.

The person struggling with substance use does not automatically need to become the villain in the family story, and neither does the family.

Recovery does not require us to find one.

It requires us to understand the problem accurately enough to determine what actually needs to change.

Sometimes substance use is the symptom everyone can see. Healing may require us to become willing to examine what has been much harder to see.

Janene Kingsley, LMFT

References and Further Reading Zhu, J., Racine, N., Devereux, C., Hodgins, D. C., & Madigan, S. Associations between adverse childhood experiences and substance use: A meta-analysis. The analysis included 102 studies and 901,864 participants and examined associations between ACE exposure and multiple forms of substance use. PubMed PubMed record and abstract

National Institute on Drug Abuse. Drugs, Brains, and Behavior: The Science of Addiction. Useful background on reward, stress, executive-control systems, neuroadaptation, craving, and compulsive substance use. NIDA IRP NIDA — Drugs, Brains, and Behavior

Substance Abuse and Mental Health Services Administration. TIP 39: Substance Use Disorder Treatment and Family Therapy. This is probably the most directly relevant clinical resource for the family-systems argument in this article. SAMHSA Store SAMHSA TIP 39

SAMHSA. Treatment Options for Substance Use Disorder. Overview of medication, behavioral therapy, counseling, and whole-person approaches to SUD treatment. Samhsa SAMHSA Treatment Options

SAMHSA. Navigating Mental Health and Substance Use Care: An Introductory Guide for Families. A particularly useful resource for families trying to understand treatment, recovery, and their own role in the process. SAMHSA Library SAMHSA Guide for Families

California State Board of Equalization. 2024–25 Annual Report. Reports that California’s Alcoholic Beverage Tax generated $415 million for the state’s General Fund during FY 2024–25. California State Board of Equalization California BOE 2024–25 Annual Report

California Department of Tax and Fee Administration. Alcoholic Beverage Tax Guide. Explains California’s alcoholic-beverage tax and how its revenue is handled. CDTFA California Alcoholic Beverage Tax Guide

Resources for People Seeking Help For someone looking for substance-use treatment rather than research, SAMHSA provides a confidential treatment locator as well as its National Helpline at 1–800–662-HELP (4357). Samhsa

SAMHSA Find Treatment

For immediate mental-health or substance-use crisis support, 988 provides 24-hour crisis assistance by call or text. Samhsa